‘Transgender’ (‘trans’) refers to people who have gender identities and expressions that differ from their assigned sex at birth.1,2 Some, though not all, trans people experience gender dysphoria, which consists of acute physical and emotional distress related to the incongruence between their gender identity and sex assigned at birth.3 Some trans people may seek gender-affirming hormone therapies4 and, in some cases, surgery. However, not all trans people experience distress or dysphoria,5 and not all seek medical intervention on the basis of their gender identity.
Despite the well-documented need for lesbian, gay, bisexual, trans and intersex (LGBTI)-inclusive healthcare internationally, trans people still experience health disparities when compared with people who are not trans (‘cisgender’), including relatively higher rates of discrimination and harassment, violence, psychological distress and suicidality.6–8 Trans people may seek healthcare for reasons unrelated to gender, but they are often negatively impacted by structural and interpersonal discrimination in health settings.9,10 For example, Australian trans people have reported negative experiences with healthcare practitioners, including invalidation of identity, misgendering and refusal of services.11 Subsequently, trans people often avoid accessing healthcare due to fear of mistreatment from healthcare practitioners.11,12 Lack of healthcare practitioner knowledge is associated with poorer care for trans people,9 whereas having access to gender-affirming healthcare practitioners is associated with improved health and wellbeing among trans people of all ages.13
Personal discomfort treating trans patients14 and lack of education and training in trans healthcare15 have been identified as barriers for healthcare practitioners to deliver high-quality care for trans patients. In 2015–16, a survey of Australian and New Zealand medical schools found an average of 0–5 hours dedicated to LGBTI medical education overall, which predominantly focused on sexuality.16 A 2019 US study17 observed that the quality of medical education may be more important than the quantity, and the transphobic views held by some medical students must first be challenged through medical education before key information about trans healthcare provision may be learned. A lack of formal training combined with limited social awareness of trans people can result in ‘inappropriate curiosity’ among healthcare practitioners when faced with trans patients, detracting from the quality of care these patients receive.18 The use of inclusive language, including pronouns (he/him, she/her, they/them19) and affirming terminology, has been identified as one important factor in delivering care to trans people.10 This can be challenging for healthcare practitioners due to the need to keep abreast of emerging gender identities and experiences.20 However, misgendering from healthcare practitioners, which occurs when a person is addressed or described with language not matching their gender identity, perpetuates discrimination and stigma for trans people.10 Healthcare practitioners must develop greater knowledge and awareness of trans-inclusive practices and referral pathways in order to treat this population with sensitivity and competence.21
Awareness of trans-affirming healthcare is increasing in Australia, as is the need for more services across the country. For example, in March 2020 the Royal Australian College of Physicians (RACP) advised the Australian Government on the treatment of gender dysphoria in children and adolescents, and recommended ‘improve[d] access to and consistency of care within and across jurisdictions.’22 However, with a few exceptions,23,24 little is known about trans healthcare provision in Australia. This study addresses these knowledge gaps by using qualitative interviews to examine healthcare practitioners’ and students’ understandings and approaches to trans healthcare in Tasmania, Australia.
Methods
This article reports on interpretive qualitative interview data that were collected as a part of a broader mixed-methods study investigating healthcare practitioners’ and students’ understandings of LGBTI-inclusive practices in Tasmania, Australia from May to September 2019.25 Key research questions of the broader study were:
- How do Tasmanian healthcare practitioners and students understand and approach LGBTI health?
- What are the challenges Tasmanian healthcare practitioners and students face in providing optimum care to LGBTI patients?
In addressing these questions, the project aimed to explore the knowledge and practices of clinicians and students with a view to informing health policy, training and curriculum development.
The research was conducted by a multidisciplinary team comprising four health sociologists and two medical practitioners. While several research team members are lesbian, gay or bisexual, none are trans. The researchers engaged local LGBTI community groups and organisations in the research project design. This article reports qualitative findings on treating trans patients, which we found made up a significant portion of data from our study.
The first phase of the broader study included an exploratory online survey, garnering 219 individual responses (207 valid at 75% complete). Inclusion criteria for the study were: >18 years of age, based in Tasmania and currently studying or working in a health-related field (eg medicine, nursing, paramedicine, psychology). Survey respondents were recruited via social media advertisements, a university staff newsletter, and medical professional association newsletters and listservs. Following completion of the survey, respondents were invited to express interest in being interviewed. This article only reports the data gathered from the qualitative interview stage of this study.
Seventeen participants were purposively selected from a larger pool of expressions of interest (n = 42). These participants were chosen, based on their demographic information obtained in the initial survey, to represent a range of age demographics, professions and areas of study, and to ensure representation of men and participants from diverse cultural backgrounds, whose experiences were underrepresented in the survey.
With participants’ informed consent, semi-structured interviews were conducted by LN, a female research assistant with expertise in social science. The interviews lasted up to one hour and were conducted via telephone, Skype, or in person at the university or participant’s workplace. All interviews were conducted using an interview guide developed from the initial survey and its emerging findings. Interviews focused on a range of open-ended questions about participants’ health professional training, professional development opportunities, clinical experiences and understandings of LGBTI-inclusive practice. Interviews were audio-recorded with consent and transcribed. No compensation or reimbursement was provided as part of this study.
The study received ethical approval from the University of Tasmania Social Sciences Human Research Ethics Committee (Reference: H0018092). Data were been de-identified and stored in a secure cloud location to ensure participant anonymity and confidentiality. Participants were assigned numerical pseudonyms and general descriptors of their role were used to provide context in the reporting of data.
Interview transcripts were analysed using reflexive thematic analysis, with a focus on developing inductive codes identified during analysis, but also deductive codes that reflected the authors’ research questions.26 QSR NVivo (v.11.2.2 Mac) was used as a software to organise data and codes. AKJS examined the data, generated initial codes and then developed draft themes to collate patterns of meaning across the data.26 AKJS conferred twice with RG to critically discuss coding and to workshop and refine themes. In developing the analysis and linking to broader literature, AKJS went back to the data to ensure that the patterns of meaning described in this article reflected the data.
Results
Participants
Participant demographics are outlined in Table 1. Although participants were not directly asked and the authors did not sample for this, during interviews, 11 participants identified themselves as part of the LGBTI community. While two participants described themselves as non-binary (identifying beyond the masculine/feminine gender spectrum), none identified binary trans identities.
A summary of the key themes resulting from data analysis is provided in Table 2.
| Table 1. Participant demographics |
| Characteristics |
Number (n = 17) |
| Age (years) |
| 18–24 |
6 |
| 25–34 |
3 |
| 35–44 |
2 |
| 45–54 |
3 |
| ≥55 |
3 |
| Gender |
| Women |
10 |
| Men |
5 |
| Non-binary |
2 |
| Identifies as member of the LGBTI community |
11 |
| Language spoken at home |
| English |
14 |
| Mandarin |
1 |
| Cantonese |
1 |
| Arabic |
1 |
| Healthcare practitioners |
n = 12 |
| Medical doctor/GP |
3 |
| Nurse |
4 |
| Psychologist/counsellor |
3 |
| Emergency specialist doctor |
1 |
| Naturopath |
1 |
| Students |
n = 5 |
| Medicine |
3 |
| Nursing |
1 |
| Pharmacy |
1 |
| Student year level |
| 1st year |
1 |
| 2nd year |
1 |
| 3rd year |
2 |
| 4th year |
1 |
| GP, general practitioner; LGBTI, lesbian, gay, bisexual, trans and intersex |
| Table 2. Results of thematic analysis |
| Theme |
Subtheme |
| Lack of training |
- Practising clinicians’ reflections on education in the past
- Recent graduates’ reflections on education
- Current students’ reflections on education
- Alternative sources of knowledge/awareness of trans health
|
| Limited resources |
- Lack of professional development opportunities regarding trans health
- Limited or unclear referral pathways for trans patients
|
| Using inclusive language |
- Awareness of the importance of gender-affirming language
- Difficulties using gender-affirming language
|
| Trans, transgender |
‘Not on the radar at all’: Lack of training in trans health
Overall, the healthcare practitioners and students in our study demonstrated little awareness of trans people’s experiences. When asked if they had received any training about trans health in their formal education, responses differed based on age and career stage. For example, experienced practising clinicians highlighted a complete lack of training:
No, there was no preparation [for inclusive practices]. When I did my medical degree, [trans health] was not on the radar at all. (Participant [P] 10 – clinician – GP)
We didn’t do anything about trans[gender] … I guess, the number of openly transgender people is much more than it was 10 years ago and recognition [has] changed a lot as well. (P8 – clinician – nurse)
In contrast, one recent nursing graduate described receiving some training:
I think there was one [case study activity] where the patient was [trans], so it was just a brief discussion about the use of pronouns and that sort of thing. But I think at least people – students – now are generally pretty good with that sort of thing just because of the greater awareness about those issues. (P6 – clinician – nurse)
Despite participants’ assumptions that contemporary health students may have a greater awareness of trans issues, this was not reflected in our findings. Like their predecessors, current students also reported receiving no formal training or clinical interactions with trans patients:
There’s been no mention of transgender people or, I guess, lesbians or anything of that nature. (P19 – student – medicine)
[Trans health] isn’t something that’s been covered at all. (P5 – student – pharmacy)
Given their lack of formal training, participants were asked whether and how they had learned about trans people. Responses differed between participants who identified as LGBTI and those who did not. For participants who did not identify as LGBT, having clinical experience working with trans patients was a key factor contributing to confidence in this area:
Initially, the first few [trans patients] had to inform me. I asked lots of questions and learnt from what they had to say, so I think over the years I’ve – again, nothing formal – but acquired a bit of knowledge just from the people I’ve looked after and the first few times, [I said] ‘Well, I know nothing, tell me,’ and they were kind enough to help me. (P11 – clinician – GP)
Although some participants believed that learning from their patients was a positive approach, this can place undue responsibility on patients to educate their healthcare practitioner.
In contrast, participants who identified as LGBTI believed they had a greater understanding of trans health, and some reported self-educating on trans issues:
Just being gay myself, I know – I’ve educated myself a lot about trans issues and things like that, so I feel like I would have some knowledge, something to go off whereas others may have no basic knowledge at all. (P5 – student – pharmacy)
I would say [I’m] well informed [about LGBTI-inclusive practices] but there are still areas where I am learning and one of those is in supporting people who identify as trans, which is kind of strange because that’s a fairly recent thing for me that I identify as non-binary. (P16 – clinician – counsellor)
Given that there are important differences between various LGBTI identities and people, belonging to one aspect of the LGBTI spectrum does not necessarily translate to expertise with others.
‘Who do you call?’: Limited resources to support trans people
Participants told us that access to resources to support trans people were a significant challenge in Tasmania. Participants across Tasmania spoke about a dearth of professional development options, and being unsure of where to go for resources beyond one or two key services or organisations. For example:
I would literally be calling up [organisation name] myself and saying, ‘What resources do you have?’ Sure, they’d be happy to be the primary referral but there’s just not enough. (P16 – clinician – counsellor)
Because the number of healthcare practitioners with expertise in trans-inclusive healthcare is limited, a retiring expert in the field created a knowledge gap:
Now we’ve recently had, I think the main medical person [with trans expertise] in Tasmania, retire. So, that’s now left a huge gap for that community, until somebody comes back into that. Now, the knowledge that the person alone had, will take other people years to actually understand. (P12 – clinician – nurse)
Similarly, it was difficult to find referrals to support patients. This participant explained:
I think that if I was caring for somebody that was trans or anything really and I didn’t know how to get them the support that they needed, I’d think I’d find that quite stressful ... as far as what services and support is available out there, I really don’t know. And that’s such an important part of nursing because we play a huge role in discharge planning and making sure that we’ve got the services and supports in place for when people leave our care and I’m not really sure about what services we have that are inclusive. (P6 – clinician – nurse)
Because expertise and familiarity with trans-affirming care is uncommon in Tasmania, some participants saw value in lists of clinicians for referrals:
It would be helpful to have – particularly for intersex and trans – to have lists of people who are experts in the state or elsewhere to refer people to because I wouldn’t know where to start. (P9 – clinician – emergency specialist doctor)
Not only did Tasmanian healthcare practitioners report limited knowledge of trans health, they also described practising in a context with little support to improve their approaches.
Box 1 is a list of resources that individuals and organisations may wish to use as a basis for their own resources list.
| Box 1. Transgender health resources |
Transgender 101: Gender diversity crash course
National services and resources
State-based services and resources
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
|
‘What are your pronouns?’: The importance and challenges of using inclusive language
Although participants reported limited formal training and resources for trans-inclusive practices, most (n = 10) described the need to use gender-affirming language to avoid misgendering patients. Participants described the importance of open discussion with patients about names, pronouns and the kinds of gendered language they used to describe their bodies. For example:
It’s got to be inclusive for that person. And sometimes talking to a trans person, I’ve got to use language, you’ve got to say to them, ‘Shall I refer to you as ‘they’ or ‘you’ or what pronoun do you prefer?’ And it made me think I didn’t feel quite as relaxed because I didn’t want to make a mistake. I didn’t want to upset the person so I wanted to check with them, ‘What would you like? How would you like me to refer to you?’ (P18 – clinician – midwife/nurse)
Although gender-affirmative language aligns with whole-person care principles, some participants problematically positioned such efforts as being reserved for ‘special’ cases, rather than for all patients. For example:
I mean, when someone is gay in the pharmacy, often it’s not immediately [obvious] ... whereas often when someone’s trans you can tell straight away. So you may have a different approach because you already know when speaking to the patient. (P5 – student – pharmacy)
I do ask people about their names and their pronouns if I think of it. And if someone flags as queer – if somebody I think might be, I am more likely to focus on gender-neutral pronouns and try and be friendly and trying to have a welcoming environment. (P9 – clinician – emergency medical doctor)
These participants described only employing inclusive approaches or gender-neutral language if they believed a patient may ‘flag as queer’. This approach is inappropriate because it involves making judgements about patients based on stereotypes associated with physical appearance and gender expression. Believing that you can determine if someone is trans based on appearance is incorrect and offensive because it relies on assumptions about what trans people ‘look like’. While participants were well-intentioned in their discussions of inclusive language, their responses demonstrated a need for deeper understanding.
Discussion
This study aimed to explore healthcare practitioners’ and health students’ attitudes to treating trans patients in Tasmania. We found that healthcare practitioners and students lacked critical awareness of trans health and were inexperienced in providing gender-affirming care. In line with previous research,27 we suggest that this was due to inadequate training, limited resources and negative assumptions about trans people. As the first study exploring healthcare practitioner attitudes to trans patients in Tasmania, this article makes a significant contribution to Australian health scholarship. It also contributes to health literature and practice more broadly in its important observations of the lack of change in health and medical education regarding trans health.
Whole-person care is a cornerstone of contemporary healthcare provision,28 and healthcare practitioners ought to work responsively with the complexity and diversity of their patients. However, trans people routinely provide education to their healthcare practitioners,11 including addressing inappropriate questions and ‘curiosity’ irrelevant to clinical care.18 As this approach can place undue burden on vulnerable groups to educate healthcare practitioners, it is necessary for healthcare practitioners to engage in education and professional development, and for healthcare practitioners and students to be further supported to provide trans-inclusive healthcare.
A limitation of the self-selected sampling method we used is that the small sample was biased towards younger women, nurses and healthcare practitioners/students who identified as LGBTI. The higher proportion of LGBTI healthcare practitioners/students was likely due to feelings of personal investment in the broader research topic of LGBTI-inclusive healthcare. LGBTI participants believed their personal experiences and community membership afforded them greater awareness of trans people and their health needs. However, it is important to note that merely identifying as LGBTI does not automatically ensure knowledge of how to provide trans-inclusive care. For example, despite being non-binary themselves, one participant described trans health as an area they were still learning about. Notably, a gay participant assumed he could ‘tell’ if a patient is trans. As noted earlier, this is not accurate, and the assumption is offensive to trans people. Thus, while learning from personal experiences and networks is valid, formalised education and professional development are also required to provide consistent standards.29
Further, this study does not capture the lived experiences of trans patients, an insight that is vital to guiding inclusive healthcare provision. However, this study is important because previous international and Australian research indicates that healthcare practitioners and students receive little formal training about LGBTI health in general,16 with trans issues an emerging area of concern.17 While the health disparities faced by trans people are becoming increasingly well documented,24,30 few studies have examined Australian healthcare practitioners’ approaches to supporting trans patients. Our findings indicate the need for improved health and medical curriculum development on the topic of trans health, and greater opportunities for professional development for health practitioners in regional and rural areas like Tasmania.
Implications for general practice
The findings of this study can be used to inform design of the medical education, professional development and referral lists that should be developed to support current and future healthcare practitioners.