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For people who are transgender, transsexual, or transitioned (trans), access to primary, emergency, and transition-related health care is often problematic. Results from Phase I of the Trans PULSE Project, a community-based research project in Ontario, Canada, are presented. Based on qualitative data from focus groups with 85 trans community members, a theoretical framework describing how erasure functions to impact experiences interacting with the health care system was developed. Two key sites of erasure were identified: informational erasure and institutional erasure. How these processes work in a mutually reinforcing manner to erase trans individuals and communities and produce a system in which a trans patient or client is seen as an anomaly is shown. Thus, the impetus often falls on trans individuals to attempt to remedy systematic deficiencies. The concept of cisnormativity is introduced to aid in explaining the pervasiveness of trans erasure. Strategies for change are identified.

BackgroundAcross Europe, Canada, and the United States, 22–43 % of transgender (trans) people report a history of suicide attempts. We aimed to identify intervenable factors (related to social inclusion, transphobia, or sex/gender transition) associated with reduced risk of past-year suicide ideation or attempt, and to quantify the potential population health impact.MethodsThe Trans PULSE respondent-driven sampling (RDS) survey collected data from trans people age 16+ in Ontario, Canada, including 380 who reported on suicide outcomes. Descriptive statistics and multivariable logistic regression models were weighted using RDS II methods. Counterfactual risk ratios and population attributable risks were estimated using model-standardized risks.ResultsAmong trans Ontarians, 35.1 % (95 % CI: 27.6, 42.5) seriously considered, and 11.2 % (95 % CI: 6.0, 16.4) attempted, suicide in the past year. Social support, reduced transphobia, and having any personal identification documents changed to an appropriate sex designation were associated with large relative and absolute reductions in suicide risk, as was completing a medical transition through hormones and/or surgeries (when needed). Parental support for gender identity was associated with reduced ideation. Lower self-reported transphobia (10th versus 90th percentile) was associated with a 66 % reduction in ideation (RR = 0.34, 95 % CI: 0.17, 0.67), and an additional 76 % reduction in attempts among those with ideation (RR = 0.24; 95 % CI: 0.07, 0.82). This corresponds to potential prevention of 160 ideations per 1000 trans persons, and 200 attempts per 1,000 with ideation, based on a hypothetical reduction of transphobia from current levels to the 10th percentile.ConclusionsLarge effect sizes were observed for this controlled analysis of intervenable factors, suggesting that interventions to increase social inclusion and access to medical transition, and to reduce transphobia, have the potential to contribute to substantial reductions in the extremely high prevalences of suicide ideation and attempts within trans populations. Such interventions at the population level may require policy change.

Given that an estimated 0.6% of the U.S. population is transgender (trans) and that large health disparities for this population have been documented, government and research organizations are increasingly expanding measures of sex/gender to be trans inclusive. Options suggested for trans community surveys, such as expansive check-all-that-apply gender identity lists and write-in options that offer maximum flexibility, are generally not appropriate for broad population surveys. These require limited questions and a small number of categories for analysis. Limited evaluation has been undertaken of trans-inclusive population survey measures for sex/gender, including those currently in use. Using an internet survey and follow-up of 311 participants, and cognitive interviews from a maximum-diversity sub-sample (n = 79), we conducted a mixed-methods evaluation of two existing measures: a two-step question developed in the United States and a multidimensional measure developed in Canada. We found very low levels of item missingness, and no indicators of confusion on the part of cisgender (non-trans) participants for both measures. However, a majority of interview participants indicated problems with each question item set. Agreement between the two measures in assessment of gender identity was very high (K = 0.9081), but gender identity was a poor proxy for other dimensions of sex or gender among trans participants. Issues to inform measure development or adaptation that emerged from analysis included dimensions of sex/gender measured, whether non-binary identities were trans, Indigenous and cultural identities, proxy reporting, temporality concerns, and the inability of a single item to provide a valid measure of sex/gender. Based on this evaluation, we recommend that population surveys meant for multi-purpose analysis consider a new Multidimensional Sex/Gender Measure for testing that includes three simple items (one asked only of a small sub-group) to assess gender identity and lived gender, with optional additions. We provide considerations for adaptation of this measure to different contexts.

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Background Intersectionality is a theoretical framework rooted in the premise that human experience is jointly shaped by multiple social positions (e.g. race, gender), and cannot be adequately understood by considering social positions independently. Used widely in qualitative studies, its uptake in quantitative research has been more recent. Objectives To characterize quantitative research applications of intersectionality from 1989 to mid-2020, to evaluate basic integration of theoretical frameworks, and to identify innovative methods that could be applied to health research. Methods Adhering to PRISMA guidelines, we conducted a systematic review of peer-reviewed articles indexed within Scopus, Medline, ProQuest Political Science and Public Administration, and PsycINFO. Original English-language quantitative or mixed-methods research or methods papers that explicitly applied intersectionality theoretical frameworks were included. Experimental studies on perception/stereotyping and measures development or validation studies were excluded. We extracted data related to publication, study design, quantitative methods, and application of intersectionality. Results 707 articles (671 applied studies, 25 methods-only papers, 11 methods plus application) met inclusion criteria. Articles were published in journals across a range of disciplines, most commonly psychology, sociology, and medical/life sciences; 40.8% studied a health-related outcome. Results supported concerns among intersectionality scholars that core theoretical tenets are often lost or misinterpreted in quantitative research; about one in four applied articles (26.9%) failed to define intersectionality, while one in six (17.5%) included intersectional position components not reflective of social power. Quantitative methods were simplistic (most often regression with interactions, cross-classified variables, or stratification) and were often misapplied or misinterpreted. Several novel methods were identified. Conclusions Intersectionality is frequently misunderstood when bridging theory into quantitative methodology. Further work is required to (1) ensure researchers understand key features that define quantitative intersectionality analyses, (2) improve reporting practices for intersectional analyses, and (3) develop and adapt quantitative methods.

BackgroundMembers of the transgender community have identified healthcare access barriers, yet a corresponding inquiry into healthcare provider perspectives has lagged. Our aim was to examine physician perceptions of barriers to healthcare provision for transgender patients.MethodsThis was a qualitative study with physician participants from Ontario, Canada. Semi-structured interviews were used to capture a progression of ideas related to barriers faced by physicians when caring for trans patients. Qualitative data were then transcribed verbatim and analysed with an emergent grounded theory approach.ResultsA total of thirteen (13) physician participants were interviewed. Analysis revealed healthcare barriers that grouped into five themes: Accessing resources, medical knowledge deficits, ethics of transition-related medical care, diagnosing vs. pathologising trans patients, and health system determinants. A centralising theme of “not knowing where to go or who to talk to” was also identified.ConclusionsThe findings of this study show that physicians perceive barriers to the care of trans patients, and that these barriers are multifactorial. Access barriers impede physicians when referring patients to specialists or searching for reliable treatment information. Clinical management of trans patients is complicated by a lack of knowledge, and by ethical considerations regarding treatments—which can be unfamiliar or challenging to physicians. The disciplinary division of responsibilities within medicine further complicates care; few practitioners identify trans healthcare as an interest area, and there is a tendency to overemphasise trans status in mental health evaluations. Failure to recognise and accommodate trans patients within sex-segregated healthcare systems leads to deficient health policy. The findings of this study suggest potential solutions to trans healthcare barriers at the informational level—with increased awareness of clinical guidelines and by including trans health issues in medical education—and at the institutional level, with support for both trans-focused and trans-friendly primary care models.

Objective. We sought to determine whether lesbians have higher rates of overweight and obesity than women of other sexual orientations.Methods. We compared population estimates of overweight and obesity across sexual orientation groups, using data from the 2002 National Survey of Family Growth.Results. Adjusted multinomial logistic regression analyses showed lesbians have more than twice the odds of overweight (odds ratio [OR] = 2.69; 95% confidence interval [CI] = 1.40, 5.18) and obesity (OR = 2.47; 95% CI = 1.19, 5.09) as heterosexual women. Bisexuals and women who reported their sexual orientation as "something else" (besides heterosexual, lesbian, or bisexual) showed no such increase in the odds of overweight and obesity.Conclusions. Lesbian women have a higher prevalence of overweight and obesity than all other female sexual orientation groups. This finding suggests that lesbians are at greater risk for morbidity and mortality linked to overweight and obesity. This finding also highlights the need for interventions within this popu- For women in the US general population, the correlates of obesity are increasing age, low education, or low economic status. 2,19-21Black and Hispanic women have higher rates of overweight and obesity than do White women.2,22-24 Among White, Black, and Hispanic women, childbearing has been linked to weight gain. [25][26][27][28][29] Nativity has also been identified as a correlate of excess body fat: immigrants tend to have a lower BMI; however, this health advantage disappears as the length of residence in the United States increases. 30-36Existing treatments and interventions focus on reducing energy intake by changing nutritional habits and increasing physical activity. 37Because obesity is particularly prevalent in Black and Hispanic women, several interventions have targeted these specific groups. [38][39][40] By comparison, there are no interventions that target sexual-minority women. Whether a need for interventions that specifically target sexual-minority women exists depends on the confirmation that lesbians have a higher prevalence of overweight and obesity compared with other sexual orientation groups.We used population-based data to test the hypothesis that lesbians have higher rates of overweight and obesity compared with