For the informants, there exists the desire for recognition of one’s identity. It speaks to the privilege of defining oneself rather than relying on others to do it for you. Informants expressed a frustration that they were not being listened to or their concerns were not taken at face value. Exasperated by the lack of communication felt from the GIAT one informant forcefully demanded of their psychologist: “What do you see?!? And then she finally said, ‘I see [informant’s name]’ and you know, I really needed that, that’s the most important thing. See me! This is me, confirm me!” (I. 5) ‘Confirmation’ of gender was wanted as an acknowledgment of being seen as “normal” or in line with prevailing norms. This was poignant as informants remarked that norms are invisible so the idea of wanting to be seen as in individual was in tension with the desire of being invisible. Being invisible for them meant being a part of the unnoticed norms that exist for cisgender society and gives a sense of belonging and safety rather than being seen through the deception frame. Another example of this tension was expressed by comparing being transgender with being left-handed. That on an individual level the left-handedness must be acknowledged in that one is operating in a right-handed world but this variation was not cause for increased attention or focus. “I’m left handed so I would need help or different tools to do my job well…That wouldn’t mean that I’m ill at all but only that I have this functional variation, I’m not so different from anyone else”. (I. 5) 5.2 Constructing the Narrative The category of Constructing the Narrative reflects the stories that informants develop for interactions with their healthcare providers and how these stories are interpreted. The two sub categories of Following the Script and Defiant Silence illustrate the tensions between the specific scripts constructed by informants that are relayed to and often expected from the mental healthcare providers and the ways in which informants resist this pre-defined narrative by not talking about issues as a means to reclaim agency. Following the Script Informants often followed a stereotypical script in defining their transition and mental healthcare needs. This script has numerous influences but it resulted in an internalized and
corresponds with the findings of a 2014 study by Levitt and Ippolito where transgender participants stressed the need to be heard and have their perspectives valued as an essential part of their identity, feelings of self-worth, and basic care needs. 6.4: Conceptual Model: The Mirror In order to understand these findings and how they relate to trans experiences with mental healthcare, it is useful to present them in a conceptual mode (See Figure 1). This model, depicting the construction of a mirror, represents the layered, interconnected and sometimes competing forces that affect care received and experiences handling mental health issues. As the categories are interwoven and reflective of one another and not clear divisions of the forces at work, the subcategories are displayed to illustrate the nuance between influences. The foundational substrate (A) for the mirror represents the essence of the transgender person. The subcategories of See Me!, Defiant Silence, and Care that Cannot Wait present the main components in how transgender persons attempt to construct their own intelligibility. Here, individuals determine their own agenda, reclaim their agency in the process, and attempt to shift the power balance into their favor. The reflective coating applied to the back (B) of the mirror that creates the image to be seen is the social constructions that develop transgender performance, narratives, and perceptions of identity. It speaks to both the external and internal influences over the formation of transgender identities. The subcategories of Following the Script and Fear of the System present the social and structural influences that determine the narratives transgender persons tell and the ways in which they feel they are at the mercy of the health care system as a whole. The reflection seen from the mirror (C) illustrates the ways that transgender persons are viewed externally by healthcare providers and by extension, society in general as well as the reflections they see of themselves. These are the perceptions, assumptions, and evaluations made regarding identity, presentation, and performance. The subcategories of Being Seen, and again Following the Script and Fear of the System are at play in forming viewpoints about transgender persons, their mental healthcare needs and the ways care is provided to them.
11. Appendix 1: Literature Review No. Author (Year) Source (Terms) Aim Method Results Notes 1 Arcelus et al. (2015) PubMed (Transsexualism, diagnosis) Measure the prevalence of transsexualism Literature review and meta-analysis of available literature. Of 1473 possible studies, 12 had sufficient data Increase prevalence over the last 50 years. 4.6/100 000; 6.8 for transwomen; 2.6 for transmen Possible use for background information on numbers only. Compare with estimates from The Williams Institute analysis. 2 Austin and Craig (2015) CINAHL (Transgender, mental health services, therapy) Introduction of adaptation of cognitive therapy interventions Review of current Cognitive Behavior Therapy (CBT) practices with considerations for transgender individuals suffering from depression, anxiety, and/or suicidality. Empirical evidence supports CBT for addressing serious mental health concerns but needs to be adapted for minority populations such as transgender persons. (From the perspective of clinical care practitioners) Addresses the assessment and management of transgender persons, not specific mental health concerns. Focus on care received while trying to obtain diagnosis but not issues associated outside of a gender affirming diagnosis. 3 Bariola et al. (2015) PubMed (Transgender, psychology) Examine the psychosocial factors associated with psychological distress and resilience among transgender National online survey sample of 169 transgender persons 46% of the sample reported high or very high level of psychological distress Highlighted the need for more tailored programs for transgender persons it did not address mental health care needs, expectations or services desired.
persons in Australia 4 Bauer et al. (2009) Embase (Transgender, transsexual, health care) Understand how erasure functions to impact transgender experiences in health care settings Qualitative study, focus groups with 85 transgender persons in Canada Focus on HIV prevention, treatment, and care. Addresses access to primary, emergency, and transition related care services. Discusses impact of erasure from research and medical design protocols. Background/justification/reflexivity 5 Benson (2013) CINAHL (Transgender, mental health care, qualitative) The purpose of the present research is to critically review historical views of transgender clients and to highlight experiences of transgender clients in therapy Feminist phenomenology informed in-depth interviews with seven people who self-identify as transgender Four themes emerged: the purposes transgender clients sought therapy, problems in practice, therapist reputation, and transgender affirmative therapy. The process is not seen as a place to address real needs but just as an access point for medical intervention 6 Carlson (2016) Web of Science (Transgender, healthcare, norms) Define the constructivist aspects of biological sex categories Analysis of constructivist theory of sex in parallel with feminist theory Norms of reproduction in defining sex categories leads to similar norms and definitions in gender categories and roles Binary limitations and adherence to strict reproduction of norms underpins policies and procedures for transgender health care that serves the system more than it serves the transgender individual 7 Davey et al. (2014) PubMed (Transgender, transsexualism, mental health) Investigate levels of social support and psychological well-being Survey of 103 transgender person attending a gender identity clinic in England, matched Transgender women perceived themselves as receiving less social support Did not address mental health services (access or availability).
among transgender individuals compared to a matched control group. with a nonclinical control group recruited via social networking websites 8 Dhejne et al. (2011) PubMed (Transsexual, Sweden, sex reassignment surgery (SRS)) Estimate mortality, morbidity, and criminal rate after SRS of transsexual persons Population-based matched cohort study of 324 persons in Sweden to receive SRS between Random population controls (10:1). Mortality rate was higher for SRS persons than for controls, particularly from suicide, also increased risks for suicide attempts and psychiatric care Often misquoted/misrepresented study regarding connections between transsexualism and M&M, psychological maladies and criminal behavior. Does emphasizing the need for “better mental health care”. See follow up series of interviews with main author Dhejne (gray literature) for contextual perspective. 9 Erasmus et al. (2015) Embase (Transgender, mental health services) Asses patient satisfaction of a gender dysphoria clinic in Melbourne, Australia 127 patients from a GDC completed a satisfaction survey assessing all healthcare services from the clinic 88,2% had overall satisfaction with services; 92,1% satisfied with psychiatric management Study addresses assessment and management, not specific mental health concerns. Only relation to mental health was framed in getting approval for diagnosis (being affirmed as transgender) but not any of the difficulties or issues associated with being transgender or other mental health care needs. 10 Gooren et al. (2014) PubMed (Transgender, mental health) Understanding use of hormones by transgender persons and mental emphasis on transgender men. Exploratory survey study of 120 transgender persons in Thailand regarding cross-sex hormone use, mental and acceptance by their family 54% of participants used hormones unsupervised by healthcare personnel. Transgender men reported higher scores of physical pain and mental health. Both groups reported poor parental acceptance. No indication of specific mental health concerns or availability of services for this population, specifically since a large number of them self-treat without supervision. 11 Hyderi et al. (2016) Embase (Transgender, health care, Understand the US clinical practices for Review of clinical care protocols Recommendations on providing sensitive care through terminology use US-centric, no concrete data finding. Addresses a culturally sensitive approach though not a culturally-centered one.
mental health) transgender transition care. and referral to mental health care providers who can assist persons trying to obtain diagnosis 12 Johansson et al. (2009) PubMed (Transgender, gender identity, SRS, transsexual) Evaluation of outcome of SRS in Sweden from both clinicians and patients Five year interviews with 42 transgender patients approved for SRS 95% reported favorable outcomes, 90% felt stable in work, partner relations, and sex life. dissatisfied with hormones, results or surgery, entire procedure, or present general health Does not address mental health specifically, either related or unrelated to transition 13 Kattari et al. (2016) PubMed (Transgender, mental health) Examine the relationship between providers and mental health outcomes in Colorado, US Secondary data analysis from Colorado health survey of 417 transgender or gender-variant persons, via the web 37% with a provider (TIP) reported depression compared to 53% who did not have a TIP. 51% with TIP reported anxiety compared to 56% without. 28% with TIP reported suicidality in previous year compared to 47% without Background stats on mental health burden (can find other sources though). Illustration of need for transgender –inclusive providers taking a holistic approach to mental health care. Mental health care was linked to obtaining diagnosis for insurance coverage 14 Linander et al. (2016) PubMed (Transgender, Sweden, healthcare, qualitative) Analyze experiences of transgender persons navigating the process in Sweden Qualitative study, interviewing 14 persons considering, actively seeking, or in the formal process of transition in Sweden Participants noted health care is difficult to navigate due to long wait times, lack of support, provider ignorance, and the relationship of dependency between provider and patient Does not address mental health specifically but does provide insight into provider/client relationships and the limitations seen in the current Swedish system 15 Lindroth (2016) Embase (Transgender, healthcare Describe how transgender persons Qualitative study, interviewing 20 transgender or Healthcare professionals working with this population need an Excellent example of constructivist grounded theory. Focus on sexual health and rights, not on transition care or mental health needs.
services) experience meetings with healthcare professionals concerning their sexual health and rights non-binary persons on their sexual health related experiences with healthcare services in Sweden increase in transgender knowledge especially in a system built on heteronormative expectations Looked at general care providers not specifically the Swedish gender identity team 16 McCann (2014) Embase (Transgender, mental health) Elicit views and opinions of transgender persons in relation to mental health care concerns Qualitative study, semi-structured interviews done in Ireland. Was part of a larger study, with a survey from 125 persons who identified at LGBT, 20 who fell into the LGB category and four identifying as transgender. Participants were critical of services (wait times and costs), lack of support from family, friends, and society, spoke of concerns over depression, anxiety, suicidality and lack of easily accessible care Different system from Swedish, mental health care not a requirement for transition. Most critique seems to be of a larger issue of a lack of general mental health care service in Ireland 17 McCann and Sharek (2015) PubMed (transgender, mental health) Establish the mental health service needs of transgender persons through a review of studies that address the experiences of this group Literature review that began with 217 possible articles narrowed down to 10 for review (each qualitative, with the inclusion of transgender persons and addressed various aspects of mental health) Notes a substantial lack of studies that specifically examine mental health care needs of transgender persons. Themes: accessing services, discrimination, transphobia, vulnerability, relationships with family, friends, and partners, risk-taking behaviors, service developments Excellent review, highlights gaps but also falls short in some areas (can’t cover everything). Misses some nuances of mental health care and transition that are systemic not personal. Valuable study to keep in mind especially for reflexivity
18 Poteat et al. (2013) Embase (Transgender, healthcare services, qualitative) Understanding stigma and discrimination experiences in healthcare and the effects on transgender persons Qualitative study in the US, interviewed 55 transgender persons and 12 medical providers Interpersonal stigma reinforces medical power and authority thus reinforcing inequalities in health care services. Main concerns were access for HIV prevention and care Good examination of the power of authority in provider /client relationships. Valuable for reflexivity 19 Reisner et al. (2016) Embase (Transgender, health care, mental health, public health) Assess the global health burden and needs for transgender persons Literature review of 116 studies from 30 countries demarcating health outcomes and health-related data Mental health is the most commonly studied area of transgender health (n=303 datapoints; 31%). Wide variation in screening tools, prevalence, and clinical practices. The majority of research (n=161 of 303 datapoints, 53%) reports prevalence data only. Measures of association of risk factors are needed for future research as well as addressing specific gaps in care Notes*Majority of research comes from the US. Emphasis on improving data collection methods and standardized practices 20 Rosqvist et al. (2014) Embase (Transgender, SRS, Sweden, transition) Explore how discourse is reproduced in transsexual negotiations in Sweden Interviews from nine health care professionals, observations from two clinical conferences, one focus group discussion among members of a General defense of the repertoire as a nuanced understanding of patients and their sense of authenticity. Notes it can psychologize patients as having an identity crisis rather than being Discussion on determining the “authenticity” of a person’s experience and making broad connections to a person’s maturity level. Very “gatekeeper” centric
second clinical team and four individual interviews with persons who worked at clinics transgender. See benefits and limits to using this model and needs further exploration 21 Rutherford et al. (2012) CINAHL (Mental health, LGBT, healthcare services) Explore how providers with LGBT-focused practices develop their capacity for working with these populations Eight interviews with mental health service providers with extensive experience serving LGBT individuals with a phenomenological approach Recommendations for mandatory LGBT sensitive mental health services, education curricula, terminology usage, interview questions, and engaged training with this community Note* Not transgender specific. Illustrates the issue of transgender being lumped in with lesbian, gay, and bisexual without delineating their specific and unique healthcare needs and concerns (although a minority population LGB emphasizes sexual orientation concerns not necessarily gender identity). “Gatekeeper” perspective 22 Selvaggi and Giordano (2014) PubMed (Transgender, transsexual, mental health) Examine the ethical issues concerning the role of mental health professionals in gender reassignment surgeries (GRS) Review and discussion of the Standards of Care (SoC) by the World Professional Association of Transgender Health (WPATH) with a focus on autonomy and non-discrimination Reifies the purpose of psychotherapy is to explore gender identity, address the negative impact of Gender Dysphoria (GD) on mental health, alleviate internalized transphobia, enhance social and peer support, improve body image, promote resilience and assist surgeons in prepping patients for SRS and follow-up. It is not a form of negative discrimination or an “To treat people as equal does not mean that they should be treated in the same way, but with the same concern and respect, so that their unique needs and goals can be achieved” (pg. 1177). Offering assistance as opposed to mandating it? change
attack on the patient’s autonomy. Offering psychological assistance is a form of responsible care 23 Trujillo et al. (2016) Scopus (Transgender, mental health) Explore patterns of discrimination, mental health, and suicidality in transgender individuals and if social support moderates these relationships National online survey in the US, 78 respondents evaluated social support and the relation to discrimination, mental health and suicidality Discrimination was the most positive predictor for mental health symptoms and suicidal ideation. Depression and suicidality was prominent among those without strong social support Imbrication of mental health concerns tied to social stigma and discrimination. Does not directly address psychological care 24 von Vogelsang et al. (2016) PubMed (Transgender, Sweden, SRS, qualitative, transsexual) Describe transsexual persons’ experiences of encounters with healthcare professionals during the sex reassignment process Manifest qualitative content analysis from interviews with six persons who had either had SRS or were awaiting surgery Experiences were positive when respect was shown from providers and the transgender person’s integrity was preserved. Negative experiences were associated with lack of provider knowledge, exploitative positions of power, withholding information, stereotypical gender attitudes, condescension resulting in feelings of vulnerability, high levels of dependency on providers and external General healthcare providers, not specific to mental health although still related to the process of transition requirements in Sweden
18. Appendix 8: Sample of Initial Codes - Categories Initial Codes Focused Codes Subcategories Categories Feeling judged Performing a particular gender Feeling stigmatized Dealing on a daily basis Passing and performance Study object Caught in the crosshairs Unwanted attention Being Seen Objectification vs. Subjectivity See me! Having identity confirmed Being seen as capable Being left-handed Needing to survive Feeling relief Having a functional variation Tangible manifestations See Me! Being suitable to be trans Doing drag Answering in specific ways Being a stereotype Seeing a checklist Going through the steps Having two stories to tell How to define ourselves Following the Script Constructing the Narrative Not admitting I was abused Not feeling trust Standing up for myself Not degrading trans stories Continuing to exist Making a choice Feeling overwhelmed by it all Knowing your position Defiant Silence Being in the dark Long, complicated process Fearing delays in care Desperate for the diagnosis The process Systems of oppression Labyrinth of approvals Deciding the fate of others Fear of the System Reflections of Care Having practical needs Wanting someone that understands Needing more information for me Mental health unrelated to being trans Future directions Need for education Salvaging mental health Including trans persons Care that Cannot Wait