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Transgender Health
Snelgrove et al. BMC Health Services Research 2012, 12:110 http://www.biomedcentral.com/1472-6963/12/110

RESEARCH ARTICLE

Open Access

“Completely out-at-sea” with “two-gender medicine”: A qualitative analysis of physician-side barriers to providing healthcare for transgender patients
John W Snelgrove*, Amanda M Jasudavisius, Bradley W Rowe, Evan M Head and Greta R Bauer
Abstract
Background: Members 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. Methods: This 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. Results: A 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. Conclusions: The 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


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Bauer GR, Hammond R, Travers R, Kaay M, Hohenadel KM, Boyce M: "I don 't think this is theoretical; this is our lives": How erasure impacts health care for transgender people. J Assoc Nurses AIDS Care 2009, 20:348–361. 14. Namaste VK: Invisible lives: The erasure of transsexual and transgendered people. Chicago: University of Chicago Press; 2000. 15. Mayer KH, Bradford JB, Makadon HJ, Stall R, Goldhammer H, Landers S: Sexual and gender minority health: What we know and what needs to be done. Am J Public Health 2008, 98:989–995. 16. Health Canada: Canada 's health care system (Medicare). 2011. Available online: http://www.hc-sc.gc.ca/hcs-sss/medi-assur/index-eng.php. Accessed 21/09/2011. 17. Ontario Ministry of Health and Long-Term Care: Relisting of sex reassignment surgery under OHIP. Bulletin 2008, 4480:6–20. 18. Government of Alberta: Budget 2009: Building on our strength. 2009:4–7. 19. Government of Alberta: Gender Reassignment Surgery Program modified phase-out. Special bulletin to psychiatrists.: ; Available online: http://www. health.alberta.ca/professionals/bulletins-medical.html. Accessed 21/09/2011. 20. American Psychiatric Association: Diagnostic and statistical manual of mental disorders. Washington, D.C: DSM-IV-TR; 2000. 21. Lev AI: Disordering gender identity: Gender Identity Disorder in the DSMIV-TR. Journal of Psychology & Human Sexuality 2005, 17:35–69. 22. Dewey JM: Knowledge legitimacy: How trans-patient behavior supports and challenges current medical knowledge. Qual Health Res 2008, 18:1345–1355. 23. Feldman JL, Goldberg J: Transgender primary medical care: Suggested guidelines for clinicians in British Columbia. Vancouver: Vancouver Costal Health Authority; 2006. 24. Greenaway K: LGBT Health Program: Part 1: Protocol for treatment hormone therapy. In Guidelines and protocols for comprehensive primary health care for trans clients. Toronto: Sherbourne Health Centre; 2009. Conclusions This exploratory study provides a novel inquiry into physician-side barriers to healthcare provision for trans patients. Barriers previously identified by the trans community were found to limit care provision by physicians as well, including the inaccessibility of resources and appropriate referrals, inadequate medical knowledge and training, the limitations of GID diagnosis, and the low availability of trans healthcare services. This study presents additional insight to physician-side barriers involving the ethics of providing transition-related medical care. The findings contribute to an emerging debate regarding models of trans healthcare organisation, and how these may address some of the barriers faced by trans people and their physicians within the healthcare system. While the findings of this study elucidate some of the barriers faced by physicians, more research is needed to fully understand healthcare provision barriers, and to develop solutions that are acceptable to both the medical and trans communities. Additional file Additional file 1: Participant interview schedule. Abbreviations CME: Continuing Medical Education; DSM: Diagnostic and Statistical Manual of Mental Disorders—refers to DSM-IV TR unless otherwise specified.; GID: gender identity disorder; HIV: human immunodeficiency virus; LGBT: lesbian, gay, bisexual or transgender; SRS: sex reassignment surgeries, which may include hysterectomy, oophorectomy, phalloplasty, metoidioplasty, mastectomy and chest reconstruction, orchiectomy, and vaginoplasty. Competing interests The authors declare that they have no competing interests. Acknowledgements We wish to acknowledge the thirteen physician participants involved with this study. 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Cobos DG, Jones J: Moving forward: Transgender personas as change agents in health care access and human rights. J Assoc Nurses AIDS Care 2009, 20:341–347. 40. Gates GJ: How many people are lesbian, gay, bisexual, and transgender? In The Williams Institute, UCLA School of Law. 2011. Available online: http:// wiwp.law.ucla.edu/wp-content/uploads/Gates-How-Many-People-LGBT-Apr2011.pdf. Accessed 10/10/2011. doi:10.1186/1472-6963-12-110 Cite this article as: Snelgrove et al.: “Completely out-at-sea” with “twogender medicine”: A qualitative analysis of physician-side barriers to providing healthcare for transgender patients. BMC Health Services Research 2012 12:110. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit
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