A “weapon of survival”: the importance of material culture in trans re/presentation

Background: As awareness of the possibilities for trans people to attain parenthood grows, trans, non-binary and other people with diverse genders are increasingly accessing perinatal care as part of their family-building journeys. International literature confirms that midwives can feel clinically challenged by, and poorly prepared for, working with pregnant trans people, but also that they are motivated to provide high quality care and desire professional support to do so. This two-phase study included interviews with trans people who were or had been pregnant, and/or whose partners were or had been pregnant, which informed the development of a nationwide perinatal care workforce survey. Aim: Phase Two aimed to identify current practice relating to inclusion, and the knowledge, beliefs and education needs of the perinatal care workforce in relation to working with pregnant trans people. Method: An online nationwide survey of perinatal care providers was undertaken in 2022. Data were collected through single- and multi-response questions, Likert scales and open-ended text boxes. Analyses included descriptive statistics and content analysis of open-text responses. Results: Of 476 respondents, this paper reports only the midwives’ responses (67%; n = 317). Fewer than 25% of midwives recalled receiving any specific education about providing culturally safe care for trans people, but most (78%) identified interest in accessing education if it were made available. Midwives are knowledgeable regarding some clinical aspects of gender affirming care, e.g., the effects of hormone therapy on fertility, but we identified some knowledge gaps. Most articulated positive attitudes towards caring for pregnant trans, takatāpui and intersex people but a minority raised concerns about what they perceived as the ‘erasure of women’ within wider efforts to be inclusive. Many noted workforce pressure as a barrier to progressing change. Conclusion: Some midwives are already implementing inclusive practices, primarily led by Lead Maternity Carers (LMCs) who champion affirming and inclusive community-based care. Ensuring that trans people and whānau can anticipate consistently affirming care when they engage in services beyond their LMC, particularly during hospital-based care, needs prioritisation as a workforce development strategy. To date, midwives have not been well prepared to provide inclusive care to this community, but they are willing to engage in education to support affirming and inclusive practice.

The voices of Lesbian, Gay, Bisexual, Trans, Queer, Intersex, and Asexual (LGBTQIA+) people who have experienced dietetics, as students, interns, and dietitians, have rarely been heard. Particularly the experiences of trans people, who have lived through dietetic education, and are currently some of the most marginalized voices in cisheteronormative and LGBTQIA+ spaces. Exploring and understanding the lived experiences of trans people in dietetics is essential to identifying discourses, assumptions, and taken-for-granted cultural norms of the dietetics profession, as well as how these impact LGBTQIA+ people. This chapter aims to shine a light on the perspectives and lived experiences of queer/trans people who have gone through dietetic education and training using a collaborative autoethnographic conversation. This conversation highlights the personal experiences of the authors, three trans people who have been students in dietetic education, in addition to a critical discussion about those experiences, to expose dominant discourses of dietetics, as a self-sustaining, cisheteronormative, white supremacist, classist, and oppressive system that functions to promote and uphold rigid, binary knowledge in the minds and bodies of its practitioners and clients. During our conversation, we explored topics such as the binary conceptualization of health, food, and bodies represented in dietetics, the morality of food and bodies, the subjugation of alternative ways of thinking and being within dietetics, and ultimately how these constructed knowledges live in the bodies of questioning, trans, and queer people exposed to it. Finally, and in contrast to narratives about trans people as primarily vulnerable victims, we offer a new narrative of resistance and potential in trans people’s knowledge as guideposts to excavating subjugated knowledge in dietetics, reframing and offering alternative ways of engaging with food, bodies, and health beyond the binary.

Disclosure: D. Stroumsa: None. E.E. Marsh: None. P.N. Pfeiffer: None. C. Jiang: None. A. Vrolijk: None. M.B. Moravek: None. Bridging the Gap: Utilization of Emergency Services by Transgender People in the United States, 2006-2018Introduction: Transgender or nonbinary (Trans) people face significant health disparities, including in access to primary and preventive care. These disparities are driven by structural, interpersonal, and individual stigma, which lead to barriers accessing care and avoidance of primary care, and to increased reliance on emergency care. We aimed to characterize ED use by Trans patients, and changes in such use over time. Methods: Data was obtained from the Nationwide Emergency Department Sample (NEDS) , which is a weighted stratified sample of hospital-based ED visits. Using gender-dysphoria related ICD-9 and ICD-10 diagnostic codes, we compared visits among trans people to those without such a diagnosis, adjusting for age, region, urbanicity, primary payer, and income quartile. We evaluated rates of chronic condition and mental health conditions as primary diagnosis at presentation and at admission. Presence of chronic conditions was assessed using the ICD-9 Chronic Condition Indicator for 2006-2014. Results: There was a rapid temporal increase in the proportion of visits with a trans-related diagnosis, from 0.001% of visits in 2006 to 0.016% in 2018. There were significant demographic differences between trans people and others. Trans people were significantly more likely to be admitted, adjusting for payment, age group, region, income and mental health condition (overall 52.4% vs. 17.3%, adjusted OR= 7.368 95% CI (6.771, 8.017)). A large proportion of ED visits by trans individuals was associated with a mental health diagnosis (28.7%, compared with 3.9% for others, p<0.001; adjusted OR =2.01, 95% CI 1.91-2.11) and/or with a chronic condition (58.2% vs. 19.2%, p<0.001; adjusted OR =3.65, 95% CI 3.61-3.69). Similarly, hospital admission among trans people was much more likely to be linked to a mental health condition (37.2% vs. 5.3% , p<0.001; adjusted OR = 2.78, 95% CI 2.44-3.16) or chronic condition (67.3% vs 41.3%, p<0.001; adjusted OR = 2.21, 95% CI 1.78-2.75) Discussion: The high admission rates, and high proportion of trans people with a chronic condition or with mental illness, may represent worse overall health due lack of primary care, or a delay in seeking emergency care among Trans people. Lastly, these findings could be a manifestation of a higher likelihood of a trans-related diagnostic code being charted among trans people at admission, or bias towards higher likelihood of trans people receiving a mental-health related diagnosis. There is a need for increasing access to affirming primary and mental health care among trans people, and increased training of emergency clinicians. Presentation Date: Saturday, June 17, 2023

BackgroundThe health inequalities experienced by lesbian, gay, bisexual, trans and intersex (LGBTI) people are well documented with several reviews of global research summarizing key inequalities. These reviews also show how the health‐care needs of LGBTI people are often poorly understood whilst suggesting that targeted initiatives to reduce inequalities should involve LGBTI people.ObjectivesTo determine what is known about the health‐care inequalities faced by LGBTI people? What are the barriers faced by LGBTI people whilst accessing health care, and health professionals when providing care? What examples of promising practice exist?DesignRapid reviews of grey literature were co‐produced with LGBTI people in 27 countries followed by a thematic analysis and synthesis across all data sets. The review included grey literature from each country that might not otherwise be accessible due to language barriers.Main resultsRapid reviews showed that LGBTI people faced various inequalities and barriers whilst accessing health care. Where heterosexuality, binary gender and assumed male/female sex characteristics were upheld as the norm, and where LGBTI people differed from these norms, discrimination could result. In consultations where LGBTI people feared discrimination and did not disclose their LGBTI status, health professionals lacked the information required for appropriate assessments.ConclusionWith greater understanding of sexual orientation (LGB people), gender identity (trans people) and sex characteristics (intersex people), combined with access to contemporary knowledge and training, health professionals can work in collaboration with researchers, policymakers and LGBTI people to develop systems that are better attuned to the needs of all service users.

Gender diversity is becoming increasingly visible within society, with more trans, non-binary and gender diverse people coming forward throughout the life course. In settings such as social care, welfare services, housing and associated health disciplines, practitioners and service providers will see an increasing number of trans and non-binary service users as more trans people ‘come out’ and existing trans populations age. Drawing upon theoretical perspectives from social gerontology, as well as contemporary research and the direct lived experience of older trans and gender diverse people, the book focuses on practical support for ageing trans, non-binary and gender diverse people, with an emphasis on person-centred care. Expertise is contributed by scholars from a range of disciplines, with particular attention to the scholarship of trans, non-binary and gender diverse people. The book is aimed at professionals and practitioners working internationally in a range of public and social welfare services for older people, as well as students training for such roles, and educators involved in delivering professional training. Each section concludes with practical learning activities, designed to support professional practice.

Background Trans rage is a sense of rage toward cisgenderism that is commonly, but not exclusively, experienced by trans peoples, individually and collectively. Despite its revolutionary history, trans rage and the ways in which it manifests for trans and non-binary peoples has remained an under researched area in trans studies. Aims This paper aims to investigate how trans peoples’ experiences of cisgenderism impact their feelings of trans rage, how trans rage manifests for trans peoples, how trans peoples channel their feelings of trans rage, and how trans rage can be harnessed to challenge cisgenderism. Methods 26 trans and non-binary people aged 18+ living in Australia were interviewed about their experiences with family, shame, and resilience, with a subsection of resilience focused on trans rage. Thematic analysis was used to explore participants’ experiences of trans rage. Results Through thematic analysis four themes were developed: 1) Cisgenderism as a source of trans rage, 2) Constructive and destructive manifestations of trans rage, 3) Trans rage as a motivating force, and 4) Collective trans rage as a challenge to cisgenderism. Conclusions Through an exploration of participants’ experiences of trans rage, the research findings demonstrate its potential as a motivating force to challenge cisgenderism through activism, solidarity building, and community organizing. In a time where trans rights are being used as a key political wedge issue, we must better understand how we can harness the transformative power of trans rage in order to push back against anti-trans bigotry, and to begin dismantling the cisgenderist belief systems that support it. This paper concludes by calling for ongoing theorization of trans rage and its applications, and a call-to-action to expand these applications across a broad range of settings, beyond academia, in an intersectional manner building solidarity with cis people as they too would benefit from challenging cisgenderism.

In this article, I explore how caste-oppressed Dalit and Bahujan trans and gender-variant people in India are organizing for equity and distributive justice by raising the demand for horizontal reservations. Through sustained, equity-centred activism, they are laying legitimate claims on just redistribution by insisting that the Indian state make caste central in imagining and devising affirmative action policies for the most impacted, multiply marginalized, and historically oppressed Dalit, Bahujan, Adivasi, and caste-oppressed Muslim trans and intersex people. Through protests, demonstrations, judicial activism, public statements, press releases, signature campaigns, media appearances – and through organizing efforts centred around redistribution – caste-oppressed trans activists have been demanding that the Indian state implement reservation policies to actively enable the continuation of life, sustenance, and prosperity of not just upper caste trans people belonging to the middle classes but also Dalit, Bahujan, Adivasi, and caste-oppressed Muslim trans and intersex people who are structurally immiserated and are also primarily working class and lack generational wealth. I observe that anti-caste, equity-focused activism and organizing, prominently led by caste-oppressed Dalit and Bahujan trans and gender-variant people, is putting pressure on the Indian state to provide multiply marginalized trans and intersex people with life-sustaining and life-enhancing opportunities. And by doing so, they are also resisting caste-denialism – as well as the tokenization of trans lives – prominent within upper caste and upper and middle class queer and trans activist spaces in India today.

Medical research largely fails to consider or even acknowledge the existence of transgender and intersex people. This results in a lower likelihood of people, firstly, receiving appropriate medical care as the information to provide that care may not exist and, secondly, accessing medical care because they fear harm resulting from inappropriate medical treatments. This spotlight reviews how poorly recent medical research papers concerning gender have engaged with the realities, experiences, and needs of trans, intersex, and gender diverse people. The spotlight highlights the importance of using trans, intersex, and non-binary people’s expertise to improve this.

Transgender and non-binary (trans) people face unique challenges when considering decision-making about their reproductive futures. These may include navigating gendered parenthood roles and the potential impacts of medical gender affirmation on their fertility. While fertility preservation offers a way of having biologically related children, barriers to accessing these services among trans people have been identified in literature. This qualitative study sought to understand how trans young adults view and experience fertility preservation, in relation to their desire for family and parenthood. Through a thematic analysis of in-depth interviews with 13 trans and non-binary people in Aotearoa New Zealand, we identified four themes: variability in seeking accurate fertility preservation information; the compounding costs of trans reproduction; experiencing and anticipating cisnormativity in reproductive health services; and (re)imagining family. Overall, participants expressed diverse views on fertility preservation, informed by interpersonal and structural factors. Notably, we found discrepancies between uptake of sperm and egg cryopreservation due to public funding disparities, despite participants agreeing services should be offered equitably to all trans people. These structural barriers require further attention in healthcare, policy and community settings when working with trans young adults considering fertility preservation.

Building on findings demonstrating that transgender and gender non-binary (trans) people’s participation in physical activity is impacted by their experiences in locker rooms, this study examines how trans people navigate transphobia and cissexism in locker rooms. I consider the concepts of membership and belonging to illuminate how locker room access impacts trans people’s participation in the public sphere. Drawing on interviews with trans people, this study suggests that—because of iterative encounters of surveillance, scrutiny, harassment, and violence—trans people regularly adopt strategies for navigating locker rooms as nonmembers. To access locker rooms despite a denial of membership, trans people employ various strategies to minimize the visibility of their transness and/or gender non-conformity through managing the perceived threat their gender expression poses to a “cisgendered reality.” Strategies such as hurrying, avoiding nudity and eye contact, and recruiting ally support function to facilitate locker room access by minimizing attention to trans nonmembership. The findings of this study suggest that whiteness broadens the availability of strategies for navigating locker rooms. This study offers insight into how people respond to stigma, evade surveillance and exclusion, and access public space despite a denial of membership.

Does a post-vaginoplasty vagina have a G-spot? Why do some trans people find they enjoy anal sex more after testosterone? And can people with post-surgical vaginas experience vaginismus? Written by renowned sex blogger and educator Kelvin Sparks, Trans Sex is the essential guide to sex and bodies for all trans, non-binary and intersex people. Covering everything from post-surgical anatomy and hormone replacement therapy to sex toys, kink and safe sex, this empowering and practical guide also explores desire, pleasure and arousal (and why these aren’t the same thing), how to navigate sex and consent with other people, as well as the difficulties many trans people experience in relation to sex, such as dysphoria and violence. Raw, honest and nothing like the sex education you received at school, this guide is here to help you on your journey to sexual discovery and fulfilment.

Transgender and nonbinary people experience inequity in terms of treatment and outcomes when interacting with healthcare services. Clinicians should treat Trans people with sensitivity in a context of cultural safety to minimise repeat trauma and ensure the delivery of quality, person-centred care. The aim of this paper is to explore the general and specific needs of Transgender and nonbinary people when interacting with renal services and identify practice recommendations and further research needs. This paper reviews a selection of literature relating to the care of Trans people both generally within healthcare and with respect to specific issues that arise within renal care. Estimation of renal function relies on eGFR formulae that include a sex-signifier, so there are issues as to which are the appropriate versions of the formulae to use in Trans people. Research indicates that for Trans men (assigned female at birth) 6 months or more into transition-related hormonal therapy, equations used should be based on gender identity rather than sex assigned at birth. For Trans women and people who identify as nonbinary, the research is less clear and alternative means of assessing GFR may be needed. Complications of urogenital gender-affirming surgery can also have implications for acute and chronic kidney disease progression and for the management of such patients in the clinical environment. Trans people within the renal setting should be treated with sensitivity. Specific considerations are required in terms of assessing kidney function and considering the potential implications of urogenital surgery.

Background Common and unique experiences of internal barriers (e.g. feeling anxious about others reactions), external barriers (e.g. inadequate bathroom/changing facilities), and gender-based bullying (e.g. from venue staff, other patrons, team members) have been observed among trans and gender diverse (trans) people in sport and fitness settings though little research has considered the potentially deleterious mental health outcomes associated with these experiences. Methods Data was derived from a national, online cross-sectional survey of trans people aged ≥16 years, currently living in Australia open between February and April 2023. Multivariate logistic regression models and postestimation orthogonal polynomial contrasts tested (dose-response) associations between sport and fitness-specific internal barriers, external barriers, and bullying experiences with mental health (past 30-day psychological distress; past 12-month self-harm and suicidal thoughts and behaviors), controlling for age and gender. Results Non-binary respondents reported the highest average number of internal barriers, external barriers, and bullying experiences relative to trans men and trans women. Trans people who reported ever being bullied or excluded based on their gender by sports team members and parents/guardians of other team members reported between 5.5 to 8.4 times increased odds of reporting a suicide attempt in the preceding 12 months, regardless of age and gender. Levels of psychological distress proportionately increased with the number of internal barriers, external barriers, and bullying episodes experienced by participants, each in a dose-response fashion. Conclusions Internal barriers, external barriers, and bullying experiences, commonly and uniquely faced by trans people in sport and fitness settings are significantly associated with increased levels of psychological distress and odds of self-harm and suicidality. Strategies to promote inclusion of trans people, particularly non-binary people, should be considered by sport and fitness organizations, especially when making policies for the inclusion of trans people in elite and community-level sport. Keywords Trans; gender diverse; sport; physical activity; mental health

Trans and gender diverse people are globally recognised as being under-served in clinical services, with significant implications for their health. During a national reorientation of the Australian cervical screening programme – from Papanicolaou smears to human papillomavirus screening – we conducted interviews with 12 key informants in cancer policy, sexual and reproductive health and trans health advocacy to understand how trans people’s needs and experiences were being accounted for and addressed in health policy and practice. Themes captured the complexities of increasing visibility for trans people, including men and non-binary people with a cervix. These complexities reflect the extensive system and cultural change required in asking policymakers and practitioners to think differently about who is at risk of a disease typically associated with cisgender women. Informants drew on the language of trauma to explain the resistance many trans people feel when engaging with clinical services, particularly relating to sexual and reproductive health. In doing so, they argued for increasing resources and processes to elicit trans people’s willingness to put their trust in such services. Thinking critically about the relationship between the politics of trans visibilities, trauma and trust can support effective and inclusive approaches to transgender health.

Objective: To examine outcomes from a four-part webinar series on affirming approaches to working with trans and non-binary young people in terms of Australian psychologists’ confidence in working with this population. Method: The author designed and ran a webinar series for the Australian Psychological Society (APS) in early 2018. Of the 76 webinar registrants, 55 completed a survey both before the first webinar, and after completing all of the webinar series. The first survey collected information about demographics, past clinical and training experiences, awareness of the DSM-5 diagnosis of “gender dysphoria”, and confidence in working with trans and non-binary young people. The first survey also included open-ended questions asking participants to define “cisgenderism”, “transgender”, and “non-binary”. The second survey included the same questions and additionally asked about understandings of gender diversity, pathways to care, and awareness of the APS information sheet on affirming approaches. Results: Participants who had previously undertaken training, and previously worked with trans and non-binary people reported greater confidence prior to the webinar series. Statistically significant associations with confidence were found following the webinar series. Greater understanding of gender diversity and the APS information sheet were associated with confidence. Content analysis of the open-ended responses identified improved understandings of the three definitions for most participants after the webinar series. Conclusions: Training for psychologists providing affirming care to trans and non-binary young people is important not only for those who specifically work with this population, but also for generalists, given that many young people may require mental health care beyond that specific to gender transition. KEY POINTS What is already known about this topic: Previous training and experience in working with trans and non-binary adults are related to increased confidence in providing clinical care, Training for healthcare professionals related to trans and non-binary adults results in increased confidence and knowledge, and The evidence base for affirming approaches to clinical care for trans and non-binary young people is in its infancy. What this topic adds: Training for healthcare professionals related to trans and non-binary young people is specifically associated with confidence, Theoretically informed training opportunities are associated with knowledge about terminology pertaining to trans and non-binary young people, and The training of informed knowledgeable generalists working with trans and non-binary young people can usefully supplement existing specialist paediatric gender services.