Gender Identity Disclosure Research Articles

Facilitation of sexual and gender identity disclosure and improved healthcare for LGBTQ+ patients: current processes, shortcomings, and recommendations for change

Lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ+) people are at increased risk of physical and mental health problems compared to their heterosexual counterparts. There are significant barriers to both accessing and maintaining healthcare for LGBTQ+ people. Disclosure of sexual and gender identity should be facilitated within healthcare services to ensure LGBTQ+ people can receive appropriate healthcare. General practitioners (GPs), being the first point of access to healthcare in the UK, should therefore have knowledge of their patients’ sexual and gender identity. Currently, GPs and other healthcare professionals may not adequately facilitate disclosure of patients’ sexual and gender identity because they believe it is irrelevant or because they feel unequipped. Moreover, heterosexist behaviours from GPs and worries of experiencing discrimination may reduce the likelihood of sexual identity disclosure in patients. This article aims to discuss the current processes and shortcomings within the UK healthcare system to demonstrate that disclosure is not adequately facilitated. Evidence-based recommendations for improved practice are provided, focusing on practitioner training and the primary care environment, whilst building upon the recently launched NHS initiatives such as Pride in Practice. Current efforts to facilitate the needs of LGBTQ+ people must be prioritised and extended in order to end the current healthcare inequalities faced by this community.

Romantic Relationships in Transgender Adolescents: A Qualitative Study.

Identity formation and exploration of interpersonal relationships are important tasks that occur during adolescence. Transgender, gender diverse, and gender-nonconforming (TGNC) individuals must face these developmental milestones in the context of their transgender identity. Our aim with this article is to describe adolescents' history and experiences with romantic partners. We conducted phenomenological, qualitative semistructured interviews with transgender adolescents. Questions were focused on romantic experiences, thoughts, and perceptions. All interviews were coded by 2 members of the research team, with disagreements resolved by discussion and, if needed, with a third member of the research team. Thematic analysis was used to analyze the data, as well as descriptive categorization. In total, 30 adolescents (18 transmasculine and 12 transfeminine) between the ages of 15 and 20 years were interviewed. Themes included (1) engagement in romantic relationships, (2) disclosure of gender identity and romantic relationships, (3) experience with abusive relationships, and (4) perceived impact of gender-affirming hormone care on romantic experiences. TGNC adolescents are engaged in romantic experiences before and during social and/or medical transitioning and are cultivating relationships through both proximal peers and online connections. There is perceived benefit of gender-affirming hormone care on romantic experiences. Risk of transphobia in romantic relationships impacts the approach that transgender adolescents take toward romance and influences decisions of identity disclosure. TGNC adolescents have experience with relationship abuse in different forms. Providers can incorporate these findings in their approach to counseling and screening when caring for TGNC youth.

Patient sexual orientation and gender identity disclosure.

In the UK, 2.3% of men and 1.6% of women identify as lesbian, gay or bisexual (LGB). Of the UK population, 1% are estimated to identify as transgender (T). Of the LGB population, 46% do not disclose their sexual orientation to health care professionals (HCPs) and 18% of transgender patients avoid health care altogether. Non-disclosure of sexual orientation and/or gender identity contributes to worse health outcomes for LGBT patients. This study aimed to explore medical students' perceptions of the barriers to health care for LGBT patients and the importance of patient disclosure of sexual orientation or gender identity. Focus groups included medical students across five year-groups from a medical school in the South East of England. Discussions followed a pre-approved topic guide with a primary and co-facilitator present. Focus groups were audio-recorded, transcribed verbatim and the data underwent framework analysis. Forty-five undergraduate medical students participated (40% of whom were non-heterosexual). Most participants believed that the incorrect use of pronouns and discrimination would be a cause for non-disclosure of gender identity and sexual orientation to HCPs. Several participants thought it was more important to know a patient's gender identity than sexual orientation. Many participants felt that collecting sexual orientation information on healthcare registration forms is acceptable. More education regarding LGBT health needs and ways to encourage patient disclosure of sexual orientation or gender identity should be included in the undergraduate medical school curricula to increase the competency of future doctors when interacting with LGBT patients.

Social and Medical Gender Affirmation Experiences Are Inversely Associated with Mental Health Problems in a U.S. Non-Probability Sample of Transgender Adults.

A dearth of research has explored concurrently the associations between multiple forms of gender affirmation (or transitioning) and the mental health of transgender adults. In 2015, 288 U.S. transgender adults completed a cross-sectional, online survey assessing demographics, gender affirmation experiences, and mental health. Adjusting for age and discrimination experiences, we used mixed-effect logistic regression analyses to examine changes in self-reported suicidal ideation, suicide attempts, and non-suicidal self-injury (NSSI) before and after initiating the gender affirmation process, and linear regression analyses to examine associations between gender affirmation experiences and self-reported depressive, anxiety, and stress symptoms. Overall, 81.3% of participants identified along the female-to-male, trans masculine gender spectrum (of which 20.9% identified as non-binary) and 18.8% identified along the male-to-female, trans feminine gender spectrum (of which 7.4% identified as non-binary). Nearly all participants (98.6%) reported disclosing their gender identity to family or a coworker; 67.4% endorsed recently using hormones, and 31.3% endorsed a gender-affirming medical procedure. In multivariable models, participants were at greater odds of NSSI, contemplating suicide, and attempting suicide before initiating the gender affirmation process compared to after. In additional models, gender identity disclosure and medical procedure engagement were inversely associated with depressive and anxiety symptoms, whereas gender identity disclosure, hormone use, and medical procedure engagement were inversely associated with stress symptoms. Finally, the number of gender affirmation experiences endorsed was inversely associated with depressive, anxiety, and stress symptoms. Findings support the possibility that social and medical gender affirmation experiences may be protective against mental health problems in transgender adults.

Gender expansive youth disclosure and mental health: Clinical implications of gender identity disclosure.

Some healthcare providers work with gender expansive youth, and preliminary evidence notes that many of these youth do not disclose their gender identity to all of their healthcare providers. No previous research focused on youth has explored gender identity disclosure to healthcare providers, nor linked youth disclosure to negative mental health outcomes (e.g., symptoms of depression). Data were drawn from the LGBTQ National Teen Survey in order to test the relationship between gender identity disclosure, symptoms of depression, and self-esteem among 5,637 13- to 17-year old (M age = 15.6) participants who identified as transgender boys, transgender girls, non-binary youth who were assigned female at birth (AFAB), or assigned male non-binary youth who were assigned male at birth (AMAB). Transgender boys reported the highest symptoms of depression and the lowest levels of self-esteem in comparison to other groups. Among the full sample, 66.8% had not disclosed their gender identity healthcare providers-non-binary AMAB youth were least likely to disclose (77.6%). Symptoms of depression were the highest and self-esteem was the lowest for transgender boys with mixed levels of disclosure. Transgender girls reported the lowest symptoms of depression - these youth had also disclosed their identities the most. Findings suggest that mixed disclosure to healthcare providers is problematic for gender expansive youth, especially transgender boys. Findings suggest a need to better prepare health professionals to understand not all gender expansive youth may feel comfortable disclosing their gender identities in medical contexts. Future research should explore gender affirmative healthcare as a potential protective factor in combatting negative mental health outcomes.

Transgender Youth's Disclosure of Gender Identity to Providers Outside of Specialized Gender Centers

PurposeTransgender youth face significant health disparities and multiple barriers to receiving quality health care. Gender identity disclosure to health care providers (HCPs) is an important step in creating affirming relationships for transgender youth. The objectives of this study were to (1) determine the prevalence of voluntary disclosure and intentional avoidance to HCPs outside of gender clinics, (2) identify factors associated with voluntary disclosure and intentional avoidance, and (3) elucidate strategies to increase comfort with disclosure. MethodsA cross-sectional survey was administered to transgender youth aged 12–26 years. Bivariate analyses were conducted using χ2 or Fisher's exact tests. Two logistic regression models for each outcome variable were used to examine factors associated with voluntary disclosure and intentional avoidance. ResultsTwo thirds (65%) of youth (N = 153) identified as transmasculine, and 57% were under 18 years. Three-quarters (78%) had voluntarily disclosed their gender identity to an HCP outside of gender clinic, whereas 46% had intentionally avoided disclosure. Odds ratios (ORs) of ever having disclosed were lower for participants ≥18 years (OR = .33; 95% confidence interval [CI]: .11–.98), those out to fewer people (OR = .12; 95% CI: .02–.81) and out for <1 year (OR = .03; 95% CI: .004–.31). Odds of intentional avoidance were lower among youth with higher perceived parental support (OR = .83; 95% CI: .70–.98). ConclusionA majority of transgender youth reported having voluntarily disclosed their gender identity to an HCP outside of gender clinic, but almost half reported having intentionally avoided disclosure when they felt it was important. Parental support may play a protective role in mitigating avoidance.

Provider Practices and Perspectives regarding Collection and Documentation of Gender Identity

ABSTRACT Recent recommendations to include patient sexual orientation (SO) and gender identity (GI) in the electronic health record (EHR) aim to improve clinical care and address health disparities among sexual and gender minority patients. Collection and documentation of GI may be complex due to multiple clinically relevant components. This study explored provider practices in collecting and documenting GI across multiple specialties. Qualitative interviews with 25 healthcare providers were transcribed verbatim, and thematic analysis and principles of grounded theory were used to analyze the data. Without a protocol and absent dedicated locations in the EHR for collecting and documenting patient GI, provider practices were inconsistent and highlighted challenges for communication across clinical staff. Providers noted that patients’ disclosure of GI was typically unprompted, or was presumed through disclosure of gender affirming treatments. Findings indicate the need for provider training and appropriate EHR fields to support GI collection and documentation.

Predictors and Mental Health Benefits of Chosen Name Use among Transgender Youth.

Chosen name use among transgender youth (youth whose gender identities are different than their sex assigned at birth) can be part of the complex process of aligning gender presentation with gender identity and can promote mental health. However, little is known about the factors that predict whether or not transgender youth have a chosen name and outcomes of chosen name use, especially in specific social contexts. We examined, among a sample of 129 transgender youth from three cities in the United States, differences in sociodemographic characteristics and mental health outcomes between transgender youth with and without a chosen name and, among those with a chosen name, predictors and mental health benefits of being able to use a chosen name at home, school, and work. There were few differences between transgender youth with and without a chosen name. Among transgender youth with a chosen name, disclosure of gender identity to supportive family and teachers predicted chosen name use at home and school, respectively. Chosen name use was associated with large reductions in negative health outcomes and relatively smaller improvements in positive mental health outcomes. Our results show that chosen name use is part of the gender affirmation process for some, but not all, transgender youth and is associated with better mental health among transgender youth who adopt a chosen name.

86. Transgender Youth's Disclosure of Gender Identity To Providers Outside of Specialized Gender Centers

86. Transgender Youth's Disclosure of Gender Identity To Providers Outside of Specialized Gender Centers

Coming Out as Transgender: Navigating the Social Implications of a Transgender Identity

ABSTRACTThis study examines transgender coming-out narratives. Most previous studies of coming out as transgender have relied on psychological stage models of identity development, with little empirical verification. This study uses identity theory to reframe transgender coming out as a primarily external, ongoing, and socially situated process. The data were collected from 20 transgender people residing in the Minneapolis-St. Paul, Minnesota metro area through interviews and focus groups. The analyses reveal that coming out as transgender requires navigating others’ gender expectations, others’ reactions, and the threat of violence. The results indicate that transgender individuals do not simply decide to “come out of the closet” and then stay out. Rather, they make strategic decisions regarding the enactment of gender and gender identity disclosure based on specific social contexts. Coming out as transgender is best conceptualized as an ongoing, socially embedded, skilled management of one’s gender identity.

INTERSECTIONALITY, COGNITION, DISCLOSURE AND BLACK LGBT VIEWS ON CIVIL RIGHTS AND MARRIAGE EQUALITY

AbstractIntersectionality has contributed to the ongoing deconstruction of dichotomous and essentializing categories of identity and oppression. As some scholars have noted, however, intersectionality has debunked a sociobiological, single-node paradigm and unintentionally codified a deterministic form of social cognition. I suggest one mechanism for understanding how to untangle this intersectional dilemma: disclosure practices. Disclosure of stigmatized statuses can illuminate how macro level inequalities manifest in individual thought processes. This study adds to emerging research by showing how social actors rely on intersectional experiences to understand, think about, and frame complex social problems. I examine this topic via 197 interviews with 102 Black participants who identify as LGBT about their views on same-sex marriage as a civil rights issue before and after same-sex marriage was nationally legalized. Specifically, I argue that the Black LGBT participants’ experience with intersectional discrimination and their levels of sexual and gender identity disclosure account for their personal views on same-sex marriage and Black civil rights. Further, the majority of Black participants across disclosure practices viewed marriage equality as primarily benefitting the property interests of White gays and lesbians. Last, I discuss the implications of my findings for LGBT politics and the connections between self-interest and political perspectives.

“Sometimes You Feel Like the Freak Show”: A Qualitative Assessment of Emergency Care Experiences Among Transgender and Gender-Nonconforming Patients

Transgender, gender-variant, and intersex (trans) people have decreased access to care and poorer health outcomes compared with the general population. Little has been studied and documented about such patients' emergency department (ED) experiences and barriers to care. Using survey and qualitative research methods, this study aims to identify specific areas for improvement and generate testable hypotheses about the barriers and challenges for trans individuals needing acute care. A survey and 4 focus groups were conducted with trans individuals older than 18 years who had been to an ED in the last 5 years. Participants were recruited by trans e-mail listservs; outreach to local trans organizations; and lesbian, gay, bisexual, and transgender periodical advertisements. The interview guide was reviewed by qualitative research and trans health content experts. Deidentified participant demographic information was collected with a standardized instrument. All discussions were captured on digital audio recorders and professionally transcribed. Interview coding and thematic analysis were conducted with a grounded theory approach. Among 32 participants, 71.9% were male identified and 78.1% were white. Nearly half (43.8%) reported avoiding the ED when they needed acute care. The factors that had the greatest influence on ED avoidance were fear of discrimination, length of wait, and negative previous experiences. There were 4 overarching discussion themes: system structure, care competency, discrimination and trauma, and avoidance of emergency care. Improvement recommendations focused on staff and provider training about gender and trans health, assurance of private gender identity disclosure, and accurate capture of sex, gender, and sexual orientation information in the electronic medical record. Efforts to improve trans ED experiences should focus on provider competency and communication training, electronic medical record modifications, and assurance of private means for gender disclosure. Future research directions include quantifying the frequency of care avoidance, the effect of avoidance on trans patient morbidity and mortality, and comparing ED patient outcomes by gender identity. Further research with increased inclusion of transwomen and people of color is needed to identify themes that may not have been raised in this preliminary investigation.

Depression Among Transgender Older Adults: General and Minority Stress.

This study aims to (a) examine the direct and indirect effects internalized heterosexism, disclosure of gender identity, and perceived general stress in association with depression among transgender older adults; and (b) to assess the relative contribution of each relationship. Secondary analyses of data from a large community-based study of older sexual and gender minorities were conducted utilizing structural equationmodeling with a subsample (n=174) of transgender adults aged 50 to 86-years old. Disclosure of gender identity had no significant direct or indirect effects on either perceived general stress or depression. Internalized heterosexism did not have a direct effect on depression, but did have a significant indirect effect through perceived general stress. Finally, perceived general stress had an additional significant direct effect on depression, over and above internalized heterosexism. Total effect sizes appear to be considerable with standardized betas greater than 5.0. Perceived general stress and internalized heterosexism independently and cumulatively have significant direct and indirect effects on depression among transgender older adults. Implications for depression among transgender older adults and the role of community psychology are discussed.

Harassment Patterns and Risk Profile in Spanish Trans Persons

ABSTRACTThis article describes the harassment patterns and the risk profile in trans people living in Spain. A sample of 212 trans persons, aged 10–62, participated in this cross-sectional study. Results showed a high percentage of harassment (59.9%) and frequency of daily harassment (12.6%), especially verbal attacks (59%) that occurred in public spaces (49.1%) and within educational contexts (46.2%). Harassment is more prevalent in trans women than men. Those who disclose their gender identities at a younger age experience higher percentages and frequency of harassment than those who disclose at an older age. They also suffer more harassment of different types. The risk profile of harassment indicates that older trans women are more likely to suffer harassment than younger ones, and the risk decreases each year they delay their gender identity disclosure. The elimination of transphobic attitudes and the promotion of gender justice should be priority strategies in Spain.

Transgender sexual health in China: a cross-sectional online survey in China

ObjectiveTransgender individuals are at increased risk for HIV infection around the world, yet few studies have focused on transgender individuals in China. We conducted an online cross-sectional survey of men...

Patient Perspectives on Gender Identity Data Collection in Electronic Health Records: An Analysis of Disclosure, Privacy, and Access to Care.

Purpose: In 2015, the Centers for Medicare and Medicaid Services ruled that health organizations comply with additional requirements for electronic health records (EHRs), known as “Meaningful Use,” and develop the capacity to collect gender identity data. Research has established effectiveness of a two-step gender identity question to collect these data. This study examines transgender patient perspectives on the use of a two-step question and experiences with privacy and sensitive disclosures in EHRs and healthcare settings.Methods: Four focus groups (N=30) were conducted in Chicago, Illinois in 2014–2015. Participants were asked to compare two intake forms—one with a two-step question and one with a single question—and discuss experiences with gender identity disclosure, privacy, and access to care. Narratives were transcribed verbatim to identify patterns and themes; the extended case method was used and grounded the data analysis process in the concept of intersectionality.Results: Participants expressed appreciation for improved reliability and competencies that the two-part question may afford. Narratives reveal concerns related to patient privacy, safety, and access because of the contexts in which these data are collected and transmitted. Virtually all participants described situations whereby sensitive gender identity information had been involuntarily disclosed, misinterpreted, or abused, and safety and care were compromised.Conclusion: Participants recognized the potential of the two-part question as a measurement and competency tool, but anticipated new privacy violations and involuntary disclosures. Narratives indicate that effects of sensitive disclosures may vary intersectionally, whereby white participants experienced lesser harms than their immigrant, HIV-positive, and black trans feminine counterparts. Discrimination and privacy violations may occur regardless of a two-part or one-part gender identity question, but increasing these sensitive disclosures within expanding EHR infrastructures may require a range of mechanisms that have flexibility across contexts to safeguard sensitive information and access to care.

From patients to providers: changing the culture in medicine toward sexual and gender minorities.

Equality for sexual and gender minorities (SGMs)-including members of the lesbian, gay, bisexual, and transgender communities-has become an integral part of the national conversation in the United States. Although SGM civil rights have expanded in recent years, these populations continue to experience unique health and health care disparities, including poor access to health care, stigmatization, and discrimination. SGM trainees and physicians also face challenges, including derogatory comments, humiliation, harassment, fear of being ostracized, and residency/job placement discrimination. These inequities are not mutually exclusive to either patients or providers; instead, they are intertwined parts of a persistent, negative culture in medicine toward SGM individuals.In this Perspective, the authors argue that SGM physicians must lead this charge for equality by fostering diversity and inclusion in medicine. They posit that academic medicine can accomplish this goal by (1) modernizing research on the physician workforce, (2) implementing new policies and programs to promote safe and supportive training and practice environments, and (3) developing recruitment practices to ensure a diverse, competent physician workforce that includes SGM individuals.These efforts will have an immediate impact by identifying and empowering new leaders to address SGM health care reform, creating diverse training environments that promote cultural competency, and aligning medicine with other professional fields (e.g., business, law) that already are working toward these goals. By tackling the inequities that SGM providers face, academic medicine can normalize sexual and gender identity disclosure and promote a welcoming, supportive environment for everyone in medicine, including patients.

Trans migrations: Exploring life at the intersection of transgender identity and immigration.

In collaboration with a community-based organization, we interviewed 10 transgender women who immigrated to the United States from Latin America about their migration histories, access to work, social support networks, and experiences with discrimination in their native country and the United States. Findings revealed a link between gender identity and the need to migrate to the United States. Participants noted severe forms of violence that included physical and sexual assault, discrimination in school and the workplace, and loss of social support upon disclosure of gender identity to family and friends. The culminating effect of these experiences resulted in the need to flee their country of origin to avoid further violence, and in some cases, death. It is important to highlight that participants also demonstrated steadfast resilience in the face of discriminatory treatment and described the positive impact of social support and community-based resources on their mental health.

Disclosure of Gender Identity in Internet Forums: A Case Study of Saudi Arabian Forum Communication

Internet discussion forums provide opportunities for largely anonymous communication among participants. The extent to which these opportunities are taken up is of particular interest in cultures where gender relations are highly regulated and cross-gender communication is strictly limited, such as in Saudi Arabian society. This article studies participation in a public discussion forum of expatriate Saudi students. It focuses on the nature of information (whether accurate or not) that participants choose to reveal about themselves, and its effect on the forum participation. Particular attention is paid to whether and how the gender of the participants is revealed. The analysis demonstrates that few participants take advantage of the possibility of not revealing gender. Rather, gender is emphasized in most usernames and can usually be deduced from the message content. Although there is no pressure to reveal name, age, marital status, etc., reactions to the rare messages where the gender of the writer is not indicated show that clues to gender are considered essential to all but the briefest exchanges. This encourages participants to limit contact with participants of the opposite sex, as a result of which the forum communication remains largely gender segregated.

Gender identity affirmation among male-to-female transgender persons: a life course analysis across types of relationships and cultural/lifestyle factors

Disclosures of a transgender identity to others, and responses from others allowing for desired gender role behavior, are defining events for male-to-female (MTF) transgender persons. This study systematically examined these interpersonal acts of gender identity affirmation among 571 MTF transgender persons from New York City. Using the Life Chart Interview, biographical information about gender identity disclosure to others and desired gender role casting from others was obtained across stages of the life course (early adolescence, late adolescence, early adulthood, young adulthood and middle age) and types of relationships (parents, siblings, sexual partners, friends, fellow students and co-workers). Summaries of gender identity disclosure and gender role casting were then computed across the life course and relationships and associated with sexual orientation, ethnicity and sex work history (cultural/lifestyle factors). The two aspects of gender identity affirmation were, predictably, more likely in achieved (i.e. friends) as compared to ascribed (i.e. parents) relationships. Younger respondents (age 19–39) were generally more likely to report gender identity disclosure and desired gender role casting. Strong and highly significant differences were observed across cultural/lifestyle factors. Implications of these findings for the mental health of MTF transgender persons, and mental health therapy, are discussed.