Exploring the Inclusivity and Safety of Rural Primary Care Spaces for Trans-persons in Southern Alberta
Team Members
Peter Kellett Ph.D. R.N. (P.I.), Assistant Professor, Faculty of Health Sciences, University of Lethbridge
Lisa Howard Ph.D. R.N. (Co-I.), Assistant Professor, Faculty of Health Sciences, University of Lethbridge
Julia Brassolotto Ph.D. (Co-I.), Assistant Professor, Faculty of Health Sciences, University of Lethbridge; Alberta Innovates – New Investigator Research Chair in Healthy Futures and Well-being in Rural Settings
Collaborators/Partners
Dr. Jillian Demontigny MD
Advisory Group
A transgender and gender non-conforming (GNC) advisory group has been established to advise the research team with regards to participant recruitment, research methods, data analysis, findings, and dissemination of these findings.
Background & Rationale
The experiences of rurally-situated transgender and gender non-conforming individuals often receive little research attention, due to the urban location of many universities and the greater accessibility of transgender research participants in urban settings (Fisher, Irwin, & Coleman, 2014). This is further perpetuated by the fact that many LGBTQ2+ and trans-specific support organizations are based in urban communities, making it difficult to recruit trans-participants from rural communities (Fisher, et al., 2014; Heinz, 2015; Heinz & MacFarlane, 2013). Transgender and gender non-conforming people in rural southern Alberta are one such community, for which little data exists; therefore, the current provision of health care and support services for this community is dependent on anecdotal information from service providers and community members. With most support organizations located in the cites of Lethbridge, Calgary and Edmonton, rural transgender Albertan’s frequently must travel to these cities to access appropriate support and health care services. Even within the city of Lethbridge, trans-identified people must travel to Calgary or Edmonton for most transition services, and the wait time to access such services can be up to three years or more. Furthermore, there is a rhetoric that trans-health care is highly specialized, and rural primary care physicians are often reluctant to provide urgent and ongoing maintenance care to trans-people. The social context of Southern Alberta also includes several large religious communities that are not supportive of trans-individuals, further contributing to lack of social support, social exclusion, and the potential for structural discrimination. Transgender and gender non-conforming people frequently find it difficult to find primary care providers willing to take them on as patients, and this only potentiates the already well-documented problem of poor awareness among health care providers about the needs and appropriate care of trans-persons (Bauer, et al., 2009; Bauer, Scheim, Deutsch, & Massarella, 2014; Bauer, Zong, Scheim, Hammond, & Thind, 2015; Colpitts & Gahagan, 2016; Daley & MacDonnell, 2015; Kellett & Fitton, 2017; Roller, Sedlak, & Draucker, 2015; Scheim, Zong, Giblon, & Bauer, 2017; Snelgrove, Jasudavisius, Rowe, Head, & Bauer, 2012; Whitehead, Shaver, & Stephenson, 2016).
In general, rural Canadians possess poorer determinants of health and higher overall mortality risk (DesMeules, et al., 2006; Ostry, 2012). However, this pattern is likely intensified for transgender and gender non-conforming people, because access to informed and appropriate transgender health care and social support services is often very limited in rural communities (Colpitts & Gahagan, 2016; Heinz & MacFarlane, 2013; Whitehead, et al., 2016); and there is evidence to suggest that rural trans-people are subjected to even greater social isolation, social exclusion, discrimination, and stigma than their urban counterparts (Heinz, 2015; Heinz & MacFarlane, 2013; Israel, Willging, & Ley, 2016; Palmer, Kosciw, & Bartkiewicz, 2012; Whitehead, et al., 2016). Indeed, the situation is likely further magnified for rurally-situated two-spirit and Indigenous persons, who are also experiencing the intersectional (Bauer, 2014; Hankivsky & Christoffersen, 2008) impact of racism, colonization, intergenerational trauma, and potentially poorer determinants of health in multiple areas (Rainbow Health Ontario, 2016).
Geographic isolation from support services and appropriate trans-health care, combined with the potential for greater exposure to social exclusion and discrimination in rural settings, creates a situation where health and well-being may be compromised for trans-people (See Figure 1). Internalized transphobia further potentiates the effects of external factors by disrupting intra-group social support, and enhancing the minority stress experienced by gender minorities (Kelleher, 2009; Nadal & Mendoza, 2014).
Figure 1. Potential influences on transgender health in a rural context.
The family physician’s office is generally identified as a preferred location for non-emergent services, yet trans-people report difficulty with navigating the personal and social aspects of receiving care in this setting (Bauer, et al., 2015; Cruz, 2014). In both international and Canadian contexts, common themes of trans-experiences with the primary health system include erasure, stigma and discrimination directed towards trans-individuals, as well as ignorance of trans-health needs on the part of many health providers (Bauer, et al., 2015; Lerner & Robles, 2017). A complicating aspect of access to service is a prevailing belief among physicians that trans-care is complex and best undertaken by specialists (Bauer, et al., 2015; Cruz, 2014); a view that particularly disadvantages rural dwelling trans-people, who must often travel to specialist physicians practicing in urban locations. Seeking primary care services in small communities may also provoke concerns related confidentiality and anonymity for many rural trans-people. Even when trans-people are able to access the primary health system for routine or urgent medical care, they are often considered enigmatic and face probing questions about gender reassignment that are irrelevant to the presenting medical concern. Taken together, these negative experiences perpetuate trans-people’s vulnerability and compromise their right, as Canadian citizens, to accessible, appropriate, and timely primary health care.
While there have been efforts to address the experiences of trans-people in primary care in the provinces of British Columbia and Ontario, to date no coordinated effort to do the same has occurred in Alberta. This proposed research seeks to address the knowledge and practice gap surrounding primary trans-health care, for rurally-situated trans-people in Alberta. These data generated from this study will be used to increased awareness about the health care experiences and challenges of rural Albertan trans-persons, while informing efforts to translate this knowledge into policy and strategies to improve the accessibility, quality, and safety of primary health care for this population. In addition, the proposed study will also lay the foundation for an emerging program of research in transgender health carried out in collaboration with trans-people in the community, LGBTQ2+ community organizations, and health care providers.
Research Questions
- How does living in rural Alberta influence trans-people’s ability to attain health and access primary care services that are inclusive of gender diversity?
- What are the typical challenges and supportive features trans-people encounter when they seek out and access primary care services?
- What types of resources would be beneficial to support trans-people to access, use and navigate primary care services
Proposed Outcomes
The anticipated outcomes will provide the foundation for subsequent activity for this emerging research program and include:
- Identification of facilitators & barriers trans-people face when navigating the primary care health system in southern Alberta.
- Recommendations for service providers and/or program enhancements that are supportive of trans-people’s health attainment, as well as their engagement with the primary care health system in southern Alberta.
- Application of research findings to one or more primary care clinics in rural Alberta, with the aim to undertake a pilot project on the influence of creating inclusive spaces for trans-people in rural primary care physician office practice.
- Development of undergraduate student skill with purposeful inquiry in the Research Assistant role.
- Advancement of collaboration among partners, who support trans-people, including community agencies, researchers, health providers, advocacy groups and the trans-community for engagement in two subsequent province wide research initiatives: 1) to host a province wide symposium on trans health in primary care; 2) to explore the influence of trans-inclusive environments in rural primary care settings on health attainment for trans persons. External funding will be sought for these activities through SSHRC, the MSI Foundation, and/or CIHR- Institute of Gender and Health.
Significance & Dissemination
The anticipated findings of the proposed research are significant as follows:
- To draw attention to how rural trans-people attain health and experience primary care.
- To represent rural trans-people’a experiences with Primary Care as distinct from their urban counterparts and highlight nuanced, significant qualities of rural trans-people’s experiences when navigating this sector.
- To support rural primary care clinicians on providing caring environments supportive of transgender and GNC health.
- To provide a foundation and direction for a subsequent research on the impact of innovations in rural Primary Care in support of trangender health.
References
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