Health Communication in an Era of Disinformation: Perceived Source Credibility Among Transgender and Gender Diverse Individuals

Abstract

This study examines perceived source credibility of health information in a moment of TGD health disinformation. Through thematic analysis of in-depth interviews with thirty transgender and gender diverse (TGD) individuals, findings suggest health information is marred by anti-TGD legislation, a sociopolitical force that bleeds into health information spaces. Disinformation and TGD health communication are intertwined in complex ways, whereby disinformation can undermine trust in healthcare institutions, lead to harmful behaviors, and contribute to the spread of diseases. Health communication practitioners need to center the safety and humanity of TGD people, addressing TGD health disinformation.

Introduction

Health communication plays a crucial role in ensuring transgender and gender diverse (TGD) populations have access to accurate, inclusive, and affirming information about their health needs, rights, and available resources. Transgender is a term used to describe individuals whose gender identity differs from the sex they were assigned at birth. Transgender individuals may undergo social, medical, or legal transition to align their gender expression with their gender identity. Gender diverse is a broader term that encompasses individuals whose gender identity or expression differs from societal expectations or norms associated with their assigned sex at birth. This includes transgender individuals as well as individuals who identify as non-binary, genderqueer, genderfluid, or any other non-conforming gender identity. The purpose of this research is to examine health information seeking and perceived source credibility among TGD populations.

Health disparities in TGD communities are largely attributed to structural and social barriers individuals face in accessing health information and resources (Augustaitis et al., 2021). Health information for TGD populations is scarce because of a systematic erasure of TGD health data (Nolan et al., 2019), avoidance of non-gender-transition-related medicine and health by TGD people due to the perception of discrimination (Kcomt et al., 2020), and broader institutional limitations of healthcare access for TGD people (Feldman et al., 2021). Extant research underscores that TGD populations often avoid visiting healthcare facilities citing reasons such as hostile environments (Kcomt et al., 2021), traumatic experiences at the medical facility (Jaffee et al., 2016), as well as structural barriers such as medical costs and insurance issues (Bakko & Kattari, 2020). Furthermore, social and institutional stigma against TGD individuals has led to the exclusion of TGD care in medical training, which contributes to limited knowledge and experience in the TGD health domain (Meyer et al., 2020), resulting in provider ambivalence and uncertainty when interacting with TGD patients (Dolan et al., 2020; Marshall-Paquin et al., 2023).

TGD individuals may face challenges in accessing comprehensive and accurate health information tailored to their specific needs. Much of the available health information may not address their unique healthcare requirements (Pohjanen & Kortelainen, 2016), leading to gaps in knowledge and understanding about TGD health issues (Korpaisarn & Safer, 2018). Health information resources often lack cultural competence, meaning they may not be sensitive to the needs, identities, and experiences of TGD individuals. This can result in misunderstandings, miscommunication, and ultimately, inadequate care. Without access to accurate health information, TGD individuals may be more vulnerable to misinformation and harmful practices (Billard, 2024; Lepore et al., 2022). Misinformation and a lack of accurate and affirming health information (Augustaitis et al., 2021) can contribute to mental health disparities within TGD communities (Scheim et al., 2020), and feelings of isolation, anxiety, and depression can arise when individuals feel that their health needs are not understood or supported (Hughto et al., 2021).

Addressing health disparities in TGD communities requires efforts to ensure that health messages are inclusive, accurate, and readily accessible. Health messages are conveyed through a variety of communication methods including traditional media (e.g., television, radio, print media), digital media (e.g., websites, social media, blogs and email newsletters), mobile applications, community outreach and events (e.g., health fairs, workshops, seminars), interpersonal communication (e.g., peer-to-peer communication, consultations with practitioners) and campaigns (e.g., public service announcements, pharmaceutical advertising). Research in health communication has generated evidence that demonstrates strategic health communication can reduce health risks and incidence of disease and improve quality of life (Kreps & Neuhauser, 2015). While health communication is an important component of addressing TGD health inequities, there is a dearth of research attending to the experiences and perspectives of TGD populations (Combs et al., 2018), and a lack of research on health information seeking and source credibility among priority populations (Jackson et al., 2019). Source credibility and health information seeking are vital to ensure TGD populations receive accurate, safe, empowering, and affirming healthcare that meets their unique needs and identities.Top of Form Therefore, through in-depth interviews with 30 TGD people, we examine health information seeking and source credibility pertaining among TGD populations.

Literature Review

Health Information Seeking

Health information seeking has been long studied among non-TGD populations, and research has examined health information needs (Chiet et al., 2020; Shi & Luo, 2020; Pian et al., 2020) and the influencers of health information seeking behavior (Chang & Huang, 2020; Rowley et al., 2017) and source selection process (Zhang, 2014; Song et al., 2021). Populations may seek health information online via search engines, provider websites, and online health communities, and by utilizing online networks through social media platforms (Wang et al., 2021) Online health communities can fill information gaps, which may be useful for individuals isolated from others. Among TGD populations, health information is frequently exchanged in online communities, and users post and/or consume health information on social media platforms and user-generated information sites (see Evans et al., 2017; Hawkins & Gieseking, 2017; Karami et al., 2018; Selkie et al., 2019). Importantly, despite the wealth of health information online for TGD people, individuals must vet content on social media channels for relevance and quality (Morse et al., 2023).

Health information seeking behavior is influenced by a variety of factors, many of which have been studied extensively among non-TGD populations. Demographics play a role in how individuals seek health information. For example, younger people may be more likely to use the internet for health information, while older adults may rely more on traditional sources like healthcare providers (Miller & Bell, 2012). Perceived health status may impact online health information seeking, whereby individuals who perceive themselves as being in poor health are more likely to seek health information to address their concerns (Alwi & Murad, 2018). Availability of resources such as internet access, libraries, healthcare providers, and health insurance can influence health information seeking behavior. Lack of access to these resources may limit an individual’s ability to seek out information (Kang et al., 2022). Additionally, trust in the source of health information is critical (Rowley et al., 2017). Non-TGD individuals are more likely to seek information from sources they perceive as credible, such as healthcare providers, government agencies, and reputable websites. However, health information seeking and source credibility among TGD populations remains underexamined.

Source Credibility

Source credibility is crucial when seeking and evaluating health information, and several factors influence perceptions of credibility. Individuals are more likely to perceive information as credible if it comes from sources perceived as knowledgeable or expert in the field (Eastin, 2001). For health information, this often includes healthcare professionals, researchers, and reputable health organizations (Kivits, 2006). The reputation of the source significantly affects credibility and perceptions; therefore, established institutions, organizations, and well-known experts are generally considered more credible than unfamiliar or obscure sources (Metzger & Flanagin, 2015). Over time, consistency of information may enhance credibility with sources that provide accurate, evidence-based information may be perceived as more credible than those that frequently make errors or contradict themselves (Stella, 2003). Recommendations from healthcare professionals or reputable institutions lend credibility to health information sources (Zhao et al., 2024). While scholars have long been examining factors that influence source credibility of health information among non-TGD populations, sexual and gender minority populations have historically not been studied.

A growing body of research analyzes the factors influencing LGBTQ+ individuals’ health information seeking. Certain demographic factors are associated with online health information seeking. For example, LGBTQ participants identifying as Hispanic/Latina were less likely to seek health information online than whites (Gerke et al., 2020). Psychological factors may influence health information seeking among LGBTQ+ individuals, including sexual self-efficacy, the perceived bias of health care providers, and perceived control, with sexual health information from significant others as the best predictor of one’s sexual self-efficacy (Charest et al., 2016). LGBQ individuals who perceived provider bias were significantly more likely to seek health information on the internet and from friends and family members who were not medical professionals (Jabson et al., 2017). Physical and behavioral health information related to STDs was reported to be the most frequently sought information, with STI/STD-related topics as the principal focus of LGBTQ+ health information seeking literature (Jia et al., 2022), leading underexamined source credibility of preventive health information among this population. We understand preventive health information as knowledge intended to prevent illness, disease, or injury rather than treating them once they occur. This information contains proactive steps aimed at maintaining or improving health and well-being that can encompass a variety of activities, including screenings, vaccinations, and education about risk factors. Therefore, this study is guided by the following inquiry: How do TGD individuals perceive source credibility of health information pertaining to preventive health?

Method

Thirty semi-structured interviews were conducted online via Zoom meeting software with TGD individuals between February 21, 2023 and July 31, 2023. The interviews were conducted online to eliminate geographic barriers to participation. The inclusion criteria were that the participants had to be 19 years of age or older, identify as gender diverse (e.g., transgender, gender queer, non-binary), and live in the United States. Participants were recruited via convenience sampling. A distribution list of 32 community-based organizations and coalitions working with TGD populations was created using a Google search. Recruitment messages with attached flyers were sent through the established list. Additional recruitment was done via social media sites and publicly accessible interest groups with a TGD focus on WhatsApp, Instagram, and Facebook. Recruitment materials included a QR code and a link to a webpage with information about the study, including inclusion criteria. Interested individuals completed an online, self-administered screener survey. Eligible and interested participants provided an online informed consent form prior to continuing registration. After consent, participants completed a demographic form and selected an interview time through the online scheduling platform. Inclusion criteria were validated by self-report. Participants were provided a password-protected Zoom link upon scheduling.

Thirty (30) interviews were included in the analysis. The interviews were conducted by two interviewers trained in qualitative interviewing techniques. A short TGD-responsive resource guide for referral was created and available to interviewees as a resource during or after the interviews. Interviews lasted approximately sixty (60) minutes each (range: 41–94 minutes) and were recorded to a secure cloud online server. An interview guide was followed, including open-ended questions and probes. The script was piloted with two TGD individuals, and adjustments were made to the script based on feedback. Questions regarding source credibility included: “When it comes to your health, tell me about your trusted sources of health information” and “Tell me about why you trust these sources of information.” Participants were provided with operational definitions of key concepts such as “health communications campaigns.” Participants were given examples of health communications campaigns and clarified how these differed from direct patient communication, as needed to ensure understanding of the concepts.

Upon completion of the interview, recordings were transcribed using Otter.ai and then matched to audio recordings for quality control. Participants were provided a $100 electronic gift card as an incentive for participation. Study protocols were approved by the Institutional Review Board at The University of Texas at Austin.

Data Analysis

Audio recordings of the interviews were transcribed, and participants were de-identified. Interview transcripts were coded using NVivo software for Mac. Thematic analysis was done using inductive coding, allowing themes to emerge organically using open coding. Coding procedures and theme development were completed by two members of the research team (Creswell & Poth, 2016). The research team collectively reviewed and discussed coding and revised themes as needed. The research team developed a codebook that was used in thematic development and assessment, a process that ensured validity of the study and its analysis. The following section presents the findings of the analysis, starting with the demographic characteristics of participants.

Findings

Participant Demographics

Of the sample, 27% (n = 8) were young adults ages 19 – 24, 43% (n = 13) were ages 25 – 34, 23% (n = 7) were ages 35 – 59, and 7% (n = 2) were over 60 years old. Participants’ ages ranged from 19 to 75 years of age. Half of the sample identified as White (n = 15), 20% Native American (n = 6), 13% African American/Black (n = 4), 10% Latinx (n = 3), 3% Asian (n = 1), and 3% Multiracial (n = 1). Gender identity was relatively evenly distributed with 30% identifying as a transgender woman (n = 9), 37% identifying as a transgender man (n = 11), and 33% identifying as non-binary (n = 10). For sexual orientation, 47% of the sample identified as queer (n = 14), 13% as bisexual (n = 4), 13% as pansexual (n = 4), 10% as asexual (n = 3), 7% as gay (n = 2), 7% as lesbian (n = 2), and 3% as straight (n = 1).

Category	Sub-category	Percentage (%)	Number (n)
Age Group	19 – 24	27	8
	25 – 34	43	13
	35 – 59	23	7
	60+	7	2
Race/Ethnicity	White	50	15
	Native American	20	6
	African American/Black	13	4
	Latinx	10	3
	Asian	3	1
	Multiracial	3	1
Gender Identity	Transgender Woman	30	9
	Transgender Man	37	11
	Non-binary	33	10
Sexual Orientation	Queer	47	14
	Bisexual	13	4
	Pansexual	13	4
	Asexual	10	3
	Gay	7	2
	Lesbian	7	2
	Straight	3	1

The following themes emerged from the data: 1) perilous socio-political climate; 2) precarious mass media landscape; and 3) benevolent community-based organizations.

Perilous socio-political climate

Although participants are largely distrustful of government, when asked about general health information, federal institutions were commonly cited as sources of credible health information due to providing scientific, peer-reviewed information. Health information from federal institutions such as the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH), were most often referenced as being credible, due to their reliance on evidence-based research. However, data point to source credibility as influenced by the broader socio-political climate. Political parties in power, influence of interest groups, and elected officials in leadership play a crucial role in shaping participants’ perceptions of source credibility of health information. Many participants expressed diminishing trust and credibility in health information coming from both federal and local health agencies because of the interplay between federal agencies and government, a sentiment encapsulated by one participant:

I don’t like the government. If I’m gonna be honest, I have a lot of mistrust of the government or any authoritative like figures in that way. I mean, like, I did look at like CDC guidelines, and I do in general, like, trust the CDC. But if the governor puts out something, especially during COVID, I would always go and double check those things because I just genuinely didn’t like trust it.

Participants perceive federal institutions like the National Institutes of Health as empirically driven institutions that are like the engine driving medical breakthroughs and advancements, aiming to make life better for everyone by tackling health challenges head-on. Findings illuminate that TGD individuals do not trust state and local government officials, but they do have faith in federally funded institutions, like health research organizations and federal or state university hospitals. Several participants expressed a deep distrust of the government, uncertain about health information disseminated from state-level entities. One participant noted:

Lord, Texas is a hot mess right now. I’m just gonna be blunt. Our key officials like the Governor and the Attorney General tried having the Department of Family Services go after parents who are helping their trans youth access gender affirming services…There’s a ton of bills right now targeting the trans community, but especially youth. So, right now, the state government [is] very firmly on my distrust list.

Participants like this individual chronicled the ways anti-TGD legislation by state government officials erodes trust in government sources of health information. Another participant noted that in their home state of North Dakota, the governor signed a bill into law that restricts transgender health care in the state, making it a crime to provide gender-affirming care to people younger than 18, a ruling that goes against international health guidelines pertaining to TGD health. The participant recounted an attempt by government officials to enact a law that would require any government entity in North Dakota to use an individual’s pronouns based on their assigned sex at birth. Because of this proposed legislation, he stopped going to the government-funded public health clinic for his medication and was forced to find another provider that would use his correct pronouns and name. He expressed a complete lack of trust in health information grounded in the larger bureaucratic influence government has on health and medical institutions. Other participants noted a broader skepticism of government resources of health information, because of the historical disregard and erasure of queer people, indigenous populations, and communities of color. One participant noted:

A lot of people are very skeptical of government resources in terms of health information. I still exercise a healthy skepticism, even for government resources, because historically governments have not had the needs of queer people and indigenous people, people of color in mind.

Participants’ feelings of skepticism are rooted in a deep historical violence and erasure of queer lives in health and medicine, as well as erasure and epistemological violence that has dominated mainstream media.

Precarious mass media landscape

News media were frequently referenced as lacking credibility, and journalists’ coverage of issues pertaining to TGD people was gravely impacted by the tone of state and local level legislation on TGD communities. Journalists were referenced as not reliable, often changing their messages to gain advertising or ratings, and exhibiting bias and polarizing TGD people in their reporting. One participant shared his longstanding distrust of news media: “I’ve always been skeptical of the news, because there’s always an angle. There’s always a bias. So, I prefer unbiased sources.” For participants like him, a biased source is an uncredible source. Amidst the backdrop of the COVID-19 pandemic, a climate of misinformation shapes participants perceived source credibility of health information. One participant noted:

I’m looking at health stuff through the news. I’m finding it’s better to look at a couple different newspapers or online newspapers and compare what they’re saying. [For] example, Fox News is very right leaning. They were very much spreading misinformation about masking or vaccination at one point, or very dismissive of it. CNN can be I guess, a little more left leaning, or it’s considered more left leaning. I find they sometimes sensationalize certain things… So, I like to hop around to see how much I trust that particular statistic or recommendation before just jumping with it. In terms of anything relating to being trans, I tend to be really cautious with the news.

Participants tend to filter through health information content, making sense of messages and sources based on attitudes and beliefs they hold about media outlets.

Benevolent community-based organizations

Most participants pointed to community-based organizations (CBOs) as the most trusted source of health information. Describing her local CBO, one participant noted, “I absolutely love community-based organizations. Specifically, things like the Transformation Project here in South Dakota is something that I really trust for health information, especially regarding transgender people and healthcare specifically targeted for us.” Participants expressed a benevolence embodied by these agencies, and this perception was paired with perceived health information credibility attributable to geographic proximity and a hyper-local focus of a CBO to TGD communities served. Participants conveyed trust in the health communication information provided by these agencies, as they often employed people with TGD identities and lived experiences.

Discussion

Data from this research illuminate the complexity of perceived source credibility of health information among TGD individuals. On the one hand, TGD populations may only trust empirical, peer-reviewed health information. On the other hand, TGD populations demonstrate a distrust of any non-TGD community-based organizations. Because of the current legislative landscape in the United States, feelings about the anti-TGD political landscape creep into state and local health information sources. Based on the anti-TGD legislation in their regions, TGD populations operate from a place of deep distrust of governmental entities. Participants’ responses to questions about health information conveyed a sense of uncertainty amid the broader sociopolitical landscape and climate of health misinformation.

Misinformation refers to information sent to media consumers that subject experts have determined to be incorrect (Vraga & Bode, 2020) without an intent to deceive (Hameleers et al., 2021; Wardle, 2017). Conversely, disinformation involves the dissemination of deliberately false information, and it is thereby intentional manipulation, fabrication, or decontextualization of information to attain a particular political goal (Hameleers et al., 2021). Findings from this study point to political disinformation about TGD people that impacts source credibility of health information.

Health misinformation is a core element of contemporary public discourse on transgender rights that has been mobilized to advance state and federal policies that limit and/or prohibit transition-related health care (Billard, 2024). Findings from this study suggest health information is marred by anti-TGD legislation, a sociopolitical force that bleeds into health information spaces. While perceptions of health information sources are implicated in misinformation, a deeper understanding of the concept is needed. The concepts of misinformation and disinformation are often interconnected and conflated, but they have significant conceptual distinctions. These distinctions manifest in the findings from this study.

The relationship between source credibility and trust in health communication is pivotal in shaping TGD individuals’ perceptions, decisions, and behaviors related to their health. Most importantly, addressing disinformation is essential for health communication practitioners to effectively convey accurate and evidence-based information and promote positive health outcomes among TGD populations. Importantly, health institutions and health communication practitioners may not be aware of and comprehend the feelings TGD people have about their lives and their health. When making sense of health information, TGD people may rely on various cognitive schemas that affect how individuals perceive, interpret, and respond to health information from various messengers and media outlets. Findings suggest TGD people may seek out and interpret information in ways that confirm their pre-existing beliefs and attitudes toward health information sources, suggesting a confirmation bias. They may be more inclined to trust and accept health information sources that align with their existing worldview. TGD individuals may categorize health information sources based on generalizations about the source’s political affiliation, credibility, or biases. For example, someone might dismiss a campaign about colon cancer and colorectal screening from a local government because they perceive it as biased or untrustworthy. Health disinformation can have significant implications for TGD populations, exacerbating existing health disparities and posing risks to individual well-being. Disinformation about health can lead to confusion and distrust among TGD individuals, potentially delaying or preventing them from accessing healthcare services. Health disinformation may contribute to increased risk of adverse health outcomes, such as increased risk of gynecological cancers among TGD people with cervixes (World Health Organization, 2018) and increased risk of venous thromboembolism among TGD people who use estrogen and androgen-lowering hormone therapies (Van Bunderen et al., 2022). Future research is needed that empirically examines confirmation bias, stereotyping, and authority bias in health information seeking and source credibility among TGD populations.

Health disinformation can impede TGD individuals’ ability to make informed decisions about their own healthcare and well-being. When disinformation is widespread or presented as credible, it can be difficult for individuals to discern accurate information from falsehoods, undermining their autonomy and agency in making decisions about their bodies and identities. Health communication practitioners need to center the safety and humanity of TGD people. To address the implications of health misinformation for TGD populations, health communication practitioners need to prioritize accurate, evidence-based information within TGD populations and communities. This includes providing accessible, affirming resources and support services, increasing cultural competency among healthcare providers, combating stigma and discrimination, and fostering critical thinking skills to evaluate health information critically. Additionally, efforts to regulate and counteract misinformation through media literacy initiatives (Bulger & Davison, 2018), community education campaigns, and advocacy for policies that protect transgender rights and access to affirming healthcare (Alstott et al., 2024) are crucial for promoting the health and well-being of TGD individuals. Most importantly, the onus should not be placed on TGD populations to combat health misinformation. Political leaders and government need to be held accountable for health misinformation and the violence enacted on TGD people. Scientific misinformation has been used to uphold legislative actions in the United States, resulting in laws that threaten the health and safety of TGD people but also require health workers to practice care that is against evidence-based guidelines or face career-ending retribution (Lepore et al., 2022). However, research suggests that political accountability in the contemporary informational environment is particularly difficult (Schiff et al., 2023).

The implications of this research will be useful to health communication practitioners who can adapt messages to better address the health information needs of TGD populations. Researchers and practitioners with funding and support from governmental agencies (e.g., NIH, CDC) shouldn’t assume this affiliation is a source of credibility to their audiences. Rather, disseminating health information should begin with community-based partnerships in TGD communities. Additionally, practitioners need to translate and disseminate empirical research by way of white papers co-written with trusted TGD-affirming community health organizations.

The strong support for CBOs as credible sources of health information among participants has several implications for scholars and practitioners of health communication. Participants perceive CBOs as trustworthy sources of health information; therefore, scholars and practitioners should recognize the importance of trusted messengers within communities and the potential impact they can have on health communication efforts. Understanding who community members view as credible sources can inform the development of effective communication strategies and interventions. Scholars and practitioners should prioritize partnerships with CBOs and community leaders to ensure that health messages are culturally relevant, linguistically appropriate, and resonate with the target audience. Collaborating with CBOs can facilitate access to diverse communities, build rapport and trust, and enhance the reach and effectiveness of health communication efforts.

Our research is not without limitations. This research employed convenience sampling, and participants were recruited through social media of community-based organizations and coalitions, which could have introduced bias. These audiences may have already had interaction and rapport with social service organizations and may be more inclined to prefer online communication. The study may not have captured the responses from those with limited resources or limited access to computers and technology. The sample size was limited to only 30 individuals and is not representative of the diversity of TGD populations.

Additional research is needed that focuses on identifying, examining, and solving health inequities faced by TGD individuals by way of communication problems, specifically research that develops a deeper understanding of social media and social networks, exploring the effectiveness of partnerships with TGD content creators to lead message delivery. Additionally, a content analysis of health communications campaigns currently in rotation, including social media campaigns, is needed to confirm the communications gap in a systematic manner. Research is also needed related to the long-term effects of health communications campaigns. Additionally, while there is a growing corpus of research on health information seeking among TGD populations, this research points to the need to distinguish the experiences of non-binary populations.

Conclusion

TGD health communication involves the dissemination of accurate and understandable health information, aiming to promote health, prevent disease, and improve healthcare outcomes. In addition to policy implications, TGD health disinformation can undermine trust in health institutions, lead to harmful behaviors, and contribute to the spread of diseases among gender diverse populations. Health communication efforts can counteract TGD health disinformation by providing evidence-based, accurate, and easily understandable information to policy makers and federal institutional stakeholders. Health communication practitioners can monitor channels where disinformation spreads and address false claims with accurate information, engaging with communities, fact-checking organizations, and social media platforms to correct misinformation and prevent further dissemination.