Clinician and client perspectives regarding transgender health: a North Queensland focus

Abstract

Background: Healthcare encounters are important in ensuring safe access to medical or surgical care for transgender people. Previous literature suggests many transgender people have had negative encounters with healthcare professionals. In Australia, there is limited research about this population and their healthcare, and less from regional locations.

Aims: This study primarily aimed to explore both transgender client and clinician perspectives and experiences of healthcare interactions. A secondary aim was to investigate increased presentations to sexual health clinics in North Queensland by people wishing to transition.

Methods: Semi-structured, in-depth interviews were used to gather data from 23 participants. Interview transcripts were inductively analyzed and themes developed. Results: Four themes emerged relating to healthcare encounters and the regional setting of North Queensland. These showed that support from family and peers is important for transgender mental health and wellbeing, and that person-centered clinicians who acknowledge a holistic approach to transgender care also form part of the support network for transgender individuals particularly in the regional setting. The internet was found to play a significant role in this study’s findings.

Discussion: A collaborative holistic approach to transgender healthcare should be taken by client and clinician to best support the transgender individual during transition. The establishment of Australian guidelines and online peer support groups would facilitate this approach, particularly in rural or regional areas where specialist services are limited.

For transgender (trans) people, encounters with healthcare providers (HCP) can hold an important role in ensuring safe access to medical or surgical therapies. A 2018 literature review found four main themes relating to trans peoples’ experience of the healthcare encounter. These were HCP knowledge, HCP communication, patient-provider relationship dynamics, and the overarching healthcare system (Heng, Heal, Banks, & Preston, 2018). Also prevalent in trans research is an exploration of HCP attitudes toward trans people which indicate that while this can be quite positive, there remains a need for improved knowledge or cultural competence (Ali, Fleisher, & Erickson, 2016; Beagan, Fredericks, & Goldberg, 2012; Carabez, Eliason, & Martinson, 2016; Dorsen, 2012; Dy et al., & Transgender Education Study Group, 2016; Hancock & Haskin, 2015; Klotzbaugh & Spencer, 2014; Lapinski, Sexton, & Baker, 2014; Lefkowitz & Mannell, 2017; Shetty et al., 2016; Unger, 2015; Vance, Halpern-Felsher, & Rosenthal, 2015; White et al., 2015). A study by Riggs, Webber, and Fell (2012) surveyed a cohort of Australian undergraduate psychology students and revealed not only a difference in attitudes among men and women, whereby women were found to be more positive, but also found students who had prior contact with the trans community were more positive in their attitudes. The study also revealed that students with conservative views on gender had less positive attitudes. Studies of a range of HCPs indicated a positive attitude to trans clients, with providers of adolescent medicine and pediatric endocrinology (Vance et al., 2015), obstetrics and gynecology providers (Unger, 2015) and oncology providers (Shetty et al., 2016) indicating they were comfortable treating the trans population. One study found that medical students felt unprepared to discuss trans therapies (White et al., 2015) which emphasizes the need for improved knowledge in this area as preparedness has been shown to improve through education (Duvivier & Wiley, 2016; Kelley, Chou, Dibble, & Robertson, 2008; Sanchez, Rabatin, Sanchez, Hubbard, & Kalet, 2016; Thomas & Safer, 2015).

As Riggs et al. (2012) indicate, in an Australian setting, there is a small but valuable body of trans health research in terms of studies exploring trans attitudes to both HCPs and HCP attitudes towards trans clients. Several articles and reports have been published examining trans mental health, general health, and trans peoples’ experiences accessing the Australian health care sector. Consistent with the international literature, these studies have highlighted some disparity of experiences which can be further explored in terms of individual HCP experiences and a geographical context, where distance and rurality can play a role. Noted deterrents and barriers to care included a perception that HCPs were not sufficiently knowledgeable, poor communication, discrimination or negative attitudes, cost of treatment, long waiting times, and unclear referral pathways. Knowledgeable HCPs and trans-positive or affirming attitudes improved the individual’s experience of care (Chaplin, 2016; Couch et al., 2007; Hyde et al., 2014; Jones, del Pozo de Bolger, Dune, Lykins, & Hawkes, 2015; Kerry, 2018; Pitts, Couch, Mulcare, Croy, & Mitchell, 2009; Riggs, Coleman & Due, 2014; Riggs & Due, 2013). Difficult access to care due to geographical location was also cited as a barrier to care with some studies also discussing the experiences of trans people in regional, rural, and remote Australia compared to a more urban population (Hyde et al., 2014; Jones et al., 2015). As 70% of Australia’s population is centered in major cities which have greater numbers of HCPs per 100,000 population (National Rural Health Alliance, 2015), it is clear that regional, rural, and remote Australia is significantly less resourced and serviced than metropolitan Australia. Additionally, regional, rural, and remote Australia covers a significantly large area of Australia’s landmass (Australian Bureau of Statistics, 2012), and often large distances must be traveled in order to access services available in capital cities. Several studies reported that simply finding local general practitioners (GPs) was difficult, a challenge certainly compounded when seeking clinicians knowledgeable in trans health, causing many individuals to travel long distances to access integral aspects of their care (Hyde et al., 2014; Jones et al., 2015; Kerry, 2018). In Kerry’s study (2017; 2018) of trans people in the Northern Territory (NT), participants living in remote areas were included. Some participants sought trans healthcare in other states due to difficulty accessing knowledgeable practitioners or related services in the NT, and many participants considered HCPs unsupportive. Other studies including participants from rural locations also discussed the transience of HCPs (attributed to training programs, locums, and poor working conditions) which hindered continuity of care and resulted in the trans individual revisiting their story with new HCPs (Jones et al., 2015; Kerry, 2017; Kerry, 2018).

Comparable to the NT, Queensland is a geographically large Australian state with a large proportion of the state considered regional, rural, or remote. North Queensland (NQ) is one of Queensland’s several regions and is considered by the Australian Bureau of Statistics’ Australian Statistical Geography Standard (ASGS) to be predominantly Remoteness Area (ASGS-RA) 3 (outer regional) to ASGS-RA 4 (remote) (Australian Bureau of Statistics, 2018; Queensland Health, 2014). Outside of NQ’s more populated cities, Townsville and Mackay, most towns are small and/or geographically remote with limited health workforce and medical services (Department of Health, 2018; Department of Health, n.d.). In NQ, there have been anecdotal reports of increased presentations to sexual health clinics by trans people seeking medically-assisted transition (Heal, C, personal communication, August 11, 2016).

This study aimed to explore both trans client and HCP perspectives and experiences of healthcare encounters in a regional Australian context, particularly in the NQ setting. A secondary aim was to investigate any reason/s for the increase in presentations of trans clients.

Methods

Design and setting

This interpretive qualitative study (Bhattacharya, 2012) using in-depth, semi-structured interviews was undertaken as part of an undergraduate Honours project. Interviews were conducted at the James Cook University (JCU) campus in Townsville, and sexual health services in Townsville and Mackay. Ethics approval was granted by the Townsville Hospital and Health Service (THHS) Human Research Ethics Committee (HREC) in October 2017 (approval number HREC/17/QTHS/195), with reciprocal approval from JCU HREC (approval number H7198), and site-specific approval granted by THHS and Mackay Hospital and Health Service (approval numbers SSA/17/QTHS/237 and SSA/17/QMH/34, respectively).

Sample

Purposive and snowball sampling was used to recruit two groups of participants – trans clients and clinicians. Purposive sampling refers to the deliberate selection of cases which are determined to be most the appropriate for studying the topic of interest, whilst snowball sampling encourages already included participants to recruit others who may be suitable for the study (Flick, 2008). Advertising flyers were emailed to trans clients and staff of the sexual health services in Townsville and Mackay to invite trans adults residing in both NQ and clinicians who interact with this population to participate in the study. Flyers were sent by staff at the site and requested potential participants to contact the researcher if they were interested in participating in the study to ensure respect for participant privacy. General practitioners from these towns were also invited to participate with help from Generalist Medical Training and publicly accessible email addresses. Inclusion criteria for clients were self-identification as trans, current residence and access to healthcare in NQ, and age over 18 years old. Inclusion criteria for clinicians were current employment and residence in NQ. No restrictions were made regarding the type of HCP or their experience level. Aboriginal and Torres Strait Islander individuals were not purposively recruited, nor were they excluded from participating. Written informed consent was obtained prior to the interview including approval to disseminate study findings via publication. Post-interview, participants were encouraged to share the study flyer with their peers. Trans participants were also encouraged to share the study information with their GP.

Data collection

Between January and April 2018, 23 in-depth, semi-structured interviews were undertaken with clients (n = 15) and clinicians (n = 8). Interviews were conducted by the principal investigator and ranged in length from 20 minutes to 2 hours. Interview guides were established and piloted by the principal investigator based on participant group. The client interview guide was piloted with a leader in the trans community, while the clinician interview guide was piloted with a medical student peer of the principal investigator and a GP. This allowed feedback about question phrasing, order, and appropriateness, and provided the opportunity for alteration of the guide before debut. For clients, questions explored their life and healthcare experiences in NQ, and their experience with the local trans community. Clinician questions addressed their understanding about the trans population, their clinical experiences with trans people, and their perspectives about trans health in medical education. The interviews were audio recorded and transcribed verbatim by the principal investigator as part of data immersion and analysis.

Data analysis

Interview transcripts were stored and organized in NVivo and analysis was guided by a general inductive approach (Thomas, 2006). Transcripts were closely read multiple times and coded into both broad codes guided by interview questions and narrow codes based on the specific content. Over multiple iterations of this process, the broad and narrow codes were linked, revised and refined to create groups and categories which were narrowed down and abstracted to generate concepts relating to participants’ experience of healthcare interactions in NQ.

The principal investigator wrote memos throughout the process of data collection and analysis to document their thoughts and findings as they evolved through the timeline of the study. Triangulation of data was ensured by comparing findings within and between participant groups, discussing findings within the research team, and comparing the results of analysis to the established findings of peer-reviewed and gray literature.

Reflexivity

The principal investigator is an Asian-Australian cisgender (cis) female who is founder of the JCU Pride Alliance and an ally of the trans community. Whilst empathetic to the challenges faced by gender minorities, and influenced by her own experience as a person-of-colour who grew up in NQ, her identity as a cis female in itself inhibits a thorough understanding of trans lived experiences. During the study, the principal investigator was also a senior medical student, which could medicalise her view of the transition process including assessment, diagnosis and treatment, and reinforce a ‘gatekeeper’ role.

Results

Seven of the 15 trans participants identified as a man or non-binary transmasculine while eight identified as a woman. Ages ranged from 19 to 69 years old, with five participants aged over 50 years. Participants’ length of residence in NQ ranged from two years to all their life. Most participants ‘came out’ and began their transition in NQ, with the majority not having received transition care elsewhere. Two of the clinician participants were nurse practitioners at a sexual health clinic, four were clinical nurses at a sexual health clinic, one was a psychologist at a sexual health clinic, and one was a GP with an interest in sexual health. Seven of the eight clinicians identified as cis women, while the other was a cis man. All clinicians were currently practising in NQ and had trans clients under their care. No participants identified as Aboriginal or Torres Strait Islander. Table 1 contains a description of participants and their pseudonyms for ease of reference.

Table 1.

Participant pseudonyms and description by group.

Pseudonym	Description	Code	Role
Clients		Clinicians
Andrew	Man, 19–23 years	C1	Nurse practitioner
Brian	Man, 34–38 years	C2	Psychologist
Chloe	Woman, 54–58 years	C3	Clinical nurse
Diana	Woman, 59–63 years	C4	Clinical nurse
Evan	Non-binary transmasculine, 29–33 years	C5	Clinical nurse
Fiona	Woman, 24–28 years	C6	Nurse practitioner
Georgia	Woman, 19–23 years	C7	Clinical nurse
Hayley	Woman, 64–69 years	C8	General practitioner
Isla	Woman, 19–23 years
James	Man, 19–23 years
Kane	Non-binary transmasculine, 24–28 years
Louise	Woman, 24–28 years
Mitch	Man, 19–23 years
Nina	Woman, 49–53 years
Olive	Woman, 64–69 years

Notes: age ranges are provided for clients to minimize the identifiability of their specific age.

While a broad range of trans life and healthcare experiences were covered in the interview data, four themes were developed relating to healthcare encounters and the regional setting of NQ.

Community attitudes and support in NQ

Although this theme does not directly relate to client and clinician experiences of their healthcare encounters, it provides some insight into the atmosphere in which these interactions occur.

Community attitudes

Community attitudes influenced the social environment the trans individual was submerged in and their perspectives of the community’s social norms. Many clients shared the perspective that people living in rural or regional areas held more conservative views and would be more discriminatory. They also believed that capital cities would be more accepting of them and access to transition care would be easier due to the greater service availability in larger centers. However, while many participants could provide anecdotes of discrimination occurring to others, most clients did not report any overt discrimination occurring towards themselves. Experiences of discrimination were uncommon, and generally occurred in the workplace or healthcare setting to those who were ‘out’ to their colleagues or when first finding help to access transition. Some clients who had lived in rural areas when they had not yet realized they were trans or had not ‘come out’ yet expressed fear of returning to these locations post-transition due to perceived community values and attitudes – such as being a “very Catholic, close-knit community where you sort of have to conform to the norm,” otherwise, “getting any support is very difficult,” (Brian, man, 34-38 years).

Support

Both clients and clinicians stated that support and acceptance, particularly by family and friends, was integral to trans peoples’ wellbeing. While friends were important, family relationships were crucial as one clinician “found that most of the invalidation and resistance comes from the family members rather than friends,” (C2, psychologist). Those with supportive families were perceived to have better mental health than those who were unsupported or had relationship conflict. Most clients had supportive families; however, some described making personal sacrifices or compromises in order to maintain their relationships. Although, many clients stated they would continue with their journey and transition regardless of familial support or acceptance.

Peer support also emerged as an important aspect of wellbeing. However, many clients struggled to find a local trans community as there was “a lack of transgender groups,” (Georgia, woman, 19–23 years) while others assumed they were alone because “it was a small town,” (Andrew, trans man, 19–23 years). To compensate, clients relied on the internet and social media to find a community for support, information, and networking. Even those who were not actively involved in communities online could still find helpful resources and peer-shared advice “through YouTube videos, people talking about their experiences, reddit,” (Georgia). Additionally, the internet helped to validate the trans identity and help trans individuals feel less isolated.

Despite the significant role, the internet has played for clients, both clients and clinicians expressed a need for more local networking and peer support groups to improve shared resources, combat internet accessibility issues, and as a way to keep trans people in their regional communities rather than having them move to larger centers.

Trans healthcare is “not just a matter of hormones”

This theme focused on trans healthcare. The most pertinent finding from both groups of participants was that trans healthcare is more than just hormones and surgeries. It includes a holistic view of the client, including psychological support, and non-health aspects such as makeup, deportment, “the easiest place to get a binder, or how I could go about telling family or friends …, or even packers,” (James, man, 19–23 years). These “little things we take for granted,” were important for trans mental health and “a big step for these people who are changing their whole appearance in the community,” (C3, clinical nurse). Clients described having to learn non-healthcare aspects of their transition independently as Chloe (woman, 54–58 years) said, “there’s no training school, … where you can go and learn how to dress and learn how to walk and learn how to do this and learn how to do that. So I had to do all this by myself.” Other clients sought information online from their peers as presented previously. Legalities and documentation emerged as non-healthcare aspects important to mental health, as described by one clinician:

The legal arena is a barrier … with regards to someone's preferred pronoun not being able to be on a Medicare pathology form … that can be really quite distressing for somebody if we can't foster that, you know, desire for the way that they want their name seen on a piece of paper … because of the issues of funding of their health. (C6, nurse practitioner)

While clients did not talk about experiencing distress, they described awkwardness surrounding the mismatch of documentation and physical appearance. For example, when Evan (non-binary transmasculine, 29–33 years) “[goes] in and I present as male … It's very clearly on my- on all of my medical records that I'm not a dude.” Kane (non-binary transmasculine, 24–28 years) mentioned discomfort when filling forms due to the absence of a gender category alternative to ‘male’ and ‘female’ especially, “'cause I haven't had reassignment surgery.” While, “from a physical medical point of view, I can understand why I need to put that down, … at the same time, … I don't wanna tick that box. I just wanna leave it blank.” They suggested:

It would be a lot easier if they just had the “Other” box on every form … “Other” is so vague it could be anything … anyone regardless of how you define yourself could tick that box and feel comfortable in doing so.

An important aspect of holistic care which emerged was collaboration between the client, their regular GP (if they had one), and sexual health, facilitated by communication between all parties. Fiona (woman, 24–28 years) relied heavily on her GP as “the goal keeper at the end of the line. To stop anything from falling apart,” as part of a “wheel of communication.” When asked what should be communicated between parties, she suggested, “the current status of where they're at to know what could happen, if anything else comes up.” Some clients raised the usefulness of having their GP approved to prescribe their hormones due to increased waiting times at sexual health compared to when they first commenced treatment. However, not all participants had a regular GP and the main reason stated for this was not seeing the need to have a regular GP due to good health, convenience and “whatever was closest,” (Georgia), or choosing to visit bulk-billing clinics¹.

Clinicians who “went above and beyond to help”

This theme relates to clients’ interactions with their clinician, particularly GPs. Clients appreciated person-centered clinicians who were helpful and supportive. This was evident even where the clinician may not have been very knowledgeable about trans people or their healthcare. When talking about her regular GP, Chloe said:

I don’t know whether her level of knowledge is fantastic, but her support is fantastic. And it doesn’t really matter for me, because if I need knowledge then I’ll tell her. … or I’ll find it myself and tell her what it is that she needs to do for me.

Clinicians who appeared curious or willing to research about trans health were perceived to be taking an interest in their client. Brian’s GP would “get it a little bit mixed up but … I could see he was trying,” and while “he wasn’t aware of how it all worked, [when] I went there, he was … armed with the same information that I already had, which meant that he did actually show a genuine interest.” Fiona described how her GP “wasn’t sure about the information,” but was confident in offering his help which showed he “put in an effort.” Kane shared their perspective on having their GP research information and collaborate with other clinicians to find services for them.

It was very helpful, even if she didn't have the answers to the questions I had, she was willing to go and look for them for me; … just the fact that it felt like she went above and beyond to help me was really amazing.

This contrasts starkly with negative experiences clients had with GPs. These were generally attributed to cultural differences or differences in beliefs. Kane was told, “Nah, I don’t believe in that. I can’t help you,” when they were first looking for transition care. The GP went on to ask, “Do you have a real medical reason why you’re here today?”

Regarding GP knowledge, clients expressed that it would be useful for their GPs to know more about hormone therapy in terms of dosage, hormone levels and side effects. Louise (woman, 24–28 years) believed “hormone therapies and stuff should be covered in medical school because there's a decent amount of the community that needs that.” However, at the most basic level, clients just wanted a person-centered GP who was supportive, willing to learn or research, and who knew where to refer them to receive transition care. Clinician support was demonstrated by being “polite and courteous,” (Diana, woman, 59–63 years), which encompassed terminology “and how that functions - like, social transition, medical transition,” (Evan). The clinician should also “know to ask about pronouns and that that's important,” because “pronouns are such a personal and ever-present reminder of who we are and how the world sees us,” (Evan). Initiative to research promoted person-centredness because while “not everyone can know everything … you need to know how to learn what you need to deal with each patient,” (Louise). Clients expected their doctor “to be able to, you know, talk to you and explain things to you, and even if they don't have the information on hand, they need to know how to get it before the next appointment,” (Louise). Clients also wanted their doctors to “have the ability to say, “Look, these services are available. These are the contact numbers,”“and to “just have the information, whether it's a flyer or a contact number, or something like that,” (Nina, woman, 49–53 years). Clients who had regular GPs did not want their GP to “touch base every time,” (Fiona) in regard to being trans, but just wanted to be treated like “a normal person going in there,” (Diana).

Learning together

This theme predominantly explored how clinicians obtained their knowledge of trans health based on clinician interview data only. Clinicians described primarily obtaining their knowledge and confidence about trans health through interacting with their clients – C8, a GP, stated, “A lot of the patients teach me, which is great.” This sentiment was echoed by another clinician saying, “clients are so much more self-aware, and they’ve researched all this stuff, … sometimes I feel like I’m the novice and I want to ask them,” (C5, clinical nurse). Their knowledge was reinforced through attending conferences or learning from their more experienced peers – “just hearing the experts from the Brisbane transgender clinic just talk … Just a little bit of background reinforcement of information,” shared C3, a clinical nurse. Some clinicians also self-educated by accessing clinical journals or similar online resources.

In addition to this, clinicians appeared to put extensive thought into how to support their clients. Related to the previous theme, clinicians discussed holistic care when considering their clients as “the rest of that stuff that wraps around them is … more important,” (C6, nurse practitioner). Clinicians described how over time appointments with their clients “become more of a social event, … rather than a, you know, organic or nursing-medical type stuff,” which became a “minor issue,” (C6, nurse practitioner).

Clinicians also demonstrated an empathetic approach to understanding their clients, expressing insight into the effort and dedication required to transition as C5, a clinical nurse, exemplified:

It takes a lot of energy to continue this journey, because you're really pushing against all the other norms that have been given you your whole life, it takes a lot of mental and physical energy to go on this journey, and I think a lot of people get tired along the way. If it's not the right journey for them, I think they just self-select out.

Several clinicians also expressed a need for the creation of pathways to help streamline and regulate the assessment process for access to transition-related therapies. This included protocols and “referral pathways; so if someone presents to us, we do all the basic stuff,” and the client is referred “to the surgeon, to the whatever, and everybody is okay about that, and there will be a service there for that client,” so “we don't have to go begging for somebody to do the surgery for them. It should be, “That's it, that's the pathway.” And they get triaged like anybody else gets triaged,” (C6, nurse practitioner). The intention was “to have a very, very smooth process,” which was safe and comprehensive, and followed “the gold standards for normal transgender care,” to avoid being obstructive and having trans clients “jump through hoops,” (C1, nurse practitioner). Some clinicians emphasized the need for timely assessment and access to treatment to minimize the harm of high suicide rates or access to unprescribed hormones. As C2, a psychologist, said, “They’re choosing to go through this way because this way it’s monitored, you know, they get ongoing support, it’s reviewed, they can talk to the psychiatrist or psychologist or the clinical nurses.”

Ultimately, all clinicians seemed to hold the perspective that “it really isn't our decision whether transition is really right for them or not,” (C2, psychologist). Rather, clinicians are peripheral to the journey as “assessment is more about whether … they understand what they're getting into, whether they understand what the consequences are of it, what the ongoing impact will be, whether what's reversible, what's not reversible,” (C2, psychologist), and to provide support.

Discussion

The main themes of this study can be summarized by the idea that trans health should be managed with a collaborative holistic approach, particularly in regional areas where specialist services are limited. This holistic approach encompasses support for the trans individual’s physical and mental health, and what is needed to facilitate this; for example, support from family, friends, peers, healthcare, and non-healthcare services. Background societal norms and the presence of the internet reinforces and shapes the environment in which this occurs. A conceptual framework representing this is shown in Figure 1. These findings and the developed framework are consistent with the issues trans NT residents identified in their communities (Kerry, 2017).

Figure 1.

Visual conceptual framework of a collaborative holistic approach to transgender health and wellbeing.

Support from community, family, friends and peers was very important for the mental health of trans people living in regional areas – another finding consistent with Kerry (2017; 2018). However, this is a general finding for many trans Australians regardless of geographical location as suggested by other Australian literature (Couch et al., 2007; Hyde et al., 2014; Jones et al., 2015). Therefore, it can be concluded that support networks are important for general mental health, but in circumstances where the social landscape may be more hostile, having a support network is crucial to wellbeing. Many of the participants in our study expected more conservative views and discrimination in regional or rural areas; views which participants in Kerry’s study (2018) shared. Other Australian studies showed similar findings about rural conservatism and discrimination (Edwards, 2003; Quinn, 2003), and limited LGBTQIA + supports in rural areas (Jones, 2015). However, our findings suggest these expectations were anticipated due to the regional location and lack of available and visible trans- or LGBTQIA+-friendly services rather than actual experiences. This is supported by Couch et al. (2007) who found no differences in the reporting of stigma and discrimination between their metropolitan and rural participants. Regarding the significant role of familial support which was identified from our study, participants implied that trans people with good mental health tended to have supportive families, while those with poorer mental health tended to have more tumultuous familial relationships. This aligns with previous research about trans mental health and relationships by Riggs, von Doussa, & Power (2015), Rosenstreich (2013), and Hyde et al. (2014). Furthermore, trans and gender diverse young people had better mental health and access to mental health professionals when supported by their family (Smith et al., 2014).

Experiences of discrimination in healthcare, while present in this study, were not a common experience. This contrasts with previous literature suggesting negative experiences were most commonly encountered when accessing healthcare (Heng et al., 2018). While Heng et al.’s literature review attributed negative experiences to underlying notions of prejudice, this study found more clients attributed negative experiences to cultural differences or differences in beliefs. This may impact trans people living in regional areas as many international medical graduates (IMGs) work in regional, rural, and remote Australia as part of government schemes to increase the medical workforce in these locations (Wiseman, 2014). Other Australian studies have attributed negative experiences with healthcare to a lack of HCP knowledge about trans people or their health and having to educate the HCP (Couch et al., 2007; Hyde et al., 2013; Jones et al., 2015; Riggs & Due, 2013). This is exacerbated in geographically rural locations where less specialist services exist, and there is limited to no visible trans community (Jones et al., 2015; Kerry, 2018). However, our study found that a person-centered clinician was one of the most important factors influencing clients’ healthcare experiences. Therefore, clinicians from different cultural or belief backgrounds and those with limited knowledge who require their client to educate them may still provide good care and positive experiences if they practice in a person-centered manner. This supports established literature about patient-centered care and collaboration, and the importance of this to patient satisfaction (Delaney, 2018; Gluyas, 2015), and is consistent with previous Australian studies (Couch et al., 2007; Jones et al., 2015; Pitts et al., 2009; Riggs & Due, 2013).

Notably, several clients in our study did not have a regular GP, attributing this to minimal need or visiting the most convenient GP. However, perhaps the anonymity of visiting convenient GPs when there is a physical ailment may allow trans people to sever their trans identity from their gender expression and be perceived and affirmed as they intend – similar to going ‘stealth’ (Hyde et al., 2014; Jones et al., 2015). One client suggested that some regular GPs may ask about trans-related issues whenever their client visits them regardless of reason, which supports this concept. This was also described in Kerry’s study (2018). Previous Australian studies have attributed not having a regular GP to negative experiences (Riggs & Due, 2013; Smith et al., 2014), although in several studies most respondents did have a regular GP (Couch et al., 2007; Leonard et al., 2012; Pitts et al., 2009) which suggests that trans individuals are willing to travel or search until they find a competent or helpful GP (Jones et al., 2015; Kerry, 2018). Somewhat related to the idea of control and self-determination, trans clients in our study appeared to be self-empowered and self-educated. Heng et al.’s (2018) literature review described similar empowerment, and perhaps this empowerment compensates for low clinician knowledge and/or prepares the individual for the significant changes that come with transition.

This study also found that the internet played a significant role in finding information, reducing isolation and promoting acceptability and validation of the trans identity. This is consistent with Smith et al. (2014), who also found the internet to reduce invisibility and allow real-time and face-to-face support, and Couch et al. (2007) who found the internet to be an important source of information to supplement the lack of local service and information provision. As society is increasingly digitalized and globally networked, the internet likely plays a significant role in overcoming geographical barriers for trans people in regional or rural areas. This is supported by Smith et al. (2014) and Kerry (2018). In geographically regional, rural and remote areas, perhaps digitalized healthcare such as telehealth² may eventually help to distribute specialist trans healthcare to those living in rural areas or with limited transport. Hyde et al. (2014) also suggest this, urging doctors from major Australian cities to provide telehealth to rural and remote areas.

Lastly, regarding clinician perspective, this study found that clinicians felt more confident and knowledgeable after formal education, which supports previous studies demonstrating that education sessions can improve clinician knowledge and willingness to assist trans clients. However, clinicians in this study had clinical experience with trans clients and obtained much of their knowledge from their clients unlike in the academic setting of other published studies. A previous study of urology residents aligns with this finding where a gap was identified between the trans education these residents received and the direct patient contact they encountered (Dy et al., 2016). Another point of note is that our study’s clinicians had very positive attitudes towards their clients, which is at odds with previous studies. This may be due to an element of self-selection – for example, all clinicians who participated had experience in sexual health and had previous experience with trans clients. This may increase their willingness to be involved in a trans research project, whilst those with negative attitudes may have ignored the call for participants. However, further research is needed to further explore this phenomenon.

Strengths and limitations

Strengths of this study include its qualitative design which allows for thorough exploration of the topic and the obtaining of rich data. Findings from this study were established from almost 23 hours of interview recordings, of which the principal researcher alone transcribed verbatim reinforcing data immersion. Direct interviews of this marginalized population allow them to share their personal perspectives, thereby empowering them through actively involving them in their research. However, as the principal investigator was a cis medical student, this may have influenced the way clients interacted with her as someone who, in future, may be involved in their care. In addition, the inclusion of clinicians who had experience in trans health was a strength, but could also be a limitation as their experience may influence their perspective of the trans population and their health needs and limit the conclusions drawn about the average clinician in this region. While some information about non-sexual health personnel could be gathered from the participating clients, this does not replace the potentially rich data gathered from these clinicians themselves.

Recommendations

Recommendations of this study include the establishment of peer support groups in-person or online centered on trans people in regional, rural, or remote areas which may help to support this geographically isolated population. Additionally, the authors recommend a collaborative holistic approach to trans care including partnerships between the client, their GP, and their sexual health or trans care provider. Whilst the World Professional Association for Transgender Health have published Standards of Care (World Professional Association for Transgender Health, 2012) and some Australian guidelines and resources exist for the management of trans patients in certain states and contexts – such as trans and gender diverse children and adolescents (Telfer, Tollit, Pace, & Pang, 2018), sexually transmitted infection testing and screening (Australian Sexual Health Alliance, 2015), and a Victorian informed consent protocol for the initiation of hormone therapy (Equinox Gender Diverse Health Centre, 2017) – the production of standardized resources or guidelines for Australian clinicians would aid in ensuring basic essential knowledge and standardized management of trans clients. This may hold an important role for the care of trans people in regional, rural, and remote areas where specialist services are limited, and the process may be initiated by a local GP or visiting medical officer. Additionally, targeted education about the trans population and person-centered care for IMGs may help to curb conflict surrounding any differences in cultural beliefs. Lastly, further research centered on GPs is recommended to explore their experiences with trans clients as primary care providers and a first-line contact for those seeking transition, particularly in regional or rural areas where specialist services are limited or non-existent. Through these recommendations, it is hoped that the body of literature about trans healthcare in Australia can be improved, and this can inform methods to improve healthcare provision for trans clients, particularly in regional, rural, or remote areas.

Acknowledgements

The authors would like to acknowledge Dr Arun Menon and Natasha Miller from Townsville Sexual Health Services, Donna Pini and Maureen Ruge from Mackay Sexual Health and Assault Service, Melissa Vick, and the participants for their support and contributions to this project.