Experiences of Transgender Participants in Emergency Departments: Findings from the OutLook Study

Abstract

Purpose: Even in cases of medical emergency, mistreatment and negative experiences in life or in medical settings can deter trans patients from seeking necessary care. The purpose of this study was to identify factors associated with trans persons' emergency department (ED) avoidance in the mixed urban-rural Region of Waterloo, Ontario, Canada.

Methods: The OutLook Study was a community-based partnership that created an online, cross-sectional questionnaire for lesbian, gay, bisexual, transgender, and other sexual and gender minority community members. Participants in this analysis were 16 years of age or older, lived, worked, or attended school in Waterloo Region, and identified as trans (n=112). Binary logistic regression was used to test associations between sociodemographic, resilience, and risk variables, and ED avoidance. Sociodemographic variables statistically significant at p<0.05 at the bivariate level were included as controls to explore different combinations of resilience and risk factor in multivariable models.

Results: Participants reporting complete or partially complete medical transitions were more likely to report ED avoidance, compared to those who had not initiated medical transition. Elevated transphobia was associated with greater likelihood of avoidance. However, increasing levels of social support decreased the likelihood of avoidance. In multivariable models, social support, support from a special person, and transphobia were always significant, regardless of controlled variables.

Conclusion: Transphobia—enacted in the contexts of everyday life and health care—can deter patients from seeking care. Patient-centered care requires careful attention to trans identity and health needs, especially in emergency settings. In the absence of structural changes, providers can take steps to mitigate the erasure and discrimination trans patients experience and anticipate when accessing EDs.

Background

The Canadian health care system relies heavily on conceptualizing gender as binary, creating circumstances where transgender patients often receive inadequate care. Transphobia within health services is well documented, resulting from cissexism and systemic erasure of transgender identity in informational and institutional domains.^1,2 Gender-affirming, trans-specific care is regarded as a specialty, largely excluded from research and medical education,^3,4 resulting in a widespread lack of provider knowledge about trans identities and health needs.^5–7 Even providers educated on trans health can be influenced by gender-based bias, which translates into significant disparities in provision of care.^5,8–10

Primary care experiences factor into a trans patient's decision to seek subsequent care. In Canada, an estimated 81% of trans people have access to a primary health care provider, relative to 84% of the general population.¹¹ Yet approximately half of trans Canadians have dealt with an unmet health need in the past year compared to 4% of the general population.¹¹ Analysis of an American sample found 23% of trans participants delayed seeking health care because they were afraid of discrimination.¹² In another study of transmasculine people in America, 68% experienced mistreatment and 43% reported past-year avoidance of health services.¹³

Trans persons whose delay in seeking services was tied to fear of discrimination have been shown to have more detrimental health outcomes than those who did not delay or delayed for other reasons.^13,14 In rare cases, avoidance of health care can result in a medical emergency.^13,14 Consequences of health care avoidance clearly demonstrate the importance of ensuring access to affirming, trans-competent health services.

As a result of differential access to primary care, certain populations may be more likely to seek care in other settings, including emergency departments (EDs).^15–17 An estimated 13.4% of Canadians report using EDs as a primary access point to health care, indicating emergency physicians are well positioned to decrease health disparities.^15,18–20 EDs play a critical role in addressing urgent medical needs and in the development of a trusting, affirming relationship with health services.²¹ However, many EDs are ill equipped to accommodate trans patients, lacking proper infrastructure, policies, and procedures to provide affirming care (e.g., accommodating intake forms and absence of all-gender washrooms).^9,22–24

In the ED, providers and staff have been shown to lack experience and competence in caring for trans patients.^25,26 Trans persons report negative experiences where staff and providers are uneducated on trans issues and health, do not address them with their proper name and pronouns, and fail to remain respectful of their privacy and autonomy.^9,22,27,28

Trans patients may expect providers to be unfamiliar with their needs, anticipate having to educate their provider on the provision of their own care, or have heightened awareness of negative provider behaviors (e.g., discomfort), possibly to pre-empt discrimination.^9,24,29,30 In 2014, Bauer, Scheim, Deutsch, and Massarella investigated trans patients' avoidance of Ontario EDs, finding over half of trans patients accessing EDs had a negative experience, and 21% had avoided ever seeking emergency care.³¹

Trans people outside metropolitan areas contend with geographic barriers to care, as gender-affirming services are mostly located within large cities like Toronto, Vancouver, and Montreal, which are representative of 15.10% of Canada's population.³² The Region of Waterloo in Ontario, Canada, is made up of three cities (Cambridge, Kitchener, and Waterloo), with smaller surrounding townships and farmland. It is ∼100 km (∼60 miles) from Toronto, Ontario, the largest urban center in Canada.

It is estimated that 34.9% of Canadians reside in “mainly urban centers” with high immigrant and visible minority populations, factors forming the definition of a “health region peer group,” the largest of which includes Waterloo Region.³² This analysis aims to explore sociodemographic, risk, and resilience factors associated with avoidance of EDs in Waterloo Region.

Methods

The OutLook Study—Region of Waterloo

The OutLook Study was a community-based partnership of academic researchers, regional public health agencies, community members, and their allies. The project created an extensive online, cross-sectional questionnaire for local lesbian, gay, bisexual, transgender, and other sexual and gender minority community members. The project was approved by Wilfrid Laurier University's Research Ethics Board (REB# 4875).

Sampling procedures

Eligible participants (1) were 16 years of age or older; (2) lived, worked, or attended school in Waterloo Region; (3) identified as trans (e.g., someone who is “transgender, transsexual, gender variant, or a person with a history of transitioning sex or gender”); or (4) were with a non-heterosexual sexual orientation. The analysis for this particular article was limited to participants who indicated “yes” to identifying as “trans.” The survey was programmed based on which identities the respondent selected.

Extensive community promotion occurred online (e.g., through social network sites and calls for participants on community group websites) and through events (e.g., local Pride celebrations). Based on this, there were three broad sections of a survey participants could complete: one about experiences related to sexual orientation identity, one on issues related to gender identity and expression, and one to explore sexual health for those under the umbrella of “men who have sex with men.”

A $5 gift card for a coffee shop chain was provided for each survey section completed (i.e., honoraria value ranged from $5 to $15). Participants were required to indicate their understanding of the information letter, and consent to participate through checkbox options before entering the full survey. Data collection occurred from May to November, 2016.

Measures

The questionnaire was designed by adapting measures from the Canadian Community Health Survey,³³ and other additional community-based research projects.^34,35

Demographics

Sociodemographic variables include age; gender spectrum (calculated using two variables, “sex assigned at birth” and “current gender,” categorized as “male-to-female” or “female-to-male” spectrum); birth country (Canada vs. other country); medical transition status (completed; in process; planning, but not begun; not sure, not planning, or not relevant); and ethnoracial background, assessed through write-in responses (due to limited numbers in “non-white” categories, responses were categorized as “non-white” and “white”). Sexual orientation identity responses were categorized as “gay or lesbian,” “bisexual or queer,” and the remainder as “straight, asexual, not sure, or other.”

Additional demographic variables included “access to a regular primary care provider” with yes/no response options; education (categorized as “high school graduate or less,” “some post-secondary,” or “post-secondary graduate”); employment status (“employed full-time,” “employed part-time,” “not employed,” or “on disability”); income (categorized as “would rather not say,” “below $20,000,” “$20,000–$49,999,” or “greater than $50,000”); relationship status (“single,” “in a monogamous relationship,” or “in a non-monogamous or polyamorous relationship”); and marital status (“married or living common-law,” “separated, divorced, or widowed,” or “never married”).

Resilience factors

Social support was assessed using the Multidimensional Scale of Perceived Social Support, which measures social support from family, friends, and a “special person” (Cronbach's α=0.91, 0.93, 0.96). “Special person” may be interpreted as a significant other,³⁶ but for some may indicate another type of caregiving relationship.³⁷ The Rosenberg Self Esteem Scale was used to measure respondents' self-esteem (Cronbach's α=0.89).

Risk factors

Life experiences of transphobia were assessed using a 10-item scale (Cronbach's α=0.79) adaptation of Diaz et al.'s (2001) scale, used by Trans PULSE Ontario.³⁸ In addition, participants were asked whether they had prior experiences of silent harassment, physical violence, and verbal harassment due to their gender.

Avoidance of EDs

Participants were asked whether they have had to access health services at a hospital in Waterloo Region. Subsequently, participants were asked if they had ever avoided going to an ED in Waterloo Region when they needed care because of their gender. The outcome variable was created, excluding those who have never needed to access hospital services.

Statistical analyses

SPSS (version 24) was used for this analysis, limited to participants who indicated they were trans (n=112). We utilized the Andersen Model for health care use to organize our variables into predisposing (e.g., immutable sociodemographic factors), enabling (e.g., factors in relationship to health care use, such as education or income), and need (e.g., necessitating use of health services).³⁹ Binary logistic regression was used to test bivariate associations between sociodemographic, resilience, and risk variables, and our outcome. Sociodemographic variables statistically significant at p<0.10 were included as control variables to explore different combinations of each resilience and risk factor in multivariable combinations.

Results

Descriptive findings

Sociodemographic characteristics are summarized in Table 1. The average age of this subsample was 25.5 years (standard deviation [SD]=7.9). The majority were on the transmasculine spectrum (62.5%), and almost half were unsure, not planning, or did not feel they would transition (47.3%). Most were born in Canada (91.1%) and identified as white (75.9%). Over half (51.8%) identified as bisexual or queer. Approximately one third were employed full time (30.4%), and approximately one quarter had incomes below $20,000 per year (25.9%). Over one third of participants were single (36.6%), and over two thirds indicated they were never married (70.5%).

Table 1.

Sociodemographic Factors of Trans Participants in the OutLook Study

Variable	n=112 n (%)/mean (SD)
Age (continuous)	25.5 (7.9)
Gender spectrum
MTF spectrum (born male)	39 (34.8)
FTM spectrum (born female)	70 (62.5)
Missing	2 (1.8)
Transition status
Complete	16 (14.3)
In process	22 (19.6)
Planning not begun	18 (16.1)
Not sure, not planning, not relevant	53 (47.3)
Missing	2 (1.8)
Birth country
Born in Canada	102 (91.1)
Born outside Canada	9 (8.0)
Missing	1 (0.9)
Ethnoracial background
Racialized (non-White)	14 (12.5)
White	85 (75.9)
Missing	13 (11.6)
Sexual orientation
Gay/lesbian	11 (9.8)
Bisexual/queer	58 (51.8)
Straight/asexual/not sure/other	41 (36.6)
Missing	2 (1.8)
Geographic location
Kitchener	56 (50.0)
Cambridge	14 (14.3)
Waterloo	36 (32.1)
Outside cities	3 (2.7)
Missing	1 (0.9)
Education
High school graduate or less	30 (26.8)
Some post-secondary	31 (27.7)
Post-secondary graduate	44 (39.3)
Missing	7 (6.3)
Employment
Employed full time	34 (30.4)
Employed part time	26 (23.2)
Not employed	37 (33.0)
On disability	12 (10.7)
Missing	3 (2.7)
Income
Would rather not say	17 (15.2)
Below $20,000	29 (25.9)
$20,000–$49,999	29 (25.9)
>$50,000	36 (32.1)
Missing	1 (0.9)
Relationship status
Single	41 (36.6)
In a monogamous relationship	32 (28.6)
In a non-monogamous/polyamorous relationship	35 (31.3)
Missing	4 (3.6)
Marital status
Married/living in common-law	27 (24.1)
Separated/divorced/widowed	4 (3.6)
Never married	79 (70.5)
Missing	2 (1.8)

FTM, female-to-male; MTF, male-to-female; SD, standard deviation.

Respectively, ∼67.0%, 14.3%, and 50.0% of participants experienced silent harassment, physical violence, or verbal harassment in their daily lives, due to their gender identity (Table 2). Most indicated they had a regular primary care provider (90.2%). Of those who indicated they had ever accessed health services at a hospital in Waterloo Region (67.9%), ∼25.0% of these indicated they had avoided going to an emergency room in the Region when they needed care because of their gender identity.

Table 2.

Health Care and Psychosocial Experiences of Trans Participants in the OutLook Study (n=112)

Variable	n (%)/mean (SD)
Prior experiences of silent harassment due to gender
No	35 (31.3)
Yes	75 (67.0)
Missing	2 (1.8)
Prior experiences of physical violence due to gender
No	94 (83.9)
Yes	16 (14.3)
Missing	2 (1.8)
Prior experiences of verbal harassment due to gender
No	54 (48.2)
Yes	56 (50.0)
Missing	2 (1.8)
Regular primary care provider
No	10 (8.9)
Yes	101 (90.2)
Missing	1 (0.9)
Had to access a hospital in Region of Waterloo
No	34 (30.4)
Yes	76 (67.9)
Missing	2 (1.8)
Avoided an emergency department in Region of Waterloo when needed carea
No	48 (42.9)
Yes	28 (25.0)
Missing	36 (32.1)
Social support (family)	2.85 (1.62)
Social support (friends)	4.52 (1.45)
Social support (special person)	4.42 (1.27)
Self-esteem	16.32 (4.85)
Transphobia	13.69 (5.98)

^a Excludes participants who indicated they have never had to access health services at a hospital in the Region of Waterloo.

Bivariate associations

In predicting ED avoidance, one predisposing factor was statistically significant—transition status (Table 3). Those who had completed (odds ratio [OR]=6.77; 95% confidence interval [CI]=1.59–28.72), were completing (OR=5.52; 1.44–21.14), or planning, but not yet begun (OR=4.83; 95% CI=1.23–18.98), their transition, were more likely to have avoided an ED in the Region due to their gender. No other factors were significant at p<0.05; however as the continuous age variable's p-value was <0.10, it was retained for consideration in multivariable modeling.

Table 3.

Bivariate Analysis of Factors Associated with Avoidance of Emergency Rooms When Needed for Trans Participants in the OutLook Study

Variable	Bivariate associations
Predisposing	OR (95% CI)	p
Age (continuous)		0.082
Per 1-year increase	0.95 (0.89–1.01)
Gender spectrum		0.911
MTF spectrum (born male)	1.06 (0.39–2.90)
FTM spectrum (born female)	Ref.
Transition status		0.018
Complete	6.77 (1.59–28.72)
In process	5.52 (1.44–21.14)
Planning not begun	4.83 (1.23–18.98)
Not sure, not planning, not relevant	Ref.
Birth country		0.308
Born in Canada	Ref.
Born outside Canada	0.32 (0.04–2.88)
Ethnoracial background		0.918
Non-White	0.93 (0.21–4.10)
White	Ref.
Sexual orientation		0.615
Gay/lesbian	Ref.
Bisexual/queer	2.18 (0.39–12.25)
Straight/asexual/not sure/other	1.58 (0.27–9.31)
Enabling
Geographic location		0.421
Kitchener	Ref.
Cambridge	0.65 (0.19–2.89)
Waterloo	0.38 (0.11–1.21)
Outside cities	1.28 (0.08–21.86)
Regular primary care provider		0.468
No	0.54 (0.10–2.87)
Yes	Ref.
Educational attainment		0.037
High school graduate or less	5.42 (1.43–20.47)
Some post-secondary	4.17 (1.07–16.28)
Post-secondary graduate	Ref.
Employment		0.083
Employed full time	Ref.
Employed part time	1.77 (0.39–8.00)
Not employed	3.34 (0.87–12.82)
On disability	7.44 (1.44–38.41)
Income		0.475
Would rather not say	1.00 (0.21–4.77)
Below $20,000	1.44 (0.44–4.66)
$20,000–$49,999	2.67 (0.74–9.59)
>$50,000	Ref.
Relationship status		0.287
Single	Ref.
In a monogamous relationship	1.60 (0.41–6.19)
In a non-monogamous/polyamorous relationship	2.64 (0.77–9.00)	0.496
Marital status
Married/living in common-law	Ref.
Separated/divorced/widowed	1.00 (0.08–12.56)
Never married	2.00 (0.57–7.01)
Protective factors
Social support (family)		0.019
For every one-point increase	0.69 (0.50–0.94)
Social support (friends)		0.305
For every one-point increase	0.85 (0.59–1.21)
Social support (special person)		0.069
For every one-point increase	0.71 (0.48–1.03)
Self-esteem		0.208
For every one-point increase	0.94 (0.85–1.04)
Discriminatory factors
Transphobia		<0.001
For every one-point increase	1.25 (1.11–1.40)
Prior experiences of silent harassment due to gender		0.036
No	Ref.
Yes	5.35 (1.12–25.66)
Prior experiences of verbal harassment due to gender		0.003
No	Ref.
Yes	6.00 (1.81–19.93)
Prior experiences of physical violence due to gender		0.021
No	Ref.
Yes	3.89 (1.22–12.32)

CI, confidence interval; OR, odds ratio.

Exploring enabling factors, education was statistically significant. Namely, we saw that those with educational attainment of high school or less (OR=5.42; 95% CI=1.43–20.47) and those with some post-secondary education (OR=4.17; 95% CI=1.07–16.28) were more likely to avoid an ED in the Region due to their gender, compared to those who were post-secondary graduates. While the overall employment variable was not significant at p<0.05, one category of the variable was significant: participants who were receiving disability assistance were more likely to have avoided an ED in Waterloo Region due to their gender (OR=7.44; 95% CI=1.44–38.41).

Multivariable associations

To explore combinations of risk and resilience factors, we created a series of multivariable models, controlling for age, transition status, education level, and employment status, since these factors were significant at p<0.10 (Tables 4 and 5). When controlling for these predisposing and enabling factors, social support from family remained statistically significant (OR range=0.37–0.38 when statistically significant) in all models, except when included in a model with the continuous transphobia variable.

Table 4.

Blocks of Predisposing and Enabling Sociodemographic Factors Associated with Avoidance of Emergency Rooms When Needed for Trans Participants in the OutLook Study

Variable	Multivariate associations
Predisposing block only	OR (95% CI)	p
Age (continuous)		0.301
Per 1-year increase	0.94 (0.83–1.06)
Transition status		0.027
Complete	7.10 (0.88–57.54)
In process	7.92 (1.60–39.18)
Planning not begun	8.01 (1.34–47.74)
Not sure, not planning, not relevant	Ref.
Enabling block only
Education		0.468
High school graduate or less	1.61 (0.25–10.39)
Some post-secondary	2.70 (0.51–14.21)
Post-secondary graduate	Ref.
Employment		0.291
Employed full time	Ref.
Employed part time	2.13 (0.36–12.75)
Not employed	4.06 (0.68–24.20)
On disability	7.18 (0.79–65.34)

Table 5.

Combinations of Protective and Discrimination Factors, Multivariable Analysis of Factors Associated with Avoidance of Emergency Rooms When Needed for Trans Participants in the OutLook Study

Variablea	OR (95% CI) p-value	OR (95% CI) p-value	OR (95% CI) p-value	OR (95% CI) p-value	OR (95% CI) p-value	OR (95% CI) p-value	OR (95% CI) p-value	OR (95% CI) p-value
Analytic sample size	n=71	n=70	n=71	n=70	n=71	n=70	n=71	n=70
Protective factors
Social support (family)
For every one-point increase	0.54 (0.28–1.04) 0.067		0.38 (0.21–0.70) 0.002		0.38 (0.21–0.70) 0.002		0.37 (0.19–0.74) 0.005
Social support (special person)
For every one-point increase		0.28 (0.10–0.83) 0.021		0.30 (0.12–0.72) 0.007		0.46 (0.24–0.89) 0.021		0.37 (0.17–0.79) 0.010
Discriminatory factors
Transphobia
For every one-point increase	1.50 (1.13–1.99) 0.005	1.84 (1.25–2.72) 0.002
Prior experiences of silent harassment			7.33 (0.67–79.89) 0.102	25.92 (1.47–458.12) 0.026
Prior experiences of physical violence					2.78 (0.52–14.76) 0.23	2.51 (0.51–12.32) 0.256
Prior experiences of verbal harassment							14.04 (1.94–101.75) 0.009	32.66 (2.95–361.36) 0.004

^a Controlled for age, transition status, education, and employment.

Social support from a special person remained statistically significant (OR range=0.28–0.46) when paired with all risk factors. When considering risk factors, transphobia remained statistically significant (OR range=1.50–1.84) when considering both resilience factors. Prior experiences of silent harassment were significant (OR=25.92; 95% CI=1.47–458.12) in the model that includes support from a special person. Prior experiences of physical violence were not statistically significant when considered in a model with protective factors. Verbal harassment experiences were significantly associated (OR range=14.04–32.66) with ED avoidance in models with resilience factors.

Discussion

In this study, ED avoidance was found to be associated with transition status, education, and employment status. Those with lower levels of education and those receiving disability support were more likely to avoid EDs. Respondents reporting complete or partially complete transitions were more likely to avoid EDs than those for whom transition was not relevant, who were otherwise unsure, or who were not planning to transition.

In multivariate analyses, participants' perceived experiences of transphobia were a significant deterrent against accessing EDs, with increased transphobia associated with greater likelihood of avoidance. Conversely, in almost all instances, social support appeared protective—as support increased, likelihood of avoidance decreased. In multivariable models, support from a special person and transphobia were always significant, regardless of controlled variables.

These findings strongly suggest that various forms of transphobia deter trans patients from accessing EDs. Outness, living “full time” in one's core gender identity, and accessing gender-affirming procedures are associated with likelihood of experiencing transphobia in everyday life and emergency health care settings.^40–42 In both contexts, the unpredictability of others' reactions makes disclosure of gender identity a risk, and avoidance of health services can stem from this uncertainty. A substantial number of trans people feel uncomfortable discussing trans identity or specific health needs with an unfamiliar doctor, commonly citing fears of receiving an insensitive or hostile reaction, ridicule, or denial of treatment.^43,44

This study indicates that persons with a complete, partially complete, or planned medical transition were more likely to avoid EDs than those for whom medical transition was not relevant, who were otherwise unsure, or who were not planning to transition. Bauer et al. previously identified that patients who accessed EDs while “presenting in their felt gender” differ from those who did not, specifically regarding transition-related variables.^31(p715) Combined results suggest ED avoidance may depend on comfort with disclosure of trans identity.

“Passing,” whereby a trans person is correctly gendered by others without communicating their gender identity, may grant patients a sense of safety and respect from providers.^9,45,46 Medical transition changes a person's outward appearance and therefore has some bearing on “passing.” However, evidence suggests people who are known to be trans by select providers (e.g., those facilitating transition) may be more prone to health care avoidance, potentially because of previous negative experiences with disclosure.⁴⁷

Serano's redesignation of “passing” as “conditional cissexual privilege” demonstrates how the “privilege” of being perceived and treated as cisgender (or cissexual) can be revoked upon disclosure or discovery that a person is trans.^2(p180) This perhaps explains how ED avoidance can be influenced by the potential for disclosure of gender or medical transition status, the fear of anticipated discrimination, and the strain of hypervigilance.^45,46

Results seem to suggest multiple strategies are employed by trans people to avert discrimination; participants who were not sure, who were not planning, or for whom the concept of transitioning was not relevant were less likely to avoid EDs. Some trans people choose to conceal their trans identity in daily life and emergency settings, likely out of concern for transphobia, instead presenting in a manner that appears consistent with the gender they were assigned at birth.^31,48–49 An important stipulation regarding “passing” is that it is opposed to the diverse nature of gender identity and expression.² One in five trans people expressed a combination of masculinity and femininity, neither, or fluctuate between.⁵⁰ For some, it is counterintuitive to “pass” as a particular binary gender.

Social support broadly refers to processes and resources allowing a person access to assistance and emotional care.⁵¹ While discrimination is associated with negative health outcomes, support, acceptance, and connectedness are linked to positive outcomes, including decreased depression, anxiety, shame, suicide risk and ideation, problematic substance use and risky sexual behavior, and increased resilience and self-esteem.^38,52–57 However, trans people often report lower levels of support and self-esteem, a weaker sense of community belonging, and less positive adjustment compared to lesbian, gay, bisexual, and queer (LGBQ) samples and non-trans siblings.^57–61

Social support reduces psychological distress by helping an individual manage transphobia.^46,52,53,62 The social aspect of coping perhaps explains why support, not self-esteem, was significant in our results. In emergency situations, support benefits a patient in several ways, including actions (e.g., a ride to the ED) and expressions of concern that influence the decision to access care.¹⁷ In addition, while advocating for oneself is linked to poor ED experiences, trans patients report positive experiences when others advocated for them.²²

Eleven percent of the OutLook Study's trans sample reported receiving disability benefits and in this analysis Ontario Disability Support Program beneficiaries were more likely to avoid EDs.⁵⁸ Disabled people and trans people report similar problems when accessing health services, including insufficient provider knowledge, insensitivity, disrespect, and refusal of care.⁶³ Trans patients with disabilities may be more prone to avoidance because they anticipate transphobia and ableism or believe health services will be unable to provide adequate care.⁶⁴

Limitations

This study is limited by the small sample size and the inability to meaningfully explore ethnoracial complexities within our sample. Black and Indigenous people, as well as other people of color (BIPOC), are subject to pervasive harassment and violence everyday and at the hands of health care and social service providers.¹² Oppression has direct and indirect impacts on health and the likelihood of seeking care in the future. Thus, future research should work with BIPOC trans people, disabled trans people, non-binary people, and trans women who are at increased risk of experiencing racism, ableism, transmisogyny, and other forms of oppression that likely influence their utilization of health care services.^2,12,65 Larger quantitative samples and qualitative inquiry are necessary to explore these experiences, involving closer attention to trans embodiment and gender affirmation as they relate to ED avoidance. Speculation on transition and “passing” is complicated by participants' self-report of medical transition status. Having accessed hormone therapy, one person may list their status as “complete,” while another awaiting further surgery would select “in progress.” Gender-affirming procedures function to bring about a trans person's desired embodiment, but because the likelihood of being perceived as trans actually depends on others' perceptions of them,² its relationship to medical transition status is dynamic and changes throughout a person's life.⁴¹

In addition, some participants may have avoided EDs outside Waterloo Region, including those who indicated they accessed EDs within the Region. Trans individuals are known to travel for health care services and may do so when emergency health care needs arise.⁶⁶ Furthermore, due to differences between health care systems, findings may not be generalizable to settings outside Ontario, and within the provincial health care system, there are many factors that remain unaccounted for in this research (e.g., wait times for surgeries, procedures, and specialist appointments, access to testing and referrals, and length of stay in health care facilities).

Recommendations for practice and education

Uniform patient-centered care without regard for trans identity is not feasible; emergency health care providers must be aware of and account for the experiences of their marginalized patients within the context of societal-level inequality, including past providers' insensitive or hostile reactions and refusal of care. Providers should recognize that because of their life experiences and previous contact with health care, some trans patients will be uneasy or anxious while in their care.

Poor rapport between providers and trans patients is often attributed to a lack of training and experience.^5,9 At present, most trans health education consists of singular sessions, focused on attitudes and awareness rather than skills, indicating a need to shift toward more long-term, integrated, skill-based interventions.⁶⁷ Avoiding implicit biases and assumptions about trans people is crucial to the provision of quality care; therefore, it is strongly recommended that providers participate in training to bolster their knowledge of trans identity, health care needs, allyship, and gender-inclusive terminology.^24,58

Medical educators should additionally strive to create opportunities for learners to become engaged with their local community, encouraging contact between future practitioners and trans community members, as well as the connection of patients to empowering and health-enhancing community resources (i.e., primary care or suitable alternatives like community health clinics).^9,68 Importantly, recent evidence suggests that provider transphobia is a more significant barrier to provider knowledge than lack of education.¹⁰ Without structural changes, it is unlikely that individual shifts in practitioner attitudes can counteract the barriers trans patients face to access quality care.

For example, care must be coordinated so potentially sensitive information related to gender can be disclosed once, in a safe and private manner, after which nonconsensual disclosure of trans identity and misgendering should never occur.²⁴ This necessitates taking several other actions to combat erasure and reduce barriers trans patients face when accessing health services, including updating health policy to include protections for gender identity and expression, changing physical forms and electronic health records systems to properly record patients' names and pronouns, and providing all-gender washrooms, positive space signage, and trans-specific health information.^25,69,70

In the absence of structural changes, providers are encouraged to ask each patient for their chosen name and pronouns and what services they require, regardless of their perceived gender or the gender marker on file. Providers should also submit manual insurance claims when services that do not match a patient's gender marker are indicated.⁵⁸

Conclusion

This study, although limited in scope and specificity, provides important insights into the nature of embodiment and health care utilization. Medical transition status was identified as a significant factor in the prediction of ED avoidance, as was disability. Furthermore, life experiences of transphobia were linked to higher likelihood of avoidance, while social support appeared protective, implicating societal transphobia and lack of support in health disparities between cis and trans Canadians. Structural changes are required to provide equitable health services to trans and disabled patients.

Abbreviations Used

BIPOC

Black and Indigenous people, as well as other people of color

CI

confidence interval

ED

emergency department

FTM

female-to-male

LGBQ

lesbian, gay, bisexual, queer

MTF

male-to-female

OR

odds ratio

SD

standard deviation

Author Disclosure Statement

No competing financial interests exist.

Funding Information

Research support for this study was provided by the Ontario HIV Treatment Network.

Cite this article as: Thompson-Blum DN, Coleman TA, Phillips NE, Richardson S, Travers R, Coulombe S, Wilson C, Woodford M, Cameron R, Davis C (2021) Experiences of transgender participants in emergency departments: findings from the OutLook Study, Transgender Health 6:6, 358–368, DOI: 10.1089/trgh.2020.0112.