The Trans Care Bicycle: Examining Trans Patient Preferences When Discussing Gender & the Impact on Health Care

Background and Purpose: Gender-affirming, competent healthcare improves trans individuals’ wellbeing. However, trans patients report frequent discriminatory and unskillful experiences in health settings. Consequently, trans patients sometimes withhold gender information to avoid discrimination. Given the challenges trans patients encounter accessing quality healthcare, this study posed the following research questions: 1) What influences trans patients’ decision-making regarding sharing gender-related information with providers? 2) How do trans patients want to be asked gender-related questions? and 3) How does provider understanding of gender impact trans patients’ healthcare experiences? Methods: Findings from a qualitative study using an interpretivist phenomenological approach are presented. Recruitment took place via social media and email listservs in 2020. Participants completed a demographic questionnaire and semi-structured virtual interview in English and/or Spanish. Interviews explored participants’ experiences receiving healthcare and how providers can be more inclusive and affirming. Participants included 27 trans/nonbinary adults, ages 21-69, from 13 U.S. states. Transcripts were analyzed using Dedoose, following thematic analysis procedures. After the first author created an initial code list via inductive coding of three transcripts, the research team refined codes and completed the coding process. Results: Four major themes were identified: 1) Impact of Provider Behaviors, 2) Engaging in Relational Risk Assessment, 3) Receiving Affirming vs. Medically Competent Care, and 4) “How are you gonna fit [me] into your system?” The first theme reflects participant responses noting that individual provider actions had significant positive and negative impact on participants’ experiences, depending on how attuned, informed, and prepared the provider was. Second, respondents shared how they weighed a variety of implicit/explicit safety cues when deciding what and how to share information with their providers. Third, participants spoke at the most length and detail about affirming and medically competent care, noting that they have had to, at times, choose to prioritize one type of care over another. Lastly, participants spoke to their needs as patients often being at odds with the healthcare system status quo. Conclusion & Implications: Findings suggest that health providers be flexible and responsive to patient preferences regarding discussing gender-related information. Providers should explain how information about gender and anatomy is relevant to the patient’s medical care. Informed by these results, the Trans Care Bicycle provides one conceptual representation of necessary factors of competent and affirming healthcare for trans patients. The systems-level (e.g., policies, systems of care, protocols, culture) provides structure (i.e., the frame) that supports or hinders the presence of medically competent and gender-affirming care. It is acknowledged that people, whether individuals or groups, steer systems-level components. In order for trans patients to have equitable health care, their health care must be both medically competent and affirming of their gendered experiences (these are the two wheels of the bicycle, with spokes representing individual examples). Future policy should support all components represented in the Trans Care Bicycle. Future research has the opportunity to continue to identify the individual “spokes” within each wheel and how medical social workers play a role in ensuring trans patients have competent care.