Conceptualizing Trans-Inclusive Healthcare: Environmental and Interpersonal Factors of Healthcare Provision

Background and Purpose: Trans and gender diverse (TGD) people experience elevated rates of negative health outcomes while struggling to access competent and affirming healthcare due to frequent experiences of discrimination and gender non-affirmation. Previous research has explored these interpersonal contributors to TGD-hostile healthcare experiences, though little work has also examined the role of environmental design in TGD-inclusive healthcare. This is a crucial gap as research demonstrates the importance of environmental symbols to engagement and feelings of safety for TGD folks, and interior design studies show tranquil healthcare settings can reduce anxiety symptoms. Our study addresses this gap by simultaneously exploring the impact of both environmental and interpersonal factors in TGD healthcare experiences to develop a holistic conceptualization of inclusive healthcare.

Methods: As part of a larger project to create more inclusive healthcare environments for TGD patients, we collaborated with interior design experts to conduct four focus groups with 13 local TGD folx (M = 23 years old) to inform local efforts to create TGD-affirming healthcare spaces. Focus groups used a semi-structured interview guide and photo elicitation methods. Participants were first asked about salient healthcare services; inclusive or discriminatory healthcare experiences; and resulting thoughts, feelings, or behaviors. Participants were then shown images of traditional and novel healthcare spaces and provided feedback. A reflective thematic analysis was employed to analyze transcripts. Analysts separately open-coded one transcript and met to develop a shared understanding of codes. The remaining focus group transcripts were coded by two analysts each using the refined coding structure.

Results: Inclusive healthcare settings were those with environmental and interpersonal conditions that elicited feelings of agency, privacy, comfort, and validity among TGD patients. For environmental factors, participants discussed signage and artwork relevant to TGD people. Participants also expressed inclusivity through layouts that include gender-neutral or single-occupant bathrooms, non-fluorescent lighting with dimming options, and a variety of seating options with space for a support person. The confluence of environmental and interpersonal factors shaped the ability to navigate the healthcare space privately and comfortably. For example, participants described privacy as stemming from doors that fully close, self-check-in kiosks, and individual triage rooms (i.e., environmental), as well as medical personnel publicly using correct pronouns in waiting and check-in spaces (i.e., interpersonal). Interpersonal factors contributing to inclusivity also included using correct name and pronouns throughout treatment, ensuring consistency between medical paperwork and verbal communication, competency with TGD health needs, and support circumventing insurance and policy barriers to affirming healthcare.

Conclusions and Implications: Findings from our collaborative study provide a more holistic conceptualization of inclusive healthcare during a time of heightened anti-trans rhetoric and policy that often aims to reduce access to affirming care. Our findings address gaps in extant literature by positing both environmental and interpersonal factors as pivotal to inclusive healthcare provision and describing the way these factors relate to TGD patients’ sense of self within the healthcare space. Findings can be used to inform the development or adaptation of healthcare environments, cultural competence education for medical personnel, and to resist anti-trans policies.