Trans Health in the Context of Social and Legal Gender Affirmation in Canada: A Scoping Review

Background and Purpose: At a worldwide level, transgender (trans) populations experience pervasive health, social, and economic inequities. Gender identity and expression were added as prohibited grounds of discrimination to the Canadian Human Rights Act in 2017. However, anti-trans and intersecting stigmas remain pervasive and negatively impact the well-being and safety of trans persons in Canada. Gender affirmation refers to the multidimensional process of having your gender affirmed via psychological, social, legal, and medical affirmation and is delineated as a critical social determinant of trans health. However, the majority of trans research has focused on medical gender affirmation. Despite their significance, there's a notable gap in research regarding trans health as related to social and legal gender affirmation (social support, peer support, legal name changes, gender marker changes), especially within the Canadian context. This review aimed to (1) examine how social and legal gender affirmation has been defined and operationalized and (2) evaluate the association between these forms of gender affirmation and health outcomes among trans populations in Canada.

Methods: Through an intersectionality and gender affirmation framework and underpinned by Arksey and O’Malley’s scoping review methodology, we: (1) identified the research question, (2) identified studies, (3) selected studies, (4) charted the data, and (5) collated, summarized, and reported results. Eligible studies were identified, charted, and thematically analyzed. Databases (e.g. PubMed, ProQuest) and snowball searching were utilized to identify peer-reviewed literature published since January 2002 (the first known article published utilizing a gender affirmation framework). Extracted data included the study population, methodological characteristics, measures of social and legal gender affirmation, and study outcomes. Two reviewers were used for data extraction transparency and fidelity.

Results: We identified 12 articles that utilized both quantitative and qualitative methods for full-text review, revealing intriguing thematic and methodological considerations. Methodologically, articles differed in conceptualizing and operationalizing social and legal gender affirmation. Thematically, the articles delved into the legal recognition of transgender persons across various domains, offering novel insights into the intersection of gender affirmation and health outcomes across education, labor (sex work), HIV care continua, suicide prevention, and mental health. The included articles highlighted key findings for trans newcomers (refugees, asylum seekers, and migrants) to Canada, Indigenous communities, and trans communities living with HIV.

Conclusions and Implications: Our findings underscore the profound impact of social and legal affirmation on trans populations across different societal domains in Canada while highlighting critical areas for development in both research and practice. Social and legal affirmation can be used to stage larger-scale multilevel interventions that can improve the health and social well-being of trans communities in Canada and globally.