Background: Individuals who have a transgender or gender nonconforming (TGGNC) experience belong to a marginalized segment of the U.S. population, and healthcare can be difficult for them to navigate. Although emergency departments (EDs) traditionally serve as healthcare “safety nets” for vulnerable populations, quantitative studies outside the United States have found that TGGNC-experienced persons tend to avoid EDs and/or have negative experiences. This qualitative study primarily describes the ED experiences of people with a TGGNC history; furthermore, the study explores reasons why this population avoids U.S. EDs and their recommendations for improvements to ED care.Methods: This qualitative study used data about TGGNC-historied persons' experiences in U.S. EDs from retrospective, anonymous, written surveys (paper or web based). National data collection took place from June 2012 through December 2014. Participant responses (n=240) were examined using thematic analysis.Results: Using a framework that recognized positive and negative responses, the themes of Self-Efficacy and Power Inequity surfaced. These themes exposed the tension between patients with TGGNC experiences and clinicians who were perceived to lack training in this area, resulting in negative patient experiences. When practitioners had specific training about this population, participants reported positive care experiences.Conclusions: This study indicates that many TGGNC-historied persons who use U.S. EDs have negative experiences, largely due to lack of provider sensitivity toward and training about this patient population. Data from this investigation suggest that training of U.S. ED providers and institutional support would help improve care for this marginalized group.

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BackgroundChildren’s right to participate in data collection during emergencies has been widely recognized by humanitarian actors. However, participation in such activities can expose children to risk. Tensions have been noted between the right to participate and other principles, such as the imperative to ‘do no harm.’ With little evidence to inform guidance on addressing this tension, our study sought to identify expert consensus on whether and how children participate in emergency-related data collection activities.MethodsWe employed a three-round Delphi technique with a purposive sample of 52 child protection specialists. Respondents answered two open-ended questions in round one. A thematic analysis of responses generated a set of unique statements addressing the study questions. In the second round, respondents rated each statement on a five-point scale. In the final round, respondents reviewed the group’s average ratings for each statement with the option to revise their own ratings. A statement was said to have reached clear consensus when at least 90% of respondents agreed or strongly agreed with the statement.ResultsA total of 124 statements and 14 themes emerged from the thematic analysis, with 46.0% of statements reaching clear consensus in the third round. Respondents strongly supported children’s right to participate in data collection in humanitarian settings, while also recognizing that protecting children from harm may “over-ride” the participation principle in some contexts. Respondents identified capacity and contextual considerations as important factors influencing participation decisions, though they sometimes disagreed about how these factors should determine participation. Respondents also considered the role of individual child factors and the presence of caregivers in selecting child participants, and proposed best practice approaches for securing children’s safe and meaningful participation.ConclusionsWith almost half of statements reaching clear consensus, these findings reflect broad agreement within the sector about engaging children in data collection in emergencies. At the same time, points of ongoing debate around how to factor different risks into child participation decisions may indicate discordant practice. Further reflection is needed around how factors such as the phase of emergency, the existence of basic services, and cultural beliefs should influence whether and how children participate.Electronic supplementary materialThe online version of this article (doi:10.1186/s13031-017-0108-y) contains supplementary material, which is available to authorized users.

The Three Delays Model has proven a useful framework for examining barriers to seeking obstetric care and preventing maternal and child mortality. This article demonstrates the applicability of the Three Delays Model to the case of civil registration in rural Indonesia and examines ways that efforts to strengthen civil registration services can draw on lessons from maternal and child health programming. Twenty focus group discussions were conducted using a participatory ranking exercise in four Indonesian districts. Focus groups were stratified into four groups: (1) government officials involved in civil registration, (2) civil society organization members that assist communities in civil registration, and (3) female and (4) male community members. Transcripts were analyzed using constant comparative method and thematic analysis, revealing barriers that communities commonly faced in accessing civil registration services. In examining the categories and themes related to these barriers, the research team found a significant overlap with the factors and phases of the Three Delays Model. Participants were delayed from seeking registration services by a range of sociocultural factors and by the perceived inaccessibility and poor quality of services. Once they decided to seek care, long distances to services and poor transportation options delayed their access to registration offices. Finally, a series of bottlenecks in service provision created extended delays once applicants reached registration offices. Ownership of civil registration documents in Indonesia remains exceptionally low, with just over half of children and youth possessing a birth certificate. To strengthen civil registration and health systems more generally, it is important to understand the factors that enable and constrain civil registration, how these factors relate to one another, and how they change over a child’s life.