No abstract

Background: Transgender, transsexual, gender variant, and intersex people (TGI) have decreased access to care and poorer health outcomes compared to their LGB counterparts. Little has been studied and documented about TGI patient emergency department (ED) care experiences and barriers to care. Study Objectives: Identify major themes related to TGI patient access and utilization of emergency services and develop preliminary hypotheses about TGI patient emergency care experiences, systemic barriers to TGI access to emergency care, and potential provider-level knowledge deficits. Methods: Four focus groups were conducted in 2014 with TGI Rhode Islanders (RI) over the age of 18 years of age who had been a patient in an ED in the last 5 years. Participants were recruited from the community by email listserve announcements, outreach to local TGI organizations, and periodical advertisements. The study team developed an interview guide to elicit ED experiences and barriers to care that was reviewed by a qualitative research advisory committee. Deidentified participant demographic information was collected using a standardized instrument. All discussions were captured on digital audio recorders and professionally transcribed. The study team developed a coding guide with codes grouped into major themes and subthemes, and a final thematic framework developed collaboratively. Focus group transcripts were reviewed and coded by two independent investigators; discrepancies were resolved through discussion. Results: Among 32 participants, 43% were female-to-male or male-identified, 75% were white. Over 40% noted prior avoidance of the ED, with fear of discrimination noted as the most significant barrier. Major discussion themes on ED experiences included lack of privacy, poor provider competency and communication, and common experiences of grossly inappropriate, awkward and/or inconsiderate reactions of health care providers to revelations of gender identity. Overall, participants preferred direct communication from providers regarding their gender identity and specific health needs, but cautioned against reducing all health concerns to gender identity. Recommendations for improvement focused on provider deficits, need for provider training and education, and infrastructure changes to maintain privacy. Conclusion: Efforts to improve TGI ED experiences should focus on provider competency, communication training, and ED infrastructure changes to address safety and privacy concerns. Further research with increased inclusion of transwomen and people of color is needed to identify themes that may not have been raised in this preliminary investigation.