Cisnormativity as a structural barrier to STI testing for trans masculine, two-spirit, and non-binary people who are gay, bisexual, or have sex with men

Abstract

Trans masculine, two-spirit, and non-binary people who are gay, bisexual or otherwise have sex with men (TGBM) are under-tested for sexually transmitted infections (STI) and may face complex, intersectional barriers that prevent them from accessing STI testing. As part of a study on gay, bisexual and other men who have sex with men’s (GBM) experiences of current STI testing systems in Ontario, Canada, this paper reports on the findings from TGBM participants’ experiences with in-person STI testing in a range of venues (i.e. Family doctors, walk-in clinics, and community-based organizations) to explore testing barriers specific to TGBM. Using a community-based research approach, between June 2020 and December 2021 peer researchers who identified as GBM conducted focus groups and interviews with 38 cis and trans GBM, 13 of whom identified as TGBM. Data were analyzed following grounded theory. When questioned about past experiences with testing, TGBM participants reported several barriers to STI testing within current testing models in Ontario due to cisnormativity and heteronormativity. Cisnormativity is the assumption that everyone identifies as the gender they were assigned at birth, and those who do not are considered “abnormal”, while heteronormativity is when it is assumed that everyone is heterosexual. From our research we identified three overarching themes concerning testing barriers among TGBM participants: (1) non-inclusive clinic environments, (2) lack of provider knowledge and competency, and (3) legal documentation. Inherent cis and heteronormativity in healthcare institutions appear to be factors shaping the historical under-testing for STI in the TGBM population. These findings suggest the relevance of implementing trans-specific clinical practices that reduce the stigma and barriers faced by TGBM in STI testing contexts, including: hosting all-gender testing hours, opening more LGBTQ+ clinics, offering training in transgender health to testing providers, and conducting a review of how gender markers on health documents can be more inclusive of trans, two-spirit, and non-binary communities.

Queering Public Health: A Critical Examination of Healthcare Access and Gender Expression among Trans, Nonbinary, and Other Gender Nonconforming People during COVID-19

“…Although Taylor noted that HCPs are trying to be more inclusive of queer and trans individuals, they required the physical support of friends when accessing in-person care. Participants also emphasized that barriers to healthcare persist in other forms, such as a failure to update personal documents to refect patients' current gender identity [73]. Casey described similar challenges seeking care, adding that misgendering and bureaucratic factors signifcantly impact the quality of care they had received in the past.…”

The lactation and chestfeeding/breastfeeding information, care and support needs of trans and non-binary parents: An integrative literature review

“…A discourse based on the assumption that cis-gender is the norm and privileges this over any other form of gender identity (Stewart et al, 2022).…”

“…There is consensus within the literature that Western perinatal healthcare systems are built upon culturally and socially constructed cis-normative, heteronormative, feminine, gender binary foundations (Charter et al, 2018;Duckett & Ruud, 2019;Falck et al, 2021;García-Acosta et al, 2020;Jackson et al, 2022;MacDonald et al, 2016;McCann et al, 2021;Richardson et al, 2019;Wolfe-Roubatis & Spatz, 2015). While cis-gender is a term used when someone identifies with their gender assigned at birth, cis-normative is the assumption or belief that being cis-gender is normal and is therefore privileged over all other expressions of gender (Stewart et al, 2022). Ferri et al (2020) identify that this highly gendered assumption causes access barriers to perinatal healthcare.…”

Access to Health Care for the Lgbtq+ Population

“…According to Stewart et al, 2022, the trans gay and bisexual male population faces unique structural and individual challenges when accessing health care compared to the cisgender population. Spaces segregated by gender, lack of competence of the care provider and barriers in the legal documentation that often does not represent the correct gender identity stand out.…”

“…In the study carried out by Gahagan and Malaret (2018), health professionals also identified concerns regarding legal documentation, noting that many trans users do not have their gender identity represented in legal identification documents. This incongruity often leads to poor evaluation of these people's sexual risk behaviors (Stewart et al, 2022).…”