Monopoly and Power Implications for Trans Health Care Specialists Working in a Centralised Setting: A Qualitative Study
In the last decade, the range and number of people accessing trans health care has increased at a faster rate than previously. Globally trans health care is commonly used as a requirement for trans people to access legal gender recognition. In Europe, trans health care is often provided within centralised health systems by a limited number of specialist teams placed in monopoly positions. Through a qualitative study, we sought to understand the relationship and role these teams have with legal gender recognition. We conducted in-depth interviews with a team located in Central and Eastern Europe and consulted with local key informants working in trans health advocacy outside the team. After applying qualitative content analysis emerging themes comprised three sections: the team in context; conceptions of trans health care; and beyond the clinic.
Findings indicated that the team conceived trans identities and clinical needs in a medical framework that correlated with the process for legal gender recognition. This followed a similar historical progression across Europe. As the few respected specialists in the country, the team influenced care regulations within the ministry and held a monopoly position. While reform of some regulations was seen as needed, they were met with challenges within the health system and field. These challenges were, however, found to reflect trans health care globally rather than the team itself. Our findings suggest comparisons could be drawn to similar positioned teams throughout Europe regarding decision making, power, and influence. Increased transparency and cooperation between local trans communities and health care providers will be vital.
A.P., Garçon and Nicot V. France. 2017. nos. 79885/12, 52471/13 and 52596/13, European Court of Human Rights (Fifth Section)
th World Medical Association General Assembly 2015. Wma Statement on Transgender People. Moscow, Russia: World Medical Association.
Arcelus, J., Bouman, W. P., Van Den Noortgate, W., Claes, L., Witcomb, G. & Fernandez-Aranda, F. 2015. Systematic Review and Meta-Analysis of Prevalence Studies in Transsexualism. European Psychiatry, 30, 807-815.
Basterrechea, B. B., European Parliment & Committee on Women’s Rights and Gender Equality 2016. Report on Promoting Gender Equality in Mental Health and Clinical Research (2016/2096(Ini)). Brussels, Belgium: European Parliment.
Blind reference 1, 2016
Blinded reference 2, 2014
Blinded reference 3, 2017
Blinded reference 4, 2012
Blinded reference 5, 2018
Blinded reference 6, 2018
Bockting, W., Coleman, E., Deutsch, M. B., Guillamon, A., Meyer, I., Meyer, W., 3rd, Reisner, S., Sevelius, J. & Ettner, R. 2016. Adult Development and Quality of Life of Transgender and Gender Nonconforming People. Current Opinion in Endocrinology, Diabetes, and Obesity, 23, 188-97.
Bouman, W. P., de Vries, A. L. C. & T’Sjoen, G. 2016. Gender Dysphoria and Gender Incongruence: An Evolving Inter-Disciplinary Field. International Review of Psychiatry, 28, 1-4.
Castro-Peraza, M. E., García-Acosta, J. M., Delgado, N., Perdomo-Hernández, A. M., Sosa-Alvarez, M. I., Llabrés-Solé, R. & Lorenzo-Rocha, N. D. 2019. Gender Identity: The Human Right of Depathologization. International Journal of Environmental Research and Public Health, 16, 978.
Charmaz, K. 2014. Constructing Grounded Theory, London; Thousand Oaks, Calif., SAGE Publications.
Chiam, Z., Duffy, S., González Gil, M. & ILGA 2016. Trans Legal Mapping Report 2016: Recognition before the Law. Geneva, Switzerland.
Cho, J. Y. & Lee, E. 2014. Reducing Confusion About Grounded Theory and Qualitative Content Analysis: Similarities and Differences. The Qualitative Report, 19, 1-20.
Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., Fraser, L., Green, J., Knudson, G., Meyer, W. J., Monstrey, S., Adler, R. K., Brown, G. R., Devor, A. H., Ehrbar, R., Ettner, R., Eyler, E., Garofalo, R., Karasic, D. H., Lev, A. I., Mayer, G., Meyer-Bahlburg, H., Hall, B. P., Pfaefflin, F., Rachlin, K., Robinson, B., Schechter, L. S., Tangpricha, V., van Trotsenburg, M., Vitale, A., Winter, S., Whittle, S., Wylie, K. R. & Zucker, K. 2012. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. International Journal of Transgenderism, 13, 165-232.
Deutsch, M. B. 2016. Evaluation of Patient-Oriented, Internet-Based Information on Gender-Affirming Hormone Treatments. LGBT Health, 3, 200-7.
Deutsch, M. B., Bhakri, V. & Kubicek, K. 2015. Effects of Cross-Sex Hormone Treatment on Transgender Women and Men. Obstetrics and gynecology, 125, 605-610.
Elo, S. & Kyngas, H. 2008. The Qualitative Content Analysis Process. J Adv Nurs, 62, 107-15.
European Court of Human Rights 2017. The Requirement to Undergo Sterilisation or Treatment Involving a Very High Probability of Sterility in Order to Change the Entries on Birth Certificates Was in Breach of the Right to Respect for Private Life. In: European Court of Human Rights (ed.).
European Union Agency for Fundamental Rights 2014. Being Trans in the European Union: Comparative Analysis of Eu Lgbt Survey Data. Vienna, Austria: European Union.
Eyssel, J., Koehler, A., Dekker, A., Sehner, S. & Nieder, T. O. 2017. Needs and Concerns of Transgender Individuals Regarding Interdisciplinary Transgender Healthcare: A Non-Clinical Online Survey. PLOS ONE, 12, e0183014.
Green, J. & World Professional Association for Transgender Health 2015. Wpath Statement on Legal Recognition of Gender Identity. World Professional Association for Transgender Health.
Hammarberg, T. 2009. Human Rights and Gender Identity. In: Rights, C. F. H. (ed.) CommDH/IssuePaper(2009)2 ed. Strasbourg, France: Council of Europe.
Hartline, F. r. 2019. Examining Trans Narratives in the Wake of Norway’s Gender Recognition Law. a/b: Auto/Biography Studies, 34, 67-87.
ILGA-Europe 2016. Rainbow Map Index May 2016.
James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L. & Anafi, M. 2016. The Report of the 2015 U.S. Transgender Survey. In: Equality, N. C. F. T. (ed.). Washington, DC.
Krumsvik, E. K. 2019. Gender Affirmative Monopoly: Who Is "Trans* Enough" to Receive Gender Affirmative Treatment in Norway? CUNY Academic Works.
Mayring, P. 2010. Qualitative Inhaltsanalyse. In: Mey, G. & Mruck, K. (eds.) Handbuch Qualitative Forschung in Der Psychologie. Wiesbaden: VS Verlag für Sozialwissenschaften.
Mepham, N., Bouman, W. P., Arcelus, J., Hayter, M. & Wylie, K. R. 2014. People with Gender Dysphoria Who Self Prescribe Cross Sex Hormones: Prevalence, Sources, and Side Effects Knowledge. The Journal of Sexual Medicine, 11, 2995-3001.
Motmans, J., Nieder, T. O. & Bouman, W. P. 2019. Transforming the Paradigm of Nonbinary Transgender Health: A Field in Transition. International Journal of Transgenderism, 1-7.
Nieder, T. O., Eyssel, J. & Koehler, A. 2019. Being Trans without Medical Transition: Exploring Characteristics of Trans Individuals from Germany Not Seeking Gender-Affirmative Medical Interventions. Archives of Sexual Behavior.
Nieder, T. O. & Richter-Appelt, H. 2011. Tertium Non Datur – Either/or Reactions to Transsexualism Amongst Health Care Professionals: The Situation Past and Present, and Its Relevance to the Future. Psychology & Sexuality, 2, 224-243.
Nord, I. 2019. Body, Migration, Re/Constructive Surgeries: Making the Gendered Body in a Globalized World. In: Griffin, G. & Jordal, M. (eds.) Body, Migration, Re/Constructive Surgeries: Making the Gendered Body in a Globalized World. London; New York, N.Y.: Routledge.
Office of the United Nations High Commissioner for Human Rights 2015. Discrimination and Violence against Individuals Based on Their Sexual Orientation and Gender Identity. Geneva, Switzerland: Human Rights Council.
Open Society Foundations 2013. Transforming Health: International Rights-Based Advocacy for Trans Health. Public Health Program. Open Society Foundations.
Open Society Foundations. 2014. An Essential Legal Right for Trans People Open Society Foundations. Available at: https://www.opensocietyfoundations.org/explainers/essential-legal-right-trans-people, last accessed October 14, 2019.
Organisation for Economic Co-operation and Development. Dac List of Oda Recipients Effective for Reporting on 2014, 2015, 2016 and 2017 Flows Available at: http://www.oecd.org/dac/financing-sustainable-development/development-finance-standards/DAC_List_ODA_Recipients2014to2017_flows_En.pdf, last accessed 27 February 2020.
Schreier, M. 2014. Qualitative Content Analysis. The Sage Handbook of Qualitative Data Analysis. London: SAGE Publications Ltd.
Sharpe, N. 2017. Being Transgender and Seeking Healthcare in the World’s Most Liberal City. Independent Study Project (ISP) Collection.
Sweileh, W. M. 2018. Bibliometric Analysis of Peer-Reviewed Literature in Transgender Health (1900 – 2017). BMC International Health and Human Rights, 18, 16.
Thorne, N., Yip, A. K.-T., Bouman, W. P., Marshall, E. & Arcelus, J. 2019. The Terminology of Identities between, Outside and Beyond the Gender Binary – a Systematic Review. International Journal of Transgenderism, 1-17.
Transgender Europe. 2016. Trans Rights Europe Map & Index 2016 Berlin, Germany: Transgender Europe. Available at: http://tgeu.org/trans-rights_europe_map_2016/, last accessed October 14, 2019.
Transgender Europe. 2019. Trans Rights Europe & Central Asia Map 2019 Berlin, Germany: Transgender Europe. Available at: http://tgeu.org/trans-rights_europe_map_2016/, last accessed 28 February 2020.
Transgender Europe, Smiley, A., Burgwal, A., Orre, C., Summanen, E., García Nieto, I., Vidić, J., Motzmans, J., Kata, J., Gvianishvili, N., Hård, V. & Köhler, R. 2017. Overdiagnosed but Underserved. In: Köhler, R. (ed.).
van der Ros, J. 2017. The Norwegian State and Transgender Citizens: A Complicated Relationship. World Political Science.
Winter, S., Diamond, M., Green, J., Karasic, D., Reed, T., Whittle, S. &
Wylie, K. 2016. Transgender People: Health at the Margins of Society. The Lancet, 388, 390-400.
World Health Organization 2016. International Statistical Classification of Diseases and Related Health Problems 10th Revision. 10 ed. Geneva, Switzerland: World Health Organisation.
World Health Organization 2018. International Classification of Diseases for Mortality and Morbidity Statistics Eleventh Revision. 10 ed. Geneva, Switzerland: World Health Organisation.
Wylie, K., Knudson, G., Khan, S. I., Bonierbale, M., Watanyusakul, S. & Baral, S. 2016. Serving Transgender People: Clinical Care Considerations and Service Delivery Models in Transgender Health. The Lancet, 388, 401-11.
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