Gender-Affirming Care and Homelessness: An Annotated Bibliography

REPORT

Gender-Affirming Care and Homelessness: An Annotated Bibliography June 2023

Introduction Gender diversity is a social determinant of both health and housing. 1 2 Trans homelessness has increased 113% since 20163 and trans individuals disproportionately experience unsheltered homelessness, further exacerbating health inequities that exist among this population. As such, gender-affirming care is an important component of Health Care for the Homeless (HCH) services. The phrase “gender-affirming care” often refers to health care sought by trans and non-binary individuals that is trauma-informed and patient-centered. Gender-affirming care can range from medical interventions, including surgical interventions and hormone replacement therapy, to non-medical gender affirmation, including support for social and legal pathways to transition. 4 While data exists exploring the link between gender diversity and homelessness, the connection between trans identity, housing status, and access to gender-affirming health care has not been well documented in the literature. Most studies seek to understand trans identity in relation to housing status or health care separately and research on clinical gender-affirming care outcomes and delivery rarely includes disaggregation based on housing status. People experiencing homelessness face unique challenges to accessing health care. Trans and genderdiverse individuals’ access to gender-affirming care should be understood in this context.

Some questions that motivated this publication include: • • •

What are outcomes of gender-affirming care for unhoused trans individuals?

What are outcomes of gender-affirming care for unhoused vs. housed trans individuals?

How does housing status impact access to gender-affirming care?

1 Blondeel, Karel, de Vasconcelos, Sofia, García-Moreno, Claudia, Stephenson, Rob, Temmerman, Marleen. et al.

(2018). Violence motivated by perception of sexual orientation and gender identity: a systematic review. Bulletin of the World Health Organization, 96 (1), 29 - 41L. World Health Organization.

2 Ecker, J., Aubry, T., & Sylvestre, J. (2019). A review of the literature on LGBTQ adults who experience homelessness. Journal of Homosexuality, 66(3), 297–227. 10.1080/00918369.2017.1413277 3 “Transgender Homeless Adults & Unsheltered Homelessness: What the Data Tells Us” (National Alliance to End Homelessness, July 2020), https://endhomelessness.org/wp-content/uploads/2020/07/Trans-Homelessness-BriefJuly-2020.pdf.

4 Kelli Klein, “Gender-Affirming Care and HCH: Definitions, Resources, and Opportunities,” National Health Care for the Homeless Council (blog), March 14, 2022, https://nhchc.org/gender-affirming-care-and-hch-definitionsresources-and-opportunities/. www.nhchc.org

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This annotated bibliography provides a summary of the literature at each intersection of the following domains: 1. Trans Identity 2. Homelessness 3. Gender-Affirming Care

Trans Identity

Homelessness

GenderAffirming Care

The goal is to provide a comprehensive overview of past and current research on the intersection of gender-affirming care and homelessness, while demonstrating the need for starting and expanding gender-affirming care in HCH health centers. In understanding pieces of the puzzle, this overview identified several opportunities for deepening the understanding of this critical intersection of experiences through research and practice.

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Table of Contents Introduction .................................................................................................................................... 1 Methods.......................................................................................................................................... 4 Annotated Bibliography ................................................................................................................. 6 Housing, Homelessness, and Trans Identity ............................................................................... 6 Homelessness and Gender-Affirming Care ............................................................................... 16 Trans Identity and Gender-Affirming Care ................................................................................ 18 Trends in GAC Access ............................................................................................................ 18 Quality of Life Outcomes ....................................................................................................... 23 Homelessness, Gender-Affirming Care, and Trans Identity ...................................................... 27 Other, Context ........................................................................................................................... 28 Additional Resources ................................................................................................................... 34

Authors Lauryn Berner-Davis, MSW, MPH Senior Research Manager National Health Care for the Homeless Council Pronouns: she/her | lberner@nhchc.org Joseph Kenkel, BS Research Associate National Health Care for the Homeless Council Pronouns: he/him | jkenkel@nhchc.org Kelli Klein, BA Clinical Manager National Health Care for the Homeless Council Pronouns: she/her | kklein@nhchc.org

This publication is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $1,967,147 with 0 percent financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official view of, nor an endorsement by, HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

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Methods The aim of this project is to provide a comprehensive summary of literature in a format that is useful and actionable for stakeholders at the intersection of gender-affirming health care and homelessness, including researchers, providers, consumers, and administrators of communitybased providers (e.g., Health Care for the Homeless programs). Accordingly, the methods were kept flexible to yield as much information as possible around this evolving topic to include a wide range of sources.

Databases Authors used seven databases for identifying articles: Cumulative Index of Nursing and Allied Health Literature (CINAHL) Complete, American Psychological Association (APA) PsycInfo, Medical Literature Analysis and Retrieval System Online (MEDLINE), PubMed, Embase, Global Health, and Academic Search Premier. These resources were chosen based on topical relevance to gender diversity, homelessness, and medical services. Databases were also included based on their inclusion of different publication types, ranging from peer reviewed research studies to clinical frameworks and recommendations.

Search Criteria The following search terms were identified for this review: “Homelessness,” or “Homeless,” with the additional fields, “Gender-Affirming Care,” “Transgender,” “Non-Binary,” and other terms associated with specific medical services (including hormone therapies and surgical interventions). Articles were excluded from this search if they were published before 2010, resulting in a final search for literature published between January 1st, 2010 and October 1st, 2022. Relevant articles were not excluded based on location or country. Though most were peer reviewed studies, the search also resulted in several types of articles including clinical guidelines, frameworks, and provider recommendations.

The final criterion for the search required that articles contain relevance and contribution to the understanding of trans and gender-diverse experience as they relate to homelessness and health care. Articles were included if they discussed outcomes, interventions, or emerging concerns at this intersection.

Identifying Themes This search produced 45 unduplicated articles, which were then reviewed by a team of National Health Care for the Homeless Council (NHCHC) staff. Staff summarized and sorted articles based on the following themes: Housing, Homelessness, and Trans Identity; Homelessness and Gender-Affirming Care; Trans Identity and Gender-Affirming Care; Homelessness, GenderAffirming Care, and Trans Identity; and Other, Context. These five categories were identified

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after several rounds of discussion and review.

Gender-Affirming Care Work Group This literature scan co-occurred with the convening of a NHCHC-organized Gender-Affirming Care workgroup. This workgroup was made up of a diverse group of experts from across the U.S. with experience in academic, clinical, and community-based settings. This workgroup provided feedback on the methods and resulting themes of this review to ensure they reflect the experience of providers and consumers of gender-affirming care.

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Annotated Bibliography Housing, Homelessness, and Trans Identity Abramovich, Alex, Nelson Pang, Amanda Moss, Carmen H. Logie, Michael Chaiton, Sean A. Kidd, and Hayley A. Hamilton. “Investigating the Impacts of COVID-19 among LGBTQ2S Youth Experiencing Homelessness.” PLoS ONE 16, no. 9 (September 21, 2021): e0257693. https://doi.org/10.1371/journal.pone.0257693.

This article by Abramovich et al. focuses on the impact of COVID-19 on LGBTQ2S youth in the Toronto, Canada area. Using a mixed-methods approach, the authors identified a convenience sample of participants using services at partner organizations and conducted a series of surveys and semi-structured interviews. Results showed that there was a significant increase in the number of youth living in public spaces and additional challenges accessing safe housing. Many participants reported experiencing poor mental health, self-harm, and suicidality. Most youth experienced a change in access to health care, including missing or delaying appointments, or delayed medical procedures.

Almost two-thirds of transgender youth participating in the study postponed or canceled transition-related appointments and half postponed gender-affirming surgery.

Virtual appointments were found to both help address barriers to accessing care and create barriers to care. The authors identified a need to provide preventive and longterm mental health care for LGBTQ2s youth, better access to inclusive, affirming services and providers, and continued options for virtual care that address privacy concerns for virtual appointments.

Category: Housing, Homelessness, and Trans Identity

Beltran, T., Allen, A. M., Lin, J., Turner, C., Ozer, E. J., & Wilson, E. C. (2019). Intersectional Discrimination Is Associated with Housing Instability among Transgender Women Living in the San Francisco Bay Area. International Journal of Environmental Research and Public Health, 16(22), 4521. https://doi.org/10.3390/ijerph16224521 This study aimed to determine whether the experiences of discrimination were associated with poor housing outcomes among transgender women in the San Francisco Bay Area. Beltran et al. analyzed responses of the Transgender *National study, a study of HIV prevalence among transgender women, focusing only on 629 responses from the San Francisco Bay Area. Results showed that discrimination was very common, with

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more than half of all participants having experienced intersectional discrimination.

Results showed that transgender women who reported intersectional anti-transgender and racial discrimination had a higher likelihood of experiencing housing instability.

These results support the need for policies and interventions that focus on both race and gender. Authors suggest that resources and services should be affirming and welcoming to transgender women with intersecting identities. Beltran et al. also suggest that wrap-around services (e.g., supportive services in housing, employment, and health) should be culturally appropriate and made accessible to transgender women with intersecting identities.

Category: Housing, Homelessness, and Trans Identity

Côté, P.-B., & Blais, M. (2019). Between resignation, resistance and recognition: A qualitative analysis of LGBTQ+ youth profiles of homelessness agencies utilization. Children and Youth Services Review, 100, 437–443. https://doi.org/10.1016/j.childyouth.2019.03.024 This Montreal-based qualitative analysis sought to document the diversity of experiences with homelessness agencies among LGBTQ+ youth, ages 17-25 years old (n=17). The study is a secondary analysis of a larger research project. The authors note that although considerable research has documented drivers of LGBTQ+ youth homelessness and their health impacts, little research has been done exploring the heterogeneity of LGBTQ+ youth experiences with homelessness services specifically. The authors identified three primary themes from interviews with participants: 1) resigning oneself to using homelessness agencies to meet basic needs and assure one’s survival despite potential heteronormative and cis-normative victimization; 2) resisting homelessness agencies to protect oneself from heteronormative and cis-normative victimization; and 3) having a positive experience marked by feelings of acceptance and recognition within homelessness agencies. The authors note that the snowball sampling approach used in participant recruitment likely resulted in underrepresentation of LGBTQ+ youth who are on the margins of social assistance networks.

Category: Housing, Homelessness, and Trans Identity

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Dopp, Alex R., Sean McKenna, Marylou Gilbert, and Sarah B. Hunter. “Supportive Housing for Sexual and Gender Minority Individuals With Criminal Justice Histories: Challenges and Opportunities Identified by Providers and Clients.” Housing Policy Debate 0, no. 0 (May 10, 2022): 1–24. https://doi.org/10.1080/10511482.2022.2055615.

This qualitative study by Dopp et al. explored the experience of supportive housing and available services for Sexual and Gender Minority Clients (SGM) with a history of incarceration, interviewing ten clients and eleven providers at supportive housing organizations in Los Angeles, California. Researchers found five cross-cutting themes: 1) a need to increase investment in comprehensive services supporting this population, 2) trans and non-binary clients are particularly marginalized and need additional supports, 3) careful selection and training is critical to cultivating an affirming environment, 4) supportive housing providers must be prepared to help this population navigate societal discrimination, and 5) it is important to understand how SGM identity, homelessness, and criminal justice involvement are intertwined in complex ways. Investment is needed to ensure the capacity to serve SGM clients and address the lack of supportive housing options. There is a need for more research and interventions to be led by people they serve. The authors also note that there is a need to increase enforcement of legal protections and reduce criminalization of this population through policy.

Category: Housing, Homelessness, and Trans Identity

Ecker, J., Aubry, T., & Sylvestre, J. (2019). A Review of the Literature on LGBTQ Adults Who Experience Homelessness. Journal of Homosexuality, 66(3), 297-323. https://doi.org/10.1080/00918369.2017.1413277 This literature review analyzes four themes in current LGBTQ+ homelessness research: 1) pathways into homelessness; 2) support needs; 3) targeted programming; and 4) exits out of homelessness. The review included 16 articles focused on LGBTQ+ adults (18+ years old), most of which were published in the United States in the past 10 years. The authors noted that many of the studies did not disaggregate the gender identity category “transgender” into “transgender man,” “transgender woman,” and “gender non-conforming” and that this is an important area for methodological improvement considering potential differing subgroup needs. Local, regional, and national Point-InTime Counts were particularly identified as a potentially rich source of data. Notably, the authors found that the majority of the studies on LGBTQ adults who experience homelessness have focused on cisgender males and HIV. Overall, the study emphasizes that although research on LGBTQ youth is essential to the field, the results from these

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studies are not necessarily generalizable to LGBTQ adults and more research is needed on the potentially unique needs of this age group.

Category: Housing, Homelessness, and Trans Identity

Ferguson, M., Peled, M., & Saewyc, E. M. (2022). Health and Healthcare Service Use: The Experiences of Runaway Transgender Adolescents Compared to their Peers. Journal of Homosexuality, 69(5), 821–835. https://doi.org/10.1080/00918369.2021.1892404 This study focused on the experiences of runaway transgender adolescents. By analyzing a 2013 survey of adolescents in British Columbia, Canada, researchers measured differences in health outcomes, healthcare access, healthcare experiences, and the presence of social supports. Results showed that transgender adolescents were more likely than male (4.25 times) and female adolescents (3.0 times) to have run away in the past 12 months. Adolescents who had run away from home were more likely to have poor or fair overall health, mental health, and to have missed necessary health care in the past 12 months. Among all those having run away, transgender adolescents were the most likely to report poor or fair health. Self-reported reasons for not accessing physical or mental health care varied, but were informed by the experience of stigma, strains in parental relationships, and issues related to healthcare access. This study highlights the need for low barrier gender-affirming services that address specific needs of transgender adolescents that have run away from home.

Category: Housing, Homelessness, and Trans Identity

Glick, J. L., Lopez, A., Pollock, M., & Theall, K. P. (2019). “Housing Insecurity Seems to Almost Go Hand in Hand with Being Trans”: Housing Stress among Transgender and Gender Nonconforming Individuals in New Orleans. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 96(5), 751–759. https://doi.org/10.1007/s11524-019-00384-y This targeted ethnography explores housing insecurity among Trans and Gender-NonConforming Individuals (T/GNCI) in New Orleans, Louisiana, where the infrastructural landscape is marked by an underinvestment in housing stock and disaster capitalism. Indepth semi-structured interviews were conducted with 17 T/GNCI (n = 17) living in New Orleans. Respondents discussed an array of circumstances that contribute to housing insecurity, including intersectional stigma and discrimination coupled with gentrification and a changing housing landscape in the city (e.g. an increase in short-term rentals in

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the city core, a lack of transportation into the city core, etc.). Results found that housing was intricately intertwined with employment and that social support and queer family structures emerged as a key source of resilience, coping, and survival. The study supports an increase of resources for T/GNC housing access and interventions that address discrimination, housing stock, and employment issues this population faces with a consideration of the historical and current structural barriers impeding their access to safe, stable, long-term housing.

Category: Housing, Homelessness, and Trans Identity

Glick, J. L., Lopez, A., Pollock, M., & Theall, K. P. (2020). Housing insecurity and intersecting social determinants of health among transgender people in the USA: A targeted ethnography.

International Journal of Transgender Health, 21(3), 337–349. https://doi.org/10.1080/26895269.2020.1780661 This ethnography explores the prevalence of homelessness, housing insecurity, and other social determinants of health among transgender people in the U.S. Glick et al. conducted interviews with 41 transgender people, composed of questions regarding demographic and socioeconomic information, sexual orientation and gender identity, previous and present life stressors, and experiences seeking healthcare. Resulting themes included (1) housing, intersectionality, and the social determinants of health, (2) the pervasiveness of housing insecurity, (3) the causes and buffers of housing insecurity, (4) the implications of housing insecurity, and (5) recommended solutions for transgender people experiencing housing instability. Results point to the pervasive crisis of homelessness disproportionately effecting the transgender population. Results also suggest the need for multi-level, multi-disciplinary responses to transgender housing insecurity, including trauma-informed interventions that address housing status while also addressing the effects of mental health conditions and discrimination. The authors describe the importance of societal transformation and system-level changes to root out institutional and structural transphobia and racism.

Category: Housing, Homelessness, and Trans Identity

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Greenfield, Brett, Edward J. Alessi, Dean Manning, Caroline Dato, and Meredith Dank. “Learning to Endure: A Qualitative Examination of the Protective Factors of Homeless Transgender and Gender Expansive Youth Engaged in Survival Sex.” International Journal of Transgender Health 22, no. 3 (2021): 316–29. https://doi.org/10.1080/26895269.2020.1838387.

This article highlighted a study by Greenfield et al. that utilized a resilience framework and perspective to understand protective factors of transgender and gender expansive youth engaged in survival sex in a large city in the Northeastern United States. A total of 57 transgender and gender expansive youth ages 17 to 26 who are experiencing homelessness and engaged in survival sex were part of the study, which was a secondary analysis of qualitative interviews. Respondent driven sampling was used for recruitment of participants. Three protective factors were identified in the study (1) relying on oneself and others to avoid violence, (2) accessing gender-affirming health and mental heat care, and (3) proactively maintaining sexual health. Based on the findings, the authors recommend developing policies to address vulnerability, such as expanding free and low-cost mental health services, expanding legal protections for youth engaged in survival sex, and for providers to evaluate what constitutes genderaffirming health and mental health services. The authors acknowledge a need for additional research.

Category: Housing, Homelessness, and Trans Identity

Gutman, S., Precin, P., & LaForest, M. (2022). A Scoping Review Examining Interventions Intended to Help LGBTQIA+ Youth Transition Out of Homelessness. International Journal on Homelessness, 2(2), 223–250. https://doi.org/10.5206/ijoh.2022.1.14128 This scoping literature review examined peer-reviewed literature to determine how many journal articles have been generated that addressed a) the assessment of client satisfaction or b) the effectiveness of intervention designed to help LGBTQIA+ homeless youth transition from homelessness to stable tenancy. The authors identified 19 articles that described programming, reported intervention outcomes, or outlined policies and recommendations intended to help LGBTQIA+ youth transition out of homelessness and analyzed them for assessment inclusion. The publishing date of the articles spanned from 2006 to 2021. Of the 19 articles, only 5 (26.31%) reported program evaluation, an assessment of intervention effectiveness, or an analysis of client satisfaction. The dearth of literature on this subject is noted and the authors call upon scholars and researchers to generate this needed public health research protocol, which should include service recipient perspectives to target outcomes and interpret findings.

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Category: Housing, Homelessness, and Trans Identity

Kattari, S. K., Call, J., Holloway, B. T., Kattari, L., & Seelman, K. L. (2021). Exploring the Experiences of Transgender and Gender Diverse Adults in Accessing a Transgender Knowledgeable Primary Care Physician. International Journal of Environmental Research and Public Health, 18(24), 13057. https://doi.org/10.3390/ijerph182413057 This article from Kattari et al. describes a secondary analysis of the 2015 United States Transgender Survey (USTS), a nationwide survey of 24,161 healthcare consumers identifying as transgender. Results showed that, within transgender and gender-diverse populations, different identities and demographic variables were associated with different outcomes in healthcare access and experience. The authors found that access to primary care, frequency of doctor’s visits, and the likelihood of having a transknowledgeable provider all depended on participants’ gender, sexual orientation, race, ethnicity, housing status, and more. Results point to the need for primary care providers to be knowledgeable about transgender-related healthcare. The authors suggest that medical schools can facilitate change by integrating more about transgender and gender-diverse identities into their curriculums. Education should also explore the intersecting variables and determinants (e.g., gender, sexual orientation, race and ethnicity, etc.) to facilitate more appropriate and culturally responsive care.

Category: Housing Homelessness and Trans Identity

McCann, E., & Brown, M. J. (2021). Homeless experiences and support needs of transgender people: A systematic review of the international evidence. Journal of Nursing Management, 29(1), 85–94. https://doi.org/10.1111/jonm.13163 This systematic review explores the experience of homelessness and common service needs among transgender people in the U.S. and Canada. McCann and Brown reviewed twelve papers and identified common themes regarding: pathways into homelessness (e.g., stress, trauma, substance use disorders, behavioral health conditions, limited social networks), experiences during homelessness (e.g., couch surfing, sleeping outdoors, engaging in survival sex, stigma and discrimination, and the importance of skilled, trans-knowledgeable staff), and experiences while transitioning out of homelessness (e.g., hopes for gender-inclusive and affirming spaces, barriers to housing programs, the importance of social support networks during housing transitions).

Results point to the need for (1) coordinated and effective collaborations between

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providers and transgender people experiencing housing instability and (2) improved training for clinical nurses and other providers to recognize and respond to distinct trans-related needs.

Category: Housing, Homelessness, and Trans Identity

Montgomery, Ann Elizabeth, Jillian C. Shipherd, Michael R. Kauth, Keith W. Harris, and John R. Blosnich. “Use of Veterans Health Administration Homeless Programs Among Transgender and Non-Transgender Veterans Experiencing Self-Reported Housing Instability.” Journal of Health Care for the Poor and Underserved 31, no. 2 (2020): 909–19. https://doi.org/10.1353/hpu.2020.0068.

This study by Montgomery et al. utilized Veterans Health Administration (VHA) records to identify transgender and non-transgender veterans who had self-reported housing instability between 2013 and 2016 to understand the extent to which unstable housed veterans participated in VHA homeless programs. A total of 491 transgender veterans and 473 non-transgender veterans were included in the study. Results showed that transgender veterans with housing insecurity were more likely to identify as female, younger, and less racially diverse. This population also experienced more medical comorbidity and more likely to use at least one VHA Homeless program than nontransgender veterans. They were significantly more likely to access the HUD-Veterans Affairs Supportive Housing and Supportive Services for Veteran Families programs. The authors note that transgender veterans’ greater access to some supportive services suggests that these services are meeting some needs through the VHA. There is a need for research to assess long-term housing outcomes among transgender veterans and why some programs are less accessible. The authors also highlight the need for research with consumers of services to understand experience and specific needs of this population.

Category: Housing, Homelessness, and Trans Identity

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Noble, A., Owens, B., Thulien, N., & Suleiman, A. (2022). “I feel like I’m in a revolving door, and COVID has made it spin a lot faster”: The impact of the COVID-19 pandemic on youth experiencing homelessness in Toronto, Canada. PLOS ONE, 17(8), e0273502. https://doi.org/10.1371/journal.pone.0273502 This qualitative study aimed to understand the impact COVID-19 had on sheltered youth ages 16-24 experiencing homelessness in Toronto, Ontario, and to identify recommendations for future waves of COVID-19. The study included some staff interviews. The authors used thematic analysis on transcribed interviews and found two main subthemes of results: 1) the pandemic created new and exacerbated existing structural barriers to employment for youth, and 2) the pandemic exacerbated previous mental health issues and led to an increase in substance use as a coping mechanism for many youth. The authors note findings that there were a lack of culturally appropriate spaces for indigenous youth, blatant discrimination in housing and employment towards Black youth, and a lack of trans community. The authors recommend service providers be particularly vigilant in providing outreach and support to youth that identify as 2SLGBTQ+ and ensure a balance between containing viruses and ensuring youth have access to in-person services and supports.

Category: Housing, Homelessness, and Trans Identity

Thomas, Jacinthe A., Mary K. Irvine, Qiang Xia, and Graham A. Harriman. “Service Utilization and HIV Outcomes among Transgender Women Receiving Ryan White Part A Services in New York City.” Edited by Kwasi Torpey. PLOS ONE 16, no. 7 (July 1, 2021): e0253444. https://doi.org/10.1371/journal.pone.0253444.

This retrospective analysis of secondary data by Thomas et al. identified disparities in access and outcomes along the HIV care continuum among 455 transgender women participating in New York City’s Ryan White Part A (RWPA) program, compared to 4,906 cisgender women, and 9,699 cisgender men. Records showed that transgender women had lower use of food and nutrition services despite being more likely to have a documented need for food and nutrition, harm reduction, or housing assistance. They were slightly more likely to be prescribed antiretroviral therapy but less likely to be virally suppressed than other participants. Transgender women were more likely to have a need for mental health services than cisgender men. The authors recommend that housing needs should be met due considering the impact of unstable housing in viral suppression. They noted that needs were not consistently met with RWPA. There is a need for research on greater integration of services data and data sources to identify

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unmet needs. There should be efforts to strengthen outreach, promote genderaffirming care service delivery, and increase engagement.

Category: Housing, Homelessness, and Trans Identity

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Homelessness and Gender-Affirming Care Clark, Kirsty, Jesse B. Fletcher, Ian W. Holloway, and Cathy J. Reback. “Structural Inequities and Social Networks Impact Hormone Use and Misuse Among Transgender Women in Los Angeles County.” Archives of Sexual Behavior 47, no. 4 (May 2018): 953–62. https://doi.org/10.1007/s10508-017-1143-x.

This article by Clark et al. summarized a study of 271 transgender women in Los Angeles, California aged 18 and older to understand hormone use and misuse in relation to social networks and sociodemographics. The study found that transgender women who are Black/African American, younger, and those who engage in sex work were more likely to report hormone misuse. Hispanic/Latinx transgender women or older transgender women were more likely to use non-hormone filler injections. Medically monitored hormone use was more common for those with stable housing and insurance, and good health. Income alone was not a predictor of medically monitored hormone use.

Transgender women who use the internet to find friends were more likely to use medically monitored hormones. Participants with larger networks of transgender women who use hormones were more likely to misuse hormones. The authors note a need to consider social network dynamics and social needs when providing genderaffirming care. They suggest that transgender women who are unstably housed, are uninsured or participate in sex work should be prioritized for gender transition interventions.

Category: Homelessness and Gender-Affirming Care

Deutsch, M. B. (2016). Gender-affirming Surgeries in the Era of Insurance Coverage: Developing a Framework for Psychosocial Support and Care Navigation in the Perioperative Period. Journal of Health Care for the Poor and Underserved, 27(2), 386–391. https://doi.org/10.1353/hpu.2016.0092 This journal article offers a framework for presurgical processes among traditionally underserved groups preparing for gender-affirming surgeries. Due to the expansion of Medicaid coverage for gender-affirming surgeries, Deutsch suggests the need to bolster presurgical processes for those covered by Medicaid. This proposed framework expands the preexisting framework from the World Professional Association for Transgender Health (WPATH) to include multiple presurgical assessments and care navigation.

Domains of expanded presurgical assessments include psychosocial functioning, health system literacy, housing status, a social support inventory, among others. Deutsch states

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that health systems and insurers should provide the resources for providers to implement this type of framework. All the while, structural-level interventions will be needed to ensure that housing resources and psychosocial supports are accessible and culturally appropriate for transgender people.

Category: Homelessness and Gender-Affirming Care

Douglass, K. M., Polcari, A., Najjar, N., Kronenfeld, J., & Deshpande, A. R. (2018). Health Care for the Homeless Transgender Community: Psychiatric Services and Transition Care at a StudentRun Clinic. Journal of Health Care for the Poor and Underserved, 29(3), 940–948. https://doi.org/10.1353/hpu.2018.0070 This case study describes the Lotus Wellness Center, a student-run clinic in Miami, Florida that provides care to transgender individuals experiencing homelessness. In a three-year span, Lotus Wellness Center supported six transgender consumers in their journey through hormone therapy, establishment of medical care, and mental health services. This clinic is a unique example of the role that medical students can play in addressing needs for comprehensive gender-affirming care. This is an emerging model but shows promise in both care coordination and expanding medical training on transgender health care. Lessons learned among the staff at this program include the importance of following consumers as they transition out of homelessness and shelter settings to ensure they continue to receive appropriate support and care.

Transportation and scheduling issues are also a significant contributor to long-term connection to services. The authors advocate for more opportunities for future physicians to work in transgender health, which will ultimately expand access for and improve the healthcare experience of transgender people across the U.S. Category: Homelessness and Gender-Affirming Care

Souza, E. S. de, & Tanaka, L. H. (2021). Healthcare: action research with transgender people living on the streets. Revista Brasileira de Enfermagem, 75. https://doi.org/10.1590/0034-71672021-0016 The purpose of this study was to analyze healthcare provider perspectives on utilization and access to services among transgender people experiencing homelessness in Sao Paulo, Brazil. Authors interviewed thirteen transgender health care providers, which resulted in several common themes. Provider interviews suggested that (1) transgender people experiencing homelessness have greater medical vulnerability than other

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groups, (2) transgender health care includes technical, ethical, and aesthetic considerations that exist beyond traditional medical care, (3) a crucial component of transgender health care is addressing stigma and the harm caused by traditional health care, which has historically pathologized transgender identity, and (4) reductionist conceptions of care tend to guide the development of policing and surveillance practices rather than meet the needs of individuals. Interview results support the need for provider trainings in clinical and academic environments around gender, race, and class.

Authors also note the importance of including transgender people experiencing homelessness in the planning of programming to improve cultural humility.

Category: Homelessness and Gender-Affirming Care

Trans Identity and Gender-Affirming Care Trends in GAC Access Bhatt, N., Cannella, J., & Gentile, J. P. (2022). Gender-affirming Care for Transgender Patients.

Innovations in Clinical Neuroscience, 19(4–6), 23–32. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9341318/ These clinical guidelines promote the adoption of gender-affirming principles that reduce harm and improve health outcomes. Bhatt, Cannella, & Gentile include specific recommendations for all health providers to better meet the needs of their patients, including: (1) never assuming patient gender or pronouns, (2) viewing gender identity on a spectrum, which is subject to change, (3) adopting trauma-informed care as a pillar of treatment for transgender and LGBTQ+ patients, (4) integrating gender-affirming principles into behavioral health services to address disparities in psychiatric illness, (5) implementing gender-affirming principles across all points of contact, beginning with the first encounter with a patient, (6) working toward a gender-affirming environment that includes nondiscrimination statements, gender-neutral restrooms, gender-neutral language, practice of staff sharing pronouns, and staff education. Authors suggest that providers can make a significant impact on a patient’s experience, regardless of their title or status. Gender-affirming care includes smaller inclusive steps that can make an enormous impact. Staff training should include strategies on this continuum of genderaffirming care.

Category: Trans Identity and Gender-Affirming Care

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Goldstein, Deborah A., Eleanor Sarkodie, and W. David Hardy. “Transgender and Nontrans Patients Do Not Receive Statistically Different Quality Primary Care at Whitman-Walker Health, 2008–2016.” Transgender Health 4, no. 1 (September 1, 2019): 200–208. https://doi.org/10.1089/trgh.2019.0022.

This retrospective study by Goldstein, Sarkodie, and Hardie utilized an electronic patient records review at an HIV and LGBT-focused community health center in Washington, DC between 2008 and 2016. A total of 1,822 patients over age 18 who self-identified as transgender at intake. They evaluated sociodemographic information, gender-affirming care status, HIV testing and infection, and primary care outcomes. The researchers found a high engagement in primary care driven by using a gender-affirming care model.

Transgender men were less likely to be tested for HIV and receive the influenza vaccine but were more likely to receive tobacco and lipid screening. The sample had a high proportion of transgender women with HIV infection. Demographically, transgender men were more likely to be between white, privately insured, and have stable housing.

Transgender women more likely to identify as African American and/or Hispanic/Latinx, be unstably housed, and have public health insurance. The majority of transgender patients traveled to the clinic from outside of DC. The authors note the need for appropriate clinical guidelines to ensure screening and immunization are recommended for patients.

Category: Trans Identity and Gender-Affirming Care, Trends in access

Jalil, E. M., Wilson, E. C., Luz, P. M., Velasque, L., Moreira, R. I., Castro, C. V., Monteiro, L., Garcia, A. C. F., Cardoso, S. W., Coelho, L. E., Liu, A. Y., Veloso, V. G., McFarland, W., Buchbinder, S., & Grinsztejn, B. (2017). HIV testing and the care continuum among transgender women: population estimates from Rio de Janeiro, Brazil. Journal of the International AIDS Society, 20(1), 21873. https://doi.org/10.7448/IAS.20.1.21873 This study’s aim was to estimate population-level connections to the HIV-care continuum and to explore the factors associated with viral suppression among transgender women in Rio de Janeiro. Of 345 transgender women in the study, 82% had been previously tested for HIV, 67.2% had been diagnosed with HIV, 67.2% had linkage to care, 62.2% were currently in antiretroviral therapy, and 32.4% had an undetectable viral load. Participants who were black, self-identified as low-income, or as having unstable housing were significantly less likely to have viral suppression. Study results suggest there are significant disparities in HIV clinical outcomes, with transwomen experiencing low rates of viral suppression. This is especially true among transwomen

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within underserved populations who have social and psychosocial needs. Results support the need for multidisciplinary interventions to prevent and address these disparities, improve outcomes, and reduce transmission. The authors recommend gender-affirming care as an important tool for reaching these goals.

Category: Trans Identity and Gender-Affirming Care

Ker, Alex, Gloria Fraser, Antonia Lyons, Cathy Stephenson, and Theresa Fleming. “Providing Gender-Affirming Hormone Therapy through Primary Care: Service Users.” Journal of Primary Health Care 12, no. 1 (March 2020): 72–78. https://doi.org/10.1071/HC19040.

This article highlights a small qualitative study of four service users, ages 18 to 26, and four health care providers at the Victoria University of Wellington in New Zealand. The intervention involves a session with a counselor and a general practitioner to assess barriers to starting hormone therapy. The general practitioner prescribed hormones with an endocrinologist present. Ker et al. found that the intervention alleviated stress in seeking care for the service users and that relationship-centered care allowed participants to openly discuss their health needs. Providers reported the importance of partnership and feedback in providing gender-affirming care. Providing gender-affirming care and agency in the primary care setting was found to be more welcoming, addressing provider concerns around gatekeeping care. The model was believed to be generalizable to other primary care settings, but there are concerns related to capacity and balancing providing hormone therapy with addressing mental health care. Further recommendations included conducting research comparing gender-affirming care in primary care versus specialty care settings and considerations around implanting this model in a rural setting.

Category: Trans Identity and Gender-Affirming Care

Kia, H., Rutherford, L., Jackson, R., Grigorovich, A., Ricote, C. L., Scheim, A. I., & Bauer, G.R. (2022). Impacts of COVID-19 on transgender and non-binary people in Canada: a qualitative analysis of responses to a national survey. BMC Public Health, 22(1), 1284. https://doi.org/10.1186/s12889-022-13684-x This study analyzed responses to an open-ended question about the effects of the COVID-19 pandemic on transgender and non-binary individuals. This question (“Can you tell us how the COVID-19 pandemic has impacted you as a transgender or non-binary

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person, whether positive or negative?”) was a component of the broader 2020 Transgender PULSE Canada Survey. Several themes emerged from the responses, including (1) diminished access to health care, including gender-affirming care, (2) exacerbation of financial, employment, and housing insecurity, (3) negative impacts of physical distancing on social support networks, (4) increased victimization, and (5) fewer experiences of gender affirmation. Implications of these themes include the need to target health care access, socioeconomic stability, social support networks, safety, and gender affirmation as domains for public health policy and intervention. They also point to the need for trans-inclusive services to be designed and delivered in conjunction with measures that reduce discrimination and enhance the provision of trans-affirming health care, improve employment and housing security, and improve the capacity of peer support networks to thrive.

Category: Trans Identity and Gender-Affirming Care

Lacombe-Duncan, A., Newman, P. A., Bauer, G. R., Logie, C. H., Persad, Y., Shokoohi, M., O’Brien, N., Kaida, A., de Pokomandy, A., & Loutfy, M. (2019). Gender-affirming healthcare experiences and medical transition among transgender women living with HIV: a mixedmethods study. Sexual Health, 16(4), 367. https://doi.org/10.1071/SH19011 This study explored barriers and facilitating factors for accessing medical transition among transgender women living with HIV. Lacombe-Duncan et al. analyzed the results of the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (20132015) and conducted a set of supplemental interviews. Results showed that housing instability, transphobia, HIV-related stigma, and barriers to accessing care determined whether someone had access to services or resources for medical transition. Authors found transgender women living with HIV had to maintain good HIV clinical health in order to access gender-affirming surgeries. Results also showed that transgender women who had not yet begun medical transition experienced higher levels of HIVrelated stigma. The authors suggest that HIV care providers can improve patient experience and outcomes by adopting gender-affirming care in their practices. This study also provides evidence for the importance of comprehensive support that address social needs (e.g., income and housing), which can increase access to medical transition and promote equitable access to gender-affirming care for all transgender women.

Category: Trans Identity and Gender-Affirming Care (Trends in GAC Access)

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Lee, K., Trujillo, L., Olansky, E., Robbins, T., Brune, C. A., Morris, E., Finlayson, T., Kanny, D., Wejnert, C., National HIV Behavioral Surveillance among Transgender Women Study Group, & National HIV Behavioral Surveillance among Transgender Women Study Group. (2022). Factors Associated with Use of HIV Prevention and Health Care Among Transgender Women - Seven Urban Areas, 2019-2020. MMWR. Morbidity and Mortality Weekly Report, 71(20), 673–679. https://doi.org/10.15585/mmwr.mm7120a1 This study by Lee et al. surveyed access to yearly HIV testing and use of Pre-Exposure Prophylaxis (PrEP) among transgender women. Authors analyzed the results of 1,608 responses to the Center for Disease Control’s National HIV Behavioral Surveillance Survey (2019-2020). 42% of respondents recently received a positive HIV result, while 38% reported having received a positive result in the past. Low income, experience of homelessness, and severe food insecurity were all common among this population and were associated with a lack of HIV prevention and treatment. Having a health care provider with whom participants could talk about gender-related health issues was associated with improved HIV prevention and treatment outcomes, including HIV testing, PrEP initiation, and viral suppression. Results suggest that gender-affirming approaches can support connection to services and lead to better HIV outcomes. This study also provides evidence for the high occurrence of socioeconomic challenges, food insecurity, and housing insecurity among transgender women and points to the need for interventions that address these types of needs among transgender women experiencing these conditions.

Category: Trans Identity and Gender-Affirming Care (Trends in GAC Access)

Puckett, J. A., Cleary, P., Rossman, K., Newcomb, M. E., & Mustanski, B. (2018). Barriers to Gender-Affirming Care for Transgender and Gender Nonconforming Individuals. Sexuality Research & Social Policy : Journal of NSRC : SR & SP, 15(1), 48–59. https://doi.org/10.1007/s13178-017-0295-8 This qualitative study queried 256 transgender and gender nonconforming (TGNC) individuals on barriers the participants faced in accessing gender-affirming care. The data for the analysis came from a combined data set: one set that was part of a daily diary protocol from a larger study including transgender women and transgender men, and a one-time survey to supplement the former data set with participants who identified as other identities (e.g., genderqueer, non-binary, etc.). Notably, this study solicited feedback from a community advisory board (CAB) on study questions, design, and recruitment materials/methods. Results found that the most common barrier to

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gender-affirming care was financial access, including lack of insurance coverage due to unemployment or underemployment. Other reported common barriers to care were a lack of TGNC-competent health care providers, concerns about social consequences of medical transition, and a lack of information about what gender-affirming care services exist.

Category: Trans Identity and Gender-Affirming Care (Trends in GAC Access)

Quality of Life Outcomes Almazan, A. N., & Keuroghlian, A. S. (2021). Association Between Gender-Affirming Surgeries and Mental Health Outcomes. JAMA Surgery, 156(7), 611–618. https://doi.org/10.1001/jamasurg.2021.0952 This secondary analysis of the 2015 U.S. Transgender Survey aimed to evaluate the associations between gender-affirming surgeries and mental health outcomes, including psychological distress, substance use, and suicide risk. The study included transgender women, transgender men, and non-binary participants, and compared a cohort that had undergone one or more types of gender-affirming surgery in the past two years and a cohort that had not undergone surgery but endorsed a desire for one or more types of surgery. After adjustment for sociodemographic factors and exposure to other types of gender-affirming care, undergoing one or more types of gender-affirming surgery was associated with lower past-month psychological distress, smoking, and suicidal ideation.

The results contribute new evidence to support the provision of gender-affirming surgical care for transgender people.

Category: Trans Identity and Gender-Affirming Care (Quality of Life Outcomes)

Javier, Christienne, Charlie R. Crimston, and Fiona Kate Barlow. “Surgical Satisfaction and Quality of Life Outcomes Reported by Transgender Men and Women at Least One Year Post Gender-Affirming Surgery: A Systematic Literature Review.” International Journal of Transgender Health 23, no. 3 (July 3, 2022): 255–73. https://doi.org/10.1080/26895269.2022.2038334.

This systematic literature review by Javier, Crimston, and Barlow looked at surgical satisfaction at least one year post-gender-affirming surgery in 79 studies pre-October 2021. Nine studies used prospective research methods. None of the studies examined long-term outcomes of facial masculinization surgery or vocal cord surgery in

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transgender men. Positive outcomes, including satisfaction, psychological outcomes, and minimal regret, were found for chest surgery for both transgender men and transgender women, genital surgery, facial feminization surgery, vocal cord surgery for transgender women, and Adam’s apple removal. Out of 28 that looked at satisfaction post-phalloplasty only one study found relatively low rates of satisfaction with sexual functioning. Out of 8 studies looking at satisfaction post-vocal cord surgery for transgender women, one found dissatisfaction with relationships with friends and/or family. The authors note a need for more research on the impact of gender-affirming surgery on depression and anxiety. They also note the importance of conversations around expectations to ensure positive outcomes. Overall, this review found overwhelmingly positive outcomes with a small minority of individuals reporting dissatisfaction or regret.

Category: Trans Identity and Gender-Affirming Care, Quality of Life

Leyns, C., Papeleu, T., Tomassen, P., T’Sjoen, G., & D’haeseleer, E. (2021). Effects of speech therapy for transgender women: A systematic review. International Journal of Transgender Health, 22(4), 360–380. https://doi.org/10.1080/26895269.2021.1915224 This systematic review aimed to analyze the body of literature concerning speech therapy outcomes for transgender women who have not received phonosurgery. The review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and identified 14 studies whose preliminary results showed positive acoustic and perceptual outcomes, including quality of life measures, from speech therapy. The authors note, however, that consistent methodological issues including small sample sizes, lack of control groups, lack of clearly described methodologies, and high risks of experimenter bias point to an urgent need for more high-quality research on speech therapy outcomes to guide clinical practice.

Category: Trans Identity and Gender-Affirming Care (Quality of Life Outcomes)

McNichols, Colton H. L., Devin O’Brien-Coon, and Beverly Fischer. “Patient-Reported Satisfaction and Quality of Life after Trans Male Gender Affirming Surgery.” International Journal of Transgender Health 21, no. 4 (October 10, 2020): 410–17. https://doi.org/10.1080/26895269.2020.1775159.

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This article by McNichols et al. evaluates the timing and sequence of gender-affirming surgery and the impact on patients in Baltimore, Maryland. A survey of 246 transgender men looked at demographics, timing and type of surgical procedures, quality of life measures, social measures, psychiatric morbidity, and issues faced during surgical transition. The study found that most patients undergo surgical procedures one to two years after starting hormone therapy. Those who have a hysterectomy typically will have this before a mastectomy, and a phalloplasty was always the last procedure completed, though only 1.5% of patients surveyed had a phalloplasty. This low percentage was due to concerns over complications, cost, plans to do so in the future, distance, or feeling happy as they are. Of those surveyed, 98% did not regret the decision to have gender-affirming surgery. There was some evidence showing improvement in psychiatric disorders post-surgery. The authors note a need for prospective studies using validated instruments and a need for similar studies among transgender women and non-binary individuals.

Category: Trans Identity and Gender-Affirming Care, Quality of Life

Nguyen, H. B., Chavez, A. M., Lipner, E., Hantsoo, L., Kornfield, S. L., Davies, R. D., & Epperson, C. N. (2018). Gender-Affirming Hormone Use in Transgender Individuals: Impact on Behavioral Health and Cognition. Current Psychiatry Reports, 20(12), 110. https://doi.org/10.1007/s11920018-0973-0 This article from Nguyen et al. reviews literature from 2013-2018 on Gender-affirming Hormone Therapy (GAHT) and how it impacts mood and cognition. The authors focused on longitudinal and cross-sectional studies to show the longer-term impacts of this intervention. Results of these studies showed that GAHT leads to lower depressive symptoms, a reduction in anxiety among middle aged and elderly adults, decreased cortisol response and self-reported stress, lower levels of gender dysphoria, psychiatric stress, and psychoneurotic distress. GAHT was found to have mixed effects on emotional functioning. This review suggests that hormonal intervention is a crucial tool for improving behavioral wellness in transgender populations. More research is needed on how GAHT affects cognitive processes and executive functioning.

Category: Trans Identity and Gender-Affirming Care (Quality of Life Outcomes)

Rider, G. Nic, Jennifer A. Vencill, Dianne R. Berg, Rachel Becker-Warner, Leonardo CandelarioPérez, and Katherine G. Spencer. “The Gender Affirmative Lifespan Approach (GALA): A

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Framework for Competent Clinical Care with Nonbinary Clients.” International Journal of Transgenderism 20, no. 2–3 (July 3, 2019): 275–88. https://doi.org/10.1080/15532739.2018.1485069.

This article by Rider et al. explores the Gender Affirmative Lifespan Approach (GALA), a psychotherapy framework based in health disparities theory and research. GALA asserts that therapeutic interventions focused on combatting internalized oppression can improve mental health, overall health, and well-being for clients. The interventions are tailored to the development phase of each client. The philosophical foundations are: (1) trans-affirmative care; (2) intersectionality; (3) transparency; (4) developmental differences in care across the lifespan; and (5) an interdisciplinary approach. The intervention’s core components are: 1) developing gender literacy; (2) building resiliency; (3) moving beyond the binary; (4) exploring pleasure-oriented positive sexuality; and (5) making positive connections to medical interventions. GALA addresses specific stressors and centers all clients and identities’ rights to sexual empowerment and pleasure and assist in the identification of providers are aware and competent in providing care to non-binary patients. The model needs additional validation, and the framework should be studied to understand the impact on the therapeutic working alliance, rapport, and relational factors for non-binary clients.

Category: Trans Identity and Gender-Affirming Care, Quality of Life/Behavioral Health

Sorbara, Julia C., Lyne N. Chiniara, Shelby Thompson, and Mark R. Palmert. “Mental Health and Timing of Gender-Affirming Care.” Pediatrics 146, no. 4 (October 1, 2020): e20193600. https://doi.org/10.1542/peds.2019-3600.

The study summarized in this article looked at self-reported rates of mental health concerns and medication used based on age of presentation for gender-affirming medical care, pubertal stage at presentation, social transition status, and assigned sex.

Sorbara et al. conducted a chart review of patients with gender dysphoria under the age of 18 in Toronto, Canada, with 116 “younger presenting youth” under age 15 and 184 “older presenting youth” ages 15 and older at presentation for gender-affirming medical care. The authors found that 78% of youth had at least one mental health condition, with depression and anxiety having the highest prevalence. More older presenting youth had a diagnosis of depression, a history of self-harm, suicidal ideation, suicide attempts, and required psychoactive medications than younger presenting youth. Later pubertal stage and older age at presentation for care were associated with worse mental health outcomes. The authors note the need for additional research to

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understand the trajectory of mental health status, age at gender-affirming care initiation, and adult psychological well-being.

Category: Trans Identity and Gender-Affirming Care, Behavioral Health Outcomes OR Trends in Access

Homelessness, Gender-Affirming Care, and Trans Identity Gamarel, K. E., King, W. M., Mouzoon, R., Xie, H., Stanislaus, V., Iwamoto, M., Baxter, K., Suico, S., Nemoto, T., & Operario, D. (2021). A “tax” on gender affirmation and safety: costs and benefits of intranational migration for transgender young adults in the San Francisco Bay area.

Culture, Health & Sexuality, 23(12), 1763–1778. https://doi.org/10.1080/13691058.2020.1809711 This qualitative study aimed to explored experiences of intranational migration among trans young adults who relocated to San Francisco, California seeking gender affirmation, including medical affirmation, social affirmation, and legal affirmation.

Participants included 61 trans young adults ages 18 to 29 who identified as non-binary, trans women, or trans men. 84% identified as a person of color. Results found that migration for gender affirmation and safety placed many informants at risk for structural vulnerabilities including homelessness and racism, but that many participants were willing to “pay” the price to access gender affirmation and safety. Findings underscore the importance of state, regional, and federal action to ensure access to gender-affirming care. This study is also notable in its findings that lack of access to gender-affirming care can directly result in increased risks of homelessness.

Category: Homelessness, Gender-Affirming Care, and Trans Identity

Gonzalez, K. A., Abreu, R. L., Rosario, C. C., Koech, J. M., Lockett, G. M., & Lindley, L. (2022). “A center for trans women where they help you”: Resource needs of the immigrant Latinx transgender community. International Journal of Transgender Health, 23(1–2), 60–78. https://doi.org/10.1080/26895269.2020.1830222 This qualitative study aimed to identify comprehensive resource needs of immigrant Latinx transgender people living in a large metropolitan city in Florida. The authors note that there is a body of research on health care needs for this population, but little research on comprehensive resource needs. The study interviewed 18 immigrant Latinx

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participants ages 21-69 who accessed resources at a local nonprofit. The authors identified 5 themes of resource-related needs through a thematic analysis: 1) Trans health care/resources (72.22%); 2) Public education (38.89%); 3) Financial aid (27.7%); 4) Homelessness resources (16.67%); and 5) Addictions care (11.11%). The authors also identified several themes of barriers to resource access, including documentation papers and legal aid, clinical competence of medical providers, and law enforcement interactions. This study emphasizes the need for comprehensive wrap-around services in health centers and connection to health care in community-based organizations.

Category: Homelessness, Gender-Affirming Care, and Trans Identity

Other, Context Bouman, Walter Pierre. “Transgender and Gender Diverse People’s Involvement in Transgender Health Research.” International Journal of Transgenderism 19, no. 4 (October 2, 2018): 357–58. https://doi.org/10.1080/15532739.2018.1543066.

This editorial by Bouman digs deeper into previous recommendations on criteria for transgender health research, focusing on the recommendation that: “Whenever possible, research should be grounded, from inception to dissemination, in a meaningful collaboration with transgender community stakeholders.” The editorial board for the International Journal of Transgenderism, not the International Journal of Transgender Health, recommends that research in transgender health should meaningfully involve stakeholders, with the many benefits of involving transgender and gender-diverse partners including improving research quality and addressing bias. The board recommendations include having cisgender researchers in this field mentor junior transgender researchers, among other forms of engagement. To act on this recommendation, the International Journal of Transgenderism now requires authors to report on the extent of community stakeholder involvement in their clinical research and report on their plans to disseminate their research back to the participants and community.

Category: Other, Context

Goldsmith, Leo, and Michelle L. Bell. “Queering Environmental Justice: Unequal Environmental Health Burden on the LGBTQ+ Community.” American Journal of Public Health 112, no. 1 (January 2022): 79–87. https://doi.org/10.2105/AJPH.2021.306406.

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This literature review by Goldsmith and Bell explored the literature based on the conceptual framework for environmental health disparities for the LGBTQ+ population.

The authors found that LGBTQ+ individuals face discrimination in social institutions, including health care and employment, as well as environmental exposure to ambient air pollutions, environmental disasters, and secondhand smoke; they identified disparities in respiratory illness, HIV infection, and mental health. The authors note that intersectionality plays a role in the impact of environmental health disparities. The findings indicate a need to implement anti-discriminatory policies and cultural competency training, and policies to help obtain appropriate identification documents for transgender and non-binary people. There is a need to focus tobacco cessation campaigns to the LBGBTQ+ community, partner with all levels of government in disaster response to address access and discrimination, incorporate LGBTQ+ issues into environmental justice research, and improve data collection on sexual orientation and gender identity.

Category: Other, Context

Motmans, Joz, Timo O. Nieder, and Walter Pierre Bouman. “Transforming the Paradigm of Nonbinary Transgender Health: A Field in Transition.” International Journal of Transgenderism 20, no. 2–3 (July 3, 2019): 119–25. https://doi.org/10.1080/15532739.2019.1640514.

This editorial by Motmans, Nieder, and Bouman follows the ideology of gender and pathologies that have come from the gender binary as the dominant ideology (e.g., transgender identity, gender incongruence and dysphoria as part of the Diagnostic and Statistical Manual of Mental Disorders). They explore a movement towards including non-binary identity and the need to expand this language as it centers the binary. The editorial highlights a summary of articles included in a special issue of the journal. The authors highlight a need to continue broadening research and centering those who do not fall into a binary perspective on gender.

Category: Other, Context

Nicholas, Lucy. “Queer Ethics and Fostering Positive Mindsets toward Non-Binary Gender, Genderqueer, and Gender Ambiguity.” International Journal of Transgenderism 20, no. 2–3 (July 3, 2019): 169–80. https://doi.org/10.1080/15532739.2018.1505576.

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This article by Nicholas uses social theories to address transphobia and build positive attitudes towards non-binary gender identities and highlights school-based strategies and programs that have been successful. The author describes a lack of resources to culturally understand gender outside a binary as is reflected in research categories.

Through the lens of queer theory and feminist post-structuralism, Nicholas proposes we can understand why identity lens to hierarchies that enforce bias, discrimination, and violence. The idea of bigenderism prevents many from understanding and recognizing non-binary genders. The lack of resources and discourse makes binary gender seem neutral and genderqueer identities seem socially impossible. Nicholas notes the need for queer ethics and allophilia, as well as disrupting and challenging social tendencies to think of people in hierarchies. The author states that queering as a practice that is normcritical and can leverage lessons from how the feminist movement changed cultural narratives.

Category: Other, Context

Salas-Humara, C., Sequeira, G. M., Rossi, W., & Dhar, C. P. (2019). Gender-affirming medical care of transgender youth. Current Problems in Pediatric and Adolescent Health Care, 49(9), 100683. https://doi.org/10.1016/j.cppeds.2019.100683 These clinical guidelines from Salas-Humara et al. focus on gender-affirming care for different phases of youth and adolescence, providing evidence-based clinical recommendations for hormone therapies within pre-pubertal, pubertal, and postpubertal periods of development. The authors recommend that no medical interventions occur in the pre-pubertal period. Recommendations for eligible interventions in the pubertal period include puberty blockers, such as hormone agonists (e.g., gonadotropin). Recommendations for eligible interventions in the post-pubertal period include feminizing or masculinizing hormone therapies. Previous short-term studies have shown that hormone treatment with estradiol and testosterone is safe, improves mental health, and improves quality of life outcomes. Salas-Humara et al. point out the importance for clinicians to understand that the desire for medical intervention is highly personal and that discussions exploring individuals' desires for hormone or surgical treatment is recommended. Finally, researchers address the need for long-term studies to better understand the implications of these types of treatment on physical and mental health.

Category: Other, Context

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Sevelius, J., & Jenness, V. (2017). Challenges and opportunities for gender-affirming healthcare for transgender women in prison. International Journal of Prisoner Health, 13(1), 32–40. https://doi.org/10.1108/IJPH-08-2016-0046 This publication examines current literature on victimization, housing placement, and healthcare provision for transgender women detained in jails, prisons, and other types of detention facilities to provide policy recommendations for gender-affirming health care for transgender women. Recommendations include all-staff training on and accountability to gender-affirming policies and procedures, assigning housing placement for transgender women on a case-by-case basis, provision of private hygiene facilities when possible, and ensuring access to gender-affirming health care without requiring proof of past care. This publication may be useful to the Health Care for the Homeless field in that it addresses challenges and opportunities for sex-segregated housing and its intersection with gender-affirming health care. Other similar directions of inquiry that could benefit the development of best practices for gender-affirming shelter include domestic violence shelters and rehabilitation facilities.

Category: Other, Context

Vandenburg, T., Groot, S., & Nikora, L. W. (2022). “This isn’t a fairy tale we’re talking about; this is our real lives”: Community-orientated responses to address trans and gender diverse homelessness. Journal of Community Psychology, 50(4), 1966–1979. https://doi.org/10.1002/jcop.22606 This New Zealand-based discussion article outlines an indigenous-based approach to meaningful research with trans and gender-diverse people experiencing homelessness.

The authors note the importance of community psychology for transcending rigid disciplinary divides in research and argue that scholar-activism, social justice, relationality, and collaboration should inform every stage of the research process when engaging with minoritized communities. This article is notable in that it provides an international, indigenous-based approach to field of Community-Based Participatory Research that is considered best practice among Health Care for the Homeless researchers in the United States and offers some concrete recommendations for ethical research practice.

Category: Other, Context

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Vincent, B. (2019). Breaking down barriers and binaries in trans healthcare: the validation of non-binary people. International Journal of Transgenderism, 20(2–3), 132–137. https://doi.org/10.1080/15532739.2018.1534075 This editorial explores the harms and challenges of a sex/gender-binary approach to gender-affirming care and suggests approaches and practices for supporting non-binary people. The editorial begins with an etymological and ontological examination of gendered language and suggests that continued social capacity for nuanced gendered language and providers’ capacity to respect individual language preferences is essential to providing affirming health care for non-binary individuals. This includes moving beyond binary descriptions of gender-affirming health care interventions such as “masculinizing” or “feminizing” hormone therapy/surgery and instead learning organand intervention-based language for medical treatments. The author also acknowledges the need for legal and institutional acknowledgement of non-binary identities on paperwork, Electronic Health Records (EHRs), and legal documents. Many of the challenges and opportunities the author describes in this editorial are relevant to the Health Care for the Homeless field as part of a larger collective effort to affirm diversity in human experience in order to ensure individual and social well-being.

Category: Other, Context

Zhang, Q., Goodman, M., Adams, N., Corneil, T., Hashemi, L., Kreukels, B., Motmans, J., Snyder, R., & Coleman, E. (2020). Epidemiological considerations in transgender health: A systematic review with focus on higher quality data. International Journal of Transgender Health, 21(2), 125–137. https://doi.org/10.1080/26895269.2020.1753136 In this 2020 systematic review, Zhang et al. update the field on epidemiological questions among transgender populations in various nations. Articles in this scan, including regions of U.S., Sweden, The Netherlands, Belgium, and Taiwan, observe general populations and stratified age groups to estimate total numbers of people identifying as transgender. Authors found that, per 100,000 people, 17-33 identify as transgender. When asked specifically about transgender identity, 0.3 – 0.5% of adults responded affirmatively, while 1.2 – 2.7% of children and adolescents responded affirmatively. When asked specifically about gender incongruence or gender ambivalence, 0.5 – 4.5% of adults responded affirmatively, while 2.5 – 8.4% of children and adolescents responded affirmatively. High quality of data and up-to-date population

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Annotated Bibliography

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estimates are necessary to adequately support the health needs of transgender people.

More research is needed to better understand the size and needs of trans groups, specifically gender identities that do not fall within diagnostic categories (e.g., genderfluid, non-binary).

Category: Other, Context

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Annotated Bibliography

June 2023

Additional Resources Trans Health and Homelessness Foundations of LGBTQIA+ Health Care and Homelessness: Terminology, Concepts, and Best Practices, Webinar, NHCHC, 2022 Engaging the Families of Transgender and Gender Diverse Children, NHCHC and National LGBTQIA+ Health Education Center, 2021 ‘Seeing People as They See Themselves’: Health Care Access for Transgender Individuals Experiencing Homelessness, NHCHC, 2015 Toolkit for Practitioners/Researchers Working with Lesbian, Gay, Bisexual, Transgender, and Queer/Questioning (LGBTQ) Runaway and Homeless Youth (RHY), National Resource Center for Permanency and Family Connections, Silberman School of School of Social Work, 2012 Clinical Guidelines Standards of Care for the Health of Transgender and Gender Diverse People, World Professional Association for Transgender Health, 2022 Medical Care of Trans and Gender Diverse Adults, Fenway Health, 2021 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People, University of San Francisco, 2016 Gender-Inclusive Shelter Gender-Integrated Shelters: Experience and Advice, FORGE, 2016 Shelter for All Genders: Best Practices for Homeless Shelters, Services, and Programs in Massachusetts in Serving Transgender Adults and Gender Non-Conforming Guests, Massachusetts Transgender Political Coalition Policy Committee, 2013 Transitioning Our Shelters: A Guide to Making Homeless Shelters Safe for Transgender People, National Gay and Lesbian Task Force, National Coalition for the Homeless, 2003

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