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Improving Health Practitioners’ Knowledge of Transgender Health Care:
Measuring the Efficacy of the ECHO Project
Transgender (trans) is an umbrella term used to describe individuals with gender dysphoria. Gender dysphoria involves a conflict between a person’s assigned sex and gender at birth, and the gender in which a person identifies (Reisner, Radix, & Deutsch, 2016). There is currently no exact data on the number of trans people in Canada, however, it is estimated that 1 in 200 people in Ontario alone identify as trans (Scheim & Bauer, 2015). Many trans people undergo the process of gender affirmation, where trans individuals receive recognition and support of their gender identity and expression through social, medical, and legal approaches (Reisner, Radix, & Deutsch, 2016). In addition to unique gender-affirming health requirements, trans people also have primary and preventative health care needs that are similar to the general population (Safer et al., 2016). However, despite increasing social support, literature shows that the trans population continues to endure a variety of health disparities and lack access to adequate health care (Carabez, Eliason & Martinson, 2016).
Factors behind barriers to accessing health care in the trans population are multifaceted. Patient circumstances related to fear of discrimination and stigma, financial barriers surrounding hormone therapies and gender-affirming surgeries, and socioeconomic factors have been described in literature (Safer et al., 2016). Health systems issues, including inappropriate electronic records, forms, lab references, and inadequate clinic facilities have also been suggested (Safer et al., 2016). However, among these barriers, research shows that the single largest component to inhibiting access to care is the lack of competent health care providers that are knowledgeable in trans health (Safer et al., 2016). Emerging studies suggest that integrating culturally competent trans health care into health professionals’ curriculum can improve knowledge, attitudes and overall trans health (Yingling, Cotler & Hughes, 2016). However, trans-specific care is not taught in conventional curricula and remains to be a low priority for educational institutions (McDowell & Bower, 2017; Paradiso & Lally, 2018). In fact, many health care providers have acknowledged discomfort in caring for trans patients due to the lack of knowledge, resources, uncertainty, and fear (Paradiso & Lally, 2018). As a result, health practitioners continue to care for trans patients inadequately, while patients fear discrimination and encounters with practitioners who lack knowledge of their specific health care needs (Carabez, Eliason, & Martinson, 2016).
The consequences of barriers described have resulted in a lack of access not only to trans-specific care, but also to primary and preventative health services, resulting in the delayed treatment of routine health issues (Safer et al., 2016). For example, a recent study completed at St. Michael’s Hospital in Toronto reported that screening rates for cervical, breast and prostate cancer are extremely low for the trans population (Kiran et al., 2019). The study found that trans patients were 70% less likely to be screened for breast cancer, 60% less likely to get tested for cervical cancer, and 50% less likely to be screened for colorectal cancer (Kiran et al., 2019). Patients who have transitioned through hormone therapy and gender-affirming surgeries are also found to have misconceptions regarding their heath care needs, and thus require better guidance from knowledgeable health practitioners (Kiran et al., 2019; Vogel, 2014). There is therefore a call for research to be conducted to further determine the gaps in knowledge and biases of current health practitioners, and a specific need to determine whether health providers receive adequate training in trans care (Safer et al., 2016). Researchers in support of improving access to trans care call on health providers to further determine gaps in knowledge, assist in generating solutions, and validate the effectiveness of proposed solutions (Safer et al., 2016)
As an answer to the call on improving health provider knowledge and trans health care access, the Centre for Addiction and Mental Health and the University of Toronto launched the ECHO Project in May 2018. The ECHO Project is a knowledge translation method that connects health care providers in rural and underserved areas across Canada with experts on trans and gender diverse health care. The project consists of eight online videoconference sessions that are aimed at improving the knowledge and skills of allied health practitioners in order to reduce disparities and improve health care access for trans patients (Centre for Addiction and Mental Health [CAMH], 2018). The sessions are free for all interdisciplinary healthcare professionals and require only a commitment of active involvement in the peer learning community through sharing of experiences and presentation of cases (CAMH, 2018).
In a multicultural society such as Canada, it is imperative that health practitioners practice cultural competence care in their care. Culturally competent care is the ability of health care providers to effectively deliver care that meet the social and cultural needs of all patients (Canadian Nurses Association [CNA], 2010). It is a nursing standard and a component of quality practice environments that contributes to overall improved health outcomes (CNA, 2010). Given their large presence across systems of health care, nurses are uniquely positioned to alleviate the barriers faced by trans people, and are integral to creating environments that promote and integrate culturally competent trans health care (Yingling, Cotler & Hughes, 2016).
The ECHO project is a promising tool that combats the barriers to health care access by addressing the lack of knowledge and increasing the capacity of health practitioners when providing trans health care. However, its efficacy has yet to be determined. It is important to determine the validity of solutions in order to measure its adequacy and effectiveness so that wasted resources may be reduced, and further improvements can be made. The purpose of this study is to therefore determine the efficacy of the ECHO Project in increasing health provider knowledge and competency, thus improving access to and the delivery of trans health care.
- Canadian Nurses Association. (2010). Promoting cultural competence in nursing. Retrieved from https://www.cna-aiic.ca/-/media/cna/page-content/pdf-en/6—ps114_cultural_competence_2010_e.pdf
- Carabez, R. M., Eliason, M. J., & Martinson, M. (2016). Nurses’ knowledge about transgender patient care: A qualitative study. Advances in Nursing Science, 39(3), 257-271. doi:10.1097/ANS.0000000000000128
- Centre for Addiction and Mental Health. (2018). ECHO Ontario trans and gender diverse health – supporting clients with medical and surgical transitions. Retrieved from https://camh.echoontario.ca/trans-health/
- Kiran, T., Davie, S., Singh, D., Hranilovic, S., Pinto, A. D., Abramovich, A., & Lofters, A. (2019). Cancer screening rates among transgender adults: Cross-sectional analysis of primary care data. Canadian Family Physician Medecin De Famille Canadien, 65(1), e30.
- McDowell, A., & Bower, K. M. (2016). Transgender health care for nurses: An innovative approach to diversifying nursing curricula to address health inequities. The Journal of Nursing Education, 55(8), 476-479. doi:10.3928/01484834-20160715-11
- Paradiso, C., & Lally, R. M. (2018). Nurse practitioner knowledge, attitudes, and beliefs when caring for transgender people. Transgender Health, 3(1), 47-56. doi:10.1089/trgh.2017.0048
- Reisner, S. L., Radix, A., & Deutsch, M. B. (2016). Integrated and gender-affirming transgender clinical care and research. JAIDS Journal of Acquired Immune Deficiency Syndromes, 72 Suppl 3, S235-S242. doi:10.1097/QAI.0000000000001088
- Safer, J.D., Coleman, E., Feldman, J., Garofalo, R., Hembree, H., Radix, A., & Sevelius, J. (2016). Barriers to health care for transgender individuals. Current Opinion in Endocrinology, Diabetes and Obesity, 23(2), 168-171. doi: 10.1097/MED.0000000000000227
- Scheim, A. I., & Bauer, G. R. (2015). Sex and gender diversity among transgender persons in Ontario, Canada: Results from a respondent-driven sampling survey. The Journal of Sex Research, 52(1), 1-14. doi:10.1080/00224499.2014.893553
- Vogel, L. (2014). Screening programs overlook transgender people. CMAJ: Canadian Medical Association Journal = Journal De l’Association Medicale Canadienne, 186(11), 823-823. doi:10.1503/cmaj.109-4839
- Yingling, C. T., Cotler, K., & Hughes, T. L. (2017). Building nurses’ capacity to address health inequities: Incorporating lesbian, gay, bisexual and transgender health content in a family nurse practitioner programme. Journal of Clinical Nursing, 26(17-18), 2807-2817. doi:10.1111/jocn.13707
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