RESUMO
Among transgender, non-binary, and/or gender expansive (TNG) persons, interest in medical and/or surgical forms of gender affirmation is heterogenous, as is access to those forms of medically necessary health care. Yet, the literature characterizing TNG persons' interest in medical and/or surgical gender-affirming care, barriers to accessing that care, and how societal narratives and expectations impact TNG individuals' self-image and mental health, as well as their personal choices regarding gender-affirming care remains sparse. Here we present qualitative research exploring TNG participants' interest in gender-affirming care and how such interventions impact identity formation. We conducted loosely structured interviews with a convenience sample of 54 TNG persons in the U.S. and Canada from Facebook pages used to recruit TNG research participants. One-hour interviews were conducted by an openly TNG researcher; participants were compensated. The most frequently sought gender-affirming care was hormone therapy, followed by chest ("top") surgery, genital ("bottom") surgery, electrolysis, breast augmentation, hysterectomy, and voice training. Less commonly desired interventions included fertility preservation, facial feminization/masculinization, and vocal surgery. Participants described four main categories of access barriers: financial (e.g., cost of medical/surgical care, inadequate insurance), logistical (e.g., no local providers, gatekeeping policies around body size and mental health, pandemic-related delays), personal fears about sub-optimal outcomes (e.g., complications, loss of sensation, undesired aesthetic and/or functional results), and societal discrimination (e.g., familial rejection, job loss, safety concerns). Participants reported primarily seeking this healthcare for social legibility, alleviating dysphoria/pursuing euphoria, and/or gender exploration. All who sought gender-affirming care reported improved mental health-including depression, anxiety, dissociation, and eating disorders-and social relationships, though many struggled to find TNG-competent mental health providers. This work provides key insights into how gender-affirming care can contribute to improving mental health for TNG communities, which will assist health providers in optimally treating TNG patients.
RESUMO
BACKGROUND: Suicide attempts and suicide death disproportionately affect sexual and gender minority emerging adults (age 18-24 years). However, suicide prevention strategies tailored for emerging adult sexual and gender minority (EA-SGM) groups are not widely available. The Safety Planning Intervention (SPI) has strong evidence for reducing the risk for suicide in the general population, but it is unclear how best to support EA-SGM groups in their use of a safety plan. Our intervention (Supporting Transitions to Adulthood and Reducing Suicide [STARS]) builds on content from an existing life skills mobile app for adolescent men who have sex with men (iREACH) and seeks to target core risk factors for suicide among EA-SGM groups, namely, positive affect, discrimination, and social disconnection. The mobile app is delivered to participants randomized to STARS alongside 6 peer mentoring sessions to support the use of the safety plan and other life skills from the app to ultimately reduce suicide risk. OBJECTIVE: We will pilot-test the combination of peer mentoring alongside an app-based intervention (STARS) designed to reduce suicidal ideation and behaviors. STARS will include suicide prevention content and will target positive affect, discrimination, and social support. After an in-person SPI with a clinician, STARS users can access content and activities to increase their intention to use SPI and overcome obstacles to its use. EA-SGM groups will be randomized to receive either SPI alone or STARS and will be assessed for 6 months. METHODS: Guided by the RE-AIM (reach, efficacy, adoption, implementation, and maintenance) framework, we will recruit and enroll a racially and ethnically diverse sample of 60 EA-SGM individuals reporting past-month suicidal ideation. Using a type-1 effectiveness-implementation hybrid design, participants will be randomized to receive SPI (control arm) or to receive SPI alongside STARS (intervention arm). We will follow the participants for 6 months, with evaluations at 2, 4, and 6 months. Preliminary effectiveness outcomes (suicidal ideation and behavior) and hypothesized mechanisms of change (positive affect, coping with discrimination, and social support) will serve as our primary outcomes. Secondary outcomes include key implementation indicators, including participants' willingness and adoption of SPI and STARS and staff's experiences with delivering the program. RESULTS: Study activities began in September 2021 and are ongoing. The study was approved by the institutional review board of the University of Pennsylvania (protocol number 849500). Study recruitment began on October 14, 2022. CONCLUSIONS: This project will be among the first tailored, mobile-based interventions for EA-SGM groups at risk for suicide. This project is responsive to the documented gaps for this population: approaches that address chosen family, focus on a life-course perspective, web approaches, and focus on health equity and provision of additional services relevant to sexual and gender minority youth. TRIAL REGISTRATION: ClinicalTrials.gov NCT05018143; https://classic.clinicaltrials.gov/ct2/show/NCT05018143. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/48177.