Thesis advisor: Susan Kelly-Weeder / Background: Stigma, discrimination, and victimization are common occurrences in the lives of TGGD persons (e.g. non-binary, genderqueer, agender, and other non-cisgender identities) in the U.S., including occurrences in healthcare settings. Additionally, TGGD people in the U.S. experience numerous disparities related to physical health, mental health, substance use, and health risk behaviors. Suicide prevalence data provide the strongest and most urgent indication that healthcare organizations, and mental health providers specifically, are not optimally meeting the needs of this marginalized, at-risk population. TGGD persons have experiences of stigma and discrimination in healthcare settings, and these experiences are directly associated with provider behaviors, staff cultural competence, and institutional policies/practices. Minority Stress Theory suggests that experiences of stigma are directly linked to health outcomes and health disparities. It also suggests disparities may be mitigated by one’s internal coping skills and by level of support available from affirming others. Purpose: This dissertation’s research sought to better understand the relationship between stigma/discrimination and sexual/gender minority (SGM) population health and to better understand the experiences of TGGD persons who receive mental health services in the United States. Therefore, this dissertation begins to address this critical need and fill the gap in science. Three discrete manuscripts are proposed to fully explicate three concepts: 1) How state-level policies may affect SGM mental health (a secondary data analysis); 2) A comprehensive understanding of TGGD persons’ mental healthcare experiences (an integrative review); and 3) TGGD persons’ inpatient mental healthcare experiences (a qualitative study). Methods: First, we conducted a secondary data analysis examining state-level inclusivity for SGM populations, and relationships with indicators of mental health and health risk behaviors in those states; we sought to determine whether and to what extent there is a relationship between states’ SGM policies and practices, and the mental health and health risk behaviors of those states’ SGM residents. Second, we conducted an integrative review examining the mental health treatment experiences of TGGD adults; we sought to synthesize and characterize the existing health literature regarding the mental health experiences of TGGD adults. Third, we conducted a qualitative descriptive study examining the inpatient mental health and substance disorder treatment experiences of TGGD adults; we sought to better understand the inpatient mental health and/or substance treatment experiences of TGGD persons and to identify and characterize facilitators of/barriers to gender-affirming care in inpatient mental health and/or substance treatment settings. Results: In Chapter Two of this dissertation, an ecological secondary analysis of the BRFSS data set showed statistically significant relationships between LGBTQ persons’ state of residence and self-reported mental health symptoms and risk behaviors of the LGBTQ persons who live there. Restrictive state policy environments were shown to function as a distal stress factor and inclusive state policy environments were shown to function as a resilience factor. In Chapter Three of this dissertation, integrative review results suggest that TGGD persons experience incidents of stigma and discrimination in mental health treatment settings. In Chapter Four of this dissertation, participants reported both stigmatizing aspects and welcoming/affirming aspects of inpatient mental health/substance treatment experiences. Conclusions: This dissertation explored the mental health of TGGD persons through a Minority Stress Theory conceptual framework, including potential distal stress factors, proximal stress factors, and resiliency factors. This program of research has made substantial and meaningful contributions towards an enhanced understanding of TGGD mental health experiences, sources of TGGD stigma, and sources of coping/resiliency. In each chapter, findings suggested the presence of MST concepts of distal stress factors, proximal stress factors, and resiliency factors. Nursing remains underrepresented in health literature, and dissertation results highlight ample opportunities to advance TGGD population health through nursing practice, nursing education, nursing scholarship, and nursing policy. / Thesis (PhD) — Boston College, 2021. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

Substantial research documents higher rates of eating disorders (EDs) in transgender and gender diverse (TGD) samples as compared to cisgender samples. The purpose of this literature review is to explore the vulnerability factors that explain poorer mental health outcomes in the TGD community and the resiliency factors that inform prevention and treatment strategies. The vulnerability factors identified include minority stress, particularly for TGD individuals with multiple nonprivileged identities; inadequate access to health care; experiences of trauma and abuse; food insecurity; co-occurring mental health disorders; and body dissatisfaction rooted in gender dysphoria. The resiliency factors identified include access to gender-affirming healthcare, community support, and family support. The implications section integrates the research on vulnerability factors and resilience factors and offers guidance for working with the TGD community in the prevention and treatment of eating disorders. These strategies include screening TGD patients for EDs with the goal of early intervention, screening ED patients for gender dysphoria, treating gender dysphoria concurrently with the ED, integrating gender issues in treatment, connecting TGD patients with community resources, supporting the families of TGD patients with EDs, and addressing access to care issues. The limitations of this body of research include the overrepresentation of privileged identities within the TGD community; complications arising from catch-all diagnostic categories; the use of instruments not designed or normed on the TGD community; insufficient statistical power of small sample sizes; discrepancies in the language; and inconsistent adherence to proposed ethical standards for conducting research about the TGD community. The lack of research on eating disorders in the TGD community means significant potential for future research. Future study is needed to determine lifetime prevalence of EDs in the TGD community, introduce or refine an assessment tool that screens for EDs in TGD samples, identify additional resiliency factors, parse out subgroup gender differences, understand intersections of privileged and nonprivileged identities, assess the effectiveness of community level interventions, and develop strategies that address access to care issues.

According to the Human Rights Campaign (n.d.), the nation’s largest LGBTQIA+ civil rights organization, there are approximately two million people living within the U.S. who identify as transgender. Gender-affirming healthcare encompasses a variety of services, including hormone therapy, surgical interventions such as genital and top surgery, and mental health services. While surgery may or may not be part of an individual’s personal transition roadmap, research indicates that gender-affirming surgery can significantly improve quality of life (Stroumsa, 2014). However, a study by De Brouwer et al. (2021) found that 65% of transgender individuals reported the desire for increased post-operative care including guidance and education regarding “what are you allowed to do and what not” to do following surgery (p. 1925). The transition process can impact a person’s occupational identity, occupational competence, and overall occupational well-being (Bar et al., 2016). Although deficits in occupational performance and satisfaction have been reported within transgender and gender-diverse (TGD) populations (Swenson et al., 2022), occupational therapy services are not typically provided or included within the gender-affirming care model. Occupational therapy services have the potential to decrease deficits experienced by TGD individuals due to the holistic nature of the profession and its focus on client-centered care. you, AFFIRMED is an innovative program that will provide occupational therapy services pre- and post- gender-affirming top surgery through a six-week program delivered virtually for improved access to healthcare services. you, AFFIRMED aims to improve post-surgical outcomes and general well-being for TGD individuals undergoing gender-affirming top surgery through the provision of individualized occupational therapy services. Furthermore, the program intends to increase the representation of occupational therapy within multidisciplinary gender-affirming healthcare services. Finally, the program intends to further improve access to occupational therapy services through telehealth modalities due to deficits in accessing qualified healthcare professionals and challenges with financial coverage of services.

"In this study we sought to compare eating disorder attitudes and behaviors, and proneness to an eating disorder ("ED proneness"), between gay men, lesbian women, and transgender and gender non-conforming (TGNC) adults. A further aim was to identify and compare risk and protective factors, and examine a mediational model based on the interpersonal theory of eating disorders (IPT-ED), whereby the association between interpersonal factors and ED proneness would be mediated by psychological constructs pertaining to the self and negative affect. Data was obtained from a larger national study of health risk and protective factors among sexual minority and gender diverse populations. The sample included 97 gay men, 82 lesbian women, and 138 TGNC adults. Participants completed the National College Health Assessment, Eating Disorders Screen for Primary Care, Patient Health Questionnaire Depression scale, Generalized Anxiety Disorder 7 scale, Self-Compassion Scale-Short Form, Negative Social Exchange subscale of the Multidimensional Health Profile, Interpersonal Needs Questionnaire, and Perceived Stigma Scale. There was a significant difference between groups in ED proneness, with lesbian women (66.7%) having a significantly higher percentage than gay men (47.6%). There was also a significant difference between groups in weight-based self-worth, with the lowest percentage in gay men (63%) and the highest percentage in lesbian women (82%), as well as dissatisfaction with eating patterns, with the highest percentage in TGNC adults (69.8%) and the lowest percentage in gay men (47.7%). There was a low percentage of inappropriate compensatory behaviors, with no significant difference between groups. Logistic regression analyses showed that the predictor variables of ED proneness were depression, perceived stigma, and self-compassion in gay men; depression in lesbian women; and self-compassion in the TGNC adults. Mediation analyses showed that thwarted belongingness (i.e., an unmet to belong) and perceived stigma had an indirect association with ED proneness that was mediated by self-compassion and depression (for perceived stigma alone) in gay men, depression in lesbian women, and self-compassion in TGNC adults. The interpersonal theory of eating disorders therefore extends to sexual minority and gender diverse populations; however, the results suggest a broadening of theoretical models and intervention programs to include the role of stigma and self-compassion."

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The nursing profession perpetuates an outdated model that fails to address the health concerns of racialized gender-diverse people. Evidence supports that this population experiences poorer health outcomes, care-avoiding habits, and incompetent healthcare providers. A literature review illuminated gaps in the nursing lens when considering gender-diverse identities outside of Whiteness. An intersectionality framework and cultural humility were used to explore the contexts in which nurses provide care. To fill this knowledge gap, the proposed research question was: How prepared are nurses to provide care to racialized gender-diverse people? A questionnaire was developed by modifying three pre-existing instruments. The online questionnaire served as a pilot feasibility study to collect preliminary baseline descriptive cross-sectional data about Ontario nurses' training, education, knowledge, attitudes, and beliefs about racialized gender-diverse people. Findings indicated potential gaps in training and education that may affect racialized gender-diverse peoples' healthcare. Recommendations are provided for future research and interventions.

The transgender and gender diverse (TGD) patient population consists of a diverse group of people with unique needs who have, unfortunately, been underserved by the medical community. These individuals share a disproportionate burden of discrimination and disease when compared to cisgender persons. However, despite this, they continue to receive inequitable treatment, and transgender health topics still comprise just a small portion of medical education training. While efforts to improve awareness and training regarding transgender health care needs are underway, these take time to gain traction. It also relies heavily on changing medical providers’ own biases. Telemedicine has been proposed as a way to potentially bridge the gap and increase the access and availability of quality, informed medical care to this community. Although telemedicine has demonstrated its ability to do this in other areas of medicine, the existing research on whether it has the capacity to do so for transgender health care delivery is scant. The majority of the existing literature on the topic consists of retrospective qualitative feedback provided during a time where telemedicine was still emerging as a commonplace medium through which medical care is provided. Therefore, this thesis proposes to perform a randomized controlled trial investigating whether instituting a hybrid telemedicine approach has the capability to expand the accessibility of specialty transgender health care services as compared to fully in person medical care while maintaining a high standard of health care quality and patient satisfaction. This study would have the capacity to help inform future health care policy and provide support for continued telemedicine offerings and reimbursement moving forward.

Between 4.8% and 26% of adults presenting to gender dysphoria clinics have an autism diagnosis. Both autistic people and gender-diverse people have higher rates of mental health conditions including anxiety and depression and more difficulties with executive functioning, all of which impact quality of life. Some work suggests that gender affirmation leads to better mental health outcomes, including better executive functioning, but this has not been studied directly in autistic adults who identify as gender-diverse or transgender. As such, we elected to explore the relationships among these variables at this intersection of gender diversity and autism. In a sample of 54 gender-diverse individuals, almost half of whom were autistic, we found that having planned, scheduled, or completed gender-affirming surgical procedures were associated with improved anxiety and depression symptoms, and with better executive functioning. We noticed that within this group there were high levels of anxiety, so much so that the anxiety appeared to be overwhelming our other analyses. In all of our analyses, increased anxiety was associated with worse executive functioning, and in many of our analyses, further steps in gender affirmation was associated with decreased anxiety. Findings suggest that clinicians can support gender-diverse people by helping them with their mental health, particularly with managing their anxiety.

Gender diverse individuals experience stigma, discrimination, and transprejudice regularly, in response to daily interactions with society. These negative experiences lead to the development of physical, mental, and emotional instability. Gender diverse individuals experience transprejudice and discriminatory experiences in transpohobic counseling environments. Furthermore, current research highlights the need for counselors to increase training and knowledge to work with gender diverse individuals. The purpose of this hermeneutic phenomenological study, grounded in a Heideggerian philosophy, was to illuminate the lived experiences of professional counselors engaging in counseling with gender diverse clients and bridge the gap in the current literature. Data were collected from 7 licensed professional counselors with experience counseling gender diverse clients. using a semistructured interview and followed a structured thematic analysis process incorporating components of interpretive phenomenological analysis, ensuring thematic saturation. The results of this study highlighted 10 major themes and seven subthemes inclusive, but not limited to education and training, understanding gender diversity issues, intentional bias, and professional experience. These study findings provide insight regarding the potential to improve counselor training and preparation. Ultimately increasing knowledge and education may impact and improve the lives for the gender diverse clients by reducing transprejudice, transphobia, and other forms of bias.