Transgender people still face various types of discrimination, threat and violence on a global level. Even though the work against this societal problem proceeds in Sweden, studies have shown that transgender people often feel disrespected and discriminated within the health care context. This study aims to find a deeper understanding of discrimination against transgender people within the Swedish health care system, by analyzing and interpreting the stories of nursing students on the treatment of transgender people. In addition to this, the study aims to understand which social norms and values that are taught to the students in relation to discrimination against transgender people, and how the students relate and present themselves in relation to the social norms and values.  In order to analyze the results of the study various theories and concepts are being used, such as queer theory, new institutionalism, stigma and Goffman’s dramaturgical perspective. The study is based on semi-structured interviews with eight nursing students, studying semester three to six at various universities in Sweden. The outcome of the study shows that three main norms and values seem to be of importance to the maintenance of institutional discrimination against transgender people within the Swedish health care system. These are the societal heteronorm, knowledge gap about transgender people, and stigmatization. The nursing students carry varying degrees of knowledge about trans gender people, but all participants seem to be open and receptive to the thought of meeting and caring for a transgender person in their future worklife.

Family acceptance is life-saving for transgender and gender expansive youth (TGEY) and is predictive of TGEY mental health (Olson, Durwood, DeMeules, & McLaughlin, 2016; Olson- Kennedy et al., 2016; Pariseau et al., 2019; Ryan, Huebner, Diaz, & Sanchez, 2009). Family related factors such as stress, minority stress factors, lack of knowledge, isolation, and gendered expectations may make it difficult for parents to support TGEY. Multifamily group services (MFGs) target parental behaviors, attitudes, and parental minority stress to increase family acceptance of TGEY (Malpas, Glaeser, & Giammattei, 2018). MFGs have yet to be quantitatively evaluated for their impact on parental behavior and attitude change and parental minority stress. Using a real-world effectiveness approach, this study proposed to expand the field by examining the relationship of MFGs on parental behavior and attitude change and parental minority stress over time. It was hypothesized that parents would increase their affirmative attitudes and behavior over time and that parental minority stress would decrease over time as based on MFG attendance. It was also hypothesized that parental attitudes and behaviors would predict parental minority stress toward TGEY after attending MFGs. Results suggest that hypotheses were partially supported as mothers increased affirmative behavior and attitudes throughout the intervention period, but fathers did not. For all caregivers, parental minority stress factors were predicted by affirmative behaviors and attitudes. Conclusions and implications are discussed.

In 2011 the National Academy of Medicine identified research gaps related to transgender populations and suggested a research agenda that included, among other goals, investigating health outcomes related to transition related care. The overarching goal of this dissertation therefore is to add to the body of knowledge about the state of health of transgender individuals, including utilization of gender-affirming care, preventive care and screening practices for human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). This dissertation includes three manuscripts. The first is a retrospective chart review including 1670 transgender patients, aged 18 and up (mean age 35.57 years), at a community health center to examine utilization of gender-affirming procedures as well as investigate the prevalence of smoking and uptake of colon cancer screening compared to New York City benchmarks using data from the New York City Community Health Survey (NYC CHS). The results revealed transgender individuals had high uptake of gender affirming hormones (81.9%) but fewer had undergone gender-affirming surgeries (31.5%). Transgender individuals had almost double the rate of current cigarette smoking compared to adults aged 18 and up in the New York City Community Health Survey (OR=1.92, 95% CI=1.61, 2.28) and also had suboptimal colon cancer screening rates compared to New Yorkers aged 50 and older (OR=0.16, 95% CI=0.11, 0.23). The second paper is a scoping review of the literature to investigate postoperative outcomes related to vaginoplasty procedures in transgender women. One hundred and three articles met inclusion criteria and provided information on immediate as well as long term health outcomes. The review demonstrated many inconsistencies in the timing of follow-up as well as how outcomes were measured, but provided invaluable information on the many types of postoperative issues that may be seen after vaginoplasty surgery. Lastly, the third paper examined the prevalence of HIV and STI testing behavior and prevalence of HIV infection among transgender people in a community health center setting. This analysis demonstrated that HIV screening rates were lower than expected (55.7%) given the elevated HIV prevalence in the population. In the multivariate analysis the odds of HIV screening among transmasculine individuals was higher in those who had undergone gender affirming surgeries (OR=1.67, 95% CI= 1.08, 2.58), had a substance use history (OR=5.18, 95% CI=1.41, 18.99) and a history of genital warts (OR=4.64, 95%CI=1.24, 17.34). Among transfeminine individuals the odds of HIV screening were higher in those with only cisgender male partners (OR=2.18, 95% CI=1.52, 3.11), gender affirming surgery (OR=2.56, 95% CI=1.53, 4.31), substance use history (OR=2.76, 95% CI=1.23, 5.78) and genital warts (OR=2.69, 95% CI=1.20, 6.02). HIV prevalence was higher among transfeminine compared to transmasculine individuals (28.1% vs. 2.8%, p<.001). In the multivariable analysis having only cisgender male sex partners increased the odds of HIV infection among transmasculine individuals (OR=10.58, 95% CI=1.33, 84.17), while having at least a high school diploma reduced the odds of infection (OR=0.08, 95% CI=0.01, 0.72). Among transfeminine individuals increased odds of HIV-infection were seen in those who were unemployed (OR=1.7, 95% CI=1.1, 2.64) and those who had a history of genital warts (OR=2.54, 95% CI=1.37, 4.70). White individuals had a lower likelihood of HIV infection (OR=0.40, 95%CI=0.21, 0.73). Overall these three studies provide important information about transition-related, primary and preventive healthcare for transgender populations. The findings of elevated cigarette smoking, underutilization of colorectal cancer screening and low HIV and STI screening rates occurred in this study despite the fact that transgender people were engaged in medical care. Clinics and other health settings that provide transgender health services should include robust metrics for monitoring uptake of preventive health care services and work to improve uptake of services when disparities are evident.

This dissertation explores multidimensional social support across the perinatal period among sexual and gender-diverse (SGD) childbearing individuals living in the United States. The Social-Ecological Model (SEM) of Health Promotion and resilience theory guided this dissertation. Chapter One provides an overview of emerging health disparities among SGD childbearing people and compelling evidence of their risk for mental health disparities. It also identifies our limited understanding of perinatal social support among this population — an important modifiable risk factor for adverse mental health. Thus, social support was identified as a promising topic for this dissertation that could promote perinatal health and well-being among an understudied childbearing population. Chapter Two, Childbearing at the Margins: A Systematic Metasynthesis Review of Sexual and Gender Diverse Childbearing Experiences, evaluated and synthesized data from 25 studies on SGD childbearing. Three main themes were identified (1) Systematic Invisibility: Erasure, Structural Exclusion, Discrimination; (2) Creating Personhood Through Parenthood; and (3) Resilient Narratives of Childbearing. We found widespread structural and interpersonal harm and discrimination across the childbearing period while also emerging evidence of positive social experiences and resilience. Gaps in the literature were identified, including data on racially and geographically diverse SGD childbearing populations, perinatal support experiences beyond the healthcare context, and data derived from prospective studies. Chapter Three, “Through Our Resiliency We…Find Joy”: A Community-Placed Qualitative Study of Social Support Among Sexual And Gender Diverse Childbearing People, introduces The Study of Queer and Trans Perinatal Resilience and Experiences of Gestation (PREG). This chapter sought to understand perinatal risk and resilience among SGD childbearing individuals at the inter-and intrapersonal levels of the SEM — namely, coping skills and social support. Four main themes were identified: 1) Entering a New Season of Life, 2) Community is Family, 3) The Pain We Bear, and 4) Obligatory Resilience. We found that this new season of life came with unique support needs and sources of support. Support systems were robust and generally diffuse. Family formation signaled a time to heal old wounds among families of origin while simultaneously a time of increased harmful experiences and sacrifices to maintain access to support. Due to a history of stigma and discrimination, SGD individuals had well-developed coping strategies that mitigated harm. They found building a family a profoundly meaningful experience that provided great joy and purpose. Chapter Four, “You’re Preparing for People to Assess Whether You Can Have Your Own Child”: Structural Failures to Support Sexual and Gender Diverse Childbearing Parents, explores social support and social needs at the community, organizational, and policy levels of the SEM to understand how structural factors support or fail to support SGD childbearing people. Three main themes were identified: 1) When Protections Fail to Protect, 2) The Burden Is on Our Shoulders, and 3) When Privilege Is Protection. We found that despite advances in legal protection of SGD people, numerous factors undermine the ability to access protections across the childbearing journey. Thus, SGD individuals are faced with impossible choices when building their families and are forced to advocate for themselves, educate others, and pay to access structural support. Class and racial privilege may play a role in protecting SGD people from these burdens. Chapter Five summarizes the findings from the three manuscripts in this dissertation, highlighting the strength and weaknesses of the studies, and research, clinical practice, and policy implications. Taken together, the heterocisnormative framework of family formation creates structural stigma and contributes to interpersonal conflict and exclusion that may increase vulnerability to perinatal mental health disparities among SGD childbearing individuals. However, SGD individuals also demonstrated resilience by using well-developed coping strategies and robust social support networks, achieving what was for many a lifelong dream of having a family. This dissertation provides an important contribution to the scientific literature by describing and characterizing perinatal resilience and stigma at each level of the SEM and, in doing so, provides a roadmap to inform clinical practice, policy, and future research in pursuit of promoting perinatal health equity among a marginalized childbearing population.

Bakgrund: Könsdysfori är en beskrivande term som redogör för individens känslo- eller tankemässiga missnöje med det kön som tilldelats vid födseln vilket medför ett lidande för individen. Personer med könsdysfori har hög förekomst av samtidiga psykiatriska diagnoser. Syfte: Syftet med studien var att beskriva hur personal inom psykiatrin erfar omvårdnaden av personer med könsdysfori. Metod: Kvalitativ studie med semistrukturerade intervjuer. Urvalet bestod av tio respondenter arbetandes inom psykiatrisk öppenvård och slutenvård. Materialet har analyserats med tematisk innehållsanalys. Resultat: Det framkommer att patientgruppen kan upplevas som utmanande att möta utifrån olika aspekter. Detta är delvis kopplat till personalens vilja att ge god vård och bidra till minskat lidande för patienterna samtidigt som personalen ofta känner osäkerhet i mötena. Omvårdnadshandlingar sker främst via samtal och psykiatripersonalen visar delvis förståelse för patientens livsvärld och lidande. Utöver detta framkommer det också att personalen upplever kunskapsbrist och ser ett behov av ökad kunskap. Konklusion: Att möta patienter med könsdysfori kan upplevas komplext och svårt. Inom vården finns en okunskap som sannolikt adderar till redan befintligt stigma. Dock utförs omvårdnadshandlingar som ligger i linje med aktuell forskning samt nationella och internationella riktlinjer. / Background: Gender dysphoria is a descriptive term that describes the individual's emotional or mental dissatisfaction with the gender assigned at birth, which causes suffering for the individual. People with gender dysphoria have a high incidence of concomitant psychiatric diagnosis. Aim: The purpose of the study was to describe how staff in psychiatry experience the care of people with gender dysphoria. Method: Qualitative study with semi-structured interviews. The sample consisted of ten respondents working in psychiatry. The material has been analyzed using thematic analysis. Results: The results shows that the patient group can be experienced as challenging to meet based on different aspects. This is partly linked to the staff's willingness to provide good care and contribute to reduced suffering for the patients, while the staff often feel insecurity. Nursing actions take place mainly through conversations and the psychiatric staff show a partial understanding of the patient's lifeworld and suffering. In addition to this, it also appears that the staff experience a lack of knowledge and sees a need for increased knowledge. Conclusion: Meeting patients with gender dysphoria can be experienced as complex and difficult. Healthcare services sometimes lacks knowledge that probably adds to an already existing stigma. However, to some extent nursing actions are delivered in line with current research as well as national and international guidelines.

This paper investigated the discrimination against transgender people in the Swedish rental housing market, and is one of the first correspondence studies to examine this question at hand. A total of 800 applications were sent to various landlords advertising rental vacancies on Blocket.se. In total, the cisgender applicants attained a call back rate of 60.7 %, while the transgender applicants attained a rate of 59.0 %. Furthermore, no unequal treatment was found in positive employer responses for being transgender, when compared to the cisgender group. In the case, where the cisgender and transgender groups were evaluated separately, a favoring of having a woman as a tenant over a man was prominent when comparing the testers within the cisgender  group.  A penalty of 12.6 % in positive landlord responses was found for the trans man, in terms of likelihood of getting an invitation to additional contact or to showing, when compared to the cis woman. Similarly, the trans woman had a 7.4 % lesser likelihood in getting an invitation to showing than the cis woman. With regards to these results, one can conclude that there exists both discrimination based on gender and gender identity in the rental housing market in Sweden.

Bakgrund: Transpersoner är en minoritetsgrupp i samhället som historiskt sett av sjukvården blivit behandlad annorlunda, exempelvis då det tidigare har setts som en psykisk sjukdom. Idag ser situationen annorlunda ut och transpersoner har samma rättigheter till god vård som andra patienter och har vissa särskilda behov. Sjuksköterskor har ett ansvar gentemot sina patienter att tillhandahålla vård på ett jämlikt sätt. Syfte: Syftet var att beskriva transpersoners upplevelser av vårdpersonals bemötande. Metod: Litteraturöversikt som omfattar elva vetenskapliga artiklar. Resultat: De fyra teman som framkom var vårdpersonals kunskap om transpersoner, vårdpersonals språk gentemot transpersoner, att få frågor som inte är relevanta för ens vård och stigmatisering, diskriminering och utfrysning och dess påverkan. Sammanfattning: Transpersonerna beskrev upplevelser av både positivt och negativt bemötande och en mängd olika faktorer som påverkade upplevelsen av bemötandet. Vårdpersonal som hade mer kunskap om transpersoners behov, och använde ett inkluderande språk, skapade oftare positiva upplevelser. Vid frånvaron av dessa faktorer förekom det att transpersoner avstod från att söka vård. / Background: Transgender persons are a minority group in society that historically has been treated differently than other patient groups in a healthcare setting. Being transgender has for example been viewed as a mental illness. Today the situation has changed, and transgender people have the same rights to healthcare as any other patient and nurses have a responsibility to provide equal care no matter the patient’s gender. Aim: The aim of the study was to describe transgender persons experiences of interactions with healthcare personnel. Method: Literature review consisting of eleven scientific papers. Results: The four themes that emerged were healthcare personnel’s knowledge about transgender people, healthcare personnel’s language toward transgender people, receiving questions that are not relevant to your care, and discrimination and being excluded. Summary: Transgender people described both positive and negative interactions with health personnel and different factors affected the interactions. The use of inclusive language and general knowledge about transgender patients led to more positive experiences. Transgender people who experienced an absence of these factors sometimes avoided seeking healthcare.

The Kin Selection Hypothesis proposes that the genes associated with male androphilia (i.e., sexual attraction/arousal to adult males) may be maintained over evolutionary time if the fitness costs of not reproducing directly are offset by increasing one’s indirect fitness. Theoretically, this could be accomplished by allocating altruism toward kin which would increase the recipient’s ability to survive and reproduce. Evidence for this hypothesis has been garnered through research conducted in Samoa however, no support has been garnered from research conducted in more industrialized cultures (i.e., USA, UK, Japan). In this thesis, I use a Canadian population to examine: (1) the role geographic proximity plays in the expression of androphilic male avuncularity and (2) whether androphilic males direct altruism toward the children of friends who might represent proxies for nieces and nephews in more industrialized cultures. Other sociocultural factors that potentially influence the expression of androphilic male avuncularity are also discussed. / ix, 81 leaves ; 29 cm

This is a comparative study between binary and nonbinary transgender people based on their everyday experience of difficulties. Previous studies show that many transpeople experience violence, infringement and oppression. Studies also show that suicide rate among transgender people is much higher than among the common (cisgender) population. Those studies rarely make an analysis based on specific gender identity, which shows the diversity among transgender people.To analyse the individual experiences, this study made four interviews with binary and nonbinary transgender people. The interviews were analysed with a queer-theoratical perspective to show and focus on the oppressional mechanics that heteronormativity has. The results show clear differences and similarities between binary and nonbinary transgender people's experiences of everyday life difficulties and oppression. Nonbinary transgender people elucidate their nonexistence in the majorities knowledge as a big difficulty; that people in their everyday surroundings and society in general are not aware of them. Binary transgender people's experiences have instead been focusing on their bodies and social context of their transitions. / Denna studie avser att undersöka och jämföra transpersoners erfarenheter kring svårigheter i vardagen. Jämförelsen görs mellan binära och ickebinära transpersoner. Tidigare forskning visar att många transpersoner blir utsatta för våld, kränkningar och förtryck. Den visar även att självmordsfrekvensen bland transpersoner är mycket högre än hos populationen i övrigt. I dessa undersökningar kring transpersoners hälsa och situation görs det sällan eller aldrig analyser baserade på den mångfald gällande identitet som finns inom gruppen transpersoner. För att undersöka dessa individuella erfarenheter genomfördes ett antal intervjuer med binära och ickebinära transpersoner. Intervjuerna analyserades utifrån en queerteoretisk utgångspunkt för att belysa de förtryckande mekanismer som heteronormen medför. Resultatet visar att det finns tydliga likheter och skillnader i binära och ickebinära transpersoners erfarenheter kring svårigheter och förtryck. Ickebinära transpersoner tar upp omgivningens omedvetenhet kring deras existens som en stor svårighet, att personer i deras vardagliga omgivning och i samhället i stort inte känner till att de finns medan svårigheterna för binära transpersoner snarare har varit i förhållande till deras kroppar och sociala sammanhang.

The transgender population is makes up about 0.3% of the U.S. population (Gates 2011). The term transgender is both an identity and an umbrella term used to describe people who do not adhere to traditional gender norms (Institute of Medicine 2011). Transgender people experience many barriers to services, negative health outcomes, and discrimination (Fredrikson-Goldsen et al. 2013; Institute of Medicine 2011; Eliason et al. 2009; Hendricks & Testa 2012). Mental health clinics are an important site for understanding transgender peoples' experiences due to being a gatekeeper for other medical services and their role in helping transpeople with issues surrounding coming out, victimization, and discrimination (Grant et al. 2011; Youth Suicide Prevention Program 2011). The mental health field has a contested relationship with the transgender population due to a history of pathologizing gender variance, barriers to accessing services, and insensitivity from mental health providers (American Psychiatric Association 2013; Eliason et al. 2009). I conducted secondary data analysis using the National Transgender Discrimination Survey (2008) in order to understand the relationships between gender non-conforming identities, others' perception of one's gender identity, and discrimination at mental health clinics. Results suggest that there is an association between gender identity, others' perception of one's gender identity, and discrimination. This association depends on which gender identity, the degree to which an individual identifies with each term, and the type of discrimination. Logistic regression results reveal that identity and others' perception are not significant predictors for experiencing discrimination. Rather, income and race are significant predictors for experiencing discrimination at metal health clinics.