EXPLORING TRANSGENDER ADULTS’ PERCEPTIONS OF, AND EXPERIENCES WITH, PRIMARY AND EMERGENCY CARE IN NOVA SCOTIA by Ella Vermeir Submitted in partial fulfilment of the requirements for the degree of Master of Arts at Dalhousie University Halifax, Nova Scotia July 2016 © Copyright by Ella Vermeir, 2016 TABLE OF CONTENTS List of Tables ................................................................................................................... viii List of Figures .................................................................................................................... ix Abstract ................................................................................................................................x List of Abbreviations ......................................................................................................... xi Acknowledgements ........................................................................................................... xii Chapter 1: Introduction ....................................................................................................1 The Research Problem .........................................................................................................3 Statement of Purpose ...........................................................................................................4 Research Question ...............................................................................................................4 Scope of the Research Study ................................................................................................5 Significance of the Study .....................................................................................................8 Chapter 1 Summary .............................................................................................................9 Chapter 2: Literature Review .........................................................................................10 Terminology .......................................................................................................................10 Transgender Identity in the DSM ......................................................................................14 Transgender Identity in Nova Scotia .................................................................................17 Transgender Health Inequities Rooted in the Social Determinants of Health ...................22 Barriers to Care for Transgender Individuals ....................................................................26 Reluctance to Disclose Gender Identity .................................................................26 Health Care Provider Knowledge, Understanding, and Experience ......................29 Health Care Settings and the Wider Environment .................................................34 ii Gaps in the Existing Literature ..............................................................................37 Health Concerns in the Transgender Population ...............................................................38 Chapter 2 Summary ...........................................................................................................40 Chapter 3: Methodology ..................................................................................................43 Research Approach ...........................................................................................................43 Qualitative Approach .............................................................................................43 Research Paradigms ...........................................................................................................45 Social Constructivism ............................................................................................45 Queer Theory .........................................................................................................46 Social and Physical Environment Framework .......................................................47 Reflexivity: Researcher Identity ............................................................................48 Methodological Approach .................................................................................................52 Framework Analysis ..............................................................................................52 Research Design .................................................................................................................54 Inclusion Criteria ...................................................................................................54 Sample Size and Sampling Strategies ....................................................................54 Recruitment Strategies ..........................................................................................56 Data Collection and Analysis .............................................................................................58 Data Collection ......................................................................................................58 Interview Questions ...............................................................................................61 Data Analysis .........................................................................................................62 Ethical Considerations .......................................................................................................66 Participant Vulnerability ........................................................................................66 Informed Consent ...................................................................................................67 iii Confidentiality and Anonymity .............................................................................67 Potential Harms and Benefits to Participants .........................................................69 Data Quality and Trustworthiness .....................................................................................70 Study Limitations ...............................................................................................................72 Knowledge Transfer ...........................................................................................................74 Chapter 3 Summary ...........................................................................................................75 Chapter 4: The Importance of Relationships ................................................................76 Participants’ Socio-Demographic Profile ..........................................................................77 Theme 1: The Importance of Relationships .......................................................................81 Relationships with Health Care Providers and Staff ..............................................81 Provider/Staff Knowledge .........................................................................82 Provider/Staff Sensitivity ...........................................................................91 Client Providing Education for Provider/Staff ........................................105 Provider/Staff Attitudes ...........................................................................110 Impact of the Clients’ Personal Attitude on the Relationship with Provider/Staff ...........................................................................................115 Comparing Physicians and Nurses ...........................................................118 Relationships with Peers, Family, and Community .............................................118 Interpersonal Social Support ....................................................................119 Secondhand Experiences: The Impact of Witnessing or Hearing About Peers’ Health Care Encounters .....................................................120 Relative Gratitude ....................................................................................122 Impact of the Transgender “Community” ................................................123 Chapter 4 Summary .........................................................................................................125 iv Chapter 5: The Influences of the Physical and Social Environments .......................127 Theme 2: The Role of Place and the Physical Environment ...........................................127 Place .....................................................................................................................127 Geographic Place: Rural Versus Urban Experiences ...............................128 Site of Care: Continuity of Care and the Impact of Having a Family Physician ..................................................................................................132 Site of Care: Occasional Care Environments ...........................................134 Physical Environment ..........................................................................................136 Washrooms ..............................................................................................136 Information and Resources ......................................................................138 Indications of a “Safe Space” ..................................................................141 The Physical Organization of Health Care Environments: Waiting Rooms, Changing Rooms, and Emergency Departments ........................143 Intake Forms ............................................................................................146