Multilevel Understanding of a Health Issue
Multilevel Approaches to Understanding Health - Beyond the Individual
Social epidemiology examines how social factors and determinants have an effect on not just individual, but entire population health (Honjo, 2004). Socioeconomic advantages and disadvantages play an important role in a broad range of health outcomes. For example, disadvantaged pregnancies are more likely to yield premature births, disadvantaged working adults are more likely to retire early due to disability and individuals with increased advantages do not suffer the same adverse health outcomes (Kawachi, 2018).
Working in frontline healthcare has me constantly updating my knowledge base. Genderqueer, non binary, nonconforming.....all words I have heard at home and at work, but have to look up the definitions. I have decided to use a Social Ecological Model to examine health disparities, particularly mental health, for transgender and nonconforming persons.
Davidson (2007) identified transgender as an umbrella term for individuals whose gender identity or expression differs from the gender associated with their assigned birth sex. Transgender individuals define their gender identity and express their gender in a variety of ways, which may vary according to racial/ethnic background, socioeconomic status, and place of residence (Valentine, 2007). A person can transition socially (names, pronouns, social) and/or medically (cross-sex hormones, surgery) (Davidson, 2007).
According to Phelan et al. (2008), stigma is the social process of labeling, stereotyping, and rejecting human differences as a form of social control. Stigma creates health disparity in transgender populations, due to the fact that it causes stress (which adversely affects health) and limits access to 'health protective resources' (knowledge, money, power) (Hatzenbuehler et al., 2013).
The socio-ecological model (Baral et al., 2013), can be used to break the experience of stigma into three categories - structural, interpersonal, and individual. Structural stigma pertains to society's norms and policies that restrict a person/population's access to resources. Interpersonal stigma speaks to verbal and physical violence due to a person's gender identity/expression. Individual stigma is all about a person's own feelings about themselves, and how other's make them feel, which contribute to shaping their behavior and how they respond to discrimination. All three forms of stigma are commonly reported among transgender people and been found directly connected to negative health outcomes, such as depression, anxiety, suicide, substance abuse, and HIV (Clements-Nolle et al., 2006, Reisner et el., 2014).
Types of structural stigma include lack of healthcare provider training and education, healthcare access barriers, economic and gender inequality. Some structural interventions include creating non-discrimination policies, access to care policies, and increase in time to train health professionals in caring for the nonconforming population. During my nursing degree, there was no class or even major section of learning focusing purely on the healthcare needs of this marginalized population. I have been working as a full-time Registered Nurse in Dartmouth, Nova Scotia for eight years and I have received a one-hour presentation on the barriers associated with accessing healthcare for the transgender and non-conforming population. When I look at the Nova Scotia Health Authority Website there are few resources available for learning more as a frontline healthcare provider. A PDF entitled Affirmative Care for Transgender and Gender Non-Conforming People: Best Practice for Frontline Healthcare Staff (2016), is a 28-page document that speaks to some fundamental guidelines more geared towards administrative staff and the initial contact for a transgender or non-conforming individual in a healthcare setting. It does not address topics such as going to an operating room for instance . There are currently no mandatory learning modules in our health authority to educate healthcare employees.
Types of interpersonal stigma include healthcare discrimination, workplace discrimination, family rejection, hate crimes, sexual and physical assault. Some interpersonal interventions include family/partner support groups and healthcare provider training. Types of individual stigma include concealment of stigma, avoidance of stigma and internalizing of stigma, and interventions include counselling and therapy, self-affirmation, support groups, and collective activism. (White et al. 2015)
Each year about 500 Canadian youth die by suicide (StatsCan). Thirty-three percent of LGB youth have attempted suicide compared to 7% of youth in general. (Saewyc, 2007). The LGBTQ youth are four times more likely to attempt suicide than their heterosexual, cis-gendered peers (Massachusetts Department of Education, 2009)
The following are a few resources currently available and easily found on the Nova Scotia government and healthcare websites.
On the Nova Scotia Health Authority website, you can easily find the prideHEALTH webpage that hosts many resources for people to access.
"prideHealth works to improve access to health services which are safe, coordinated, comprehensive, and culturally appropriate for people who are gay, lesbian, bisexual, transgender, Two-Spirited, intersex, queer, and questioning (members of the LGBTIQ+ community). The prideHealth navigator works with individuals and groups to help members of the LGBTIQ+ community connect with:
Services within the Health System, such as STIBBI (sexually transmitted and blood borne infections) testing, and services related to gender transition
Resources in the community such as peer supports, social groups, and advocacy
prideHealth provides the following services:
Navigation through the health system
Workshops and learning opportunities on LGBTIQ+ health
LGBTIQ+ cultural competency training for health professionals and family practices
General health and wellness information
Sexual health information
Referrals for addictions, mental health, and other health services
Information and referrals for transgender and gender identity issues
prideHealth is a partnership between the NSHA and the IWK Health Centre." (NSHA Website, prideHEALTH 2018)
Another very active group in Nova Scotia is The Youth Project (https://youthproject.ns.ca). This community group is sponsored by the Nova Scotia Department of Health & Wellness and was created in 1993 to represent the gay and lesbian community at that time. It has shortened its name and expanded its mandate to support youth in Nova Scotia with their sexual and gender identity. The Youth Project also supports the 'GSA - Gay Straight Alliance ' program in collaboration with the Nova Scotia Department of Education, where youth led school groups work together to make schools a safer place for the LGBT population.
I am happy that these resources were easy to find, and very positive, informative forums to research information and access trained individuals. Every person deserves an open, kind, and safe place to experience care for their health!
References
Affirmative Care for Transgender and GenderPractices For Frontline Healthcare Staff (2016) National LGBT Health Education Center. Retrieved on November 3, 2018 from : https://www.lgbthealtheducation.org/wp- content/uploads/2016/12/Affirmative-Care-for-Transgender-and-Gender-Non- conforming-People-Best-Practices-for-Front-line-Health-Care-Staff.pdf
APA. Diagnostic and Statistical Manual of Mental Disorders, (DSM-II). Washington, DC: American Psychiatric Association; 1968.
APA. Diagnostic and Statistical Manual of Mental Disorders, (DSM-V). Washington, DC: American Psychiatric Association; 2013.
Baral, Stangl, A., Lloyd, J., Brady, L. & Holland, C. (2013) A Systemic Review of Interventions To Reduce HIV-Related Stigma from 2002 to 2013. Journal of International AIDS Society. 16(3S2).
Berkman, L., Kawachi, I. & Glymour, M. (2014) Social Epidemiology (2nd ed). Oxford University Press, New York.
Clements-Nolle, K., Marx, R. & Katz, M. (2006) Attempted Suicide Among Transgender Persons: The Influence of Gender-Based Discrimination and Victimization. Journal of Homosexuality. 51(3), 53-69.
Coburn, D. (2015) Income Inequality, Welfare, Class and Health. Social Science & Medicine. 146, 228-232.
Davidson, M. (2007) Seeking Refuge Under the Umbrella: Inclusion, Exclusion, and Organizing within the Category Transgender. Sexuality Research & Social Policy. 4(4), 60-80.
Eckersley, R. (2015) Beyond Inequality: Acknowledging the Complexity Of Social Determinants of Health. Social Science & Medicine. 147, 121-125.
Eisenberg, M., Gower, M., McMorris, J., Rider, N. & Coleman, G. (2017) Risk and Protective Factors in the Lives of Transgender/Gender Nonconforming Adolescents. Journal of Adolescent Health. 61(4), 521-526
Hatzenbuehler, ML., Keyes, KM. (2013) Inclusive Anti-bullying Policies and Reduced Risk of Suicide Attempts in Lesbian and Gay Youth. Journal of Adolescent Health. 51, S21-S26.
Honjo, K. (2004) Environmental Health and Preventive Medicine. Social Epidemiology. 9(5), 193-199.
Ichida, Y., Hiram, H., Kondo, K., Kawachi, I., Takeda, T., & Endo, H.(2013) Does Social Participation Improve Self-Rated Health in the Older Population? A Quasi-Experimental Intervention Study. Social Science & Medicine, 94, 83-90.
Kawachi, I. (2018) Social Epidemiology for the 21st Century. Social Science & Medicine, 196, 240-245.
Lawlis, S., Donkin, H., Bates, J., Britto, M. & Conard, A. (2017) Health Concerns of Transgender and Gender NonConforming Youth and Their Parents Upon Presentation to a Transgender Clinic. Journal of Adolescent Health. 61(5), 642-648.
Massachusetts Department of Education. (2009). Massachusetts High School Students and Sexual Orientation: Results of the 2009 Youth Risk Behavior Survey. Youth Risk Behavior Survey. Massachusetts. Retrieved from https://www.doe.mass.edu/cnp/hprograms/yrbs/.
Moore, S. & Kawachi, I. (2017) Twenty Years of Social Capital and Health Research: A Glossary. Journal of Epidemiology & Community Health. 71(5), 513-517. Nova Scotia Health Authority (NSHA) Website. PrideHEALTH. Retrieved November 3, 2018 from https://www.nshealth.ca/content/pridehealth
Reinsert, S., Katz-Wise, S.,Gordon, A., Corliss, H. & BrynAustin, S. (2016) Social Epidemiology of Depression and Anxiety by Gender Identity. Journal Of Adolescent Health. 59(2), 203-208.
Reisner, SL., Greytak, EA., Parsons JT. & Ybarra, ML. (2014) Gender Minority Social Stress In Adolescence: Disparities in Adolescent Bullying and Substance Abuse by Gender Identity. Journal of Sex Research, 52(3), 243-252.
The Rural Health Promotion and Disease Prevention Toolkit. (2015) Federal Office of Rural Health Policy, US Dept of Health and Human Services. Retrieved from: Https://www.ruralhealthinfo.org/toolkits/health-promotion/about-this-toolkit
Valentine, D. (2007) Imagining Transgender: An Ethnography of a Category. Durham, NC: Duke University Press; 2007.
Valentine S. & Shipherd J. (2018) Review: A Systematic Review of Social Stress and Mental Health Among Transgender and Gender Non-Conforming People in the United States. Clinical Psychology Review. Retrieved from: doI:10.1016/j.cpr.2018.03.003
White, J., Reisner, S. & Pachankis, J. (2015) Transgender Stigma and Health: A Critical Review of Stigma Determinants, Mechanism, and Interventions. Social Science & Medicine. 147, 222-231.