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Transgender clients at a youth mental health care clinic: Transcending barriers to access.

The current study investigated the service access pathways of transgender youth at a mental health clinic. Demographic and service information from youth (aged 17-25) at a Canadian mental health clinic (n = 1,504) was collected. Four separate chi-square analyses were conducted to measure potential differences in service access between cisgender and gender diverse clients (those identifying as transgender, gender queer, non-binary, or other). Compared to cisgender clients, transgender and gender diverse clients were significantly more likely to self-refer for treatment. These findings highlight the importance of a self-referral option for young gender diverse clients and provide needed data about the mental health service access of transgender youth.

KEY WORDS: Gender diverse, mental health, service access, transgender, youth

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Transgender and gender diverse (trans) individuals experience unique forms of discrimination, life stressors, and persecution (Hendricks & Testa, 2012). However, providing mental health services that adequately address the needs of trans individuals remains an ongoing concern for researchers, clinicians, and administrators. While the literature on the mental health of trans individuals is relatively nascent, existing research describes several concerning trends. For instance, when compared to the general population, trans individuals are almost three times more at risk of developing an anxiety disorder (Bouman et al., 2017) and experience point prevalence depression rates as high as 44.1% (Bockting, Miner, Swinburne Romine, Hamilton, & Coleman, 2013), markedly higher than the approximately 7% of adults diagnosed with major depressive disorder within a 12-month period (Pearson, Janz, & Ali, 2013). Results from the Canadian Trans Youth Health Survey indicate that almost two-thirds of younger trans youth (ages 14 to 18) seriously contemplated suicide and more than one-third had attempted suicide within the past 12 months (Veale, Saewyc, Frohard-Dourlent, Dobson, & Clark, 2015). The heightened mental health risks experienced by trans individuals extend throughout the lifespan. Compared to their cisgender counterparts, older transgender adults are at higher risk for a variety of health issues, including symptoms of depression, perceived stress, and poorer physical health (Fredriksen-Goldsen et al., 2014).

Despite these increased rates of mental health issues, trans individuals often do not access adequate mental health care. In a study of 130 transgender individuals, Shipherd, Green, and Abramovitz (2010) found that 52% of participants experienced psychological distress in the past year, but did not seek out mental health services. The authors highlighted that common barriers to accessing care (in addition to the cost of treatment) were previous negative experiences with mental health care, stigma, and fear of what treatment might entail. These barriers are consistent with the results from other studies of how trans clients use mental health services (Sanchez, Sanchez, & Danoff, 2009; Veale et al, 2015). For example, when interacting with health care systems, trans populations often experience "informational erasure," defined as a general lack of knowledge about trans individuals and trans issues, as well as "institutional erasure," which refers to insufficient policies (and lack of motivation to establish policies) that accommodate trans individuals (Bauer et al., 2009).

Mental health disparities are especially pronounced amongst trans youth (Connolly, Zervos, Barone, Johnson, & Joseph, 2016; Guss, Shumer, & Katz-Wise, 2015; Olson, Schrager, Belzer, Simons, & Clark, 2015). At the population level, Veale, Watson, Peter, and Saewyc (2017) investigated the prevalence of mental health issues amongst Canadian youth. The authors found that transgender youth in Canada are at higher risk for a variety of mental health issues, such as psychological distress and major depressive episodes, with 65% of 14-18 year old and 40% of 19-25 year old trans youth reporting seriously having considered suicide in the past year.

In contrast, 13% of 14-18-year-old and 5% of 19-25-year-old cisgender respondents (those whose gender identity corresponds with the sex they were assigned at birth) reported seriously considering suicide (Veale et al., 2017). These findings are consistent with investigations on the presenting features of trans individuals in a clinical setting. Reisner et al. (2015) found that when compared to cisgender youth, transgender youth are twice to three times more at risk of experiencing depression, anxiety, suicidal ideation, and suicide attempts, among other mental health problems.

Although existing research has begun to outline the mental health and service access pathways of trans individuals, there is limited data available about the characteristics of trans youth in a clinical mental health setting. Given that 75% of cases of mental disorder emerge before the age of 24 (Kessler et al., 2005), there is a strong impetus to understand and address the mental health needs of youth. To help better understand the mental health needs of trans youth in a clinical setting, the current study examined the service access characteristics of trans clients at a youth mental health clinic--the Youth Wellness Centre (YWC)--in Hamilton, Ontario. The objectives of this article are therefore: 1) to identify any potential service access pathways that distinguish trans and gender diverse clients from cisgender clients, and 2) to discuss ways to adequately address these needs in the broader context of transgender youth mental health care.

METHOD

Participants and Procedures

Participants were all clients of the Youth Wellness Centre (YWC; n = 1,504), which serves as an accessible, youth-friendly, community-based service working with youth with mental health concerns. The data for the current study came from clients who presented for services at the YWC between March 2015 and March 2018. The database, which is managed by clinicians at the YWC, consisted of self-reported demographic information, referral information, and basic screening measures. Participants provided written informed consent at intake to have their clinical information be inputted into the research database used in this study. Approval for this study was provided by the Hamilton Integrated Research Ethics Board.

Measures

The demographic information analyzed in the current study was referral type and self-reported gender. Youth complete screening measures electronically prior to their first appointment, which includes information on their gender with a range of options (female, male, agender, gender queer, non-binary, transgender, other (specified). In addition, if clients do not complete these measures for some reason, clinicians may also enter the clients gender once it is clearly disclosed by the client. Clients who reported their gender to be male or female were categorized as "gender conforming." Clients who identified as agender, gender queer, non-binary, transgender or other were categorized as "gender diverse." We created these higher order categories to include individuals whose gender category had an insufficient sample size to be analyzed independently. With regards to referral type, clients could be referred to the YWC by their health care provider, a family member or friend, or they could self-refer.

Statistical Analyses

Chi-square analyses were conducted for two categorical variables: gender and referral pathway. Four separate chi-square analyses were conducted. In the first, we compared the frequencies of cisgender male, cisgender female, and transgender clients (but not other gender diverse individuals) for each of the three referral pathways (family/friend, health care provider, self). In the second analysis, we collapsed all gender diverse clients (transgender, agender, gender queer, non-binary, other) into one category. The rationale for this second analysis was to determine whether any pathways identified comparing transgender to cisgender clients extended to all gender diverse clients. In the third analysis, we compared gender conforming clients (cisgender male and female) to gender diverse clients across the three referral pathways. In the fourth analysis, we collapsed "family/friend" and "health care provider" into a single referral pathway category called "other-referral," and compared gender conforming and gender diverse clients across self-referral and other-referral.

RESULTS

Demographic Characteristics

Table 1 outlines the gender characteristics of clients. Of the 1,504 clients in the research database, 882 (58.6%) identified as cisgender female, 544 (36.2%) identified as cisgender male, 56 (3.7%) identified as transgender, 8 (0.5%) identified as gender queer, 8 (0.5%) identified as non-binary, and 6 (0.4%) identified as other. When transgender, gender queer, non-binary, and other clients were considered collectively, 78 (5.19%) were defined as gender diverse while the remaining 1,426 clients (94.8%) were defined as gender conforming.

Referral Pathways

The results of the referral pathway analyses can be seen in Table 1. In terms of how clients accessed services, transgender clients were significantly more likely to self-refer (60.7%) than cisgender male (44.4%) and cisgender female (38.6%) clients, [chi square](4) = 14.026, p < .01, V = 0.068. When all gender diverse clients were included in the analysis, a similar pattern emerged: gender diverse clients were significantly more likely to self-refer (56.4%) compared to cisgender male and female clients, [chi square] (4) = 12.591, p < .05, V = 0.065. Likewise, gender diverse clients were significantly more likely to self-refer than gender-conforming clients (42.2%), [chi square] (2) = 6.105, p < .05, V = 0.064. Finally, when the referral categories were collapsed into either "self-referral" or "other-referral", gender conforming clients once again were significantly more likely to self-refer than gender diverse clients, [chi square] (1) = 6.081, p < .05, V = 0.064.

DISCUSSION

This study assessed the service access characteristics of cisgender and gender diverse clients at a youth mental health care clinic and expands upon the scant evidence examining the features of trans youth in a clinical setting. The primary finding of this study is that, across all four of our chi-square analyses, gender diverse (transgender, gender queer, non-binary, other) clients self-referred more frequently than gender conforming clients (cisgender male, cisgender female). These results highlight the utility of including a self-referral option for both transgender clients specifically, and all gender diverse clients generally.

One possible explanation for why trans and gender diverse clients self-referred more frequently is because they did not discuss their mental health concerns with a health care professional, and thus would not be referred via a health care provider. Support for this explanation comes from previous findings that trans clients are less likely to access health care services (Sanchez et al., 2009; Shipherd et al., 2010). It is also possible that trans and gender diverse clients were more willing to refer themselves to the YWC (rather than to a health care professional) given its advocacy for transgender rights and its commitment to be a gender-inclusive space. For instance, the YWC serves on community transgender advocacy coalitions and employs trans-identified staff dedicated to serving trans youth. Alternatively, the option for self-referral--a rarity for hospital-run mental health care facilities--may have empowered trans youth to get the help they needed on their own terms, as opposed to a more formal medical referral.

Future research might consider further investigating the factors influencing trans youth mental health service access, which would examine the specific factors that make a self-referral option particularly beneficial to this population. Regardless of the mechanism responsible for the increased frequency of self-referred trans and gender diverse youth, this is the first study (to our knowledge) that demonstrates this mental health care service access pathway for trans youth. This finding is particularly important given that most mental health concerns emerge before the age of 24 (Kessler et al., 2005), that trans youth experience mental health concerns at high rates (Reisner et al., 2016; Veale et al., 2017), and that trans individuals often do not adequately access health services (Shipherd et al., 2010).

There are several limitations of the present study that must be considered when interpreting its results. First, the effect sizes for each chi-square analysis were small, indicating that although the results of these tests were statistically significant, the relationship between gender and referral pathway was modest. This small effect size may reflect the multifarious factors influencing referral pathway beyond ones gender. Second, the number of transgender and gender diverse clients in our sample is relatively small, which limits our ability to make inferences about the trans youth population. However, this limitation is inherent in studying a population that comprises a small fraction of the general population. In fact, the proportion of trans clients (3.7%) and gender diverse clients (5.2%) in our sample might actually be over-representative of estimates about the proportion of trans individuals at the population level which range between 0.3% (Gates, 2011) to 0.5% (Conron, Scott, Stowell, & Landers, 2012) of the adult population. A third limitation is the limited number of non-transgender gender diverse clients (e.g. agender, gender queer, non-binary, other). These groups of clients were not analyzed individually given their small size. Unfortunately, this broad categorization does not capture the unique psychosocial issues that impact different gender minority subgroups (Warren, Smalley, & Barefoot, 2016). A fourth limitation of this study is that our data are incomplete, despite having a large sample--only clients with complete data (i.e. both referral pathway information and gender information) were analyzed. Clients may present at intake but may not complete some of our measures because they do not attend another session. Additionally, we do not make assumptions about the gender of clients; we instead enter a client's gender into our database once it has been disclosed or asked directly. Thus, clients who leave treatment prematurely may not have disclosed their gender. However, although our data is incomplete, it is an ecologically valid and naturalistic description of the mental health service use of transgender youth at a busy mental health care clinic. As a result, our findings provide a necessary contribution to limited existing research on transgender youth in a mental health care context.

CONCLUSION

The present study has provided much-needed data towards the advancement of trans and gender diverse youth mental health care. Our results demonstrate that trans and gender diverse individuals were significantly more likely to self-refer compared to cisgender male and female clients. Thus, the majority of transgender and gender diverse clients may not have accessed our services without the option to self-refer. These findings highlight the positive impact of providing a self-referral option for gender-nonconforming youth seeking mental health services as this option may make these services more accessible to these individuals.

REFERENCES

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Connolly, M. D., Zervos, M. J., Barone, C. J., Johnson, C. C., & Joseph, C. L. M. (2016). The mental health of transgender youth: Advances in understanding. Journal of Adolescent Health, 59(5), 489-495. https://doi.org/10.1016/j.jadohealth.2016.06.012. Medline:27544457

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Kessler, R. C., Berglund, P., Demler, 0., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of distributions of DSM-IV disorders in the national comorbidity survey replication. Archives of General Psychiatry, 62(June), 593-602. https://doi.org/10.1001/archpsyc.62.6.593. Medline:15939837

Olson, J., Schrager, S. M., Belzer, M., Simons, L. K., & Clark, L. F. (2015). Baseline physiologic and psychosocial characteristics of transgender youth seeking care for gender dysphoria, Journal of Adolescent Health, 57(4), 374-380. https://doi.org/10.1016/j.jadohealth.2015.04.027. Medline:26208863

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Sanchez, N. F., Sanchez, J. P., & Danoff, A. (2009). Health care utilization, barriers to care, and hormone usage among male-to-female transgender persons in New York City. American Journal of Public Health, 99(4), 1431-1438. https://doi.org/10.2105/ajph.2007.132035. Medline:19150911

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Eamon G. H. Colvin (1) Juliana I. Tobon (2,3), Lisa Jeffs (2), and Albina Veltman (3)

(1) School of Psychology, University of Ottawa, Ottawa, ON

(2) Youth Wellness Centre, St. Joseph's Healthcare Hamilton, Hamilton, ON

(3) Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON

Acknowledgements: The authors would like to thank all of the staff and clinicians at the Youth Wellness Centre for their work in maintaining and updating our research database.

Correspondence concerning this article should be addressed to Eamon G. H. Colvin, PhD Candidate, School of Psychology, University of Ottawa, Faculty of Social Sciences, 136 Jean-Jacques Lussier, Vanier Hall, Ottawa, ON KIN 6N5 Canada. Telephone: 613-882-3969. E-mail: ecolv008@uottawa.ca
Table 1. Gender Characteristics and Referral Type Amongst Clients

                       Gender Conforming, n (%)       Gender Diverse,
                                                          n (%)

Gender                    Male            Female       Transgender

                    544 (36.2)          882 (58.6)   56 (3.7)
Referral Type       Male                Female       Transgender
  Family/Friend     102 (18.8)          129 (14.6)   6 (10.7)

  Provider          232 (42.6)          361 (40.9)   16 (28.6)

  Self              210 (38.6)          392 (44.4)   34 (60.7)

Referral Type       Male                Female       Gender Diverse
  Family/Friend     102 (18.8)          129 (14.6)   10 (12.8)

  Provider          232 (42.6)          361 (40.9)   24 (30.8)

  Self              210 (38.6)          392 (44.4)   44 (56.4)

Referral Type       Gender Conforming                Gender Diverse

  Family/Friend     231 (16.2)                       10 (12.8)

  Provider          593 (41.6)                       24 (30.8)

  Self              602 (42.2)                       44 (56.4)

Referral Type       Gender Conforming                Gender Diverse

  Other             824 (57.8)                       34 (43.6)

  Self              602 (42.2)                       44 (56.4)

                        Gender Diverse, n (%)

Gender              Gender    Non-binary    Other    Test statistic
                     Queer

                    8 (0.5)   8 (0.5)      6 (0.4)
Referral Type
  Family/Friend                                      [chi square](4) =
                                                     14.026 **
                                                     V = 0.068.

  Provider

  Self

Referral Type
  Family/Friend                                      [chi square](4) =
                                                     12.591 *
                                                     V = 0.065

  Provider

  Self

Referral Type

  Family/Friend                                      [chi square](2) =
                                                     6.105 *
                                                     V = 0.064
  Provider

  Self

Referral Type

  Other                                              [chi square](l) =
                                                     6.081 *
                                                     V = 0.064
  Self

* p < .05, ** p < 0.01.
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Author:Colvin, Eamon G.H.; Tobon, Juliana I.; Jeffs, Lisa; Veltman, Albina
Publication:The Canadian Journal of Human Sexuality
Geographic Code:1CANA
Date:Dec 1, 2019
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