Research & Study Results

Journal Articles

The publication of research findings in peer-reviewed journals is an important step in making data more widely available. Peer-reviewed publications also provide a much stronger validation and authority to research findings. This authority is important for health professionals as well as those working in other fields where evidence-based practice requires that professional practice is built on data published in such venues. While they are very important for these reasons, we realize that journal articles should not be the only output of a research project. We recognize that peer-reviewed journal articles are not accessible, financially or conceptually, to the vast majority of people. Articles are expensive to purchase if one is not connected to a post-secondary institution. In response to the cost issue, we aim to publish as many of our articles as possible in open-access journals. These journals allow everyone access to the publication at no cost. Articles from journals that are not open access can be requested through forms on this website, located to the left of the respective article abstract.

Health care availability, quality, and unmet need

A comparison of transgender and cisgender residents of Ontario, Canada

Evidence suggests that transgender (trans) individuals in Canada are a medically underserved population; barriers range from lack of provider knowledge on trans issues to refusal of care. This paper provides the first formal estimation of health care inequalities between trans and cisgender individuals in Ontario, Canada.

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Heavy Episodic Drinking Among Transgender Persons

Disparities and Predictors

Drawing on a survey of transgender people in Canada’s most populous province, we estimate the frequency of heavy episodic drinking (HED), compare HED prevalence to the age-standardized background population, and examine associations with socio-demographics, gender transition, and social exclusion.

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Factors Impacting Transgender Patients’ Discomfort with Their Family Physicians

A Respondent-Driven Sampling Survey

Representing approximately 0.5% of the population, transgender (trans) persons in Canada depend on family physicians for both general and transition-related care. However, physicians receive little to no training on this patient population, and trans patients are often profoundly uncomfortable and may avoid health care. This study examined factors associated with patient discomfort discussing trans health issues with a family physician in Ontario, Canada.
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Intervenable Factors Associated with Suicide Risk in Transgender Persons

A Respondent Driven Sampling Study in Ontario, Canada

Across Europe, Canada, and the United States, 22–43 % of transgender (trans) people report a history of suicide attempts. We aimed to identify intervenable factors (related to social inclusion, transphobia, or sex/gender transition) associated with reduced risk of past-year suicide ideation or attempt, and to quantify the potential population health impact.
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Intersecting Impacts of Transphobia and Racism on HIV Risk among Trans Persons of Colour in Ontario, Canada

Minority stress theory suggests enhanced HIV risk for those experiencing social marginalization, while an intersectionality framework posits that forms of marginalization may interact. The purpose of this paper is to understand how race/ethnicity- and gender-based discrimination may impact HIV risk among transgender or transsexual (trans) people.

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Barriers to Well-being for Aboriginal Gender-diverse People

Results from the Trans PULSE Project in Ontario, Canada

Despite health inequities experienced by Aboriginal and transgender (trans) communities, little research has explored the well-being of Aboriginal trans (gender-diverse) people. This paper aims to describe barriers to well-being in a sample of Aboriginal gender-diverse people in Ontario, Canada.

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Sex and Gender Diversity Among Transgender Persons in Ontario, Canada

Results From a Respondent-Driven Sampling Survey

Recent estimates suggest that as many as 1 in 200 adults may be trans (transgender, transsexual, or transitioned). Knowledge about dimensions of sex and gender in trans populations is crucial to development of inclusive policy, practice, and research, but limited data have been available, particularly from probability samples.

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‘Community Control’ in CBPR

Challenges Experienced and Questions Raised from the Trans PULSE Project

Newer forms of community-based participatory research (CBPR) prioritize community control over community engagement, and articles that outline some of the challenges inherent in this approach to CBPR are imperative in terms of advancing knowledge and practice. This article outlines the community control strategy utilized by Trans PULSE, an Ontario-wide research initiative devoted to understanding the ways in which social exclusion, cisnormativity (the belief that transgender (trans) identities or bodies are less authentic or ‘normal’), and transphobia shape the provision of services and affect health outcomes for trans people in Ontario, Canada. Read more

Reported Emergency Department Avoidance, Use, and Experiences of Transgender Persons in Ontario, Canada

Results From a Respondent-Driven Sampling Survey

Transgender, transsexual, or transitioned (trans) people have reported avoiding medical care because of negative experiences or fear of such experiences. The extent of trans-specific negative emergency department (ED) experiences, and of ED avoidance, has not been documented.

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Suicidality among Trans People in Ontario/ La suicidabilité parmi les personnes trans en Ontario

Implications for social work and social justice

Abstract: While transgender and transsexual (trans) communities have been documented to experience high rates of suicidality, little attention has been paid to how this may vary based on experiences of social injustice. Using survey data from the Trans PULSE Project (n=433), we estimated that suicidal thoughts were experienced by 36% of trans Ontarians over the past year, and that 10% attempted suicide during that time. Moreover, we documented that youth and those experiencing transphobia and lack of support are at heightened risk. Suicidality varied greatly by medical transition status, with those who were planning to transition sex, but who had not yet begun, being most vulnerable. Recommendations are made for improving wellbeing in trans communities, through policy advocacy, service provision, access to transition care, and fostering accepting families and communities.

Résumé: Bien qu’on ait déjà établi que les membres des communautés transgenre et transsexuels (trans) connaissaient des taux de suicidabilité élevés, on n’a que très peu porté attention jusqu’ici à la façon dont ces taux pouvaient varier en fonction d’expériences d’injustice sociale. Read more

Nonprescribed Hormone Use and Self-Performed Surgeries

“Do-It-Yourself” Transitions in Transgender Communities in Ontario, Canada

Objectives. We examined the extent of nonprescribed hormone use and self-performed surgeries among transgender or transsexual (trans) people in Ontario, Canada.

Methods. We present original survey research from the Trans PULSE Project. A total of 433 participants were recruited from 2009 to 2010 through respondent-driven sampling. We used a case series design to characterize those currently taking nonprescribed hormones and participants who had ever self-performed sex-reassignment surgeries.

Results. An estimated 43.0% (95% confidence interval = 34.9, 51.5) of trans Ontarians were currently using hormones; of these, a quarter had ever obtained hormones from nonmedical sources (e.g., friend or relative, street or strangers, Internet pharmacy, herbals or supplements). Fourteen participants (6.4%; 95% confidence interval = 0.8, 9.0) reported currently taking nonprescribed hormones. Five indicated having performed or attempted surgical procedures on themselves (orchiectomy or mastectomy). Read more

Sexual Health of Trans Men Who Are Gay, Bisexual, or Who Have Sex with Men

Results from Ontario, Canada

Recent reports have addressed the sexual health of female-to-male transgender or transsexual people who are gay, bisexual, and/or have sex with men (trans GB-MSM) using urban convenience samples. The Trans PULSE Project conducted a multimode, respondent-driven sampling survey in Ontario, Canada, in 2009–2010. Weighted estimates were calculated for trans GB-MSM (n = 173) for sexual orientation, behavior, partners, and HIV-related risk, as well as for psychosocial stressors and sexual satisfaction. An estimated 63.3% (95% CI [50.4, 73.5]) of trans men were GB-MSM (173/227). Results indicate great diversity in sexual behavior and experiences. Implications for sexual health promotion, counseling, and medical care are addressed. Read more

High Heterogeneity of HIV-Related Sexual Risk Among Transgender People in Ontario, Canada

A Province-Wide Respondent-Driven Sampling Survey

Background  Studies of HIV-related risk in trans (transgender, transsexual, or transitioned) people have most often involved urban convenience samples of those on the male-to-female (MTF) spectrum. Studies have detected high prevalences of HIV-related risk behaviours, self-reported HIV, and HIV seropositivity.
Methods  The Trans PULSE Project conducted a multi-mode survey using respondent-driven sampling to recruit 433 trans people in Ontario, Canada. Weighted estimates were calculated for HIV-related risk behaviours, HIV testing and self-reported HIV, including subgroup estimates for gender spectrum and ethno-racial groups.
Results  Trans people in Ontario report a wide range of sexual behaviours with a full range of partner types. Read more

Prevalence of and Risk and Protective Factors for Depression in Female-to-Male Transgender Ontarians

Trans PULSE Project

Although depression is understudied in transgender and transsexual communities, high prevalences have been reported. This paper presents original research from the Trans PULSE Project, an Ontario-wide, community-based initiative that surveyed 433 participants using respondent-driven sampling. The purpose of this analysis was to determine the prevalence of, and risk and protective factors for, depression among female-to-male (FTM) Ontarians (n=207). We estimate that 66.4% of FTMs have symptomatology consistent with depression. In multivariable analyses, sexual satisfaction was a strong protective factor. Conversely, experiencing transphobia and being at the stage of planning but not having begun a medical transition (hormones and/or surgery) adversely affected mental health in FTMs.

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Depression in Male-to-Female Transgender Ontarians

Results from the Trans PULSE Project

High prevalences of depression have been reported in male-to-female (MTF) transgender communities. We explored factors associated with depressive symptomatology among MTF spectrum trans people in Ontario, using data from the Trans PULSE Project Phase II respondent-driven sampling survey (n=433 participants, including 191 MTFs with data needed for this analysis). We estimated the prevalence of depression at 61.2%. Factors associated with higher odds of depressive symptomatology included living outside of Toronto, having some college or university (vs. completed), being unemployed, and experiencing higher levels of transphobia. Increasing social support was associated with reduced odds of depressive symptomatology. Multivariable analyses suggested complex relationships between these factors, passing, and childhood abuse, which require additional study.

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“I Don’t Think This Is Theoretical; This Is Our Lives”

How Erasure Impacts Health Care for Transgender People

For people who are transgender, transsexual, or transitioned (trans), access to primary, emergency, and transition-related health care is often problematic. Results from Phase I of the Trans PULSE Project, a community-based research project in Ontario, Canada, are presented. Based on qualitative data from focus groups with 85 trans community members, a theoretical framework describing how erasure functions to impact experiences interacting with the health care system was developed. Two key sites of erasure were identified: informational erasure and institutional erasure. How these processes work in a mutually reinforcing manner to erase trans individuals and communities and produce a system in which a trans patient or client is seen as an anomaly is shown. Thus, the impetus often falls on trans individuals to attempt to remedy systematic deficiencies. The concept of cisnormativity is introduced to aid in explaining the pervasiveness of trans erasure. Strategies for change are identified.

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