A guide with lived experience of gender diversity and a primary care setting made patients feel safer.
The lived experience of trans and gender diverse (TGD) “peer navigators” working on the frontline of gender-affirming health care in a primary care setting is key to improving access to safe and accessible treatment for patients.
The 2021 Health and well-being of transgender Australians national community survey showed that just 34% of respondents described their health as “very good” or “excellent”, with self-reported diagnoses of depression and anxiety running at 73% and 67% respectively. Barriers to care-seeking for TGD people include a lack of both cultural safety and trans-friendly environments.
In Australia, most gender-affirming hormone treatment is delivered in acute clinics in major metropolitan settings, a situation which not only reduces access to those TGD people living outside big cities, but also creates a culture of “medicalisation and pathologisation” that disincentivises TGD patients from seeking care.
Moving gender-affirming hormone treatment into primary care settings has been touted as a possible way of improving healthcare outcomes for TGD people. Providing peer navigators – TGD healthcare workers with lived experience to guide clients – is another.
Research published in the Australian Journal of Primary Health this week evaluated the first two years of the Trans and Gender-Diverse People in Community Health (TGDiCH) program, the first in Australia to provide gender-affirming hormone treatment in a primary care setting, using a peer navigator model.
The TGDiCH program included two multidisciplinary clinics, one in regional Victoria and one in metropolitan Melbourne, with links to a gender clinic, a statewide training program for healthcare professionals, and peer navigators.
“The PN model was intended to optimise engagement with mainstream health through reduction of stigma and establishing a culturally safe environment,” wrote the authors, led by Dr Samantha Clune from La Trobe University.
“Clients were directed to the peer navigator as the first point of contact at either location, whereupon they were able to describe their health priorities and desired outcomes.”
For many clients, the peer navigator completely changed their health care experience.
“When I first reached out to the peer navigator, I was feeling very unsupported and like I had no knowledge or access to the mental health networks which I needed,” said one participant in the metropolitan location. “They helped me figure out a pathway through all of that.”
A client in the regional setting articulated a common concern: “I wanted a validating experience of something to be celebrated, not something to be pathologised,” they said. “Seeing that there was a peer navigator was a positive thing.”
Clune et al wrote that the client feedback they had gathered as part of their research showed that “because of the presence of the peer navigator, services were perceived to be more ‘appropriate’ and clients developed an increased ‘ability to engage’ with a more appropriate model of care”.
“[The] value of the peer navigator and informed consent models within gender-affirming hormone treatment and the location of services in primary care, particularly community health services, were integral aspects of program success,” they wrote.
“Increasing the number of service locations has done little to affect Tudor-Hart’s inverse care law – whereby services most needed by identified population groups are often difficult to access – but the addition of peer navigation [has created] an environment where TGD people are more likely to present for care.”
While The TGDiCH program has proved a winner with TGD clients, staff and stakeholders raised key concerns such as financial sustainability and longevity of the program.
“We work off the smell of an oily rag sometimes … because we’re not charging gap fees, so we just go off Medicare,” said one metropolitan staff member.
The personal vulnerability of peer navigators was also seen as a concern.
“[Peer navigators] draw from their lived experience while dealing with clients who may have complex trauma,” wrote Clune et al.
“There was a clear sense of the need to protect the peer navigators, understanding the complexity of working within, and representing, a system that can be traumatising to both peer navigator and client alike.”
There is hope that the TGDiCH program will both ease pressure on acute clinics, while increasing access and safety for TGD clients.
“The key elements for success of the TGDiCH program are the PN model, Informed Consent and availability of appropriate community-based, gender-affirming care for TGD people,” Clune and colleagues concluded.
“By moving gender-affirming hormone treatment into the community health setting, potential access is increased in real terms.
“However, the key to effective engagement and utilisation is the introduction of a peer navigator into the model of care.”
