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Abstract
Introduction In recent years, there has been strong interest in making digital health and social tools more accessible, particularly among vulnerable and stigmatised groups such as transgender people. While transgender people experience unique physical, mental and sexual health needs, not much is currently known about the extent to which they use information and communication technologies such as short messaging service and videoconferencing to access health services. In this paper, we discuss our protocol for a scoping review of the literature about the delivery and utilisation of digitally mediated health services for transgender populations.
Methods and analysis This scoping review of the provision and experience of telemedicine among transgender people will follow the methodological framework developed by Arksey and O’Malley. The search will be conducted using three online databases, namely PubMed, CINAHL and Scopus, with additional literature explored using Google Scholar to identify grey literature. Relevant English-language studies will be shortlisted after completing a title and abstract review based on defined inclusion criteria. Following that, a final list of included studies will be compiled after a full-text review of the shortlisted articles has been completed. To enable the screening process, a team of researchers will be assigned refereed publications explicitly referring to the provision and experience of transgender healthcare through telemedicine. Screening performed independently will then collaboratively be reviewed to maintain consistency.
Ethics and dissemination The research is exempt from ethics approval since our analysis is based on extant research into the use of digital technologies in providing healthcare to transgender people. The results of this study will be disseminated through peer-reviewed academic publications and presentations. Our analysis will guide the design of further research and practice relating to the use of digital communication technologies to deliver healthcare services to transgender people.
- Telemedicine
- Organisation of health services
- sexual medicine
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Strengths and limitations of this study
This is among the first scoping reviews of the digital communication tools and methods used in the delivery of healthcare services to transgender populations.
This scoping review will identify methods that have been effective in improving healthcare uptake among transgender populations.
This scoping review will inform further research on health promotion regarding how providing healthcare to transgender populations can be improved.
This scoping review may be limited to literatures from resource-privileged and English-speaking countries because not all contexts have the resources and infrastructure to support research on, and the delivery of, telemedicine for transgender communities.
Introduction
Transgender is ‘an umbrella term for persons whose gender identity, gender expression or behaviour does not conform to that typically associated with the sex to which they were assigned at birth’.1 While gender identity can be understood as a person’s internal sense of being a man, woman or something else, gender expression refers to how a person indicates gender identity to others in society through overall behaviour, clothing, hairstyle, voice and other body characteristics.1
Despite the increasing social acceptance of gender diversity in various parts of the world, transgender people often experience social exclusion due to the stigma associated with transgressing social norms of gender.2–5 This stigmatisation generally refers to a social process embedded in various social structures (ie, family, religion, gender and law) through which social actors label and ostracise certain population segments, thereby impeding transgender persons’ access to power and resources.4 Researchers have for years been revealing that stigma associated with being transgender contributes to social disadvantage in many areas, including family, education and the formal job market, that have consequences for health.6–9
The studies reveal that negative treatment of transgender people in society further results in adverse health outcomes. For instance, transgender people who are rejected by their families are more likely to experience mental illness including depression, anxiety and suicidal ideation.6 10 11 The minority stress theory posits that transgender people routinely experience stressful events including prejudice and discrimination—not usually encountered by their cisgender counterparts—that negatively affect their psychological well-being.12 Various researchers have used minority stress theory and found a significant association between social stress and psychiatric problems among transgender people.13–15 Additionally, a lack of family support, as well as joblessness, means that transgender people may engage in survival sex, placing them at greater risk of HIV and other sexually transmitted infections (STIs),9 16–18 with the Joint United Nations Programme on HIV/AIDS finding that nearly 19% of the transgender women worldwide live with HIV.19 Also, transgender people’s likelihood of substance misuse often increases due to a lack of social support, lack of adequate financial resources, health issues and peer pressure.20–22
In addition to the heightened risk of HIV/STIs, mental distress and drug/alcohol use, transgender people often have unique health needs regarding gender affirmation. The fundamental aim of gender affirmation is to affirm a person’s sense of self.23 Understanding gender affirmation is not always straightforward, as transgender people may choose various ways including social/legal/medical interventions to achieve it.24 For youth, gender affirmation may encompass social and/or medical transitions (ie, puberty blockers, gender-affirming hormone treatment and sometimes surgery).25 To address ethical dilemmas about transitioning before legal adulthood, families, schools and medical/clinical institutes are involved in providing gender affirmation to transgender youth.25 26 In addition to social and medical transitions, transgender adults may also pursue legal transition by changing their name and gender identity markers in institutional records.27 Experiences regarding gender affirmation care significantly vary specifically among those who have completed the transition process, those undergoing it, and those who intend to do it, and hence, it requires adequate healthcare resources. While gender affirmation care is completely missing in many resource-poor and conservative settings, transgender people may experience challenges in utilising it due to discrimination in healthcare settings, a shortage of endocrinologists, a lack of adequate health insurance and financial constraints.26 28 29
Researchers suggest that improving transgender people’s access to healthcare can improve their health outcomes.30 Information and communication technologies (ICT) including computers, mobile phones and the internet can potentially be useful in addressing some of the challenges faced by low/middle-income and developed countries in providing accessible, cost-effective and high-quality healthcare services. Telemedicine draws on these technologies to overcome geographical barriers and increase access to healthcare services, notably among disadvantaged and stigmatised populations.31 Indeed, because the COVID-19 pandemic restricted physical interactions to reduce the spread of the virus, the use of ICT has been very useful in continuing to deliver healthcare.32
There has also been strong interest in the use of telemedicine to overcome social and spatial barriers to deliver adequate healthcare to transgender populations, largely in resource-privileged countries.32 Telemedicine services that include the use of videoconferencing have been a useful tool for providing postoperative care to individuals who undergo gender affirmative surgeries,33 particularly in situations where access is impeded, such as during the COVID-19 pandemic.34 Additionally, telemedicine has helped to overcome the stigma barrier when it comes to HIV/STI screening/care among transgender populations.35 36
However, while some surveys have shown an increased acceptance of healthcare delivery through telemedicine among transgender populations, an analysis of its outreach, delivery methods, effectiveness and challenges is lacking.37 38 A recent systematic review has suggested digital health interventions are important for young sexual minority people (aged 12–25).39 Nevertheless, the complexity and compatibility of delivering healthcare services to transgender people across the lifespan through ICT remain underexplored. This makes a review of the current use of telemedicine in transgender care interesting and timely.
Objectives
In our scoping review, we aim to synthesise the existing evidence for the use of telemedicine in healthcare delivery among transgender populations. Through our analysis, we endeavour to identify, within the context of transgender health, the effective methods, potential gaps and areas of improvement needed in telemedicine methods. We hope this review will help researchers, practitioners, policy-makers and other stakeholders who are involved in transgender healthcare to advance ICT-related service delivery, thus contributing to a more equitable, accessible and effective provision of health services for such marginalised groups in the digital era.
Methods and analysis
The development of this protocol was guided by the frameworks developed by Arksey & O’Malley,39 and the PRISMA-ScR checklist.40 As we are exploring an area by looking at emerging evidence and are not testing a hypothesis (for which a systematic review, which requires a stronger evidence base, would be more suitable), we decided to adopt a scoping review approach that considers relevant literature from diverse study modalities. Such an approach allows us to achieve a broader and clearer understanding of the various concepts, definitions, intervention types and knowledge gaps relating to the use of digital technologies in the provision and receipt of transgender health services. We hope that our efforts will help summarise and amplify knowledge on the types of work done under this topic, thereby informing hypothesis generation, empirical research, policy-making, clinical practice and health promotion work.
English-language literature that describes services and interventions that directly target transgender people worldwide will be included in the scoping review. Literature unrelated to the development or evaluation of digitally mediated healthcare services (such as studies using ICT only as a means of participant recruitment and data collection), and those that describe services and interventions that do not directly target transgender people (eg, articles discussing skills development for healthcare workers) will be excluded. The search will be conducted by using three major online databases, namely PubMed, CINAHL and Scopus, with additional literature explored using Google Scholar. Relevant studies will be shortlisted after the completion of a title and abstract review based on defined inclusion criteria. Following that, a final list of included studies will be compiled after a full-text review of the shortlisted articles has been completed.
The rest of this review will be structured according to Arksey & O’Malley’s scoping study framework,39 which supports analytical and process rigour. The framework comprises five steps: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data and (5) collating, summarising and reporting the results.
Step 1: identifying the research questions
As we seek to understand how digital platforms have been used in transgender health and the factors that facilitate and obstruct delivering and receiving care through such platforms, our research question is: What does the extant research say about the delivery and receipt of transgender health services through digital means? Based on what we might find, this research question might be refined throughout the scoping review, or additional research questions might be added.
Our operational definition of ‘delivery of telehealth service for transgender people’, a modification of Scalvini et al’s definition of telemedicine, is as follows:
The digitally-mediated delivery of health services and interventions by clinicians and other health professionals to identify, mitigate and deter illness and overall lack of wellbeing, with the aim of improving the health of transgender individuals by increasing access to timely and appropriate healthcare.
In our review, we will use the American Psychological Association’s definition of ‘transgender’,1 as ‘an umbrella term for persons whose gender identity, gender expression or behaviour does not conform to that typically associated with the sex to which they were assigned at birth’.1
Step 2: identify relevant studies
In line with the purpose of scoping studies to be as comprehensive and broad as practicable, our comprehensive search strategy, developed through consensus among team members with the support of an experienced librarian, begins with a literature scan of peer-reviewed publications, research methods and disciplines. The literature must be related to transgender and gender diverse people, and include any form of digital technology used, such as video and telephone consultations, short messaging service reminders, social media and mobile applications. Due to time and cost considerations, we will not include material other than English even though relevant materials might be published in other languages. Works published until January 2022 will be included.
The search queries were first developed for PubMed using medical subject headings (MeSH), and then extended to two scientific databases: CINAHL and Scopus. An additional search will be conducted using Google Scholar. We will first run an individual search using a broad list of terms across three components developed based on MeSH/CINAHL subject headings: telemedicine (eg, m-health, e-health, digital health, telehealth), transgender persons (eg, transgender, gender diverse, transman, transfeminine, gender non-binary) and delivery of healthcare (eg, health service delivery, health promotion, consultation and access to care). We will then combine these search terms to narrow our search to literature containing these three components and compare the results from the consolidation of terms to each of the initial three lists, to determine if the consolidated list captures relevant articles. We will then recalibrate the search protocol based on the initial search results. A list of search terms using PubMed is provided in table 1.
Search terms in PubMed
Stage 3: study selection
Once it has been determined that the consolidated list captures suitable literature, a selection of articles will be presented to all team members for feedback as to whether they should be included in the review, to ensure consistency and to develop the screening frame further.
The initial inclusion criteria will be international literature on how digital technologies have been used in transgender health. With additional literature exploration using Google, Google Scholar and citation mining, a range of published and grey literature, including peer-reviewed publications commentaries, book chapters, reports, conference proceedings, and theses will be considered. Articles published up to January 2022 will be included, with the details of potentially relevant literature published after this date included in an appendix. At every stage, eligibility criteria will be discussed and reached through consensus among all members of the team.
AC, CT, HW and IA will then independently screen abstracts and shortlist pieces of literature that are directly relevant to the research question for inclusion into the scoping review. Each article will be reviewed by two members independently. An Excel spreadsheet will be used to finalise the list of articles for inclusion, with the spreadsheet noting publication information (type of publication, authors, publication year, title, journal, volume and issue, page numbers, URL and keywords) and abstracts. As we found from an initial scan that some articles conflate populations (eg, conflating the experiences of transgender people with that of men who have sex with men), we will include a column that asks if each study focuses solely on gender diverse people or more broadly includes sexuality and gender diversity. Nonetheless, these articles targeting transgender people with other lesbian, gay, bisexual, transgender, intersex and queer (LGBTIQ)/sexual minority populations will be included in the review to identify specific recommendations on proving ICT interventions to transgender people.
Full-text screening will be conducted by two members independently to determine if they are relevant for inclusion. Articles whose relevance is unclear will be independently read in full by HTHW with the final determination being made through discussion and consensus. A flow chart of the study identification and selection process is shown in figure 1.
Flow chart of study identification and selection.
Step 4: charting the data
Following step 3, key points of information will be extracted from the reviewed material and then sorted. All members of the team will be tasked with reading a set of five articles and analysing them according to an analytical frame on an Excel spreadsheet that includes study information and outcomes. The data extraction plan will consist of publication information (authors, article type, country and year of publication), types of ICT intervention used, target audience, total number of participants, total number of transgender participants, enablers and challenges described, specific recommendations to transgender people, limitations of study methodology and key takeaways of the study. Nonetheless, as data extraction and conceptual refinement is an iterative process, it is expected that categories would evolve during the process and over several discussions. After all doubts and inconsistencies are resolved through discussion and consensus, each member of the analysis team will be assigned to assess different sets of publications from the final list.
Stage 5: collating, summarising and reporting the results
The framework for collating, summarising and reporting the results will be developed following the discussions at stage 4. As we are examining literature from diverse sources and disciplines, we expect to encounter a range of concepts and methodologies. We will note areas of focus in the literature, document significant gaps, and note the range of interventions used, paying attention to the benefits and disadvantages of various interventions, and any geographical differences in the use of such interventions. As not much is currently known about this topic, it may be difficult to make comparisons across intervention types or geographical regions, but we will endeavour to do so if appropriate.
Ethics and dissemination
The research is exempt from ethics approval since our analysis is based on publicly available research into the use of digital technologies in providing healthcare to transgender people. To the best of our knowledge, our scoping review is the first study on the use of ICT to deliver healthcare services that are specifically for transgender people of different ages. From its broad evaluation of what is known and not known, it may guide the design of further studies and interventions at the intersection of transgender health and digital technology. Results from the review will be disseminated through an open-access peer-reviewed publication targeting a public health audience, and through academic and practitioner conferences in medicine, public health and the social sciences.
Ethics statements
Patient consent for publication
References
Footnotes
JC, SKP and MNN are joint first authors.
JC, SKP and MNN contributed equally.
HTW, IYA and CT contributed equally.
Contributors JC, MNN and SKP contributed equally to the drafting and writing of this protocol. IYA, CT and HTHW also contributed equally through critically reviewing and revising the proposal. MNN, SKP and HTHW are researchers in the fields of sexuality, culture and health. They initiated the research idea and provided advice on the social and clinical aspects of transgender health. JC, CT and IYA are social health researchers and they participated in designing and refining the study protocol. HTHW developed the keyword search strategy and coordinated the trial literature search. He also performed a trial search on PubMed and CINAHL. IYA and SKP were responsible for the trial search on Google Scholar and SCOPUS retrospectively. CT, HTHW, IYA and JC performed a trial abstract scanning.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.