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Linander, I., Alm, E., Goicolea, I. & Harryson, L. (2019). 'It was like I had to fit into a category': care-seekers' experiences of gender regulation in the Swedish trans-specific healthcare. Health, 23(1), 21-38
Open this publication in new window or tab >>'It was like I had to fit into a category': care-seekers' experiences of gender regulation in the Swedish trans-specific healthcare
2019 (English)In: Health, ISSN 1363-4593, E-ISSN 1461-7196, Vol. 23, no 1, p. 21-38Article in journal (Refereed) Published
Abstract [en]

The few previous studies investigating regulation of gender in trans-specific healthcare are mainly based on text material and interviews with care-providers or consist solely of theoretical analyses. There is a lack of studies analysing how the regulation of gender is expressed in the care-seeker's own experiences, especially in a Nordic context. The aim of this study is to analyse narratives of individuals with trans experiences (sometimes called transgender people) to examine how gender performances can be regulated in trans-specific care in Sweden. The conceptual framework is inspired by trans studies, a Foucauldian analysis of power, queer phenomenology and the concept of cisnormativity. Fourteen interviews with people with trans experiences are analysed with constructivist grounded theory. The participants' experiences indicate that gender is constructed as norm-conforming, binary and stable in trans-specific healthcare. This gendered position is resisted, negotiated and embraced by the care-seekers. Norms and discourses both inside and outside trans-specific care contribute to the regulation and limit the room for action for care-users. We conclude that a trans-specific care that has a confirming approach to its care-users, instead of the current focus on gender norm conformity, has the potential to increase the self-determination of gender performance and increase the quality of care.

Place, publisher, year, edition, pages
Sage Publications, 2019
Keywords
gender and health, grounded theory, patient–physician relationships, phenomenological approaches, post-structuralism/postmodernism
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-141444 (URN)10.1177/1363459317708824 (DOI)000454118500002 ()28523938 (PubMedID)
Note

Article first published online: May 19, 2017

Available from: 2017-11-03 Created: 2017-11-03 Last updated: 2019-01-18Bibliographically approved
Perez-Urdiales, I., Goicolea, I., San Sebastian, M., Irazusta, A. & Linander, I. (2019). Sub-Saharan African immigrant women's experiences of (lack of) access to appropriate healthcare in the public health system in the Basque Country, Spain. International Journal for Equity in Health, 18, Article ID 59.
Open this publication in new window or tab >>Sub-Saharan African immigrant women's experiences of (lack of) access to appropriate healthcare in the public health system in the Basque Country, Spain
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2019 (English)In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 18, article id 59Article in journal (Refereed) Published
Abstract [en]

BackgroundImmigrant populations face diverse barriers to accessing appropriate healthcare services on several levels. In the Basque Country, Sub-Saharan African women were identified as facing the largest barriers to access them. The aim of the study is to analyse Sub-Saharan African immigrant women's perceptions and experiences of access to appropriate healthcare in the public health system in the Basque Country, Spain.MethodsFourteen women from eight Sub-Saharan African countries who have used the Basque public healthcare services were interviewed. A qualitative content analysis was applied: meaning that units were identified, coded and the resulting codes were then organized into three categories.ResultsThe first category, Fearing to enter a health system perceived as not friendly for immigrants, included factors, mainly those related to legal conditions for accessing healthcare services and lack of lawful documentation, that made women avoid or discontinue seeking out healthcare.The second category, Being attended on professionals' own communication terms, comprised how the lack of effective communication compromised not only the access of the immigrant women to healthcare services, but also their health.Lastly, the third category, Is mistreatment based on racism or merely on bad luck? described how being an immigrant and black influenced the way they were (mis)treated in the health system.ConclusionFor Sub-Saharan African immigrant women, accessing appropriate healthcare in the Basque Country was perceived to be subject to institutional barriers. At the legal level, barriers included lack of entitlement, difficulties in fulfilling legal access conditions and lack of documentation. The lack of communication with health centre staff and their attitudes, guided by a stereotyped social image of immigrants and black people, also hindered their possibilities of receiving appropriate healthcare. Facilitators for accessing healthcare included strategies from individual professionals, personal networks and social actors to help them to cope with the barriers. There is a need of reinforcing inclusion values and rights-based approach to attention among staff at the health centres to have more non-discriminatory and culturally appropriate health systems.

Place, publisher, year, edition, pages
BMC, 2019
Keywords
Health access, Immigrant health, Health services research, Health disparities, Barriers to healthcare, men's health, Undocumented immigrants, Illegal immigrants, Immigration, Qualitative research
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:umu:diva-158946 (URN)10.1186/s12939-019-0958-6 (DOI)000465474200001 ()31014337 (PubMedID)
Available from: 2019-05-27 Created: 2019-05-27 Last updated: 2019-05-27Bibliographically approved
Linander, I., Goicolea, I., Alm, E., Hammarström, A. & Harryson, L. (2019). (Un)safe spaces, affective labour and perceived health among people with trans experiences living in Sweden. Culture, Health and Sexuality, 21(8), 914-928
Open this publication in new window or tab >>(Un)safe spaces, affective labour and perceived health among people with trans experiences living in Sweden
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2019 (English)In: Culture, Health and Sexuality, ISSN 1369-1058, E-ISSN 1464-5351, Vol. 21, no 8, p. 914-928Article in journal (Refereed) Published
Abstract [en]

Lack of safe space has been connected to ill health among people with trans experiences. This study analyses trans people’s experiences of being in public, semi-public and community spaces using the analytical concept of safety/unsafety in relation to perceived health. The analytic framework draws on the concepts of cisgenderism, orientation, lines and comfort. The material analysed consisted of 18 individual interviews with people with trans experiences, which were analysed using constructivist thematic analysis. The analysis resulted in the identification of three themes: straightening devices creating limited living space, orienting oneself in (cis)gendered spaces and creating safer (?) community spaces for healing. Experiences of unsafety ranged from incidents and fear of different kinds of violence in public and semi-public spaces to the lack of a transpolitically informed agenda in, for example, feminist spaces. Safer spaces helped participants to feel a sense of belonging, to share their experiences and to heal. Experiences of unsafety and discomfort are important as they will help us to understand the health situations of people with trans experiences. It is important to facilitate the creation of safer spaces to improve the health of members of this group.

Place, publisher, year, edition, pages
Routledge, 2019
Keywords
Sweden, Transgender, affective labour, safety, space
National Category
Public Health, Global Health, Social Medicine and Epidemiology Gender Studies
Identifiers
urn:nbn:se:umu:diva-152679 (URN)10.1080/13691058.2018.1527038 (DOI)000473015600004 ()30601097 (PubMedID)
Funder
Swedish Research Council, 344-2011-5478
Note

Originally included in thesis in manuscript form

Available from: 2018-10-17 Created: 2018-10-17 Last updated: 2019-09-06Bibliographically approved
Linander, I. (2018). “It was like I had to fit into a category”: people with trans experiences navigating access to trans-specific healthcare and health. (Doctoral dissertation). Umeå: Umeå Universitet
Open this publication in new window or tab >>“It was like I had to fit into a category”: people with trans experiences navigating access to trans-specific healthcare and health
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Alternative title[sv]
"Det va som att jag skulle passa in i en kategori" : personer med transerfarenheter navigerar sig fram till transspecifik vård och hälsa
Abstract [en]

Background: Trans issues have received increased attention over the last couple of years and important changes have been made in the legislation relating to gender reassignment and in trans-specific healthcare practices. At the same time, many people with trans experiences report poor mental health, bad experiences when encountering the healthcare and a tendency to postpone seeking care due to being badly treated. Previous research has also shown that gender norms guide the evaluation that precedes access to gender-confirming medical procedures. Critical studies examining practices within trans-specific healthcare in the Swedish context and health among people with trans experiences are limited, especially qualitative interview studies involving people with trans experiences.

Aim: To analyse how constructions of trans experiences and gender can affect trans-specific healthcare practices, experiences of navigating access to gender- confirming medical procedures, inhabitancy of different spaces and, ultimately, health.

Conceptual framework: Three areas of theory are used for the conceptual framework: trans studies, queer phenomenology and Foucauldian theories of power and governmentality.

Methods: The thesis includes three sub-studies (generating four articles): two interview studies that build on interviews with 18 people with trans experiences, and a policy analysis of the guidelines for trans-specific healthcare published by the Swedish National Board of Health and Welfare. For the interview studies, grounded theory and thematic analysis were used as the analytical method. The guidelines were analysed using Bacchi’s method: “What’s the problem represented to be?”.

Results: The participants experienced trans-specific healthcare as difficult to navigate due to waiting times, lack of knowledge and/or support and relationships of dependency between healthcare users and providers. In the evaluation, gender is reconstructed as linear – stereotypical, binary and stable – and the space for action available to care-seekers is affected by discourses existing both inside and outside trans-specific healthcare. The difficulties in navigating access to care were experienced as creating ill-health. In order to negotiate access to gender-confirming medical procedures, the participants took responsibility for the care process by, for example, ordering hormones from abroad, acquiring medical knowledge and finding alternative support. The linear gendered positioning was variously resisted, negotiated and embraced by the participants.

The analysis of the guidelines showed that gender identity is constructed as a fixed linear essence but that the guidelines also open up space for a non-linear embodiment. Gender dysphoria is closely constructed in relation to psychiatric knowledge and mental health and the gate-keeping function among mental healthcare professionals is reconstituted in the guidelines. Hence, care-seekers are constructed as not competent enough to make decisions concerning access to gender-confirming medical procedures.

The participants experienced several different spaces, such as bars, public toilets and changing rooms, gyms and cafés, as unsafe and as contributing to ill-health. In order to overcome the barriers to comfortably inhabiting spaces, the participants performed a kind of labour; for example, preparing in order to visit public baths and to answer transphobic comments and questions. Some spaces, such as trans-separatist, feminist and queer spaces, were experienced as safer and contributed to improved health through experiences of belonging, being able to share bad experiences and being able to relax.

Conclusions: Trans-specific healthcare practices need to become more affirming and change so that care-seekers have more space for self- determination. Trans-specific healthcare needs more resources in order to decrease waiting times, improve knowledge and support, and hence to improve access to gender-confirming medical procedures. Actions need to be initiated to make spaces safer in order to improve the health of people with trans experiences.

Abstract [sv]

Bakgrund: De senaste åren har transfrågor uppmärksammats allt mer. Viktiga juridiska förändringar har skett, såsom borttagande av krav för sterilisering vid juridisk könsbekräftelse, och transvården har fått sina första officiella riktlinjer för vård vid könsdysfori. Samtidigt visar flera rapporter att många personer med transerfarenheter rapporterar ett dåligt allmänt hälsotillstånd, psykisk ohälsa och brister i mötet med vården. Tidigare forskning visar också att normer kring kön påverkar utredningen som personer med transerfarenheter måste gå igenom för att få tillgång till könsbekräftande vård. Syftet med den här avhandlingen är att analysera hur konstruktioner av transerfarenheter och kön kan påverka praktiker inom den trans-specifika vården, erfarenheter av att navigera tillgång till könsbekräftande vård samt upplevelsen av olika typer av rum och hälsa.

Metod: Avhandlingen bygger på fyra artiklar som är uppdelade i tre delstudier. Två av delstudierna bygger på totalt 18 intervjuer med personer med transerfarenheter och en delstudie bygger på en policyanalys av Socialstyrelsens riktlinjer för transspecifik vård. Intervjustudierna har analyserats med grundad teori respektive tematisk analys och riktlinjerna har analyserats med Bacchis metod som undersöker hur problem framställs i en text. Delstudie 1 handlar om hur vårdsökande personer med transerfarenheter navigerar och förhandlar sig till att få könsbekräftande vård. I den andra delstudien undersöker jag hur utredning, diagnostisering och kriterier för tillgång till könsbekräftande vård är beskrivna i riktlinjerna från Socialstyrelsen för transspecifik vård. I den sista delstudien har jag undersökt hur trygghet och otrygghet i olika typer av rum kan påverka hälsan hos personer med transerfarenheter.

Resultat: Analysen av intervjuerna visar att deltagarna upplevde det svårt att navigera sig fram till, och inom, transvården. Kunskapsbrist, brist på psykosocialt stöd, väntetider och en beroenderelation till utredarna är hinder som deltagarna berättar om i sina möten med transvården. Kön rekonstrueras som binärt, stabilt och stereotypt inom transvården och handlingsutrymmet i relation till kön påverkades av normer både inom och utanför transvården. Flera av dessa hinder skapar upplevelser av ohälsa. För att överkomma hindren i transvården så tog flera deltagare kommando över vårdprocessen genom att ta reda på information, beställa hormoner via nätet och hitta psykosocialt stöd utanför transvården. Deltagarna omfamnade, förhandlade och gjorde motstånd mot den binära, stabila och stereotypiska konstruktionen av kön, exempelvis genom att använda strategiska berättelser och göra kön på andra sätt utanför transvården.

Analysen av riktlinjerna för transvården visade att kön konstrueras som en fixerad linjär essens, dvs. att könsidentiteten bör vara stabil över tid och matcha den sociala könsrollen för att personer ska få tillgång till könsbekräftande vård. Samtidigt säger riktlinjerna att alla vårdsökande inte behöver ha alla medicinska insatser, vilket öppnar upp möjligheter för en kropp som inte följer normen. Riktlinjerna pekar på hur psykisk ohälsa hos personer med könsdysfori kan bero på cisnormativitet. Likväl så knyter riktlinjerna könsdysfori tätt till lidande, psykiatrisk kunskap och mental ohälsa och rekonstruerar därmed könsdysfori som en psykisk sjukdom. Riktlinjerna slår även på så sätt fast den grindvaktande position som psykiatriker har inom transvården och de vårdsökande får därmed inte möjlighet att själva bestämma över tillgången till könsbekräftande vård.

Deltagarna upplevde en rad olika rum och platser som otrygga eller obekväma vilket påverkade deras hälsa. Till exempel berättade många deltagare om barer och pubar som otrygga platser där de hade erfarenheter av att bli utsatta för fysiskt våld, verbala trakasserier och ifrågasättande. Könsuppdelade offentliga toaletter och omklädningsrum var andra viktiga plaster i berättelserna om otrygga rum. Deltagarna upplevde att det var svårt att välja vilken toalett eller vilket omklädningsrum dom skulle besöka och att det kunde vara svårt att passa in i något av dom. Transseparatistiska, feministiska och HBTQ-rum upplevdes av många som tryggare och var viktiga för att kunna dela med sig av erfarenheter, känna gemenskap och återhämta sig från erfarenheter av otrygghet. Dock fanns det erfarenheter av att dessa rum också kunde vara exkluderande.

Slutsatser och implikationer: Sammanfattningsvis har transvården har genomgått flera förbättringar, men den upplevs fortfarande som problematisk av vissa vårdsökande och även i riktlinjerna konstrueras kön och könsdysfori på problematiska sätt. Att få tillgång till könsbekräftande vård är viktigt för många personer med transerfarenheter, men vägen till vård kan i sig själv ha negativa hälsokonsekvenser för de vårdsökande. Transvården återskapar kön som binärt, stabilt och stereotypt vilket inte stämmer överens med vissa av de vårdsökandes förståelse av sig själva. Vårdgivare inom psykiatrin har fortsatt makt att bestämma vilka som ska få tillgång till vård vilket kan bidra till att transpersoner har svårare att få tillgång till adekvat vård för psykisk ohälsa. Flera olika vardagliga platser upplevs som otrygga och skapar ohälsa. För att överkomma hindren, både inom transvården och i andra rum, utför deltagarna ett affektivt arbete som också kan innebära negativa hälsokonsekvenser. Utifrån studien resultat behövs flera förändringar för att skapa utrymme för mer självbestämmande hos de vårdsökande och för att förbättra tillgången till könsbekräftande vård. Det behövs även mer resurser till transvården för att minska väntetiderna, öka tillgången till stöd för de vårdsökande och kunskap hos vårdgivarna. För att förbättra hälsan hos personer med transerfarenheter är det nödvändigt att skapa fler trygga rum.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet, 2018. p. 151
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1990
Keywords
Transgender, Gender dysphoria, Qualitative, Access to healthcare, Health inequalities, Affective labour, Trans studies, Queer phenomenology, Foucault, Governmentality, Sex reassignment
National Category
Public Health, Global Health, Social Medicine and Epidemiology Gender Studies
Research subject
Public health; genusvetenskap
Identifiers
urn:nbn:se:umu:diva-152817 (URN)978-91-7601-962-7 (ISBN)
Public defence
2018-11-23, Aulan, Vårdvetarhuset, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Funder
Swedish Research Council, 344-2011-5478
Available from: 2018-11-02 Created: 2018-10-25 Last updated: 2018-11-14Bibliographically approved
Gustafsson, P. E., Linander, I. & Mosquera, P. A. (2017). Embodying pervasive discrimination: a decomposition of sexual orientation inequalities in health in a population-based cross-sectional study in Northern Sweden.. International Journal for Equity in Health, 16, Article ID 22.
Open this publication in new window or tab >>Embodying pervasive discrimination: a decomposition of sexual orientation inequalities in health in a population-based cross-sectional study in Northern Sweden.
2017 (English)In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 16, article id 22Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Studies from Sweden and abroad have established health inequalities between heterosexual and non-heterosexual people. Few studies have examined the underpinnings of such sexual orientation inequalities in health. To expand this literature, the present study aimed to employ decomposition analysis to explain health inequalities between people with heterosexual and non-heterosexual orientation in Sweden, a country with an international reputation for heeding the human rights of non-heterosexual people.

METHODS: Participants (N = 23,446) came from a population-based cross-sectional survey in the four northernmost counties in Sweden in 2014. Participants completed self-administered questionnaires, covering sexual orientation, mental and general physical health, social conditions and unmet health care needs, and sociodemographic data was retrieved from total population registers. Sexual orientation inequalities in health were decomposed by Blinder-Oaxaca decomposition analysis.

RESULTS: Results showed noticeable mental and general health inequalities between heterosexual and non-heterosexual orientation groups. Health inequalities were partly explained (total explained fraction 64-74%) by inequalities in degrading treatment (24-26% of the explained fraction), but to a considerable degree also by material conditions (38-45%) and unmet care needs (25-43%).

CONCLUSIONS: Psychosocial experiences may be insufficient to explain and understand health inequalities by sexual orientation in a reputedly 'gay-friendly' setting. Less overt forms of structural discrimination may need to be considered to capture the pervasive material discrimination that seems to underpin the embodiment of sexual minority inequalities. This ought to be taken into consideration in research, policy-making and monitoring aiming to work towards equity in health across sexual orientations.

Keywords
Sexual orientation, LGBQ, Health inequality, Mental health, Self-reported health, Decomposition analysis
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-131332 (URN)10.1186/s12939-017-0522-1 (DOI)000392349600001 ()28109196 (PubMedID)
Available from: 2017-02-13 Created: 2017-02-13 Last updated: 2018-06-09Bibliographically approved
Linander, I., Alm, E., Hammarström, A. & Harryson, L. (2017). Negotiating the (bio)medical gaze: Experiences of trans-specific healthcare in Sweden. Social Science and Medicine, 174, 9-16
Open this publication in new window or tab >>Negotiating the (bio)medical gaze: Experiences of trans-specific healthcare in Sweden
2017 (English)In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 174, p. 9-16Article in journal (Refereed) Published
Abstract [en]

In Sweden as well as in other western countries persons with trans experiences have to go through a clinical evaluation in order to get access to gender-confirming medical procedures. The aim of this study is to analyse care-users' experiences of navigating and negotiating access to gender-confirming medical procedures in Sweden. Biomedicalisation is used as a theoretical framework in order to analyse how technoscientific and neoliberal developments are parts of constructing specific experiences within trans-specific care. Constructivist grounded theory was used to analyse 14 interviews with persons having experiences of, or considering seeking, trans-specific healthcare. The participants experienced trans-specific healthcare as difficult to navigate because of waiting times, lack of support, provider ignorance and relationships of dependency between healthcare-users and providers. These barriers pushed the users to take responsibility for the care process themselves, through ordering hormones from abroad, acquiring medical knowledge and finding alternative support. Based on the participants' experiences, it can be argued that the shift of responsibility from care-providers to users is connected to a lack of resources within trans-specific care, to neoliberal developments within the Swedish healthcare system, but also to discourses that frame taking charge of the care process as an indicator that a person is in need of or ready for care. Thus, access to gender-confirming medical procedures is stratified, based on the ability and opportunity to adopt a charge-taking role and on economic and geographic conditions. Based on the results and discussion, we conclude that trans-specific care ought to focus on supporting the care-seekers throughout the medical process, instead of the current focus on verifying the need for care. There is also a need for increased knowledge and financial resources. A separation between legal and medical gender reassignment could contribute to a better relationship between care-providers and care-users and increase the quality of care.

National Category
Public Health, Global Health, Social Medicine and Epidemiology Sociology Gender Studies
Identifiers
urn:nbn:se:umu:diva-129677 (URN)10.1016/j.socscimed.2016.11.030 (DOI)000393931200002 ()27960120 (PubMedID)
Available from: 2017-01-08 Created: 2017-01-08 Last updated: 2018-10-25Bibliographically approved
Linander, I., Hammarström, A. & Johansson, K. (2015). Which socio-economic measures are associated with psychological distress for men and women?: A cohort analysis. European Journal of Public Health, 25(2), 231-236
Open this publication in new window or tab >>Which socio-economic measures are associated with psychological distress for men and women?: A cohort analysis
2015 (English)In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 25, no 2, p. 231-236Article in journal (Refereed) Published
Abstract [en]

Background: There are contradictory results regarding whether there is a social gradient in common mental disorders or not, or if this relation differs for different indicators or by gender. We analysed the relation between various measures of socio-economic position and later psychological distress among men and women in a Swedish context. Methods: The study is based on data from the Northern Swedish Cohort (N= 1001, 93.5% response rate), a 27-year prospective study. Logistic regression was used to explore the relation between various indicators of socio-economic position at age 30 (occupation, education, financial strain, cash margin, unemployment and living primarily on social welfare or unemployment insurance) and psychological distress (age 42), controlling for earlier psychological distress (age 21) and parental occupational class. Register data were used to measure unemployment. All other variables were self-reported, and measured by a questionnaire. Results: Financial strain and living on social welfare or unemployment insurance at age 30 were associated with psychological distress at age 42 for men and women. Poor cash margin and unemployment were only associated with psychological distress in women, after controlling for potential confounders. Low occupational class and low education were not significantly related to later psychological distress. Conclusion: The two most commonly used measures of socio-economic position, occupation and education, were not significantly associated with psychological distress while other, less studied measures were. This study highlights the importance of measuring socio-economic position in several ways when studying common mental disorders, as well as to take gender into account.

Place, publisher, year, edition, pages
Oxford University Press, 2015
National Category
General Practice
Identifiers
urn:nbn:se:umu:diva-103148 (URN)10.1093/eurpub/cku137 (DOI)000352201500013 ()25172836 (PubMedID)
Funder
Swedish Research Council Formas, 259-2012-37
Note

The study was financed by grants from FORMAS, grant number 259-2012-37, the County Council of Västerbotten, grant number 322941, and the Swedish Research Council, grant number 344-2011-5478.

Available from: 2015-05-26 Created: 2015-05-18 Last updated: 2018-06-07Bibliographically approved
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0001-6401-889x

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