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  • 1.
    Gustafsson, Per E.
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Linander, Ida
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mosquera, Paola A.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Embodying pervasive discrimination: a decomposition of sexual orientation inequalities in health in a population-based cross-sectional study in Northern Sweden.2017In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 16, article id 22Article in journal (Refereed)
    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.

  • 2.
    Linander, Ida
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS).
    “It was like I had to fit into a category”: people with trans experiences navigating access to trans-specific healthcare and health2018Doctoral thesis, comprehensive summary (Other academic)
    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.

  • 3.
    Linander, Ida
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Alm, Erika
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Harryson, Lisa
    Umeå University, Faculty of Social Sciences, Department of Sociology.
    'It was like I had to fit into a category': care-seekers' experiences of gender regulation in the Swedish trans-specific healthcare2019In: Health, ISSN 1363-4593, E-ISSN 1461-7196, Vol. 23, no 1, p. 21-38Article in journal (Refereed)
    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.

  • 4.
    Linander, Ida
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS).
    Alm, Erika
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Harryson, Lisa
    Umeå University, Faculty of Social Sciences, Department of Sociology.
    Negotiating the (bio)medical gaze: Experiences of trans-specific healthcare in Sweden2017In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 174, p. 9-16Article in journal (Refereed)
    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.

  • 5.
    Linander, Ida
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS).
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Alm, Erika
    Hammarström, Anne
    Harryson, Lisa
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    (Un)safe spaces, affective labour and perceived health among people with trans experiences living in Sweden2019In: Culture, Health and Sexuality, ISSN 1369-1058, E-ISSN 1464-5351, Vol. 21, no 8, p. 914-928Article in journal (Refereed)
    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.

  • 6.
    Linander, Ida
    et al.
    Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS). Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Socialmedicin.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Johansson, Klara
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Which socio-economic measures are associated with psychological distress for men and women?: A cohort analysis2015In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 25, no 2, p. 231-236Article in journal (Refereed)
    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.

  • 7. Perez-Urdiales, Iratxe
    et al.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Irazusta, Amaia
    Linander, Ida
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Sub-Saharan African immigrant women's experiences of (lack of) access to appropriate healthcare in the public health system in the Basque Country, Spain2019In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 18, article id 59Article in journal (Refereed)
    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.

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