Transgender individuals and the health care system in Poland – attitudes, experiences, and challenges

INTRODUCTION

The gender that is officially assigned to us at birth – either female or male – is based on physical characteristics. It may, however, be incompatible with gender identity, i.e. what we feel and consider our gender to be. The concept of sex in the strict sense of the word refers to biological differences between men and women, physiological and biological features allowing one to define a person as a male or a female, or biological structures concerning genetic, anatomical, physiological, and hormonal features [1]. Transgender is a term that collectively describes those people who have a discrepancy between their perceived cultural sex (their gender) and their biological, usually assigned at birth, sex [2]. According to recent studies, transgender people make up 1% of society [3].
People who identify as such can be divided into 2 groups – binary (locating their gender in the binary gender division: woman or man) and non-binary (embedding their gender identity “in-between”). In the binary system, sex is connected with gender by the cultural meanings that are accepted by the sexual body. Both the concepts of sex and gender are constructs sustained by culture and society – socialization and gender role theories hold that, in addition to considering sex as biologically determined and gender as something taught by culture, both should be regarded as established according to a complex biosocial interaction [1]. Gender dysphoria is the discomfort experienced by transgender people, caused by the discrepancy between gender identity and officially assigned gender [4].
It might manifest itself as a:
• clear mismatch between the experienced/expressed gender and the primary and/or secondary sex characteristics,
• strong desire to get rid of primary and/or secondary sexual characteristics due to a clear inconsistency with the experienced/expressed gender,
• strong desire for the primary and/or secondary sex characteristics of the other sex,
• strong desire to be of the other sex,
• strong desire to be treated as the other sex,
• strong conviction that one has typical feelings and reactions of the other sex [5].
The World Professional Association for Transgender Health develops international healthcare standards, with the organization issuing recommendations regarding not only the principles of providing healthcare to transgender people during the initial diagnosis process but also concerning psychological support, hormonal therapy, and gender reaffirming surgical procedures. The aim is not only to establish ways of providing transgender people with the best possible care, tailored to each individual, but also to make healthcare providers confident in their ability to educate and increase awareness among transsexual people about procedures that can help reduce gender dysphoria and their potential out-comes. Currently, the seventh edition of the Standards, published in 2012, is in force [6, 7], with an eighth edition planned to be published in the near future.
Although the World Professional Association for Transgender Health classifies being transgender as a sign of diversity, and not a pathology, the stigmatization of gender-nonconforming people still exists in many countries, often resulting in prejudice and discrimination against those who identify themselves as members of this group, who as result suffer from “minority stress” – a sociological concept explaining how difficult social situations lead to chronic stress and poor health among minority individuals [2]. Although institutions of high societal impact, such as the Catholic Church, which rejects the possibility of surgical sex change [8], alienate transgender people, it must be noted that the exclusion of gen-der-nonconforming people is also present in the lesbian, gay, bisexual, and transgender LGBT community, as some believe that transgenderism does not fit into the “traditional” model of femininity and masculinity and therefore has no place in the gay and lesbian community.
All activities related to the medical care of transgender people should serve to provide them with the greatest possible comfort when living following their gender identity while maintaining both health security [9] and health practices. It remains, nevertheless, a multidimensional challenge, both on a medical level, as care for transgender people should include interdisciplinary cooperation between specialists in various fields, including psychiatrists, psychologists, psychotherapists, audiophoniatrists, endocrinologists, and surgeons, and on the more personal one, given the crucial role of the financial situation of the patient and the political and legal conditions in the country in which they reside.
Medical care for transgender individuals in Poland is gradually improving. However, the model faces numerous challenges. In recent years, public awareness of transgender issues has been increasing, leading to greater interest in this topic within the medical community. In 2020, the Polish Sexological Society (“Polskie Towarzystwo Seksuologiczne”) published the first official guidelines on healthcare for transgender adults. This represents an important step toward standardising medical care in this area [7].
This article aimed to analyse transgender people’s experiences of being a patient in Poland. The topic of transgenderism is relevant and should be addressed during academic classes conducted for future medical professionals.
The study used a non-standardized questionnaire, with 30 questions consisting of the following parts:
• questions related to personal and demographic data, including questions about gender identity and transition stage (both social and medical aspects of it),
• questions regarding the frequency of interactions with the healthcare system (primary and specialist care, including psychiatric and psychological) and overall experiences with it, with emphasis on instances of discriminatory behaviour on the part of healthcare professionals and factors potentially limiting the use of medical care by transgender people.
The Health Behaviour Inventory (IZZ; “Inwentarz Zachowań Zdrowotnych”) is a survey created by Zygfryd Juczyński, which contains 55 questions focused on 3 groups of behaviours: those that impact – by either increasing or lowering the risk of getting sick, those that help maintain health or reduce the risk of getting sick, and those related to patients’ general compliance level [10]. The questionnaire analyses 4 types of health behaviours: eating habits, preventive behaviours, mental attitude, and health practices. In the study, 25 questions were used.

MATERIAL AND METHODS

DATA COLLECTION

The study was conducted in March and April of 2022. The approval number of the Bioethical Committee of the Jagiellonian University Collegium Medicum is 1072.6120.65.2021. For this purpose, a questionnaire created in the MS Forms software, available via the Internet, was used. As part of the survey, the participants were informed about its didactic and scientific purpose, and by filling out the questionnaire they agreed to participate in the study.
The respondents were acquired by sharing the survey form on groups dedicated to transgender people and issues related to non-cisnormativity on Facebook, with the greatest number of answers obtained from members of the Transgender Support Group (“Grupa Wsparcia dla Osób Transpłciowych”), which has over 8.7 thousand users.
The study included people who identify as transgender – specifying their gender binary as “female” or “male”. Cis-gender and non-binary individuals were excluded from the study.

DATA ANALYSIS

The collected data were analysed with Statistica 10 software. The values of categorical variables are presented in terms of absolute values and percentages. For such variables, the significance of differences within particular groups was verified by the chi-square test (Pearson’s χ²). P-value < 0.05 was deemed statistically significant.

RESULTS

In the group of 106 subjects, there were 22 (20.8%) women and 84 (79.2%) men. 97 (91.5%) of them functioned in society according to their perceived sex, and 9 (8.5%) according to the sex assigned at birth.
At the time of analysing the results, half of the respondents described their well-being as “on an average level”. Seventy-three (68.9%) of the respondents were undergoing hormone therapy, 30 (28.3%) were planning to start it, and 3 (2.8%) had halted the hormonal transition process. Sixty-two (58.5%) of those who filled out the questionnaire had experienced discrimination from medical professionals. When describing their experience regarding the use of preferred names and pronouns by employees of medical facilities, 29 (27.4%) stated that they had had only positive experiences (meaning they were only addressed by such), 27 (25.4%) had had only negative experiences, and 50 (47.2%) claimed the experiences had varied depending on the facility.
Among the respondents, 74 (69.8%) cited the fear of discrimination, mostly stemming from the inconsistency of the perceived gender with the one shown in their documents, as the main factor preventing them from using medical services. Subsequently, 73 (68.9%) people feared the lack of knowledge regarding the specifics of medical care of transgender patients among medical personnel. Forty-nine (46.2%) reported anxiety related to potential reactions from the environment, 18 (17.0%) believed that they did not need medical care, and 17 (16.0%) respondents declared no fears related to the use of medical care. Among other factors preventing them from using medical services in health care facilities, 13 (12.3%) people reported a lack of trust toward medical staff, 11 (10.4%) felt fear of being outed and ridiculed, 3 (2.8%) had yet to update official documents, 2 (1.9%) indicated a lack of willingness to provide explanations regarding being transgender as the reason, with the same number of respondents citing lack of funds, one (0.9%) per-son indicated a problem with obtaining a referral, one person cited discomfort related to the necessity of being cared for, and one person claimed reluctance to undergo additional treatment when taking hormones. Apart from medical visits necessary to conduct the transition process, 47 (44.3%) respondents did not see any other doctor regularly, claiming they believed that the doctors overseeing their transition provided sufficient medical care, 29 (27.4%) attended recommended routine check-ups, 25 (23.6%) required specialist care due to presence of other chronic diseases, and 13 (12.3%) did not participate in the transition process.
Of all participants, 54 (51%) had noticed differences in the approach toward noncisnormative individuals between public and private institutions, claiming that those employed in private institutions respected their chosen gender identity to a greater extent. Twenty-eight (26.4%) of the respondents had not noticed these disparities, and 24 (22.6%) had encountered discrimination in both types of establishments.
Among factors taken into consideration when choosing a medical facility and a specialist providing medical care, 81 (76.4%) declared the opinions of others, particularly those focused on the approach towards transgender people, 72 (67.9%) claimed they would make a choice based on opinions on professionalism and the general level of care provided by the facility or the specialist, for 59 (55.7%) the choice was determined by geographical factors, for 51 (48.1%) the most important aspect was the cost of the service, whereas 3 (2.8%) respondents claimed that none of the mentioned factors played a relevant role in the decision-making process.
Of the respondents, 53 (50%) had been diagnosed with depression, 31 (29.2%) had an anxiety disorder, 5 (4.7%) had ADHD, 4 (3.8%) respondents had a borderline personality disorder, 4 (3.8%) had been diagnosed with autism, 4 (3.8%) with eating disorders, 4 (3.8%) with other personality disorders, 3 (2.8%) with adjustment disorder, 2 (1.9%) with Asperger’s syndrome; one (0.9%) with bipolar disorder, and 20 (17.9%) reported having no psychiatric diagnosis. Forty-one (38.7%) of the respondents were either currently or had been in the past in psychotherapy, 26 (24.5%) felt no need to start this process, 32 (30.2%) were unable to afford it, and 7 (6.6%) were waiting for an available slot.
When analysing the frequency of visiting a primary care physician, 48 (45.3%) of the respondents did it less than once a year, 51 (48.1%) did it several times a year, 5 (4.7%) once a month, and 2 (1.9%) of those surveyed saw their primary care physician more than once a month. Among the respondents, 58 (54.7%) indicated that their primary care physician was familiar with the concept of gender identity, whereas the physicians of the remaining 48 respondents (45.3%) had no knowledge regarding this topic. When asked about precise knowledge on transgenderism, 40 (37.7%) people believed that their doctor did not have sufficient knowledge about transgenderism and 8 (7.5%) of the respondents felt that the doctor knew about special health conditions in transgender people. When asked whether the doctor provided comprehensive care, 55 (51.9%) of the respondents said no, claiming that the visits were focused only on somatic issues and omitted mental health issues, whereas 11 (10.4%) of those surveyed described their visits as focused not only on typical medical needs but also on potential psychiatric difficulties. Twenty (27.4%) respondents said that the visits were conducted in an atmosphere of support and understanding, but 9 (8.5%) patients remembered an atmosphere of hostility and misunderstanding.
When asked about their approach toward gynaecological care, 14 (16.7%) of the surveyed transgender men used private healthcare, 3 (3.6%) used the public healthcare system, and the 3 required no such care (n = 3, 3.6%). Sixty-four (76.2%) of them did not visit a gynaecologist at all, with 33 (39.3%) citing fear of discrimination as a reason, and 31 (36.9%) indicating other reasons. Among transgender women, one (4.5%) visited a urologist available through the public health care system, and one (4.5%) was attending visits in a private facility. Twenty women did not go to a urologist – 7 (31.8%) were afraid of discrimination, the same number (n = 7, 31.8%) did not need such care, and 6 (27.4%) cited other reasons.
Among the respondents, 29 (27.4%) were hospitalised in the last 12 months. Out of those, 11 (37.9%) reported that all members of the hospital staff respected their gender identity and used both the preferred first name and pronouns; 8 (27.6%) respondents indicated that some of the staff respected gender identity and used first name and pronouns, the same number (n = 8, 27.6%) interacted with medical personnel who had no knowledge regarding gender identity. In 2 (6.9%) cases, none of the hospital staff respected gender identity, first name, or pronouns.

RESULTS OF THE IZZ HEALTH BEHAVIOUR INVENTORY

The results obtained in the Health Behaviour Inventory were analysed in the following categories:
• preventive behaviours,
• positive mental attitude,
• health practices.
The average result scored when describing dedication to preventive behaviours (Table 1) was 18 points, and the standard deviation was 4 points. What is interesting, the average number of points was also the median value – half of the respondents scored no more than 18 points. The lowest intensity of preventive behaviours was presented by a person who scored 8 points, and the highest by a person who received 28 points.
The average score in the questions (Table 2) dedicated to positive mental attitude was also 18 points, as was the median. The standard deviation was 5 points, the lowest amount of points was 6, and the highest score was 28 points.
When describing the average level of their health practices (Table 3), respondents scored 19 points on average, with the median being 20 points and the standard deviation being 5 points. The lowest record was 6 points and the highest was 30 points.
In general, the average number of points scored was 72, and the standard deviation was 13 points. Half of the respondents scored no less than 73 points. The lowest level of intensity of health behaviours was presented by a person who received 42 points, and the highest level by an examined person who had 98 points.
The second goal of the study was to identify the factors preventing the respondents from interacting with healthcare professionals in facilities being part of the public healthcare system. The results are presented in Table 4.
The results show that there are statistically significant reasons limiting the use of the public health care system. It is important to note that almost 70% of respondents reported fearing discrimination and insufficient knowledge regarding transgenderism among medical staff.
An analysis of discriminatory attitudes on the part of medical staff was also made, with the results presented in Table 5; nevertheless, there was no statistical significance observed. Statistically significant results were, however, obtained when analysing differences in past and current approaches and acceptance towards non-cisnormativity by the general public, with precise data presented in Table 6.
When asked about differences in degrees of tolerance for people with non-conforming gender identities in public and private institutions, most of the respondents noted that private institutions respect gender identity to a greater ex-tent than public institutions, with the difference reaching the level of statistically significant, as shown in Table 6.

DISCUSSION

In general, when interacting with healthcare professionals, transgender people are met with more prejudice – according to the survey, more than half of the respondents had experienced discriminatory behaviours from medical personnel. Additionally, healthcare professionals usually have limited knowledge about the specifics of caring for transgender individuals [11]. As a result, transgender people often abstain from visiting a doctor and neglect recommended preventive medical check-ups.
There is a consensus among researchers that, compared to the general population, transgender people are much more likely to experience mental health problems, with the social stress model (the aforementioned minority stress) being the explanation dominating the scientific literature. It assumes that social stressors in the form of stigmatisation and discrimination encountered by members of this subpopulation may contribute to discrepancies in mental health results in comparison to the general population [12, 13]. The social stress model implies that reducing the intensity of the negative stimuli would improve the situation of this at-risk group [14, 15]. Research conducted by Bockting et al. on a group of 1093 transgender people indicated the existence of a direct correlation between perceived stigma and men-tal suffering [16]. Fear of discrimination, being shamed, and not meeting societal expectations impacts the decision-making of transgender people, who then often decide to hide the truth about themselves.
In Poland, the official transition process – which begins with a psychological diagnosis and ends with a formal change of all the legal documents – is long and difficult, which is why many transgender people, even those who function in society as members of the preferred sex, are in long-term hormone therapy or even undergo gender-reaffirming surgeries, in the eyes of the law are still of the sex assigned at birth. Among all the consequences it has for the transgender person, it also impacts their interactions with healthcare professionals, as it might make both the logistics of planning the visit and the visit itself difficult.
This study further confirms that the number of various psychiatric diagnoses is prominent in transgender patients; the results, however, also show that the percentage of people who get necessary professional help is small, with more than half of the respondents believing that doctors focus mainly on somatic needs and ignore mental health issues. It is therefore clear that it is of paramount importance to provide transgender individuals with sufficient psychiatric and psychological care.
There are few data available regarding the field of providing medical care to transgender people in Poland. Most re-search on the matter is done by various NGOs, and it is usually part of a larger study dedicated to either health in the LGBT community in general or to research covering additional topics and not just medical aspects. More research focusing solely on healthcare-related experiences of transgender people can be found in foreign literature. In an Australian study of 928 transgender people, Zwickl et al. concluded that there is a great need to educate people working in the medical professions about the specific health needs of transgender people. Additionally, those surveyed showed inter-est in participating in the formulation of guidelines and standards of care for transgender patients [17]. Similar results were published in 2018, following a study conducted among 2168 American respondents identifying themselves as transgender. It was established that their actual state of health did not differ significantly from the average, although they statistically significantly less often attended routine health check-ups.
A study conducted in 2015 in Germany on the issue of medical care for transgender people showed that the needs of these people in terms of health are very diverse [18]. In another U.S. survey of transgender people’s views on medical care, respondents indicated that they find it burdensome to have their identity omitted and ignored in healthcare facilities. According to the authors of the study, responsibility for this lies with medical professionals, who should prioritise the well-being of transgender people when treating them [19]. Results of a survey filled out by 6000 transgender Americans indicated that 19% were denied health care because of their gender identity, 28% postponed necessary pro-cedures, and 33% no longer sought help because of feeling humiliated – because of jokes, mockery, ridicule, violation of confidentiality, or use of the wrong pronoun – by the medical professional [20]. For this reason, transgender people are also reported to resort to using pseudo-medical and non-medical services more often and may take part in unmoni-tored treatment with hormones [21].
Therefore, it is not only necessary to take measures to reduce the discrepancies in the access of transgender people to medical services in comparison to the general population, but also to take into account that because there are many identities with which patients identify, there might be as many individual health challenges [22]. According to researchers, a possible solution would be to introduce health centres dedicated to transgender people, which, by employing highly educated and specialised professionals, would ensure high-quality medical care for patients from this group [18].
The conducted research clearly shows that medical care for transgender people in Poland is difficult mainly due to patients’ fear of discrimination. To provide proper care to this ever-growing group of people, it is necessary to educate medical staff as well as students of medical sciences on how to properly interact with transgender patients to ensure they feel safe and well cared for. It is also very important to show acceptance for these people in a visible place of the medical care facility. By reducing anxiety in this group of patients, medical staff can encourage them to attend routine check-ups and increase their health awareness, thus significantly increasing the overall health of this subpopulation.

CONCLUSIONS

This research confirms fear of discrimination as the main reason for transgender people limiting interactions with the healthcare system in general. However, according to the respondents, the level of acceptance of those with non-conforming gender identities in healthcare facilities is increasing, although this trend is observed mainly in private facilities. The topic of transgenderism is insufficiently addressed in the vocational training program for future healthcare professionals; thus, it seems reasonable to include anti-discrimination classes in the curriculum for medical studies.

Disclosures

This research received no external funding.
The study was approved by the Bioethics Committee of the Jagiellonian University Medical College (Approval No. 1072.6120.65.2021).
The authors declare no conflict of interest.

References