Abstract
PURPOSE People who are transgender or gender diverse (PTGD) often experience difficulties navigating the health care system due to a variety of factors such as lack of knowledgeable and/or culturally competent clinicians, discrimination, and structural and/or socioeconomic barriers. We sought to determine whether a peer health navigator service in the Canadian province of Saskatchewan helped connect transgender and gender-diverse clients and health care practitioners (HCPs) to resources, and how this service changed their health care experiences.
METHODS Semistructured interviews were conducted with 9 clients and 9 HCPs. Interview transcripts were then analyzed by researchers using an interpretative phenomenological approach, with qualitative data analysis software.
RESULTS The most prevalent theme that emerged from interview data, from both clients and HCPs, was support for the navigators’ work and a desire that the service should continue. It was reinforced by 3 subthemes: the importance that the navigators were PTGD, the ability of the navigators to connect people to services and reliable sources of information, and their skill in directly supporting clients. A fourth subtheme, primarily found among clients, was the navigators’ ability to provide connections to affirming mental health care.
CONCLUSIONS Clients and HCPs alike emphasized that the navigator’s lived experience was invaluable and allowed them to empathize with PTGD and provide support. Furthermore, the navigators acted as a direct connection to health care services, which helped improve access for clients. Our findings underscore the need for navigator positions to become permanent within the provincial health system to improve the health care experiences of PTGD in Saskatchewan.
- transgender persons
- peer health navigators
- health services
- health care experiences
- access
- barriers
- primary care
- qualitative methods
- practice-based research
- vulnerable populations
INTRODUCTION
People who are transgender or gender diverse (PTGD), broadly defined as “individuals whose current gender identity differs from the sex they were assigned at birth,”1 often experience difficulties navigating health care systems due to a variety of factors, including but not limited to, a lack of knowledgeable and/or culturally competent clinicians, discrimination, and structural and/or socioeconomic barriers.2 In Saskatchewan, 2,530 people identified as transgender or gender diverse on the 2021 census; however, more recent studies have had higher estimates.3,4 There have been 3 surveys of PTGDs’ health in Saskatchewan. A 2019 national survey of PTGD found that 44.4% (978 individuals) reported an unmet health care need in the previous year.5 For the 81 participants from Saskatchewan, there was a 43.6% adjusted predicted probability of being on a waitlist for gender-affirming care among those who needed it. Two Saskatchewan surveys about health care practitioners (HCPs) corroborated these findings. The first surveyed primary HCPs and found that although the vast majority (96%) felt comfortable providing general care to PTGD, only 30% felt comfortable providing transition-related care6; the second surveyed people who were lesbian, gay, bisexual, transgender, and queer (LGBTQ) who reported that HCPs were frequently uncomfortable caring for people with these identities.7
Peer health navigators are members of a community whose lived experience is key to their ability to support other community members seeking health care.8 Studies involving people who are LGBTQ and peer navigation have predominantly focused on transgender women and cisgender gay men living with HIV and have found improved viral suppression, increased use of HIV pre-exposure prophylaxis, and more participants accessing peer support services.9,10 Krulic et al conducted a scoping review that included 19 studies of peer navigators for people living with HIV, concluding that, “Many studies demonstrated how peer navigation programs addressed the prevention of HIV, quality of life, mental health and wellbeing and disease self-management but fewer captured effects or detailed descriptions of the processes through which programs influence these outcomes.”11(p. 4049) We aimed to fill this gap.
METHODS
The TRANS Project
The Trans Health Research and Navigation Saskatchewan (TRANS) Project is community-driven research group that is about one-third PTGD. We pilot-tested a peer health navigator service to help PTGD access safe and affirming health care in a timely fashion. The trans health navigator role was designed with person-centered and relationship-building foci as we were aware that there were systemic factors that could not be changed. The project pilot-tested 2 navigators, at 30 hours per week—one serving the Regina area and southern Saskatchewan, the other Saskatoon and northern Saskatchewan—for a year, from April 2021 to March 2022. Combined, they worked with 259 clients and 70 HCPs.12 The job descriptions were written by our team, in part modeling similar Canadian programs, including Trans Care BC. In 2021-2022, the Trans Care BC navigators had “4,800 interactions with community members, family members, loved ones and service providers.”13 Their navigators have been shown to improve PTGDs’ access to, and quality of, health care in that province, through both peer navigation and the education of HCPs. Our literature search found no other evaluations of similar programs, highlighting the need for our project.
Study Aim
The overall purpose of the TRANS Project was to assess the effectiveness of the navigators for PTGD within the health care system.12,* The TRANS team also collected baseline data on health care access experiences among PTGD, statistics on service use, postservice surveys, and journals kept by the navigators, some of which have been reported elsewhere.12,14,* Through semistructured qualitative interviews, this study sought to understand the experiences both clients and HCPs had working with the navigators to assess the effect of the navigators on access to and satisfaction with health care services, and to determine the effect of the navigators on health care practices and service delivery.
Navigator Recruitment
The navigators were required to be PTGD and to have work experience in health care and/or community-based organizations. They were hired by a subset of the research team, including PTGD with LGBTQ organizations and the coprincipal investigators. The navigators were trained both informally by the team and through mentorship with another Canadian PTGD navigator program.
The navigators assisted clients by providing general information about transition and trans identities, recommending affirming HCPs, booking appointments, advocating for clients in medical and personal contexts, assisting with completing and notarizing legal name and gender marker change forms, and providing public education. The navigators also assisted HCPs with various tasks: providing information on an individual basis, connecting HCPs with more knowledgeable clinicians, and conducting group education sessions. The navigators were funded through a Saskatchewan Health Research Foundation–Saskatchewan Centre for Patient-Oriented Research grant for $180,000 CAD, of which approximately two-thirds went to the navigators and the rest to research costs.
Study Design and Participant Recruitment
For the current study, the navigators assisted in recruiting the interviewees by asking people they worked with if they would be interested in being interviewed after the pilot program was complete, emphasizing that there was no obligation to be interviewed and that their choice did not affect their access to services. Interested individuals were e-mailed by a researcher (G.R.), who completed recruitment. We initially planned to interview a maximum of 12 clients and 12 HCPs, but data saturation was reached after interviewing 9 clients and 9 HCPs, so further interviews were not conducted. Efforts were made to interview a diverse representation of both clients and HCPs (in locations, HCP professions, and client ages and identities).
Semistructured interviews were conducted by 2 researchers (G.R., M.R.) from May through July 2022 via Zoom videoconferencing (Zoom Video Communications Inc). Both interviewers are transgender or gender diverse, in accordance with the Canadian Professional Association for Transgender Health (CPATH) ethical guidelines to center lived experience.15 Each session was approximately 30 minutes long. The sessions were audio recorded, and the recordings were stored on a secure University of Saskatchewan server. Interviews were transcribed by the Canadian Hub for Applied and Social Research (https://chasr.usask.ca/). Interview questions are included in Supplemental Appendix 1 and Supplemental Appendix 2.
Data Analysis
The transcripts were analyzed by 4 researchers (G.R., M.R., M.C.M., and E.G.) using NVivo software (QSR International). As we were interested in the individual experiences of interviewees with the peer navigators, we used interpretive phenomenological analysis, which stresses the importance of personal experiences.9 This analysis involves researchers trying to make sense of the experiences of participants, who are trying to make sense of their own personal and social worlds.16 This methodology captures both the uniqueness of individual experiences and the pattern of meaning that emerges across participants.16 An important component of interpretive phenomenological analysis is to recognize researchers’ own lived experience; we openly attempted to acknowledge and/or resolve biases, or to relate to the experiences described by interviewees.9
The analysis team included PTGD as well as formally trained researchers (some were both) who worked iteratively to determine key thematic components. Researchers began by coding 18 transcripts based on their preliminary individual interpretations. To ensure rigor, they engaged in critical and sustained discussions as they worked together to arrive at a consensus about the final coding, the importance of the emerging themes, and the relationships among themes.10 Client and HCP interviews were grouped and coded separately, with each transcript analyzed by 4 researchers.
This study was approved by the University of Saskatchewan Behavioral Research Ethics Board (Beh-1897), and all participants provided written informed consent before participating. Participants reviewed the portion(s) of the manuscript in which they are quoted and gave written permission for the quotation(s) to be included.
RESULTS
Participants
We interviewed 9 clients and 9 HCPs. Their characteristics are shown in Table 1. The clients ranged in age from childhood to middle-age; there was equal representation of trans women, trans men, and nonbinary/gender-diverse individuals. The HCPs were professionally diverse, with representation of 6 disciplines among them.
Characteristics of Clients and Health Care Practitioners
Overarching Theme
The most prevalent theme that emerged from interview data, from both clients and HCPs, was recognition that PTGD experience structural barriers to receiving necessary health care that the navigators were able to mitigate. It was reinforced by 3 subthemes that arose equally from clients’ and HCPs’ interviews (Table 2).
Themes and Subthemes Identified, and Examples of Relevant Quotes
All clients, and many HCPs, reported that they reached out to the navigators repeatedly because of their success in assisting them and the value of the information they were able to provide. The navigators helped to alleviate struggles that clients expected to have otherwise faced navigating the health care system alone. Some clients reported that by reducing these barriers, the navigators had a positive psychosocial and emotional influence on their lives. HCPs valued the support the navigators provided to them and their patients, and the information they provided. The practitioners recognized the need for transgender- and gender-diverse–affirming health care and the valuable education the navigators provided.
Unprompted, clients and HCPs both noted that they wanted the navigator service to continue, as they were aware that it was being tested on a pilot basis, affirming the overall value and need for the program.
Subthemes
Shared Experiences Allowed for Empathy
The first subtheme was that the shared experiences of structural transphobia between clients and navigators allowed for empathy.
Clients expressed that the navigators’ shared lived experience of being PTGD and accessing health care brought a real understanding of how challenging the barriers to care are. Clients noted that this shared experience contributed to the navigators’ ability to emotionally support clients. Beyond the general lack of primary HCPs, clients acknowledged the particular lack of HCPs competent in trans-specific care. This lack meant that PTGD had to advocate for themselves. The shared experience of being trans reduced the emotional burden of facing HCPs and an oppressive health care system alone.
The HCPs reported that the navigators provided them with a deeper understanding of the experience of being a patient who is transgender or gender diverse within the health care system, which meant they were better able to provide PTGD with medical care. HCPs used the navigators’ lived experience as a bridge between medical and experiential knowledge, improving empathy and understanding.
Assisting With Access and Providing Information
The second subtheme was that navigators reduced stress by helping PTGD to access services and providing reliable information to both PTGD and HCPs.
Clients appreciated the navigators’ ability to connect them with the larger PTGD community as well as health care services. Client Jude noted that it was the navigator who “suggested the trans fund”—a microgrant provided by a community organization—for support after their top surgery. Bellamy highlighted “a social group” the navigator told them about. Clients found that these services were complementary to the health care services they received.
Clients and HCPs viewed the navigators as reliable sources of up-to-date, high-quality information about care for transgender and gender-diverse individuals. Clients found that the navigators’ assistance reduced the stress and burden of researching clinicians and services for themselves and served as assurance that the services would be affirming. For clients, this informed a sense of “what to expect,” which reduced emotional stress. The navigators provided accurate and easily understandable information, tailored to each client, about transition-related medications, surgeries, referral processes, and administrative procedures.
Affirming HCPs recognized that not all clinicians are accepting of PTGD patients. They acknowledged that finding one is difficult and that the navigator service helped alleviate this burden for clients. The HCPs also appreciated that the navigators were able to prepare clients for what to expect at appointments, provide up-to-date information, and correct misinformation that gets passed through informal networks. They found it particularly helpful for preparing people who had less experience with health care, such as adolescents, because the navigators were able to take time to prepare people with what questions to ask and to explain medical terminology. HCPs also used the navigators as resources for current information about the transition process.
Mitigating Barrier-Related Stress
The third subtheme was that navigators helped PTGD to mitigate stresses associated with structural health care barriers.
The navigators demonstrated profound championship on behalf of clients, offering guidance and mentorship through complex situations. They made appointments for clients, instead of just giving them numbers to call. Accommodating clients’ schedules when arranging appointments was part of reducing minority stress, including the stress of precarious employment and atypical schedules. Although the navigators were not trained psychological counselors and were not providing formal counselling, they used their lived experience to connect with clients of all ages. The parent of a gender-diverse child felt supported by the navigators as being trans was outside of the parent’s experience.
The HCPs had divergent impressions of the navigators’ roles. Some perceived peer support as a valuable part of the navigators’ services. Others perceived the navigators’ role to be largely educational in nature, limited to providing information or leading educational sessions. Mike described it as “just a general advisor capacity,” whereas Wallace viewed it in more specific terms: “I perceived their role as to provide us [HCPs] with education.” The HCPs who viewed the navigator role as primarily educational also valued that one of the navigators was trained as an HCP, reporting that it made them more credible. Although it was clear that some HCPs recognized the emotional value that the navigator service had, particularly in terms of PTGDs’ health and well-being, others framed the role more in terms of their own practice and knowledge.
Reducing Barriers to Mental Health Care
The fourth subtheme was that PTGD experience structural barriers to mental health care that are ameliorated by navigators.
Clients spoke more than HCPs about the importance of psychosocial support and mental health care. Only 2 HCPs, both mental health professionals, discussed the importance of mental health care for PTGD. One of them acknowledged that the navigators helped meet the critical support needs of clients on waiting lists for counselling services. For their part, clients readily identified the psychosocial supports that the navigators provided and mentioned the importance of mental health care for PTGD more broadly. Although the navigators were not providing psychological counselling, clients indicated that their services helped to alleviate burdens within the health care system that had a negative impact on their mental health. Clients discussed how both the navigator service and the navigators themselves had a positive impact on their psychological well-being.
DISCUSSION
The themes that emerged from our interviews with clients and HCPs were remarkably similar. Both clients and HCPs reported a consistently high level of satisfaction with the navigators and a strong desire for these positions to be permanently instituted in Saskatchewan. At the time of the interviews, the study’s funding had expired and there was a gap in the navigator services before the Ministry of Health began funding the positions; participants commented on the importance of the service in this context. Other studies on peer navigators have indicated comparable levels of success. The most similar to our study is the evaluation of the Trans Care BC peer health navigators, established in 2015.13 Our findings demonstrate similar benefits, on a smaller scale, because of the pilot nature of the program and the smaller population in Saskatchewan.
Findings in Context
Our study is novel in how it captured nuances in the ways peer navigators improved clients’ quality of care. The navigators were able to reduce the negative effects of structural barriers. They built empathy with clients and prepared HCPs to treat PTGD respectfully, in a culturally conscious manner. The navigators were seen as an important connection not only to the health care system, but also to other necessary services and the PTGD community. The navigators’ lived experience inspired trust among clients when accessing health care by informing their expectations. Finally, the navigators were an important source of psychosocial support for clients, which helped them to cope with structural barriers. Overall, the interviewees, both clients and HCPs, found that the navigator’s value extended far beyond the face value of the information they provided and into increased feelings of understanding, comfort, and safety.
Our study is also novel in that HCPs used the navigator service as well. We were unable to find any literature in which navigators served this dual role. HCPs viewed the navigators as educators and information sources, but also as HCPs: as part of their own networks and of the health care system itself. Although this was a valuable insight, the practitioners tended to focus on the navigators’ role in helping them provide better physical care to PTGD; the only HCPs interviewed who mentioned mental health were mental health professionals, and because we interviewed only 2 of them, this did not fully emerge as a theme.
More widely, we found similarities with studies that have examined what caring and interpersonal communication mean to patients in the context of navigators for people with breast cancer. A scoping review by Gillespie et al17 found that caring had 5 domains: positive attitudes, effective communication, relationship building, assistance with navigating health care services, and emotional engagement. All of these domains, except positive attitudes, were directly raised by interviewees; however, there is an impression of positivity in the interviews, for example, when clients discussed feeling supported, and HCPs expressed appreciation of the quality and relevance of the information the navigators provided. Gallups et al used concept mapping to explore navigators’ interpersonal communication with breast cancer patients; they found that “Empathic, Comprehensive, and Compassionate Support, Bridge to Clinical Education and Supportive Resources, and Coordinating Ongoing Individualized Care”18(p. 325) were the most important components. Again, all of these domains were directly reflected in our interviews. Both of these studies looked at caring and communication from the perspective of the patient/client. We did not find any studies in the literature that examined the perspectives of HCPs as navigator service users.17 The HCPs in our study corroborated the same themes as clients, with the exception that only mental health practitioners explicitly discussed the role of the navigators in supporting mental health.
Future Directions
The Ministry of Health has provided permanent funding for these navigator positions via a community-based organization by and for PTGD. Members of our team are working with Western Canadian PTGD navigator programs, including those in Saskatchewan, to develop mutually beneficial data collection tools and examine how navigators practice client-centered care. Future studies should also seek to address concerns of rural dwellers as they may differ from those of urban dwellers.
Strengths and Limitations
A strength of this research was the inclusion of PTGD at all stages of the research process. Not only were the navigators PTGD, but as recommended by CPATH, we involved PTGD as collaborators throughout: from study conception to writing the manuscript.19 Interviewees and research assistants were compensated for their time. Overall, the TRANS Project strove to center the voices of PTGD, included PTGD as community-based researchers, and employed PTGD as research assistants who shared authorship with academic and community researchers.
Purposeful sampling is always used in qualitative research, and we used it to ensure a diverse sample in terms of ages, geography, and genders.10 This approach may have led to selection bias toward people with positive experiences, however. Two participants, a client and an HCP, were acquainted with the peer navigator before using their services; this was inevitable in a province with a small population (and an even smaller population of PTGD), but it may have affected the interviewees’ responses. Only one navigator program operating in one Canadian province was analyzed, limiting transferability of the findings. We expected some constructive criticisms of the navigator program; however, none were shared. We did collect data for improving the service in other ways.12,14,* Finally, the concerns specific to rural interviewees were not prominent enough in the results to be themes, as researchers had a limited pool of contacts from which to draw, not all of whom agreed to be interviewed.
Conclusions
Overall, the interviewees in our study, both clients and HCPs, expressed that their experiences with the peer navigators were overwhelmingly positive and that there is a need for this work to continue. As the navigators provided socio-emotional support, information, and practical guidance, their work was appreciated by both clients and HCPs. The current study was novel for focusing on the affective domain, how people felt about their care rather than quantitative outcomes, and also for focusing on the experiences of HCPs working with navigators. The navigators demonstrated empathy and compassion while guiding clients through the health care system, underscoring the importance of having competencies in areas beyond general knowledge and practical skill. Both clients and HCPs emphasized that the navigators’ lived experience was invaluable and allowed them to connect with PTGD and provide support. Furthermore, the navigators acted as a direct connection to health care services, which helped improve access for clients. Our findings underscore the need for navigator positions to remain permanent within the provincial health system to improve the health care experiences of PTGD in Saskatchewan and beyond.
Acknowledgments
The authors would like to acknowledge the contributions of the entire TRANS Project team to the design of this study and the incredible work of the navigators, who made it possible.
Footnotes
Conflicts of interest: authors report none.
↵* Gwen Rose et al. University of Saskatchewan, Saskatoon, Canada; unpublished data; 2024.
↵* Gwen Rose et al. University of Saskatchewan, Saskatoon, Canada; unpublished data; 2024.
Funding support: This work was supported by a Sprout grant (No. 5207) jointly funded by the Saskatchewan Health Research Foundation and the Saskatchewan Centre for Patient-Oriented Research.
Disclaimer: The views expressed in the submitted article are the authors’ own, and not the official position of the University of Saskatchewan, the Saskatchewan Health Authority, the Saskatchewan Health Research Foundation, or the Saskatchewan Centre for Patient-Oriented Research.
- Received for publication December 18, 2023.
- Revision received July 29, 2024.
- Accepted for publication August 14, 2024.
- © 2025 Annals of Family Medicine, Inc.
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