The lived experiences of transgender and gender-diverse people in accessing publicly funded penile-inversion vaginoplasty in Canada.

BACKGROUND: Canada's health care systems underserve people who are transgender and gender diverse (TGD), leading to unique disparities not experienced by other patient groups, such as in accessing gender-affirmation surgery. We sought to explore the experiences of TGD people seeking and accessing gender-affirmation surgery at a publicly funded hospital in Canada to identify opportunities to improve the current system. METHODS: We used hermeneutic phenomenology according to Max van Manen to conduct this qualitative study. Between January and August 2022, we conducted interviews with TGD people who had undergone penile-inversion vaginoplasty at Women's College Hospital, Toronto, Ontario, since June 2019. We conducted interviews via Microsoft Teams and transcribed them verbatim. We coded the transcripts using NVivo version 12. Using inductive analysis, we constructed themes, which we mapped onto van Manen's framework of lived body, lived time, lived space, and lived human relations. RESULTS: We interviewed 15 participants who had undergone penile-inversion vaginoplasty; they predominantly self-identified as transgender women (n = 13) and White (n = 14). Participants lived in rural (n = 4), suburban (n = 5), or urban (n = 6) locations. Their median age was 32 (range 27-67) years. We identified 11 themes that demonstrated the interconnected nature of TGD peoples' lived experiences over many years leading up to accessing gender-affirmation surgery. These themes emphasized the role of the body in experiencing the world and shaping identity, the lived experience of the body in shaping human connectedness, and participants' intersecting identities and emotional pain (lived body); participants' experiences of the passage of time and progression of events (lived time); environments inducing existential anxiety or fostering affirmation, the role of technology in shaping participants' understanding of the body, and the effect of liminal spaces (lived space); and finally, the role of communication and language, empathy and compassion, and participants' experiences of loss of trust and connection (lived human relations). INTERPRETATION: Our findings reveal TGD patients' lived experiences as they navigated a lengthy and often difficult journey to penile-inversion vaginoplasty. They suggest a need for improved access to gender-affirmation surgery by reducing wait times, increasing capacity, and improving care experiences.

Lived experiences of transgender and nonbinary people in the perioperative context: a qualitative study.

BACKGROUND: Transgender and nonbinary (TNB) people experience obstacles that create barriers to accessing health care, including stigmatization and health inequities. Our intention was to describe the lived experiences of TNB patients and identify potential gaps in the education of health care professionals. METHODS: We conducted a qualitative descriptive study influenced by phenomenology by interviewing with TNB adults who underwent surgery in Canada within the previous 5 years. We recruited participants using purposeful and snowball sampling via online social networking sites. Audio recordings were transcribed. Two authors coded the transcripts and derived the themes. RESULTS: We interviewed 21 participants, with a median interview duration of 49 minutes. Participants described positive and negative health care encounters that led to stress, confusion, and feelings of vulnerability. Major themes included having to justify their need for health care in the face of structural discrimination; fear and previous traumatic experiences; community as a source of support and information; and the impact of interactions with health care professionals. INTERPRETATION: Participants detailed barriers to accessing care, struggled to participate in shared decision-making, and desired trauma-informed care principles; they described strength in community and positive interactions with health care professionals, although barriers to accessing gender-affirming care often overshadowed other aspects of the perioperative experience. Additional research, increased education for health care professionals, and policy changes are necessary to improve access to competent care for TNB people.

A matter of life and death: physician gender and patient outcomes after surgery.

Accumulating evidence supports an effect of physician gender (or sex, a surrogate used in many studies) on important patient outcomes such as death, complications, and hospital length of stay. Recent studies suggest that these effects result from the gender diversity of the team rather than individual physician gender. Here, we reflect on the potential mechanisms of an effect of physician gender on patient outcomes.

Association Between Anesthesiologist Sex and Patients' Postoperative Outcomes: A Population-based Cohort Study.

OBJECTIVE: To examine the association of anesthesiologist sex on postoperative outcomes. BACKGROUND: Differences in patient postoperative outcomes exist, depending on whether the primary surgeon is male or female, with better outcomes seen among patients treated by female surgeons. Whether the intraoperative anesthesiologist's sex is associated with differential postoperative patient outcomes is unknown. METHODS: We performed a population-based, retrospective cohort study among adult patients undergoing one of 25 common elective or emergent surgical procedures from 2007 to 2019 in Ontario, Canada. We assessed the association between the sex of the intraoperative anesthesiologist and the primary end point of the adverse postoperative outcome, defined as death, readmission, or complication within 30 days after surgery, using generalized estimating equations. RESULTS: Among 1,165,711 patients treated by 3006 surgeons and 1477 anesthesiologists, 311,822 (26.7%) received care from a female anesthesiologist and 853,889 (73.3%) from a male anesthesiologist. Overall, 10.8% of patients experienced one or more adverse postoperative outcomes, of whom 1.1% died. Multivariable adjusted rates of the composite primary end point were higher among patients treated by male anesthesiologists (10.6%) compared with female anesthesiologists (10.4%; adjusted odds ratio 1.02, 95% CI: 1.00-1.05, P =0.048). CONCLUSIONS: We demonstrated a significant association between sex of the intraoperative anesthesiologist and patient short-term outcomes after surgery in a large cohort study. This study supports the growing literature of improved patient outcomes among female practitioners. The underlying mechanisms of why outcomes differ between male and female physicians remain elusive and require further in-depth study.

Unmasking imposter syndrome: individual responsibility or repercussions of systemic oppression?

In contemporary and popular discourse, imposter syndrome is frequently outlined as an individual problem that can be overcome. Rather than the locus of responsibility being placed on the individual, we posit that neoliberal academic institutions contribute to imposter syndrome by (de)legitimising certain forms of knowledge.

Relinquishing control? Supervisor co-regulation may disrupt students' self-regulated learning during simulation-based training.

When uncertain, medical trainees often seek to co-regulate their learning with supervisors and peers. Evidence suggests they may enact self-regulated learning (SRL) strategies differently when engaged in self- versus co-regulated learning (Co-RL). We compared the impacts of SRL and Co-RL on trainees' acquisition, retention, and preparation for future learning (PFL) of cardiac auscultation skills during simulation-based training. In our two-arm, prospective, non-inferiority trial, we randomly assigned first- and second-year medical students to the SRL (N = 16) or Co-RL conditions (N = 16). Across two learning sessions separated by two-weeks, participants practiced and were assessed in diagnosing simulated cardiac murmurs. We examined diagnostic accuracy and learning trace data across sessions, and conducted semi-structured interviews to explore participants' understandings of their underlying choices and learning strategies. SRL participants' outcomes were non-inferior to Co-RL participants on the immediate post-test and retention test, but not on the PFL assessment (i.e., inconclusive). Analyzing interview transcripts (N = 31) generated three themes: perceived utility of initial learning supports for future learning; SRL strategies and sequencing of murmurs; and perceived control over learning across sessions. Co-RL participants regularly described relinquishing control of learning to supervisors and regaining it when on their own. For some trainees, Co-RL seemed to interfere with their situated and future SRL. We posit that transient clinical training sessions, typical in simulation-based and workplace-based settings, may not allow the ideal processes of Co-RL to unfold between supervisor and trainee. Future research must examine how supervisors and trainees can share accountability to develop the shared mental models that underlie effective Co-RL.

Peri-Operative Wearables in Elder Recover after Surgery (POWERS) study: a protocol for a multicentre, prospective cohort study to evaluate perioperative activity with postoperative disability in older adults after non-cardiac surgery.

INTRODUCTION: The ageing population has led to an increasing proportion of surgical patients with greater frailty and comorbidity. Complications and mortality within 30 days of a surgical procedure are often used to evaluate success in the perioperative period however these measures can potentially underestimate a substantial level of morbidity associated with surgery. Personal wearable technologies are now readily available and can offer detailed information on activity intensity, sedentary behaviour and sleeping patterns. These devices may provide important information perioperatively by acting as a non-invasive, and cost-efficient means to risk stratify patients. METHODS AND ANALYSIS: The Peri-Operative Wearables in Elder Recover After Surgery (POWERS) study is a multicentre observational study of 200 older adults (≥65 years) having major elective non-cardiac surgery. The objectives are to characterise the association between preoperative and postoperative activity monitor measurements with postoperative disability and recovery, as well as characterise trajectories of activity and sleep in the perioperative period. Activity will be monitored with the ActiGraph GT3X device and measured for 7-day increments, preoperatively, and at 1 week, 1 month and 3 months postoperatively. Disability will be assessed using the WHO Disability Assessment Schedule 2.0 assessed at 1 week, 1 month and 3 months postoperatively. ETHICS AND DISSEMINATION: The POWERS study received research ethics board approval at all participating sites on 1 August 2019 (REB # 19-121 (CTO 1849)). Renewal was granted on 19 May 2022.

Outcomes of COVID-19 manuscripts submitted to the Canadian Journal of Anesthesia: a retrospective audit of author gender and person of colour status.

PURPOSE: We aimed to evaluate the representation of women and persons of colour (POC) authors of COVID-19 manuscripts submitted to, accepted in, and rejected from the Journal and to evaluate trends in their representation during the pandemic. METHODS: All COVID-19 manuscripts submitted to the Journal between 1 February 2020 and 30 April 2021 were included. Manuscript data were retrieved from Editorial Manager, and gender and POC status were obtained through: 1) e-mail communication with corresponding authors; 2) e-mail queries to other coauthors; 3) NamSor software, and 4) Internet searches. The data were described using percentages and summary statistics. A two-sample test of proportions was used for comparisons and trends were analyzed with linear regression. RESULTS: We identified 314 manuscripts (1,555 authors), 95 (461 authors) of which were accepted for publication. Of all authors, 515 (33%) were women, and women were the lead and senior authors of 101 (32%) and 69 (23%) manuscripts, respectively. There were no differences in women's representation as authors between accepted and rejected manuscripts. Overall, 923/1,555 (59%) authors were identified as POC, with a significantly lower proportion of POC authors among accepted vs rejected manuscripts (41%, 188/461 vs 67%, 735/1,094; difference, -26%; 95% CI, -32 to -21; P < 0.001). We did not observe significant trends in the proportion of women and POC authors over the study period. CONCLUSION: The proportion of women authors of COVID-19 manuscripts was lower than men's representation. Further research is required to determine the factors that account for the higher proportion of POC authors across rejected manuscripts.

RéSUMé: OBJECTIF: Nous avions pour objectif d'évaluer la représentation des femmes et des personnes de couleur ayant rédigé des manuscrits portant sur la COVID-19 soumis, acceptés et rejetés au Journal et d'évaluer les tendances concernant leur représentation pendant la pandémie. MéTHODE: Tous les manuscrits portant sur la COVID-19 soumis au Journal entre le 1er février 2020 et le 30 avril 2021 ont été inclus. Les données des manuscrits ont été extraites de la plateforme de gestion des manuscrits Editorial Manager, et le sexe et le statut de personne de couleur ont été obtenus par : 1) la communication par courrier électronique avec les auteurs et autrices correspondant·es; 2) des requêtes par courrier électronique envoyées à d'autres coautrices et coauteurs; 3) le logiciel NamSor, et 4) des recherches sur Internet. Les données ont été décrites à l'aide de pourcentages et de statistiques sommaires. Un test de proportions à deux échantillons a été utilisé pour les comparaisons et les tendances ont été analysées par régression linéaire. RéSULTATS: Nous avons identifié 314 manuscrits (1555 auteurs et autrices), dont 95 (461 autrices et auteurs) ont été acceptés pour publication. Parmi tou·tes les auteurs/autrices, 515 (33 %) étaient des femmes, et les femmes étaient les autrices principales et senior de 101 (32 %) et 69 (23 %) manuscrits, respectivement. Il n'y avait aucune différence dans la représentation des femmes en tant qu'autrices entre les manuscrits acceptés et rejetés. Dans l'ensemble, 923/1555 (59 %) auteurs et autrices ont été identifié·es comme étant des personnes de couleur, avec une proportion significativement plus faible d'autrices et d'auteurs de couleur parmi les manuscrits acceptés vs rejetés (41 %, 188/461 vs 67 %, 735/1094; différence, -26 %; IC 95 %, -32 à -21; P < 0,001). Nous n'avons pas observé de tendances significatives dans la proportion d'auteurs et d'autrices femmes et de couleur au cours de la période à l'étude. CONCLUSION: La proportion de femmes autrices de manuscrits sur la COVID-19 était inférieure à celle des hommes. D'autres recherches sont nécessaires pour déterminer les facteurs qui expliquent la plus grande proportion d'autrices et d'auteurs de couleur parmi les manuscrits rejetés.

Queer(ing) medical spaces: queer theory as a framework for transformative social change in anesthesiology and critical care medicine.

Queer theory is a disruptive lens that can be adopted by researchers, educators, clinicians, and administrators to effect transformative social change. It offers opportunities for anesthesiologists, critical care physicians, and medical practitioners to more broadly understand what it means to think queerly and how queering anesthesiology and critical care medicine spaces improves workplace culture and patient outcomes. This article grapples with the cis-heteronormative medical gaze and queer people's apprehensions of violence in medical settings to offer new ways of thinking about structural changes needed in medicine, medical language, and the dehumanizing application of medical modes of care. Using a series of clinical vignettes, this article outlines the historical context underlying queer peoples' distrust of medicine, a primer in queer theory, and an understanding of how to begin to "queer" medical spaces using this critical framework.

RéSUMé: La théorie queer est une lentille perturbatrice qui peut être adoptée par la communauté de la recherche et de l'éducation, les personnes en clinique et les directions d'établissement pour apporter des changements sociaux transformateurs. Elle offre aux anesthésiologistes, aux intensivistes et aux médecins l'occasion de comprendre plus globalement ce que signifie le fait de penser de manière queer et comment la 'queer-icisation' des espaces d'anesthésiologie et de médecine de soins intensifs améliore la culture du milieu de travail et les devenirs des patient·es. Cet article s'attaque au regard médical cis- et hétéronormatif et aux appréhensions des personnes queer face à la violence dans les milieux médicaux afin de proposer de nouvelles façons de penser les changements structurels nécessaires en médecine, le langage médical et l'application déshumanisante des modes de soins médicaux. À l'aide d'une série de vignettes cliniques, cet article décrit le contexte historique sous-jacent à la méfiance des personnes queer à l'égard du monde médical. Il propose également une introduction à la théorie queer et une interprétation de la façon de commencer à rendre plus queer les espaces médicaux en utilisant ce cadre critique.

Patient reported symptoms and adverse outcomes seen in Canada's first vaginoplasty postoperative care clinic.

IMPORTANCE: Vaginoplasty is a relatively common gender-affirming surgery with approximately 200 Ontarians seeking this surgery annually. Although Ontario now offers vaginoplasty in province, the capacity is not meeting demand; the majority of trans and gender-diverse patients continue to seek vaginoplasty out of province. Out-of-province surgery presents a barrier to accessing postsurgical follow-up care leaving most patients to seek support from their primary care providers or providers with little experience in gender-affirming surgery. OBJECTIVE: To provide an account of the common postoperative care needs and neovaginal concerns of Ontarians who underwent penile inversion vaginoplasty out of province and presented for care at a gender-affirming surgery postoperative care clinic. DESIGN, SETTINGS, AND PARTICIPANTS: A retrospective chart review of the first 80 patients presenting to a gender-affirming surgery postoperative care clinic who had undergone vaginoplasty at an outside surgical center was performed. Descriptive analyses were performed for all variables. RESULTS: The sample consisted of 80 individuals with the mean age of 39 years (19-73). Most patients had surgery at another surgical center in Canada (76.3%). Many patients (22.5%) accessed care in the first 3 months after surgery, with the majority (55%) seeking care within the first perioperative year. Most patients (61.3%) were seen for more than one visit and presented with more than two symptoms or concerns. Common patient-reported symptoms during clinical visit included pain (53.8%), dilation concerns (46.3%), and surgical site/vaginal bleeding (42.5%). Sexual function concerns were also common (33.8%) with anorgasmia (11.3%) and dyspareunia (11.3%) being the most frequent complications. The most common adverse outcomes identified by health care providers included hypergranulation (38.8%), urinary dysfunction (18.8%), and wound healing issues (12.5%). CONCLUSIONS AND RELEVANCE: Findings from chart review offer valuable insights into the postoperative needs and neovaginal concerns of Ontarians who have had vaginoplasty out of province. This study demonstrates the need for routine postoperative care in patients undergoing vaginoplasty. Patients experience numerous symptoms and concerns that often correlate with clinical findings and require multiple follow-up appointments. Health care providers may benefit from further education on the more common nonsurgical issues identified in this study.

Sex differences in patient journeys to diagnosis, referral, and surgical treatment of trigeminal neuralgia: implications for equitable care.

OBJECTIVE: Trigeminal neuralgia (TN) is an orofacial pain disorder that is more prevalent in females than males. Although an increasing number of studies point to sex differences in chronic pain, how sex impacts TN patients' journeys to care has not been previously addressed. This study sought to investigate sex differences in patients' journeys to diagnosis, referral, and treatment of TN within a large national context. METHODS: Patients with classic TN (n = 100; 50 females and 50 males) were randomly selected through chart reviews at the largest surgical treatment center for TN in Canada for a cross-sectional study. Statistical tests, including Welch's t-test, the chi-square test, Pearson's correlations, and analyses of covariance, were conducted with Python. RESULTS: Key discrepancies between sexes in access to care were identified. Females had a significantly longer referral time interval (average 53.2 months vs 20.4 months, median 27.5 months vs 11.0 months, p = 0.018) and total time interval (average 121.1 months vs 67.8 months, median 78.0 months vs 45.2 months, p = 0.018) than males, despite reporting higher pain intensity at referral. Although medically intolerant patients had a significantly shorter referral time interval than medically tolerant patients (average 13.0 months vs 41.0 months, median 6.0 months vs 17.0 months, p < 0.001), medically tolerant females had a significantly longer referral time interval than medically tolerant males (average 59.9 months vs 21.7 months, median 30.0 months vs 12.0 months, p = 0.017). No statistically significant differences were detected between the sexes for diagnostic time interval (average 63.3 months vs 43.0 months, median 24.0 months vs 24.0 months, p = 0.263) or treatment time interval (average 4.6 months vs 4.7 months, median 4.0 months vs 3.0 months, p = 0.986). CONCLUSIONS: Critical sex differences in patients' journeys to TN surgical treatment were identified, with females enduring considerably longer referral timelines and expressing significantly greater pain intensity than males at referral. Taken together, our findings suggest the presence of unconscious bias and discrimination against females and highlight the need for expediting TN treatment referral for female TN patients.

Organizations in science and medicine must hold each other accountable for discriminatory practices.

Many organizations persist in working with others that engage in known, remediable structural discrimination. We name this practice interorganizational structural discrimination (ISD) and argue it is a pivotal contributor to inequities in science and medicine. We urge organizations to leverage their relationships and demand progress from collaborators.

Standing out or fitting in: A latent projective content analysis of discrimination of women and 2SLGBTQ+ anesthesiologists and providers.

INTRODUCTION: Discrimination toward sex and gender minority anesthesiologists and anesthesia trainees exists. Potential reasons for this discrimination are unclear and incompletely characterized. This study sought to better understand what discrimination looks like for sex and gender minorities in anesthesiology and the culture within anesthesiology that allows this discrimination to occur. MATERIALS AND METHODS: With institutional research ethics board approval and informed consent, we performed a qualitative analysis of free-text responses from a previously-published internet-based cross-sectional survey distributed to Canadian anesthesiology residents, fellows, and staff. The purpose of this survey was to characterize intersections between respondent gender or sexuality with experiences of discrimination in the workplace. Separate analysis of qualitative and quantitative components of this survey was planned a priori, and the quantitative component was published elsewhere. Free-text responses were independently coded by two researchers and subsequently synthesized into emerging themes using latent projective content analysis sensitized by Butler's theory of performativity. RESULTS: Out of 490 free-text responses from 171 respondents [140 (81.9%) identifying as heterosexual], two themes emerged: i) fitting in: performativity reinforcing the status quo, and ii) standing out: performativity as a means of disruptive social change. Power structures were observed to favour individuals who "fit in" with the normative performances of gender and/or sexuality. DISCUSSION: Our study illuminates how individuals whose performances of gender and sexuality "fit in" with those expected normative performances reinforce a workplace culture that advantages them, whereas individuals whose performances of gender and sexuality "stand out" disproportionately experience discrimination. The dismantling of bias and discrimination in the anesthesiology workplace requires individuals (a) who are empowered within their workplace because they "fit in" with the majority; (b) who recognize discrimination toward communities of their peers and/or colleagues; and (c) who actively choose to "stand out".

Protocol for a scoping review on transition-related surgery procedures, outcome measures and access to care.

INTRODUCTION: Transgender and gender diverse (TGD) individuals often identify with a gender different to the one assigned at birth. Transition is a term used to describe the process TGD individuals take to live as their true gender. Surgery can be a very important aspect of care for members of TGD communities. Transition-related surgery (TRS) refers to many different types of surgeries completed to meet a TGD individual's gender-related goals. While various systematic reviews have attempted to synthesise the existing peer-reviewed literature around aspects of TRS, there are few scoping reviews in this area. Our scoping review aims to address this gap through providing an up-to-date overview of the TRS literature in order to provide an overarching view of the topic. METHOD AND ANALYSIS: This review will follow the methods outlined by the Joanna Briggs Institute's methodology for scoping reviews and will be reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. A search of nine scientific databases resulted in 20 062 potential articles. After removing duplicates, articles will be screened for inclusion using Covidence. Data extraction and synthesis will be carried out using NVivo and reviewed by team members. ETHICS AND DISSEMINATION: As this study is a scoping review of the existing literature, no ethics review is required. The findings from this review will be disseminated through multiple pathways including open access publication, submission to conferences, social media and Listservs. The findings of the study will also be readily available to clinicians, organizations, interest groups, and policy-makers.

Author Diversity on Clinical Practice Guideline Committees.

ABSTRACT: Reports have demonstrated that women overall and women physicians, in particular, are underrepresented as authors of clinical practice guidelines. This analysis used publicly available information to explore the diversity of rehabilitation-related clinical practice guideline authors by gender, race, and ethnicity. Primary analysis identified authors' gender, race, ethnicity, and visible minority status. Two sets were analyzed: (1) clinical practice guidelines by Department of Veterans Affairs (VA) categorized as "Rehabilitation" or "Pain" (n = 7; VA clinical practice guidelines) and (2) a set (n = 10) published in the United States (US) from 2019 to 2021 that were selected because of low numbers of inclusion at less than 20% women authors. Key findings include that among physician authors, both the VA and US clinical practice guidelines underrepresented women (15 [24.2%] and 27 [16.7%], respectively) and those coded as a racial or ethnic minority were particularly underrepresented. Notably, women authors overall were equally represented (92 [50.0%]) in the VA clinical practice guidelines. The US clinical practice guidelines had women authors who were underrepresented (36 [19.0%]). Secondary analysis of the entire set of VA clinical practice guidelines (n = 21) found gaps in diversity-related content. Clinical practice guidelines have far-reaching health and economic impacts, and addressing disparities in the diversity of author teams and/or gaps in diversity-related content is of paramount importance.