Designing a Transgender Health Training for Correctional Health Care Providers: A Feasibility Study
| Author | Kirsty A. Clark,Jaclyn M. W. Hughto |
| Published date | 01 June 2019 |
| Date | 01 June 2019 |
| DOI | 10.1177/0032885519837237 |
| Subject Matter | Articles |
research-article2019
Article
The Prison Journal
2019, Vol. 99(3) 329 –342
Designing a Transgender
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DOI: 10.1177/0032885519837237
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Correctional Health Care
Providers: A Feasibility
Study
Jaclyn M. W. Hughto1,2 and Kirsty A. Clark3
Abstract
Limited provider knowledge of transgender health contributes to stigmatizing
interactions and access-to-care challenges for incarcerated transgender
people. Drawing on interviews with recently incarcerated transgender
individuals and correctional staff, a transgender health care provider training
was developed and piloted. Providers indicated the training gave them
the requisite competencies to offer gender-affirming care to transgender
patients. Participants also rated the intervention to be highly acceptable
and feasible and recommended it be provided to others. In addition, results
suggested that the training may increase providers’ transgender-related
knowledge. Further testing of the intervention is warranted.
Keywords
correctional health care, transgender health, continuing medical education,
health care providers, intervention development
1Brown University School of Public Health, Providence, RI, USA
2Fenway Institute, Boston, MA, USA
3UCLA Fielding School of Public Health, Los Angeles, CA, USA
Corresponding Author:
Jaclyn M. W. Hughto, Brown University School of Public Health, 121 South Main St., 8th
Floor, Providence, RI 02903, USA.
Email: Jaclyn_Hughto@Brown.edu
330
The Prison Journal 99(3)
Introduction
Transgender individuals experience widespread stigma for having a gender
identity that differs from their assigned birth sex. Due to pervasive stigma,
many transgender people are excluded from the legitimate economy and turn
to street economies such as sex work to survive or substance use to cope with
mistreatment, placing them at risk of arrest and incarceration (Garofalo,
Deleon, Osmer, Doll, & Harper, 2006; Glezer, McNiel, & Binder, 2013;
Grant et al., 2011; Nemoto, Bodeker, & Iwamoto, 2011; White Hughto,
Reisner, & Pachankis, 2015). Transgender individuals are disproportionately
incarcerated, and estimates suggest that 16% of the transgender population
have been to jail or prison (Grant et al., 2011), compared with 2.8% of the
U.S. general population (Glaze & Kaeble, 2014).
Like all detainees, incarcerated transgender people may need to access
physical and mental health services to meet their general health care needs;
some transgender inmates also require medical care to medically affirm their
gender (i.e., hormones or surgery; Coleman et al., 2012). However, research
documents that incarcerated transgender people face verbal harassment by
correctional health care providers (Clark, White Hughto, & Pachankis, 2017;
White Hughto et al., 2018), as well as the denial of general and transgender-
specific care including hormones (Brown & McDuffie, 2009; Emmer, Lowe,
& Marshall, 2011; James et al., 2016; Lydon, Carrington, Low, Miller, &
Yazdy, 2015; Reisner, Bailey, & Sevelius, 2014). Denial of necessary health
care has been linked to depression, self-injury, and death by suicide among
incarcerated transgender people (Brown, 2014; Brown & McDuffie, 2009;
Glezer et al., 2013; Tarzwell, 2006).
Research conducted in correctional and noncorrectional settings finds that
transgender patients experience widespread mistreatment by health care pro-
viders (Clark et al., 2017; Lydon et al., 2015; Poteat, German, & Kerrigan,
2013; White Hughto et al., 2018). In some cases, provider discrimination
may be grounded in stigma (Clark et al., 2017; Lurie, 2005; Poteat et al.,
2013; White Hughto et al., 2018), whereas in other cases, mistreatment, such
as referring to a patient by the wrong name or pronoun, may be due to struc-
tural factors such as lack of institutional training on how to meet transgender
patients’ needs or policies that restrict adequate care provision (Brown, 2014;
Clark et al., 2017; White Hughto et al., 2018). Furthermore, qualitative
research illustrates that insufficient provider training can create discomfort
for incarcerated transgender patients and lead to health care access barriers
via health care refusal or avoidance of care (White Hughto et al., 2018).
Trainings to increase providers’ ability to deliver gender-affirming care have
been successful in increasing their awareness and understanding of transgender
Hughto and Clark
331
patients (Hanssmann, Morrison, & Russian, 2008; Thomas & Safer, 2015). To
our knowledge, only one gender-affirming training has been evaluated in a cor-
rectional setting. The study involved the delivery of a lesbian, gay, bisexual,
and transgender (LGBT) training to New York City jails health care staff (Jaffer
et al., 2016). Together with the training, a policy addressing the provision of
medical care to transgender patients (e.g., hormone therapy) was also imple-
mented, leading to significant reductions in transgender patient health care
complaints. The New York study represents an important effort to ensure that
correctional providers receive necessary training in LGBT patient care and
related policies. However, transgender-specific trainings that are adapted to the
correctional context and focus on the population’s unique general and medical
gender affirmation needs are desirable to improve correctional health care pro-
viders’ ability to care for incarcerated transgender patients.
The present study aimed to develop and test a group-based, transgender
health training for correctional health care providers. We utilized a multistage
approach to intervention development that consisted of formative qualitative
work to understand both the correctional environment experiences of trans-
gender people and the training needs of its health care providers, as well as
the design, delivery, and evaluation of a transgender health curriculum. Here,
we provide an overview of the intervention development process, evaluation
of the intervention, and postintervention feasibility and acceptability.
Method
We utilized a staged approach (Rounsaville, Carroll, & Onken, 2001) to adapt
and evaluate a transgender health intervention for correctional health care
providers. The approach included seven stages: (a) qualitative interviews
with formerly incarcerated transgender individuals to examine their experi-
ences accessing health care in correctional settings, including structural bar-
riers and interpersonal barriers to care (White Hughto et al., 2018); (b) key
informant interviews with correctional administrators to assess training needs
and perceived feasibility of delivering a transgender health intervention to
correctional providers; (c) intervention development and Phase I feasibility
testing to assess initial acceptability of the intervention content and feasibil-
ity of delivery postintervention; (d) qualitative interviews with correctional
health care providers to assess multilevel barriers and facilitators to caring for
transgender patients (Clark et al., 2017); (e) adaptation and Phase II pilot test-
ing of the intervention to assess robust measures of intervention feasibility,
acceptability, and preliminary effectiveness using a mixed-methods, pre–
post, longitudinal design (White Hughto et al., 2017); (f) Phase III efficacy
testing of intervention via a randomized controlled trial; and (g) translation of
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The Prison Journal 99(3)
the intervention into practice. Here, we review the first three stages, with a
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