Research Article: “Primary care is primary care”: Use of Normalization Process Theory to explore the implementation of primary care services for transgender individuals in Ontario

Date Published: April 22, 2019

Publisher: Public Library of Science

Author(s): Erin Ziegler, Ruta Valaitis, Jennifer Yost, Nancy Carter, Cathy Risdon, Sherilyn K.D. Houle.


In Ontario, Canada, healthcare for transgender individuals is accessed through primary care; however, there are a limited number of practitioners providing transgender care, and patients are often on waiting lists and/or traveling great distances to receive care. Understanding how primary care is implemented and delivered to transgender individuals is key to improving access and eliminating healthcare barriers. The purpose of this study is to understand how the implementation of primary care services for transgender individuals compares across various models of primary care delivery in Ontario.

A qualitative, exploratory, multiple-case study guided by Normalization Process Theory (NPT) was used to compare transgender care delivery and implementation across three primary care models. Three cases known to provide transgender primary care and represent different primary care models in Ontario, Canada (i.e., family health team, community health centre, fee-for service physician) were explored. The NoMAD survey, a tool to measure implementation processes, and qualitative interviews with primary care practitioners and allied healthcare staff were administered.

Using the NPT framework to guide analysis, key themes emerged about successful implementation of primary care services for transgender individuals. These themes include creating a safe space for patients, identifying gaps in services, understanding practitioners’ roles, and the need for more training and education in transgender care for practitioners.

Primary care services for transgender individuals can and should be delivered in all models of primary care. Training and awareness for healthcare practitioners are needed to develop capacity in providing primary care to transgender individuals. A greater number of practitioners and organizations are needed to take on this work, embedding and normalizing transgender care into routine practice to address barriers to access and improve quality of care for transgender individuals.

Partial Text

Canada has a publicly funded, universal health insurance system which covers all medically necessary services [1]. Yet despite this accessibility, transgender individuals continue to experience marginalization and barriers to healthcare access [2–4]. Transgender individuals have expressed anxiety over the thought of disclosing their gender identity in healthcare settings due to potential negative consequences [3, 5]. A study by Grant et al. [6] found that 28% of transgender patients had been verbally harassed and 2% had been physically assaulted while attempting to access healthcare. Transgender individuals have identified that gaining access to a practitioner who is knowledgeable about transgender healthcare is a barrier [3, 7–10]. Furthermore, organizational barriers include lack of transgender-friendly spaces and gender-neutral washrooms, binary gender documentation in electronic medical records and inappropriate reference ranges for laboratory systems [3, 4, 11]. While researchers have explored experiences of transgender individuals in obtaining care, there is a paucity of evidence about primary care provider’s experiences in the implementation and delivery of care to transgender individuals. This aim of this study is to address this gap.

First, a brief description of each case and participants will be provided. Second, the qualitative and quantitative results will be presented within the four NPT framework constructs: coherence, cognitive participation, collective action and reflexive monitoring.

Qualitative and quantitative data demonstrated no differences in the delivery and implementation of primary care services for transgender individuals across cases. However, while all participants valued the effects of delivering primary care to transgender individuals had on their work there was a statically significant difference between the CHC and the FHT for this item. While participants both from the CHC and the FHT strongly agreed about the value of this care to their work, the CHC (M = 4.90) was statically higher than the FHT (M = 4.50). The authors suggest this difference could be related to the organization’s mission and values. CHC’s mission is to provide care to “hard to serve”, marginalized populations and may place a higher value on delivering care to this group. Data supports that the delivery of primary care services for transgender individuals has become normalized as part of routine work within the cases.

The scope of this study explored the implementation and delivery of transgender primary care as a snapshot in Ontario, Canada. A limitation of this study is that only three cases were explored and therefore results may not be generalizable to all primary care settings in Ontario. However, the purposeful selection of cases from three delivery models can help with the transferability to similar models of care delivery in other provinces and nations. Results may not be generalizable to organizations that do not have any transgender patients, or practitioners who do not have specialized knowledge of transgender health issues. Additionally, practitioners who may have been instrumental in the initial implementation may no longer be with the organization, therefore potentially limiting the understanding of implementation. This study’s cases were in urban areas of the province, therefore affecting the generalizability to northern or rural areas. The process of implementation was explored retrospectively which may limit the understanding over time and potentially have recall bias.

Further research is needed to expand the scope of the study and explore the implementation of transgender primary care services in other models of care delivery such as NP-led clinics and Aboriginal Health Centres. Furthermore, it is important to explore the prospective implementation of primary care services in organizations currently not providing service to transgender individuals. Further research on all models of primary care and delivery of services for transgender individuals is needed, both from a Canadian and international perspective. Exploring the delivery of care from the perspective of transgender individuals will improve our knowledge of factors which influence access and utilization of primary care services in this population.

Using the NPT framework, we were able to explore the implementation of primary care services to transgender individuals. This study provides a window into understanding how primary care services can be implemented in Ontario for transgender individuals. Providing appropriate specialized practitioner training is key to increasing practitioners’ awareness of the transgender population’s primary care needs and buildings their capacity to provide for them. More practitioners and organizations need to embed and normalize care for transgender individuals into their routine practice to ensure this populations’ access to quality primary care services. “Primary care is primary care”—whether for the general population or transgendered individuals—is a philosophy that is within the scope of general primary care practitioners to provide.




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