‘Wouldn’t it be easier if you continued to be a guy?’ – a qualitative interview study of transsexual persons’ experiences of encounters with healthcare professionals
- 這份研究對全球臨床社群有何貢獻？
1. 本研究描繪出變性者在變性醫療過程中與醫療專業者的互動經驗。
2. 醫療處遇經驗會與醫療專業者的態度、知識水平、其跨性別議題的臨床經驗有關。
3. 醫療專業者需要有跨性別與性別少數議題的進修。教育者應確保LGBT課程是被納入護理和醫學教育中的。 - 研究目的：
描述變性者在變性過程與醫療專業者的處遇經驗 - 研究背景：
不同個體的變性者會使用不同的方式來改變原生性別，像是荷爾蒙或／和手術。變性者可能會遭遇污名，而增加他們心理壓力的風險。醫療專業者的由醫療保健專家不當對待與治療是很常見的。針對變性者醫療保健經驗的質性研究是很少的。 - 研究方法：
瑞典一家非臨床樣本，包括六位被診斷為變性慾的人，已接受變性手術或正在等待手術。半結構訪談，並使用manifest qualitative content analysis進行資料分析。 - 研究結果：
共分類出三大類與15小類。當醫療專業者表現專業與尊重，且建立醫病信任，這樣的經驗會被認為是好的。然而，醫療專業者的知識水平、如何利用醫療權力、對信息的隱瞞、對性別的刻板印象與態度、甚至用錯名字等，都是造成受訪者有不同醫療經驗的因素。表示性別定型觀念，並經常用錯了名字。他們在醫療專業者的權威下感到非常弱勢，而他們無法選擇不要當變性者，且又如此地依賴於醫療專業。 - 研究結論：
變性者在變性手術過程是相當弱勢的。若醫療專業者沒有足夠的知識、利用他們的權威表露出性別刻板態度，變性者的醫療處遇經驗將會是非常負面的。一個好醫病關係應該是保持誠信、尊重、回應和信任的。 - 臨床實踐：
改進護理和醫學的跨性別教育是必要的。醫護專業人員應該要認知到，他們的態度和知識水平是如何影響變性手術過程所提供的醫療照護。 - 瑞典變性概況：
在瑞典，性別重置手術始於1960年代，並於1972年，瑞典成為世界上第一個規範變性手術與法律的國家(Dhejne等, 2014)。令人驚訝的是，瑞典很少發表性別重置手術的研究，且就我們所知，這些研究都沒有涉及到病人的經驗。
在瑞典，SRS的申請自2000年迅速增加；2001~2010是過去十年的2.5至3倍以上。 FTM約0.42/100,000，MTF約0.73/100,000。影響SRS申請的因素包括社會偏見、診斷傳統、醫療可近性、新性別的法律合法性和保險給付(Dhejne等, 2014)。
瑞典對變性者的態度，在國際上被認為是寬容的。一份瑞典調查顯示，多數瑞典人支持性別重置手術(Landen & Innala 2000)。49個歐洲國家中，瑞典在LGBTI人權中排名第四(ILGA-Europe 2015)。
在瑞典，要被診斷為變性慾，一個人表現出性別不安（gender dysphoria）必須轉介到六個專業性別團隊之一，經過約一年的評估。診斷確認後才開始性別治療，包括荷爾蒙治療與真實生活體驗。 FTM可以進行乳房切除術，MTF接受除毛和言語治療。大約兩年後，就可申請SRS許可和法律的性別改變(Dhejne等, 2014)。
在瑞典，所有的藥物治療和醫療費用皆由國民健康保險給付(Dhejne等, 2014)。
- 文獻提及醫療照護對變性者的不當對待包括：
性別不敏感，例如使用不正確代詞(Kosenko et al. 2013, Xavier et al. 2013)；
顯示出不舒服，例如凝視或坐立不安(Dewey 2008, Kosenko et al. 2013)；
拒絕或提供較差的醫療服務，例如拒絕提供性別重置手術的轉診(Kenagy 2005, Dewey 2008, Lambda Legal 2010, Kosenko et al. 2013)；
謾罵(Lambda Legal 2010, Kosenko et al. 2013)；
敵對和忽視(Xavier et al. 2013)；
醫療強迫，例如被迫接受不必要的檢查(Kosenko et al. 2013)。
一份2010Lambda Legal的調查顯示，變性者甚至經歷了醫療專業者的肢體不尊重或暴力，並因變性者的健康問題指責他們。
Dewey(2008)指出，雖然不是所有變性者都會被醫療專業者排拒，但許多人因醫療提供者的疏離而有不舒服的醫療經驗。
Poteat et al. (2013)探討了污名對醫療提供者與變性者間的互動影響。變性者表示，醫療提供者的知識是很有限的，甚至對他們的醫療需求是毫無準備的。
- 訪談問題：
如果有的話，請描述一個變性醫療處遇的正面經驗。
如果有的話，請描述一個變性醫療處遇的負面經驗。
- 一、正面的醫療處遇
1. 專業（Professionalism）
醫療提供者的專業行為，包含告知心理測試的用意、正常化變性狀態、不放大變性者的背景、專注於當下需處理的醫療行為、閱讀相關議題、不因不必要的問題而延後性別重置手術、願意與變性者好好溝通，對待變性者的態度就像對待其他患者一樣。
「My psychologist said that there is nothing to be ashamed of, it is not your fault, it is a medical condition. (Participant 2) 」
「They did not make a fuss of the transsexual background. If it’s not relevant, they don’t discuss it, and see persons for what they appear to be. (Participant 6) 」
2. 誠信與尊重（Integrity and Respect）
像是醫護人員如何保護變性者的隱私，例如在檢驗室的門口放一個屏幕避免門被意外打開；不質疑變性者對生活的選擇、不忽視變性者的感受與經驗，而是將變性者包含在醫療照護中。
「I was present when he dictated the referral [for psychological evaluation] and he asked, “does this sound ok?” And I said yes. He was just positive. Even though it was a difficult situation he did the best out of it. (Participant 2)」
3. 有反應的（Responsiveness）
在照護變性者時，醫護人員願意聆聽、表示同理與了解且是細心而體諒的。
「They were very friendly. They did not come telling me, “Now we shall do this or that.” They really listened. They were compassionate and cared about me. I was lying there in real pain and could barely push the button to make them come. [. . .] To do the little extra: “Do you want me to raise the bed for you? Another blanket?” They asked me instead of letting me having to ask. (Participant 3) 」
4. 信任（Trust and Confidence）
醫護人員讓病患感到自信與安全：「我們會照顧你，一切都會好起來的。」
「It was the encounter [with a transgender specialized physician] that made me trust him. (Participant 1)」
「I had been scared stiff of hospitals and hated doctors. Doctors are not humans one can trust [...]. But they were real nice and took really good care of me. [...]. This was not the scary doctors I’ve always happened to meet before. (Participant 3)」
5. 變性者自身的應對（The transsexual person’s own part in the encounter）
受訪者表示自己對醫病關係也有責任。像是自身的敏感度、是否對某些問題難以啟齒。
「Some [transsexual persons] cannot agree with anyone, and believe that the whole world is against them. (Participant 2)」
「I think it is the personal chemistry that does not quite match. I think much lies in that, if you meet a doctor you don’t feel confident with for some reason; that you don’t agree due to other social structures. Maybe it [the encounter] fails just there. (Participant 4)」
- 二、醫護人員的態度和照護
1. 知識水平（Level of knowledge）
像是對性別認同、性取向、性別重置手術和相關治療的知識。有時醫護人員會承認他們缺乏這類知識，而展現出好奇。有時他們僅僅是無知的。
「The woman I met [during psychological evaluation] was a bit older, and she started saying, “I don’t know anything about transsexuals.” Somewhat surprising for a person working in the field of psychology. I was in the beginning of my transition. She asked, since I see myself as a homosexual woman and am interested in women, she said, “Wouldn’t it be easier if you continued to be a guy?” (Participant 2)」
有些受訪者表示他們某種程度上已知會或教育過醫護人員，但當自己成為醫護人員對變性者的主要知識來源也是挺累人的。
「In Sweden, they didn’t even know at the reassignment ward that this existed, and to me that is stupendous. Face reconstruction, feminizing surgery. They were very interested after my operation and wanted to take photos. I said yes. They wanted to know how it was done. I was really surprised, not of the encounter, but of their lack of knowledge. (Participant 2)」
2. 他們怎麼說你以及怎麼跟你說話（How they speak to and about you）
像是錯誤的名字或代詞，幾乎所有受訪者都有過這樣的經驗。有些人表示在性別重置過程初期會比較敏感。有些人則說性別重置初期的自己是比較中性的，因此可以理解醫護人員使用錯誤的代詞。有些醫護人員會尊重地詢問要用什麼名字，但多數的經驗是，醫護人員不假思索也沒興趣知道變性者對稱呼的偏好。
「It felt bad [when they used wrong pronoun], like they are normative in their way of looking at gender. [. . .] I feel as if they doubt which sex I am. Like they didn’t quite believe me. (Participant 5) 」
3. 權力地位的利用（Exploiting position of power）
有些醫護人員會利用自己的身份貶低變性者，像是特意採取疏離的態度、單向的溝通、使用神秘的學術語言。
「It was a funny little woman, a senior physician, who held the whole [transsexual] investigation by herself. She is somewhat short, but raises her chair so that she sits looking down at you. And then she went on, continuously trying to persuade. (Participant 1)」
醫護人員甚至會利用自己的身份，要變性者揭露自己的隱私。
「My social evaluation, or the counsellor, did not feel very good, because she discussed matters that weren’t relevant. She was supposed to evaluate my social situation, whether I had the social support I needed among friends and family. Sometimes she asked very private questions, like what kind of sex I prefer, if I prefer anal or vaginal intercourse. It has not felt relevant, and very uncomfortable that she has asked that. She is in some kind of position of power towards me. It has felt very uncomfortable. [. . .] When I hesitated to tell her, she told me, “Just as well tell me now, so that we get this over.” I felt forced to answer her to get what I wanted, to get my correction. (Participant 5) 」
4. 隱藏資訊（Withholding information）
告知的不充分、故意隱瞞信息。像是因荷爾蒙治療而需要骨質疏鬆的檢查、變性的評估程序或是其它變性者需要接受的檢查之原因。
「It was very fuzzy. I expected questions concerning how I feel and so on, but it was nothing about that, it was more like looking at pictures and say what you see in it. [...] I got worried afterwards. Will she [a psychologist] assess me from what I see in a picture? I cannot see how that defines who I am? I have no clue how, and have no idea why these tests were conducted. (Participant 3)」
5. 性別刻板印象（Gender stereotypes）
受訪者會察覺到來自醫護人員的性別刻板印象，像是他們應該穿什麼、行為舉止應該怎麼樣。他們感覺自己的穿著被評估，以及受到質疑和批評。
「If you as a male-to female transsexual and not quite fulfill, or want to fulfill a typical female stereotype, they are questioning you continually. (Participant 6)」
「The psychologist also said, “I actually know a transsexual person, and she had very broad shoulders and played ice hockey, and when she did, it wasn’t odd.” (Participant 1)」
「The Rorschach pictures with inkblots you should look at and interpret, many people warned me that you absolutely not should say that it looks like a vagina or a butterfly. You could say neutral things, but not feminine things if you’re a transsexual guy. (Participant 1)」
- 三、脆弱性的看法
1. 對自我的屈就觀點（Condescending view of oneself）
變性者往往會在某個時間點覺得自己是錯誤與奇怪的，當真實生活體驗開始時，想以另外一個性別行事時，卻沒有典範可以仿效。在此期間，他們會擔心其他人是怎麼看待自己的，因為自己似乎不符合二元性別分類。
「I used to say I don’t need help to dislike myself, I have already done that for a long time. (Participant 2)」
「I was malformed, misshaped, not a real human being. I was some kind of weird thing my parents got. Something went wrong there. (Participant 3)」
2. 依賴（In dependence）
性別重置過程中，變性者是很依賴醫護人員的，因為醫護人員可以決定診斷結果，但當醫護人員對變性者的知識是有限時，就像是自己被困在無知的人手中。
「It is not possible to change doctors and there are long queues everywhere, so if you want to change investigation team it will not work. There are queues everywhere. So it is just to say “thanks” to what you get. (Participant 4)」
「I need their help, and they are deciding if I can go through with my correction or not. (Participant 5)」
3. 不被認真看待（Not being taken seriously）
可能發生在兒童或青少年變性者上。
「And they are extremely negative to everything. And they [said], “We cannot do that, we cannot send a referral if we are not sure you really are transsexual” [. . .] And there were many of them who said, “You are only 16, you don’t know what you’re talking about.” (Participant 1)」
4. 成為變性者不是可以選擇的（Cannot choose not being transsexual）
受訪者表示在性別重置的過程是相當脆弱與不安的。被醫護人員質問、且需不斷向他們解釋的狀況。讓變性者充滿情緒的動盪與疑慮。
「It is like an emotional roller-coaster up and down with hormones and transformative operations, questioning how it will go. Will it work, will I pass? Because there is no plan B. You cannot say, no I think I’ll skip this. It has to work, if it doesn’t, I’m screwed. (Participant 2)」
5. 外界的高需求（External high demands）
受訪者表示，在性別重置過程中沒有得到充分的支持，自己必須積極讓整個程序向前走，就算生病了也一樣。
「I felt I had to mature more than I was able to. (Participant 1)」
「It is formed so that I’m supposed to be the driving factor in the reassignment process, and that is pretty hard when you feel really ill. Naturally this is also reflected in the psychological support that you receive or not. If I phone and cancel a visit because I feel ill, so sure I get a new visit [. . .], but nobody calls and asks how you feel. (Participant 2)」
另外，也缺乏對於生育親生子女計畫的討論，例如冷凍卵子、精子。當性別重置手術完成後，沒人告訴他們一般的醫療照護資訊。
- 本研究發現與Mayer等人(2008)的研究結果一致：提供醫療照護給變性者的醫療專業人員是不足的，是造成性別少數病患取得良好醫療保健的主要障礙之一。
- Mayer等人(2008)認為，無論是醫學、護理學校或是進修教育課程．都沒有提供醫護人員所需的完善培訓，像是照護變性者的態度、知識與技能等。
- Rondahl(2009)發現，只有17.7%的護理與醫學生對LGBT照護有基本的知識。
- Carabez等人(2015)指出，從業護士在很大程度上缺乏對性別認同和性取向的理解。
- Mayer等人(2008)表示，若缺乏知識與教育，性別少數將會持續遭遇醫護人員對他們需求的無知與毫無準備。
Ann-Christin von Vogelsang, Camilla Milton, Ingrid Ericsson and Lars Stro€mberg
© 2016 John Wiley & Sons Ltd
Journal of Clinical Nursing, doi: 10.1111/jocn.13271
