Managing uncertainty: a grounded theory of stigma in transgender health care encounters
醫療對跨性別者的態度：
- 針對醫療提供者對變性者的態度研究之發表文獻是相當少的。大多的研究都是在探討一般大眾對LGBT整體的態度，而不是特定於跨性別者病患的(Dean et al., 2000; Dorsen, 2012; Lurie, 2005; Vanderleest & Galper, 2009)。
- 護士對LGBT病患態度的文獻回顧顯示，在所有共17篇文章中，都是持負面態度的(Dorsen, 2012)。
- 一份針對427位LGBT醫生的研究發現，65%聽過對LGBT個體的貶義評論，34%曾目擊LGBT病患受到歧視性的醫療照護(Eliason, Dibble, & Robertson, 2011)。
- 這些研究可能都低估了跨性別者受到的歧視，Norton and Herek (2012)發現，跨性別者接收到的歧視與負面態度，是顯著比LGB都多且差的。
- 最近一項研究探討美國醫學教育的LGBT課程，幾乎是沒有跨性別健康議題的(Obedin-Maliver et al., 2011)。
- 一項全國性的LGBT與愛滋病帶原者之醫療經驗調查顯示，397位跨性別者中有70%經歷過醫療照護的歧視，與LGB的56%和愛滋病帶原者的63%相比(Lambda Legal, 2010)。超過四分之一的跨性別者表示，曾因他們的跨性別認同而被醫療拒絕，而有7.7%的LGB則因性傾向、19%的愛滋病帶原者因愛滋病被醫療排拒在外。
醫療對跨性別者的認知缺乏：
- 即使跨性別者可以獲得醫療照護，他們所接受到的照護與理想中的往往相去甚遠。
- 一份針對維吉尼亞全州的評估發現，46%的跨性別受訪者表示，他們必須教育他們的醫生關於他們所需要的健康照護需求。
- The National Transgender Discrimination Survey (NTDS) (Grant et al., 2011)發現，在超過6000位跨性別者中，有50%表示自己必須教育醫療提供者關於跨性別的醫療照護。
- 除了臨床經驗的缺乏外，甚至有些跨性別者經驗到醫療機構公然的不當處置，Lambda Legal (2010)指出，有20.9%的跨性別受訪者曾受到嚴厲的措辭，其中有20.3%曾因自己的健康問題而被指責。15%表示醫療提供者拒絕觸碰他們，或是過度小心的；7.8%經驗過醫療提供者的肢體粗暴或虐待之治療。跨性別者被不當對待的比例是LGB的兩倍。
- 因為這些經驗，許多跨性別者會避免醫療系統。19%的跨性別者認為，接受過照護跨性別者培訓的醫護人員是不足的，52%擔心在他們需要的時候會被醫療服務排拒在外Lambda Legal (2010)。這些考量對跨性別者的健康具顯著影響。NTDS (Grant et al., 2011)指出33%的跨性別者會因歧視而延遲他們的預防性醫療照護，甚至有28%在他們生病或受傷時，仍會拖延尋求醫療照護。
- 對醫療照護系統的不信任，也導致跨性別者尋求體制外的照護。Xavier et al. (2007)發現，將近一半有荷爾蒙使用經驗的跨性別者不是在醫生那邊取得荷爾蒙的，46%必須自己或是由其它非醫事人員注射，其中包含71%的FTM與37%的MTF。
- 一份紐約的研究發現，具醫療可近性的跨性別者，有著較低的危害健康之行為比率，例如抽煙和非法使用荷爾蒙注射(Sanchez, Sanchez, & Danoff, 2009)。
- 很顯然，跨性別者面臨的污名與歧視深植於醫療照護中，並且影響著他們對醫療保健的獲取與使用。因此，了解污名和歧視是如何表現並作用在醫療照護互動中，是解決跨性別者健康差距的的關鍵。
- 要讓情況變好，就必須兼顧醫療提供者以及病患的觀點。但到目前為止（2013），還沒有任何探討「歧視是如何影響並作用在跨性別病患與醫療提供者之醫療處遇」的公開發表文獻。
本研究發現：
- 不確定性的管控－建立權威：
1. 污名挑戰了醫療提供者的權威地位，以及醫病間權力關係的機制。
2. 結構性與制度性污名確保了跨性別者的經驗與身體都是不存在於醫學教育與訓練中的，也讓多數的醫療提供者缺乏一個照護與醫病關係的指導方針。
3. 不確定性也導致了醫療照護的矛盾，因為跨性別者可以意識到醫療提供者對他們的需求是不了解的，便會對醫生的能力產生不確定性。
4. 醫病雙方與之間的不確定性，挑戰了傳統的醫病關係—「醫生被預設為具醫學知識的醫療權威、會作出適當的評估、並提供有效的治療」，而「病人是預期醫生提供更多醫療知識的」。
5. 人際間的污名則強化了傳統的醫病權力關係，醫療提供者與跨性別病患可能都會抗拒或參與醫療互動的污名設定。
- 結構性與體制性污名－狀態創造：
1. 跨性別者經驗過在公共場所被拒絕服務、被騷擾或毆打、求職時過關卻因性別身份被揭露而被解雇，在庇護所、治療中心或監獄等需依原生性別隔離的空間被性騷擾或性侵害。
2. 部分受訪者會將污名內化，而對自我憎恨並厭惡其它的跨性別者。大部分則預期了污名與歧視，並縮限他們對地理區域、就業與醫療保健的選擇，以避免暴露於更多的歧視之中。
3. 某些跨性別者對能擁有基本的需求覺得感激，像是不會因性別身份而被驅逐的住房。
4. 本訪談的多數醫療提供者有意識到跨性別者所面臨的困難，像是跨性別者自述的污名與歧視。醫生認為這些困難會導致心理健康與行為問題的高發病率，使跨性別者變成更難對付的病患。 一位初級保健醫生說：
「They’ve been kicked around so much in their lives because of the territory they’ve had to traverse that there tend to be a lot of maladaptive behaviors that they’ve been habituated to. No blame there, but that can make the patients a lot harder to deal with and then they in turn have a hard time integrating into the community.」
- 不確定性與矛盾：
1. 跨性別者知道，醫療提供者就向社會大眾的其它人一樣，對跨性別是呈負面態度的。跨性別者預期醫療提供者不僅對他們的醫療需求毫無準備，甚至可能沒有跨性別者是真實存在的準備。
2. 這樣的狀況讓醫病雙方都感到不舒服，一位跨性別女性說：
「Sometimes it might be a shocker [for a provider to see a transgender patient]. Yeah, but sometimes, you know, they might be scared, but at the same time, well, boy oh boy, if you think that you’re uncomfortable and you’re scared, we are, too. We are, too.」
3. 當醫療提供者不確定要用什麼名字或代詞，並缺乏對跨性別者的照護知識時，跨性別者感到相當無奈，一位跨性別男性說：
「If you see two doctors, one will use male pronouns and the other will use female pronouns and you’re kind of like, this is just awkward now, like, “should it be that hard?”. . . Ideal healthcare would be transgender services being similar to diabetes services, similar to just other services where you can walk in and people don’t look at you like, “What’s that?”」
4. 跨性別者會使用不同的策略以應對普遍的醫療提供者之知識匱乏，像是只要求開給與上次一樣的處方，而沒有其它的醫療檢測或標準照護程序。一位跨性別女性說：
「I don’t know how knowledgeable she is. She’s not an endocrinologist. She just knew that I was taking whatever medication from a previous physician, and she just duplicated that as well, so I don’t think she goes, “Well, let’s see. You might not need this much. You might– yeah, you need a little bit more.” She just went, “Okay,” so she just kept the same medication going.」
5. 較積極的跨性別者則會向醫療提供者要求更好的照護，一位跨性別男性說：
「I actually spoke to her afterward. I’m like, “You know, it’s 2009. In 2009, you’re going to have more clients like me. What are you going to do for best practices? These are unacceptable standards of care.” And she was explaining to me, “Well, this is the first time something like this has happened.” I’m like, “Granted, but you need to prepare yourself for different types of people walking into your office.」
6. 有些人會向朋友或從網路尋找有跨性別經驗的醫療提供者，一位跨性別男性說：
「I was trying to figure out what was going on with me. I didn’t want the additional burden of having to educate my provider on top of that. And the last thing I wanted was to be a training case for a practitioner who had never provided care to a transgendered person before.」
7. 即使是有經驗的醫療提供者，仍可能是知識不足的，跨性別者還是需要再教育醫生：
「I even went on the Internet myself and I printed out hormone regimens for oral and for injections and everything. . . I shouldn’t have to go online and pull up a transgendered hormone regimen because I feel as though my doctor isn’t prescribing the right hormone regimen for me. I shouldn’t have to take that in there. You should already know. So I think that’s one of the only things that kind of makes me angry.」
8. 幾乎所有醫療提供者對跨性別者是感到矛盾與沒有準備的。但一位內分泌醫生認為，醫療對荷爾蒙治療是很了解的，只是對跨性別患者的心理社會議題感到矛盾，一些醫生說自己是否要開給跨性別荷爾蒙處方的性別確認醫療是很掙扎的。一位內分泌醫生說：
「I find the whole area difficult. Nobody really understands it. I don’t. I’m accepting of it because I see it, and I believe it, but obviously we don’t understand it . . . So part of me wants to sort of say like, “Can’t you just dress as a woman,” or “Can’t you just be a tomboy and not have to get involved with hormones and stuff?」
9. 而對跨性別照護是否適當而感到矛盾的醫生，也有自己的策略。多數的醫療提供者會要跨性別者做出對原生性別的終身不適之具體敘述，以確認病患的性別不安；也有許多醫生會要求跨性別者從心理健康提供者取得性別認同障礙診斷信。
10. 所有的初級保健提供者都說第一次與跨性別病患會診時感到措手不及。他們描述了幾種策略來處理他們的準備不足，包括向經驗豐富的同事尋求資源、找書、在網路上搜尋、由病人引導並告訴他們該怎麼做、嘗試錯誤再學習，或乾脆拒絕提供服務。一位初級保健醫生說：
「When I started having some patients that were gonna come to me and I was gonna be their primary care provider, then it was like, “Oh goodness, I need to learn. I actually need to learn the fundamentals, the basics.」
- 權威建立－污名的作用：
1. 無論各醫療提供者對跨性別醫療的不確定性與矛盾是採取什麼樣的中性語言策略，他們的自述都顯示出，醫療提供者會有意識或下意識地運用污名化，以管控不確定性帶給醫學權威的威脅。以下的敘述便展示了在跨性別病患在看診時挑戰了醫學提供者的醫學知識時，他們是如何努力重新樹立權威，一位初級保健醫生說：
「My worst was actually a patient who I felt like had read too much on the internet. Had all the terms of what to do and words I didn’t even recognize and acronyms of things of feminization, surgery, and things I knew about but like these little words that I had never heard and just read so much on the internet that the whole visit was spent dispelling all those myths or all that time and I think it was the worst because even after the end of the visit you feel like that patient still doesn’t trust what you’re telling them. Following your recommendations but I think very cautious of what you’re telling him because that patient thinks– the patient at the time just thought he knew everything she had read on the internet was correct. So I think that’s what it was, leaving that visit like I don’t know if this patient actually understands or trusts my judgment.」
2. 這種對醫學權威的挑戰，也會讓醫療提供者覺得受到威脅，進而反駁病患的知識，認為是病患的迷思，即使醫生自己也承認自己並不了解患者所告訴她的資訊是什麼。在這樣負面的醫病關係中，病患會被指責為「從網路讀得太多。」
3. 污名和歧視是動態的，有些醫療提供者表示從最初的不適，漸漸地了解跨性別病患就像其它人一樣，有真實的醫療保健需求；也有些醫生努力抗拒對跨性別的歧視並保護他們。一位初級保健醫生說：
「I spent the first 15 years of my career in the emergency room. So I had a lot of transgender patients that would come through there and I would personally try to take them as patients so that they wouldn’t be discriminated or laughed or ridiculed.」。
4. 從參與污名到抵抗歧視的醫生都有，但LG醫生或是與跨性別病患有連結感的醫生，比較容易傾向於抵抗那些污名與歧視。一位初級保健醫生說：
「I’m sure that being a gay man had helped me have an early open mindedness about difference and societal misunderstanding or non-understanding of something other than what is defined as sort of normal and mainstream. So it may have been easier for me in that regard to a degree.」
5. 對污名的抵抗不限於以正向的態度看待跨性別者，也包括醫療提供者在醫病互動中，願意放下一些醫療權威，向跨性別者學習。正如一位醫療提供者說的：
「You may do some things that are unnecessary just because of the patient’s outlook and their self-comfort and or let them try something and see if it seems to make any difference. There’s a little bit of giving in I think sometimes.」另一位醫生進一步表示：
「My agenda has to change according to what the patient really needs that day.」
6. 跨性別自己也參與了對污名接受或抵抗的動態作用。一些較積極的跨性別者會抵抗污名並在醫病關係中爭取自己的權利；而一些則完全默許醫療提供者的醫學權威。但有時跨性別者對醫療保健污名的抵抗或接受，取決於他們是否有其他選擇，有時不得不默許與容忍，以取得自己需要的醫療照護。一位跨性別女性說：
「You just have to really, really stay on them and let them know, “This is what I need. This is what I want,” and talk to them. “I went online and I saw this. I think this would be good for me.” You have to really . . . I have to do the research. I have to learn as much about me and what I need than to just take what somebody gives me. So that’s a little– that makes me a little bit angry too, because I did walk away from there a couple of times– always ended up going back because there’s nowhere else to go– so I always wind up going back. But I think they need to learn how to cater to us a little bit more– understand every individual person’s needs.」
研究討論：
- 本研究發現，對跨性別的性別認同帶著不確定性的醫療提供者，比較有可能會對跨性別者表現出污名與歧視態度；而對那些認為跨性別者是天生而不得不接受性別重置過程的醫生來說，他們是比較接納跨性別者的。
Poteat T1, German D, Kerrigan D.
1Johns Hopkins Bloomberg School of Public Health, Department of International Health, 615 North Wolfe Street, Baltimore, MD 21205, USA. tpoteat123@gmail.com
