The scope and implementation of clinical practice guidelines (CPGs) frequently depends on sex or gender considerations. Ideally, who is included in CPGs and how they are implemented would consider people of all sexes and genders, including trans and gender-diverse people, even if just to state there is little evidence. We evaluated levels of inclusion of trans and gender-diverse populations in relevant Canadian CPGs.
Methods:
We identified non-transition-related CPGs with sex- or gender-based scope or implementation considerations via environmental scan and expert consultation. CPG topics had to (1) traditionally apply to cisgender individuals; (2) include sex or gender in risk assessment; or (3) include sex- or gender-based recommendations. We searched the Canadian Medical Association InfoBase from 2015 to May 2023 for eligible CPGs. We assessed whether CPGs (1) mentioned trans or gender-diverse (TGD) individuals; (2) made recommendations for TGD care; (3) addressed implementation with TGD individuals; or (4) involved TGD individuals in CPG development.
Results:
Of 49 eligible CPGs, 22 were produced by government-sponsored organizations, 15 by professional societies, and 15 by disease-interest groups (3 jointly produced). Ten (20%) mentioned trans or gender-diverse people, 2 (4%) included relevant recommendations, 1 (2%) addressed implementation, and 1 (2%) included trans and gender-diverse individuals in development.
Conclusion:
Few Canadian CPGs with sex or gender implications recognized trans and gender-diverse people. CPG producers should support equitable care by including trans and gender-diverse individuals in sex- and gender-based CPGs by making recommendations or identifying that there was insufficient evidence.
Get full access to this article
View all access options for this article.
References
1.
LightfootS, KiaH, VincentA, et al.Trans-affirming care: An integrative review and concept analysis. Int J Nurs Stud, 2021; 123:104047; doi: 10.1016/j.ijnurstu.2021.104047
2.
DeutschMB. Making it count: Improving estimates of the size of transgender and gender nonconforming populations. LGBT Health, 2016; 3(3):181–185; doi: 10.1089/lgbt.2016.0013
3.
ScheimAI, BauerGR. Sex and gender diversity among transgender persons in Ontario, Canada: Results from a respondent-driven sampling survey. J Sex Res, 2015; 52(1):1–14; doi: 10.1080/00224499.2014.893553
ColemanE, RadixAE, BoumanWP, et al.Standards of care for the health of transgender and gender diverse people, Version 8. Int J Transgend Health, 2022; 23(Suppl 1):S1–S259; doi: 10.1080/26895269.2022.2100644
6.
GreenAE, DeChantsJP, PriceMN, et al.Association of gender-affirming hormone therapy with depression, thoughts of suicide, and attempted suicide among transgender and nonbinary youth. J Adolesc Health, 2022; 70(4):643–649; doi: 10.1016/j.jadohealth.2021.10.036
7.
HuismanB, VerveenA, de GraafNM, et al.Body image and treatment desires at clinical entry in non-binary and genderqueer adults. Int J Transgend Health, 2023; 24(2):234–246; doi: 10.1080/26895269.2022.2131675
8.
HengA, HealC, BanksJ, et al.Transgender peoples’ experiences and perspectives about general healthcare: A systematic review. Int J Transgend, 2018; 19(4):359–378; doi: 10.1080/15532739.2018.1502711
9.
Trans PULSE Canada Team. Health and health care access for trans and non-binary people in Canada. Trans PULSE Canada: London, Ontario; 2020. Available from: https://transpulsecanada.ca/results/report-1/ [Last accessed: June 11, 2021].
10.
EdmistonEK, DonaldCA, SattlerAR, et al.Opportunities and gaps in primary care preventative health services for transgender patients: A systematic review. Transgend Health, 2016; 1(1):216–230; doi: 10.1089/trgh.2016.0019
11.
TanenbaumGJ, HoldenLR. A review of patient experiences and provider education to improve transgender health inequities in the USA. Int J Environ Res Public Health, 2023; 20(20):6949; doi: 10.3390/ijerph20206949
12.
GrantJM, MottetLA, TanisJ, et al.Injustice at every turn: A report of the National Transgender Discrimination Survey. The National Gay and Lesbian Task Force and the National Center for Transgender Equality: Washington D.C.; 2011. Available from: https://transequality.org/sites/default/files/docs/resources/NTDS_Report.pdf [Last accessed: February 19, 2024].
13.
ChristianR, MelliesAA, BuiAG, et al.Measuring the health of an invisible population: Lessons from the Colorado transgender health survey. J Gen Intern Med, 2018; 33(10):1654–1660; doi: 10.1007/s11606-018-4450-6
14.
SeelmanKL, Colón-DiazMJP, LeCroixRH, et al.Transgender noninclusive healthcare and delaying care because of fear: Connections to general health and mental health among transgender adults. Transgend Health, 2017; 2(1):17–28; doi: 10.1089/trgh.2016.0024
ClarkKD, LuongS, LunnMR, et al.Healthcare mistreatment, state-level policy protections, and healthcare avoidance among gender minority people. Sex Res Social Policy, 2022; 19(4):1717–1730; doi: 10.1007/s13178-022-00748-1
17.
HanssmannC, MorrisonD, RussianE. Talking, gawking, or getting it done: Provider trainings to increase cultural and clinical competence for transgender and gender-nonconforming patients and clients. Sex Res Soc Policy, 2008; 5(1):5–23; doi: 10.1525/srsp.2008.5.1.5
18.
StevensonMO, SineathRC, HawJS, et al.Use of standardized patients in endocrinology fellowship programs to teach competent transgender care. J Endocr Soc, 2020; 4(1):bvz007; doi: 10.1210/jendso/bvz007
19.
JohnstonCD, ShearerLS. Internal medicine resident attitudes, prior education, comfort, and knowledge regarding delivering comprehensive primary care to transgender patients. Transgend Health, 2017; 2(1):91–95; doi: 10.1089/trgh.2017.0007
20.
ParadisoC, LallyRM. Nurse practitioner knowledge, attitudes, and beliefs when caring for transgender people. Transgend Health, 2018; 3(1):47–56; doi: 10.1089/trgh.2017.0048
21.
ChanB, SkocylasR, SaferJD. Gaps in transgender medicine content identified among Canadian medical school curricula. Transgend Health, 2016; 1(1):142–150; doi: 10.1089/trgh.2016.0010
22.
Mains-MasonJB, UfomataE, PeeblesJK, et al.Knowledge retention and clinical skills acquisition in sexual and gender minority health curricula: A systematic review. Acad Med, 2022; 97(12):1847–1853; doi: 10.1097/ACM.0000000000004768
23.
MikulakM, RyanS, MaR, et al.Health professionals’ identified barriers to trans health care: A qualitative interview study. Br J Gen Pract, 2021; 71(713):e941–e947; doi: 10.3399/BJGP.2021.0179
24.
MuléNJ. Much to Be Desired: LGBT Health Inequalities and Inequities in Canada. In: Lesbian, Gay, Bisexual and Trans Health Inequalities International Perspectives in Social Work. (FishJ, KarbanK. eds) Policy Press: Bristol, UK; 2015; pp. 27–44.
GrahamR, MancherM, Miller WolmanD, et al. (eds). Clinical Practice Guidelines We Can Trust. The National Academies Press: Washington, DC; 2011.
28.
BocktingW, ColemanE, DeutschMB, et al.Adult development and quality of life of transgender and gender nonconforming people. Curr Opin Endocrinol Diabetes Obes, 2016; 23(2):188–197; doi: 10.1097/MED.0000000000000232
29.
ColemanE, BocktingW, BotzerM, et al.Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7. World Professional Association for Transgender Health: East Dundee, Illinois; 2012. Available from: https://wpath.org/publications/soc [Last accessed: September 28, 2021].
30.
QaseemA, LinJS, MustafaRA, et al.Screening for breast cancer in average-risk women: A guidance statement from the American College of Physicians. Ann Intern Med, 2019; 170(8):547–560; doi: 10.7326/M18-2147
31.
SiuAL. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med, 2016; 164(4):279–296; doi: 10.7326/M15-2886
32.
KlarenbachS, Sims-JonesN, LewinG, et al.Recommendations on screening for breast cancer in women aged 40-74 years who are not at increased risk for breast cancer. Cmaj, 2018; 190(49):E1441–E1451; doi: 10.1503/cmaj.180463
33.
GatesM, PillayJ, ThériaultG, et al.Screening to prevent fragility fractures among adults 40 years and older in primary care: Protocol for a systematic review. Syst Rev, 2019; 8(1):216; doi: 10.1186/s13643-019-1094-5
34.
SinghH, BellN, DickinsonJA, et al.Recommendations on screening for abdominal aortic aneurysm in primary care. Cmaj, 2017; 189(36):E1137–E1145; doi: 10.1503/cmaj.170118
35.
RadixAE. Addressing needs of transgender patients: The role of family physicians. J Am Board Fam Med, 2020; 33(2):314–321; doi: 10.3122/jabfm.2020.02.180228
36.
BeralV, Million Women Study Collaborators. Breast cancer and hormone-replacement therapy in the million women study. Lancet, 2003; 362(9382):419–427; doi: 10.1016/S0140-6736(03)14065-2
37.
JonesBA, BoumanWP, HaycraftE, et al.Gender congruence and body satisfaction in nonbinary transgender people: A case control study. Int J Transgend, 2019; 20(2-3):263–274; doi: 10.1080/15532739.2018.1538840
38.
MeggettoO, PeirsonL, YakubuM, et al.Breast cancer risk and breast screening for trans people: An integration of 3 systematic reviews. CMAJ Open, 2019; 7(3):E598–E609; doi: 10.9778/cmajo.20180028
39.
BlokCD, WiepjesCM, NotaNM, et al.Breast cancer risk in transgender people receiving hormone treatment: Nationwide cohort study in the Netherlands. Bmj, 2019; 365:l1652; doi: 10.1136/bmj.l1652
40.
GoorenLJ, van TrotsenburgMAA, GiltayEJ, et al.Breast cancer development in transsexual subjects receiving cross-sex hormone treatment. J Sex Med, 2013; 10(12):3129–3134; doi: 10.1111/jsm.12319
41.
ClarkeCN, CortinaCS, FayanjuOM, et al.Breast cancer risk and screening in transgender persons: A call for inclusive care. Ann Surg Oncol, 2022; 29(4):2176–2180; doi: 10.1245/s10434-021-10217-5
42.
RamseyI, KennedyK, SharplinG, et al.Culturally safe, appropriate, and high-quality breast cancer screening for transgender people: A scoping review. Int J Transgend Health, 2023; 24(2):174–194; doi: 10.1080/26895269.2022.2155289
43.
WelchVA, AklEA, GuyattG, et al.GRADE equity guidelines 1: Considering health equity in GRADE guideline development: Introduction and rationale. J Clin Epidemiol, 2017; 90:59–67; doi: 10.1016/j.jclinepi.2017.01.014
44.
ManafòE, PetermannL, Vandall-WalkerV, et al.Patient and public engagement in priority setting: A systematic rapid review of the literature. PLoS One, 2018; 13(3):e0193579; doi: 10.1371/journal.pone.0193579
45.
FadlallahR, El-HarakehA, Bou-KarroumL, et al.A common framework of steps and criteria for prioritizing topics for evidence syntheses: A systematic review. J Clin Epidemiol, 2020; 120:67–85; doi: 10.1016/j.jclinepi.2019.12.009
46.
MakadonHJ, MayerKH, PotterJ, et al.The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health. 2nd Edition. American College of Physicians: Philadelphia, PA; 2015.
47.
LatifRA, MohamedR, DahlanAH, et al.Using delphi technique: Making sense of consensus in concept mapping structure and multiple choice questions (MCQ). EIMJ, 2016; 8(3):89–98; doi: 10.5959/eimj.v8i3.421
48.
BourréeF, MichelP, SalmiLR. Consensus methods: Review of original methods and their main alternatives used in public health. Rev Epidemiol Sante, 2008; 56(6):e13–e21; doi: 10.1016/j.respe.2008.10.005
DeutschMB. Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people. UCSF Transgender Care: San Francisco, California; 2016. Available from: https://transcare.ucsf.edu/guidelines [Last accessed: October 8, 2021].
ShadidS, Abosi-AppeaduK, De MaertelaereA-S, et al.Effects of gender-affirming hormone therapy on insulin sensitivity and incretin responses in transgender people. Diabetes Care, 2020; 43(2):411–417; doi: 10.2337/dc19-1061
54.
MarcellinRL, BauerGR, ScheimAI. Intersecting impacts of transphobia and racism on HIV risk among trans persons of colour in Ontario, Canada. Ethn Inequal Health Soc Care, 2013; 6(4):97–107; doi: 10.1108/EIHSC-09-2013-0017
55.
ScheimAI, BauerGR, TraversR. HIV-related sexual risk among transgender men who are gay, bisexual, or have sex with men. J Acquir Immune Defic Syndr, 2017; 74(4):e89–e96; doi: 10.1097/QAI.0000000000001222
HermanJL. Gendered restrooms and minority stress: The public regulation of gender and its impact on transgender people’s lives. J Public Manag Soc Policy, 2013; 19(1):65.
58.
FitzpatrickRB. CMA infobase: Clinical practice guidelines. Med Ref Serv Q, 2008; 27(4):419–429; doi: 10.1080/02763860802368209
59.
365 M. Microsoft Corporation. Microsoft Excel. Redmond, WA; 2019.
60.
AgrestiA, CoullBA. Approximate is better than “exact” for interval estimation of binomial proportions. Am Stat, 1998; 52(2):119–126; doi: 10.2307/2685469
BelandM, BoilyG, DufourV, et al.Algorithmes d’investigation, de traitement et de suivi du cancer du sein. Institut national d'excellence en santé et en services sociaux: Québec; 2018. Available from: https://inesss.algorithmes-onco.info [Last accessed: October 8, 2021].
MehtaSR, BaineyKR, CantorWJ, et al.2018 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology focused update of the guidelines for the use of antiplatelet therapy. Can J Cardiol, 2018; 34(3):214–233; doi: 10.1016/j.cjca.2017.12.012
67.
ViraniSA, DentS, Brezden-MasleyC, et al.Canadian Cardiovascular Society guidelines for evaluation and management of cardiovascular complications of cancer therapy. Can J Cardiol, 2016; 32(7):831–841; doi: 10.1016/j.cjca.2016.02.078
68.
WeinT, LindsayMP, GladstoneDJ, et al.Canadian stroke best practice recommendations, seventh edition: Acetylsalicylic acid for prevention of vascular events. Cmaj, 2020; 192(12):E302–E311; doi: 10.1503/cmaj.191599
JainR, StoneJA, AgarwalG, et al.Canadian Cardiovascular Harmonized National Guideline Endeavour (C-CHANGE) guideline for the prevention and management of cardiovascular disease in primary care: 2022 update. Cmaj, 2022; 194(43):E1460–E1480; doi: 10.1503/cmaj.220138
71.
AbramsonBL, BlackDR, ChristakisMK, et al.Guideline No. 422e: Menopause and cardiovascular disease. J Obstet Gynaecol Can, 2021; 43(12):1438–1443.e1; doi: 10.1016/j.jogc.2021.09.010
PearsonGJ, ThanassoulisG, AndersonTJ, et al.2021 Canadian Cardiovascular Society Guidelines for the management of dyslipidemia for the prevention of cardiovascular disease in adults. Can J Cardiol, 2021; 37(8):1129–1150; doi: 10.1016/j.cjca.2021.03.016
PunthakeeZ, GoldenbergR, KatzP. Definition, classification and diagnosis of diabetes, prediabetes and metabolic syndrome. Can J Diabetes, 2018; 42 Suppl 1:S10–S15; doi: 10.1016/j.jcjd.2017.10.003
77.
EkoeJ-M, GoldenbergR, KatzP. Screening for diabetes in adults. Can J Diabetes, 2018; 42 Suppl 1:S16–S19; doi: 10.1016/j.jcjd.2017.10.004
78.
PrebtaniAPH, BajajHS, GoldenbergR, et al.Reducing the risk of developing diabetes. Can J Diabetes, 2018; 42 Suppl 1:S20–S26; doi: 10.1016/j.jcjd.2017.10.033
79.
HouldenRL, GoldenbergR, BerardL, et al.Diabetes Canada 2018 Clinical practice guidelines for the prevention and management of diabetes in Canada. Diabetes Canada: Toronto, Ontario; 2018. Available from: http://guidelines.diabetes.ca/docs/CPG-2018-full-EN.pdf [Last accessed: October 8, 2021].
80.
CrowshoeL, DannenbaumD, GreenM, et al.Type 2 diabetes and Indigenous Peoples. Can J Diabetes, 2018; 42 Suppl 1:S296–S306; doi: 10.1016/j.jcjd.2017.10.022
81.
FeigDS, BergerH, DonovanL, et al.Diabetes and pregnancy. Can J Diabetes, 2018; 42(3):337–S282; doi: 10.1016/j.jcjd.2017.10.038
82.
MeneillyGS, KnipA, MillerDB, et al.Diabetes in older people. Can J Diabetes, 2018; 42 Suppl 1:S283–S295; doi: 10.1016/j.jcjd.2017.10.021
Therapeutic Guidelines Committee. Guidance for the Use of Pre-Exposure Prophylaxis (PrEP) for the Prevention of HIV Acquisition in British Columbia. British Columbia Centre for Excellence in HIV/AIDS: Vancouver, British Columbia; 2020. Available from: https://www.bccfe.ca/hiv-pre-exposure-prophylaxis-prep [Last accessed: October 8, 2021].
TanDHS, HullMW, YoongD, et al.Canadian guideline on HIV pre-exposure prophylaxis and nonoccupational postexposure prophylaxis. Cmaj, 2017; 189(47):E1448–E1458; doi: 10.1503/cmaj.170494
MacleL, CairnsJ, LeblancK, et al.2016 focused update of the Canadian Cardiovascular Society guidelines for the management of atrial fibrillation. Can J Cardiol, 2016; 32(10):1170–1185; doi: 10.1016/j.cjca.2016.07.591
92.
WeinT, LindsayMP, CôtéR, et al.Canadian stroke best practice recommendations: Secondary prevention of stroke, sixth edition practice guidelines, update 2017. Int J Stroke, 2018; 13(4):420–443; doi: 10.1177/1747493017743062
93.
LinK, LindsayP, ShamsT, et al.A summary of the Canadian Stroke best practice recommendations, sixth edition (2018): Updates relevant to prehospital and emergency medicine providers. Cjem, 2018; 20(5):685–692; doi: 10.1017/cem.2018.438
RendonRA, MasonRJ, MarzoukK, et al.Canadian Urological Association recommendations on prostate cancer screening and early diagnosis. Can Urol Assoc J, 2017; 11(10):298–309; doi: 10.5489/cuaj.4888
98.
SoAI, ChiKN, DanielsonB, et al.Canadian Urological Association-Canadian Urologic Oncology Group guideline on metastatic castration-naive and castration-sensitive prostate cancer. Can Urol Assoc J, 2020; 14(2):17–23; doi: 10.5489/cuaj.6384
99.
MasonRJ, MarzoukK, FinelliA, et al.Update–2022 Canadian Urological Association recommendations on prostate cancer screening and early diagnosis: Endorsement of the 2021 Cancer Care Ontario guidelines on prostate multiparametric magnetic resonance imaging. Can Urol Assoc J, 2022; 16(4):E184–E196; doi: 10.5489/cuaj.7851
100.
HaiderMA, BrownJ, ChinJLK, et al.Evidence-based guideline recommendations on multiparametric magnetic resonance imaging in the diagnosis of clinically significant prostate cancer: A Cancer Care Ontario updated clinical practice guideline. Can Urol Assoc J, 2022; 16(2):16–23; doi: 10.5489/cuaj.7425
MooreA, TraversyG, ReynoldsDL, et al.Recommendation on screening for chlamydia and gonorrhea in primary care for individuals not known to be at high risk. Cmaj, 2021; 193(16):E549–E559; doi: 10.1503/cmaj.201967
106.
AngerJ, LeeU, AckermanAL, et al.Recurrent uncomplicated urinary tract infections in women: AUA/CUA/SUFU guideline. J Urol, 2019; 202(2):282–289; doi: 10.1097/JU.0000000000000296
RadixAE, LarsonEL, HarrisAB, et al.HIV prevalence among transmasculine individuals at a New York City Community Health Centre: A cross-sectional study. J Int AIDS Soc, 2022; 25 Suppl 5(Suppl 5):e25981; doi: 10.1002/jia2.25981
110.
TannenbaumC, ClowB, Haworth-BrockmanM, et al.Sex and gender considerations in Canadian clinical practice guidelines: A systematic review. CMAJ Open, 2017; 5(1):E66–E73; doi: 10.9778/cmajo.20160051
111.
AklEA, WelchV, PottieK, et al.GRADE equity guidelines 2: Considering health equity in GRADE guideline development: Equity extension of the guideline development checklist. J Clin Epidemiol, 2017; 90:68–75; doi: 10.1016/j.jclinepi.2017.01.017
112.
WelchVA, AklEA, PottieK, et al.GRADE equity guidelines 3: Considering health equity in GRADE guideline development: Rating the certainty of synthesized evidence. J Clin Epidemiol, 2017; 90:76–83; doi: 10.1016/j.jclinepi.2017.01.015
113.
PottieK, WelchV, MortonR, et al.GRADE equity guidelines 4: Considering health equity in GRADE guideline development: Evidence to decision process. J Clin Epidemiol, 2017; 90:84–91; doi: 10.1016/j.jclinepi.2017.08.001
114.
BarkerTH, DiasM, SternC, et al.Guidelines rarely used GRADE and applied methods inconsistently: A methodological study of Australian guidelines. J Clin Epidemiol, 2021; 130:125–134; doi: 10.1016/j.jclinepi.2020.10.017
115.
MolinoCdG, Leite-SantosNC, GabrielFC, et al.Factors associated with high-quality guidelines for the pharmacologic management of chronic diseases in primary care: A systematic review. JAMA Intern Med, 2019; 179(4):553–560; doi: 10.1001/jamainternmed.2018.7529
116.
KantorováL, FriessováT, SlezákováS, et al.Addressing challenges when applying GRADE to public health guidelines: A scoping review protocol and pilot analysis. Int J Environ Res Public Health, 2022; 19(2):992; doi: 10.3390/ijerph19020992
HeidariS, BaborTF, De CastroP, et al.Sex and gender equity in research: Rationale for the SAGER guidelines and recommended use. Res Integr Peer Rev, 2016; 1(1):2; doi: 10.1186/s41073-016-0007-6
119.
Transgender Professional Association for Transgender Health. Transgender Professional Association for transgender health: Trans health by trans people. n.p.; n.d. Available from: https://tpathealth.org/ [Last accessed: June 11, 2021].
120.
GLMA. GLMA: Health Professionals Advancing LGBTQ Equity. Washington D.C.; n.d. Available from: http://www.glma.org/index.cfm?nodeid=1 [Last accessed: June 11, 2021].
121.
RobertsTK, FantzCR. Barriers to quality health care for the transgender population. Clin Biochem, 2014; 47(10-11):983–987; doi: 10.1016/j.clinbiochem.2014.02.009
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
