Beyond the cis-binary: Radiation therapists' experiences caring for transgender and gender diverse patients.

INTRODUCTION: Transgender and gender diverse (TGD) people are part of a marginalized and medically underserved group that faces unique challenges in receiving appropriate cancer care. Radiation therapists play a key role in the daily care of cancer patients, and this novel study aimed to describe radiation therapists' (RT) experiences, current care practices and knowledge levels regarding TGD patient care. This is the first mixed methods study of its kind providing data on the attitudes and experiences of RTs in Canada towards caring for TGD patients, as research to date often conflates TGD patients with the broader 2SLGBTQI+ community.

METHODS: A mixed-methods study was conducted involving interviews and surveys completed by RTs utilizing voluntary response sampling methods. Interviews were conducted electronically with RTs in Alberta, and the results informed the development of an online survey that was then sent to RTs across all of Canada and contained both multiple-choice and open-response questions. Descriptive statistics were used to display quantitative survey data, and qualitative data were analyzed utilizing reflexive thematic analysis to ultimately develop four overall themes RESULTS: From five interviews and 122 surveys (n = 122), four main themes were identified: care practices, experiences, and attitudes; knowledge levels and training; gaps in care practices; and opportunities for improvement. Notably, only 43% of survey respondents indicated they were confident in their ability to care for TGD patients with current levels of knowledge and training, but confidence dropped to 31% when RTs were asked about providing side-effect education. Additionally, training levels were very low, with 78% having received no training specific to TGD patients. A vignette of current care practices and attitudes towards adapting care practices for TGD patients was provided, with RTs being most willing to use a patient's pronouns (73%), correcting misgendering of others (61%) and avoiding gender assumptions (56%). A deficiency in knowledge was identified as a major gap in care practices, particularly about interactions between cancer care and gender affirming care, as a high majority (72%) expressed uncertainty about the interaction between cancer treatment and gender affirming care. Approaches to care that profess to be egalitarian were common, with some RTs stating all patients receive the same level of care. Our study identified that there may be a small but vocal minority within the RT profession that possesses very strongly negative attitudes towards TGD patients, which could compromise the care that an already marginalized group receives.

CONCLUSION: Results suggest Canadian RTs may feel underprepared to address specific care needs of TGD patients in radiation therapy departments, and that there is a strong desire for increased training on how to adequately care for this patient population. There are significant gaps in providing optimal care, including limitations in knowledge and training opportunities, a lack of relevant patient resources and the social environment. Knowledge gaps identified in this study may be useful to develop areas of focus for future training programs for RTs on patient-centred care of TGD people: information on the diversity of gender identities, best documentation practices of gender, knowledge on interactions between gender affirming care and cancer care and how to have sensitive conversations. This study was the first of its kind, providing both qualitative and quantitative data on the current care practices, knowledge levels and attitudes of Canadian RTs towards caring for TGD patients, in addition to perceived challenges to providing optimal patient care.

PLAIN LANGUAGE SUMMARY: Transgender and gender diverse people may have specific needs when receiving cancer treatment. This study surveyed and interviewed radiation therapists across Canada about their knowledge and experiences of caring for transgender and gender diverse patients. This study found that many therapists had little training, lacked confidence in some areas of care, and wanted more education to better support these patients. This matters because improved training and resources can help make cancer care more respectful, inclusive, and patient-centred.