Measuring anti-transgender stigma in low-income and middle-income countries: a scoping review protocol.

INTRODUCTION: Globally, transgender and other gender diverse (trans) people face pervasive stigma, which contributes to health inequities across multiple health outcomes. Stigma is a fundamental cause of health inequities because it simultaneously limits access to resources, contributes to systemic vulnerability and generates chronic stress. Anti-trans stigma occurs across multiple socioecological levels, resulting in multiple possible definitions and measurements of trans stigma. Understanding how trans stigma has been measured in low-income and middle-income countries (LMICs) is critical to health promotion efforts for trans communities. Accordingly, this scoping review will identify and examine how anti-trans stigma has been measured in existing LMIC-specific research to inform best practices for measurement of anti-trans stigma that includes consideration of local context. METHODS AND ANALYSIS: This is the protocol for a scoping review of anti-trans stigma in LMICs. We will search (from January 2001 to December 2021) PubMed, WHO Global Medicus and EBSCO. Study selection will conform to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews Checklist. Original studies in English, Spanish, Arabic or Russian will be included. Reviewers will independently screen all citations, full-text articles and abstract data. Data analysis will involve quantitative and qualitative methods. A narrative summary of findings will be conducted. ETHICS AND DISSEMINATION: As a scoping review (no direct interaction with participants), this study is exempt from human subjects oversight. Understanding context-specific ways to measure anti-trans stigma is urgently needed to support trans health globally. The planned scoping review will help to address this gap. Results of the review will be disseminated in a peer-reviewed journal and likely in other media such as conferences, seminars and symposia. PROTOCOL REGISTRATION NUMBER: osf.io/qcs2v. © Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

This scoping review will examine measurement of anti-trans stigma in low-income and middle-income countries (LMICs), facilitating examination of extant measurements of anti-trans stigma across diverse LMIC contexts.

The review will use key databases for global peer-reviewed literature, apply country-specific terms for gender identity and include publications in English, Spanish, Arabic and Russian.

In some cultural contexts, gender identity is understood as separate from sexual orientation or identity. To address this, we incorporate search terms (including country-specific terms) that capture broader LGBTQ communities; we include stigma measurement based on broad understandings of LGBTQ stigma; and in the synthesis of data extraction results, we will explore the meaning of gender identity across contexts and studies.

A limitation of this study is that the scoping review team is comprised of cisgender researchers living and working in a high-income country; the application of these findings and continued work on measurement of anti-trans stigma in LMICs should be conducted in collaboration with trans communities in LMICs.

Introduction

Globally, transgender and other gender diverse (trans) people face pervasive stigma,1 which is a fundamental cause of health inequities.2 3 These inequities are seen across multiple health outcomes, including, for example, HIV, violence, substance use disorders, post-traumatic stress, depression, anxiety and suicide.4–10 Stigma’s contribution to health is linked to the simultaneous limitation to resource access, contribution to systemic vulnerability (eg, unemployment, housing insecurity and poverty) and generation of chronic stress.2 11–14

Recent extant literature has aimed to better understand how to conceptualise and measure stigma,15 16 including anti-trans stigma.17–19 However, most of the research on anti-trans stigma has occurred within the USA and other high-income countries,4 18 with a dearth of information about how anti-trans stigma is measured in low-income and middle-income countries (LMICs). Measurement of anti-trans stigma in LMICs is important for improving how we understand the role of anti-trans stigma on population health globally. To gain a contextualised understanding of anti-trans stigma, measurement should vary across LMICs in order to consider the local experiences and meanings of gender identity; however, understanding the approaches that are currently being used for developing and adapting anti-trans stigma measures across various LMICs is needed to inform future research.

There are recommendations for measuring general stigma that indicate that it is important to capture multiple dimensions of stigma (eg, enacted, anticipated and internalised) occurring across multiple levels of the socioecological model (eg, structural, community, interpersonal and intrapersonal).15 18 20 Enacted stigma refers to interpersonal, institutional or structural (eg, laws and policies) acts of stigma, and often includes experiences of discrimination, victimisation and rejection.12 21 Anticipated stigma involves the repeated expectation that stigmatising events will occur.12 21 Internalised stigma refers to the shame that occurs when an individual believes that they possess the negative attributes that society has placed on them.1 21

Anti-trans stigma captures the ways in which cultural expectations disadvantage trans people18 through multidimensional forms of stigma—enacted, anticipated and internalised.22 Specifically, anti-trans stigma includes experiences of discrimination, harassment and victimisation (enacted stigma) due to trans identity, expectations of hostility and devaluation (anticipated) due to trans identify, as well as integration of negative beliefs about one’s own trans identity (internalised) from multiple sources (eg, interpersonal relationships, media and policies).18 22 Some measures exist that work to capture these multiple dimensions of anti-trans stigma (eg, Gender Minority Stress Scales11); however, less work has been done on how these measures of anti-trans stigma are currently being adapted and/or applied across LMICs, where research is occurring with trans populations (for exceptions see Chakrapani et al and Goldenberg et al).17 23

Given that anti-trans stigma occurs across multiple socioecological levels, there are multiple possible ways to measure anti-trans stigma (eg, individual experiences and/or discriminatory policies). Measurement of anti-trans stigma needs to consider the local cultural context, especially within LMICs, that reflects an appropriate and relevant conceptualisation of anti-trans stigma. Accordingly, the purpose of this scoping review is to identify and examine how anti-trans stigma has been measured in existing LMIC-specific research to inform best practices for anti-trans stigma measurement that includes consideration of local context.

Methods and analysis

The scoping review protocol is registered within the Open Science Framework database (osf.io/qcs2v) and is being reported in accordance with the reporting guidance in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).24 This process will adhere to the indicated framework: (1) identifying eligibility criteria and information sources, (2) developing comprehensive search strategy, (3) identifying relevant studies, (4) selecting studies, (5) charting data, (6) conducting a critical appraisal of the studies and (7) synthesising and reporting results.

The scoping review team consists of 6 individuals. The overall scoping review objective is to summarise how anti-trans stigma is conceptualised and measured within the context of LMICs. The scoping review search strategy will be performed with techniques to enhance methodological transparency and improve the reproducibility of the results.

Information sources and search strategy

This search strategy is being developed in consultation with a research librarian and is informed by existing scoping reviews on stigma and trans health.4 16 18 25 26 The source of literature will be a structured search of electronic databases (from 1 January 2001 to 31 December 2021): PubMed (Medline), WHO Global Medicus and EBSCO (health source: Nursing/Academic Edition, LGBTQ+Source, PsycInfo, CINAHL and Gender Studies Database). We will use search terms (described below) to find articles for inclusion. Zotero, a bibliographic software, will be used to store, organise and manage all references.

Patient and public involvement

There are no trans people from LMICs involved in the scoping review. The impetus for the scoping review was born out of our team’s collective experience working with trans communities. It is our hope that the best practices and recommendations will inform future health promotion efforts for trans communities globally.

Eligibility criteria

Inclusion criteria

Based on the capacity of team members, we will include articles published in English, Spanish, Arabic and Russian. We will focus on original quantitative and mixed-methods studies that include a quantitative measure of anti-trans stigma to identify how different measures are used to understand and characterise anti-trans stigma in LMICs.

To be included in the review, studies will need to specifically distinguish the experiences of trans people (using an inclusive process for identification of trans participants, eg, self -report using locally appropriate terms and/or a two-step process). Studies that broadly measure stigma among sexual and gender minorities (ie, studies that measure anti-LGBTQ+stigma and not specifically anti-trans stigma) will be included only if trans people are included as a distinct group (regardless of sample size if disaggregated data is presented); however, studies that only measure stigma related to sexual behaviour or sexual orientation (and not anti-LGBTQ+stigma more broadly) will be excluded, since the goal of this scoping review is to understand stigma related to experiences of gender identity. Studies will also be included if they measure anti-trans stigma among a specific subpopulation (eg, trans women or trans youth). Since terms and definitions to understand gender identity have shifted over time, we will use search terms for gender identity that have been identified in previous scoping reviews specific to trans populations4 18 25 26 and use locally appropriate terms to capture any studies with people who are not cisgender (eg, studies with LGBTQ populations that specifically distinguish the experiences of trans people will be included).

While stigma is fundamentally intersectional,18 19 23 we will work to focus specifically on anti-trans stigma. As such, we will define anti-trans stigma broadly and include studies examining any aspect of stigma that is specific to anti-trans stigma and not only focused on other types of stigma (eg, HIV stigma and sex work stigma). Studies that specifically examine one aspect of stigma, such as enacted or internalised stigma, will be included in the review, as well as studies that simultaneously capture multiple dimensions of stigma (eg, measures of gender minority stress) across socioecological levels and across settings and contexts (eg, family and healthcare).

LMICs will be identified based on the World Bank27 and all LMIC settings will be included in the search. Studies occurring across multiple countries will be included if at least one of the countries included in the study fits the LMIC inclusion criteria, and data are presented that are specific to the LMIC setting(s).

Exclusion criteria

As we are interested in empirical studies related to measurement, we will exclude all qualitative studies as well as grey literature, including commentaries, correspondences, case reports, case series, editorials and opinion pieces. Case reports and case series often contain relatively limited evidence.28 Governmental or other agency guidelines will also be excluded.

Research studies that do not disaggregate the specific experiences of trans people will be excluded. We will also exclude studies that do not distinguish participants from LMICs versus high-income countries or have participants from LMICs but living in high-income countries.

Reviews such as systematic reviews and scoping reviews will be excluded from formal search. We will, however, consider them for introduction/background and discussion to contextualise our findings.

Screening and selection procedure

All articles identified from the searches will be independently screened by two reviewers. First, titles and abstracts of articles returned from initial searches will be screened based on the eligibility criteria outlined above. We will delete duplicates for all articles identified in the searches and exclude any studies that do not fit the eligibility criteria. Second, full texts will be examined in detail and screened for eligibility. Disagreements will be resolved by discussion, or if necessary, with a third reviewer. A flow chart showing details of studies included and excluded at each stage of the study selection process will be provided.

Data extraction

Reviewers will independently extract data from studies. Reviewers will abstract the data using a pretested data extraction template (see online supplemental appendix 1). We will use a standardised coding protocol to collect information such as title of study, authors, journal title, study setting, study design, description of the study sample, stigma definition, stigma-specific measurements and scales used, socio-ecological level of stigma, stigma setting, consideration of local context in stigma measurement, psychometrics, main findings and limitations.

Data synthesis

Outcomes and other information collected regarding selected studies will be synthesised using quantitative (eg, frequencies of measures that are broad vs those that consider the local context and frequencies of studies that focus on specific subgroups), with a narrative summary of findings conducted. The synthesis will be presented in tables (eg, grouped by world region as defined by the World Bank27), data will be summarised in graphs and maps, and individual data from each study will be reported in tables, including the strategies for developing and adapting stigma measures that consider the local context. The broad goal of the synthesis is to identify the gaps in research and present recommendations for ways to measure anti-trans stigma in LMICs.

Ethics and dissemination

The planned scoping review protocol highlights our transparent and reproducible procedure to enhance knowledge related to measuring anti-trans stigma in LMICs. We detail the process related to data sources, search strategy and data extraction. As a scoping review (no direct interaction with participants), this study is exempt from human subjects oversight.

The results will provide additional knowledge to researchers measuring anti-trans stigma in LMIC settings; this knowledge will be important for informing future research aimed at measuring and understanding anti-trans stigma in LMICs. Stigma is an important social determinant of health for trans people,5 19 and having guidelines for measuring anti-trans stigma in LMICs will improve our understanding of trans health globally.

Any amendments to this protocol will be documented in the final published scoping review with reference to saved searches and analysis. Results of the review will be disseminated in a peer-reviewed journal and likely in other media such as conferences, seminars and symposia. As per PRISMA-ScR guidelines, we will present results in a user-friendly format.24

Limitations

Our planned review should be read in the context of a few limitations. Although we will search multiple databases, include several languages, we may miss some studies (eg, studies not indexed in our included databases or published in in other languages). Additionally, we recognise the Western conceptualisation of gender identity29 and as such we have included widely known culturally specific search terms for diverse gender experiences and identity (eg, kothi, hijra, waria and berdache), but we may have missed some terms. Finally, in some countries, sexual and gender minorities may be perceived as part of the same group resulting in trans experiences not being disaggregated. These studies would be excluded (based on our exclusion criteria); thus, we could both be increasing the possibility of conflating findings across these groups and/or missing country-specific nuances. Based on our exclusion criteria, we would include studies that broadly measure anti-LGBTQ+stigma among trans people but exclude studies that only focus on sexual behaviour or sexual orientation. While this exclusion criteria is aligned with the study goals, and still allows for an understanding of broad measurements of anti-LGBTQ+stigma, it may still limit our ability to understand the ways that sexual orientation and gender identity may be grouped together in some LMIC contexts. We work to address this by including search terms that capture broader LGBTQ communities (including country-specific terms); however, in order to specifically understand anti-trans stigma, it is important that we only include studies that disaggregate the experiences of trans people.