Trans people are individuals whose gender identity (innate sense of gender) is “different, discontinuous, or more complex”1 than the gender that is culturally aligned with the sex assigned to them at birth (based on external genital anatomy). For example, a trans woman might have been designated a boy/male at birth, but ultimately identifies as a woman. “Trans” and “gender nonconforming” (TGNC) are umbrella terms including many gender identities,1–3 and TGNC people are often grouped together with sexual minorities (i.e., lesbian, gay, bisexual, queer, and other nonheterosexual) in the context of sexuality and gender minority (SGM) communities. In the context of the United States and Canada, trans populations include Indigenous people who may identify as Two-Spirit, an English adaptation of terms used by different nations to designate people who embody both diverse genders and relationships.4,5
TGNC people face substantial barriers to accessing primary, emergency, and tertiary health care.6,7 This is of particular significance since TGNC populations also face dramatic health disparities in comparison with their cisgender (non-TGNC) counterparts, including increased rates of depression, anxiety, substance use, suicide attempts, and HIV infection.8–11 Of TGNC respondents in a large U.S. survey, 28% reported delaying medical care for fear of discrimination and 50% reported having to teach their clinicians about transgender care.8 TGNC people report health care avoidance in conjunction with experiences of refusal of treatment, verbal harassment, and lack of respect in health care settings,6,9 indicating that clinician-level barriers play a role in some of these health disparities.12 Indeed, multiple studies have indicated that physicians are ill-prepared by their training to care for TGNC patients.12–15 A survey of Canadian and U.S. medical schools showed that undergraduate medical programs include a median of 5 hours dedicated to SGM health topics, with only 30.3% of participating schools reporting that gender transition is addressed in their curricula.16
Implicit and explicit biases against SGM people, reflective of prevailing social attitudes, are present in incoming medical trainees.17 However, increased student exposure to and favorable contact with SGM health issues, patients, and standardized patients are associated with increased knowledge18 and self-reported comfort19 in the care of SGM patients. Aside from cultural competency skills that SGM students may bring to individual interactions with SGM patients, increased diversity of students within medical school classes has been shown to benefit all students in the class.20 Students’ participation in studying, socializing, and participating in diversity-related extracurriculars with students from backgrounds different from their own has been associated with preparedness to work with patients from a wide variety of backgrounds.20
While the value of increasing the racial, socioeconomic, ability, sexuality, and gender diversity of medical trainees is clear, it is also clear that navigating medical training while facing minority stress takes a toll on students from underrepresented groups who gain admission.21–23 Nonheterosexual students are more likely to report harassment and isolation,24 higher stress levels, and less social support.25
Institutional initiatives to mitigate the impact of minority stress on SGM students have been promoted to support the retention of these students.23 However, though institutional initiatives may be valuable in supporting students from underrepresented communities,26 such initiatives may not stop transmission of bias through medicine’s hidden curriculum.27 Cultural changes in medical education have been posited as necessary to improve the well-being of SGM students and, ultimately, of SGM patients.27,28 Curricular and institutional culture changes were emphasized in an Association of American Medical Colleges 2014 report as crucial to improving health care for people who are SGM and/or born with differences of sex development.29
Despite these calls for culture change, in a recent survey of medical students at select U.S. and Canadian institutions regarding “outness,”30 60% of respondents who identified as TGNC reported not disclosing gender identity in academic settings because of a fear of discrimination and a lack of support. The authors of that survey echo calls for action to change the negative culture in medicine toward SGM individuals, citing the interrelation between inequities faced by SGM patients and discrimination endured by SGM trainees and clinicians.31
There have been multiple such calls to action in the context of U.S. and Canadian medical training. However, research to date has not examined the experiences of TGNC medical trainees beyond considerations of disclosure of gender identity. This study aimed to understand TGNC students’ experiences of undergraduate medical training in Canada.
We used a constructivist grounded theory approach, which we considered to be most appropriate as this project focused on understanding the experiences of TGNC medical students from the point of view of these students, with the understanding that an individual’s lived experience is constructed by the individual experiencing it.32,33 Because of the depth and complexity of data we collected, analyses were broken into several substudies according to theme.
Researcher characteristics were important in the feasibility and design of this project. At the time we conducted the study, between April 2017 and April 2018, 2 of us were medical students (K.B., A.Y.) and the third was an associate professor (A.V.) with experience working in the field of equity and diversity in Canadian medical education. All of us are part of SGM communities, and throughout the research process, we reflected on our own experiences and how these shaped our understanding of the experiences recounted by participants. In interviews, we worked to hear participants’ experiences without assuming that we understood them and asked participants to elaborate on statements implying a shared understanding.34 We used member checking, peer debriefing, and reflective memo writing to mitigate the biases that can be associated with being insiders to the community of interest and to maximize the advantages associated with this position.32,34
Prospective participants in this study were any current students or recent graduates of Canadian medical schools who identified as trans (broadly defined, including agender and nonbinary identities) and/or Two-Spirit. We included recent graduates to broaden the potential participant pool, given the small size of the population of interest and the anticipated difficulty of recruiting participants.
We began recruitment in April 2017 through closed online groups for Canadian SGM medical students and through SGM health research networks, including Rainbow Health Ontario and the Canadian Professional Association for Transgender Health. We included all individuals meeting inclusion criteria who contacted the research team, for a total of 7 participants by January 2018. Recruitment terminated when no further participants had contacted the study team for 3 months, in April 2018. While this is a small sample, it corresponds with the population we were studying. In a 2012 survey of students from 4 Canadian medical schools, 0.2% of respondents reported not identifying with the gender on their birth certificate.35 If accepted as a representative statistic, given an enrollment of 11,685 Canadian medical students in 2015–2016,36 this would give an estimate of 23 TGNC medical students in Canadian schools at the time of recruitment. As qualitative researchers, we are not necessarily attempting to achieve a representative sample, but understanding the small and hidden nature of the TGNC population is helpful to evaluate the sufficiency of our data.
We provided participants with information regarding the consent process, risks, and benefits of the study when they contacted the team. Any questions were answered before interviews, at which time participants provided written informed consent, which they either gave directly to interviewers or mailed to the research team. We also distributed a demographic form to collect data regarding age range, gender identity, region of study, completion of legal name or gender marker change, and access to trans-specific health care (see Supplemental Digital Appendix 1, available at http://links.lww.com/ACADMED/A727). We kept these demographic categories broad to avoid collecting overly specific identifying information. Participants had the opportunity to withdraw their participation or data at any point before thematic analysis and to have quotations from their interviews excluded from the final manuscript. Participants were offered a $50 gift card as an honorarium for participation, and 2 declined. This study was reviewed and approved by both the Hamilton Integrated Research Ethics Board and the McMaster University Undergraduate Medical Education Protocol Review Committee.
Between April 2017 and April 2018, we conducted semistructured interviews with 7 participants; the interview guide (see Supplemental Digital Appendix 2, available at http://links.lww.com/ACADMED/A727) was designed from findings of a literature review of SGM student experiences in health professions education.16,37–40 We chose semistructured interviews as an appropriate and accessible means of eliciting personal and potentially sensitive experiences, particularly in a population widely separated by both geographic and scheduling constraints. Two authors (K.B., A.Y.) completed interviews using the semistructured guide and asking clarifying questions as appropriate to the responses of the participant. We gathered data iteratively across participants, with subsequent interviews including questions that built on themes discussed by previous participants. Interviews were conducted in English and French, according to participant preference. We conducted interviews either in person or by video call, according to the preference and availability of participants; these were audiorecorded by the interviewer and transcribed verbatim by K.B. The team member who conducted the interview then verified the transcript with the recording. Transcripts were deidentified, and participants had the opportunity to review their deidentified transcript to confirm that identifying details had been removed and to offer additional thoughts or clarifications. Four participants did so, with 3 offering additional comments or examples, which were then integrated as additional data.
Analysis began with 1 author (K.B.) rereading all deidentified transcripts after transcription and conducting initial line-by-line coding. Transcripts from French interviews were coded in English, with excerpted quotations translated into English for publication. A second author’s (A.Y.’s) independent coding was used to reach agreement on initial coding. After the initial coding of all interviews, all coded transcripts were read again, and focused coding was completed. Discrepancy in coding was minimal and was resolved through discussion and reexamination of interview data for context. We grouped focused codes inductively to form axial codes, which we then developed into 5 overarching themes. Coders used analytic memos and diagrams to support the development of themes, and an audit trail was maintained throughout the analytic process. Redundancy of overarching themes and subthemes, or metathematic saturation,41 was reached after the fifth interview. Further nuance in focused codes would likely have been achieved with a larger sample; however, we believe that given the quality of dialogue, specificity of the sample, and the analysis strategy, the information power of our data was appropriate to our study aim.42
Seven participants completed interviews, and their demographic data are outlined in Table 1. Three participants were recent graduates (within the last 3 years), while 4 were current students. Though we did not collect demographic information on racialization, 4 participants specifically discussed the intersectional impacts of being people of color on their experiences as TGNC students, and 2 discussed the effects of being white on their experiences.
The 5 overarching themes developed through the analytic process are delineated in Figure 1, with an explanatory legend. This article will focus on the first theme, navigating cisnormative medical culture, the subthemes and focused codes of which are presented in List 1. We hope to examine the remaining themes in future publications.
Navigating cisnormative medical culture
Participants described many different manifestations of a medical culture that marginalizes the existence of TGNC people in general and TGNC learners in particular. These subthemes were: the influence of a larger cultural context in relation to conservative medical culture; interactions with classmates; “inadequate” and highly variable curriculum content; interactions with policy and administration; and accessing gendered spaces.
Culture and context.
Multiple participants noted that while they appreciated the shifts in the larger cultural discourse about trans people over the past decade, TGNC people continue to face barriers to social belonging. One participant noted:
Just generally speaking, my experience of gender has sort of felt like I was part of a social group of undesirables. . . . And so I guess I sort of carried that with me into medical school.
One participant noted that while transphobia is certainly not unique to medical culture, there is a perceived delay in the way that medicine takes up social change:
I definitely don’t think that this is an issue specific to medicine. I think this is an issue of trans people in the workplace in general. . . . In my previous job, I didn’t feel comfortable being open about it. . . . But I do think that in medicine these conversations happen slower than the progress in society in general. And actually one of the staff that I had spoken to about this had made the same comment, that progress in medicine is slower to happen.
One participant described the experience of being segregated by gender throughout medical training:
I remember from day one, there was something where they segregated us by gender—they always do that. I don’t know why they do it in medicine so much but they do that for some reason at the interview—probably just to organize us to do something, but I remember feeling really uncomfortable . . . and apparently that was just a preview for the rest of medicine [laughs].
Similarly, another student described avoiding formal ball events partially on the basis of the gender norms associated with formal dress:
There’s a lot of events . . . that are super gendered. I didn’t go to any of those . . . your first-year ball, where everybody wears gowns. . . . I think a big part of it is in terms of how to present for those events. So I didn’t go to them, it didn’t bother me that I wasn’t going. . . . But . . . if I could have gone as a queer posse, then I would have gone.
Several participants reported experiences in classroom and small-group learning contexts in which TGNC people were the target of cruel jokes. For instance:
The [facilitator] had talked about a scenario where—this was when he was a resident, and there was someone coming in that I guess had mental health issues going on, but then came into the hospital being like “I want to have a sex change”—and as a prank, they kind of sent this person to different hospitals, saying “Oh, go to the [this other hospital in town] and they’ll do it for you”—not as actual advice, but more to send this person on a wild goose chase.
Interactions with classmates.
Participants described a wide range of relationships with classmates, from general alienation to support from a core group of peers. Though few participants described being actively segregated by gender in official settings, 1 person described the experience of being gender nonbinary as intensely isolating when it came to social interactions:
It’s always like, if the guys are doing something, they don’t invite me, and if the girls are doing something, they don’t invite me either. . . .Sometimes I’m completely left out from something because the girls assume that I was invited by the guys and the guys assume that I was invited by the girls.
Another participant described the impression created by a social media interaction:
This good soul in our class made a post in the class Facebook group that sort of discussed trans issues from a more trans-positive perspective, and then there was a storm of random classmates who started jumping in and commenting and saying what I remember to be more transphobic things or just demonstrating a lack of understanding. . . . I just remember, it made this big impression on me that people in my class were publicly online making these really negative comments about trans people, and I was just thinking, “Oh gosh, these people are going to be my colleagues one day!”
Although 5 participants gave examples of the above type of alienation, an equal number described examples of classmates as important sources of support and belonging. One participant highlighted their small group’s commitment to properly reviewing materials on SGM-specific health care:
It just felt like there was a clear interest and commitment to learning the material from folks, most of whom don’t have a specific interest in doing LGBTQ2S [lesbian, gay, bisexual, trans, queer, Two-Spirit]-specific care, so that was a nice kind of feeling of the group saying, “No, this is important and we want to cover this because we’ll be taking care of these patients.”
Multiple participants noted the degree to which relationships with classmates shifted over the course of their studies, noting factors including exposure to curriculum on interacting respectfully with trans people, decreased anxiety about rejection as the end of the program approached, and increased familiarity and comfort with classmates over time:
Later in the year, just a couple of days after having our LGBTQ health session actually, [a classmate] was practicing doing a physical exam on me, and halfway through she kinda went, “Oh, I’ve never asked you—can I ask what pronouns you use?” and I was actually really impressed—I mean she definitely gets some credit, but also it just made me feel like the LGBTQ health session really did have a clear and dramatic impact in terms of giving my classmates tools—not just to take care of patients but also to interact with their colleagues.
Finally, 1 participant spoke about the impact that the intersections of racialization, sexuality, and gender had on their social experience:
I really targeted friendships with people that I thought were queer. . . . But the thing is that all of those people were white, so—in one way, yes, I felt comfortable being trans, but then I was always kind of hyperaware that when we would be doing social things, I would be the only person of color. . . . I felt like I fit in in one way but not in another. And then I would make friends with people of color, but I was always like, well, if these people knew that I was trans, would they still treat me the same way?
All participants reported having some kind of exposure to SGM health topics through the formal curriculum, with most reporting a single overview lecture. Several participants found that these lectures covered TGNC-related topics inadequately and that if TGNC-related topics were mentioned, the focus was on binary trans identities, with no mention of nonbinary or Two-Spirit people. While multiple participants explicitly acknowledged the fact that undergraduate medical curricula already cover enormous amounts of material and that lecture time is at a premium, they still perceived significant gaps regarding education on TGNC-related health topics.
A single participant described experiences of hearing TGNC people mentioned outside of a designated session:
In one of our OB/GYN lectures, they did talk about providing care for trans men. . . . One other example of teaching that I appreciated . . . a teacher was talking about the factors that affect your differential—so she was saying, “You know, say the patient has belly pain—the patient could be 5 years old, or 70 years old, and that will shape your differential—and the patient could be male, or female, or the patient could be transgender, and that will change what you’re thinking about too,” and I just really appreciated that inclusion in teaching about everyday kind of stuff.
Other participants expressed dissatisfaction with the way in which TGNC health materials were incorporated into their institution’s curriculum:
They tried to add something in, but it didn’t quite fit with the whole lecture that was being done. And I think the students were a bit confused about—“Wait, why are we talking about this all of a sudden?” The other thing that they added—we have these sessions in a simulation center . . . they added one scenario on speaking with trans patients, which was good except for the fact that there was no teaching. . . . It was better than nothing, but it wasn’t great.
Overall, participants acknowledged that curricula were rapidly changing, and several mentioned the impact of student-led events on supplementing the gaps in formal curricula.
Policy and administration.
Most participants reported hesitancy about disclosing TGNC identities to their administrators for fear of discrimination; however, 4 participants did describe cautious disclosures in relation to needs surrounding name change and access to appropriate gendered spaces. For those who worked with staff to complete legal name changes during their undergraduate training, they described an inconsistent combination of supportive interactions and the need for ongoing self-advocacy. For example, after a legal name change, 1 participant described the following supportive action by their faculty:
We have our names on our white coats, and usually you need to pay to have a second coat—so for me, I had asked at the start of the year whether I could buy another one. That was in first year, and at the start of second year, they had ordered me a new one with my new name on it—without me even asking.
Another student described the circuitous path of trying to complete a name change:
It was complicated to get a name change as a nonbinary person . . . and at one point I went to [the physician] at the [student affairs] office to talk about it, hoping that she would give me a letter, because she was an MD and they wanted a letter from an MD. . . . But she wasn’t very helpful or open and she refused to write me a letter because she said she didn’t have a therapeutic relationship with me. . . . I eventually ended up with [the counselor] and I asked her and she was very nice about it. We had a long discussion about it and then she wrote me the letter, and then she even got [the physician] to cosign it with her.
Notably, some participants who had completed legal name changes had studied in Quebec, where the provincial college has specific requirements regarding how legal names are listed for medical students and physicians. Two participants specifically described some of the factors that made them decide to complete a name change during school:
So if I had not changed my legal name, then every . . . new hospital [my former legal name] would be the name that they would get. And there was one time where they assigned me to a female change room—so I ended up feeling a little bit pressured to have to legally change my name. . . . Until I legally changed my name, I had to constantly be like, “Okay, where could this be an issue? Okay, I need to contact the administrators about that”—there wasn’t something in place for students already.
With regard to antidiscrimination policies, participants reported mixed views regarding their utility. One participant expressed feeling reassured by the specific inclusion of gender identity and appropriate pronoun use in their institution’s antidiscrimination policy, and another felt it was very important for gender identity to be explicitly included, while several others questioned whether schools could effectively follow through with supporting students if they faced discrimination based on gender identity or presentation. For example:
It’s a nice thing to see, but I also feel a little bit cynical, where there are so many places that will say that [they are supportive] and are actually not, so I’m not sure it would have made any difference whether or not a school actually had some kind of policy posted or not.
While 1 participant did not report any issues with accessing appropriately gendered spaces, as someone who was seen as cisgender, all other participants described some degree of stress related to these spaces. As mentioned above, 1 student was assigned to an inappropriate change room before their legal name change. Another student requested accommodations without shared showers on a school trip and subsequently faced some inflexibility from the administration:
I asked, “Would it be possible, could you please put me somewhere, with whatever group, so that I won’t be in shared showers?” . . . And they said, “We can’t guarantee it” and “We don’t make exceptions for anyone except for people with allergies.”
Our study was designed to understand the experiences of TGNC medical students in Canadian training programs and elicited rich and enlightening data on this topic. This first theme of navigating a cisnormative medical culture was developed as it became evident that participants were describing a cultural context in which it was almost never acknowledged that TGNC people might be part of their patient population, classroom, or clinical team. This cultural context led to recurrent and jarring experiences for participants, many of whom began medical training with the explicit goal of advocating for better care for TGNC patients.
The process by which the existence of TGNC people is precluded in health care has been termed “erasure” and described as taking place through both informational and institutional processes.43 Participants’ descriptions of curricula that posit normative patients as cisgender and assume a strict correlation between masculine gender and male sex, and between feminine gender and female sex, constitute informational erasure. Institutional erasure is illustrated by participants’ descriptions of infrastructure that make related assumptions, that is, automatically assigning students to gendered locker rooms based on legal gender markers.
The assumptions underlying these processes are termed “cisnormative” because the normative individual is assumed to be cisgender. This assumption is present in the stories recounted by participants about lecturers or preceptors framing TGNC people as the topic of jokes or appropriate targets for cruel pranks rather than as people deserving of dignity and respect. The circumstances in which faculty disrupted this cisnormative culture by explicitly framing TGNC people as possible patients, such as the obstetrics–gynecology lecturer who mentioned the care of trans men, were viewed as exceptional and as very positive by participants. Participants’ framing of the exceptionality of these circumstances further emphasizes both the pervasiveness of cisnormative assumptions in the rest of their experiences and the power that minute changes can have in creating a more inclusive culture.
Cisnormative medical cultures reinforce the continued ignorance of medical trainees regarding TGNC people and their health needs, thereby continuing to contribute to the disparities suffered by TGNC patients seeking care.27,28 These contexts also undercut institutional efforts to increase the ability of medical trainees to care for diverse populations, as TGNC students are unlikely to disclose TGNC identity in these contexts.30,44 This could preclude sharing of any skills that may “out” them as TGNC to staff and classmates who are immersed in a culture that holds TGNC people as pathological or the object of ridicule. This inhibits non-TGNC trainees’ abilities to learn from their TGNC peers’ lived experiences and develop the skills they need as medical learners to serve vulnerable populations.
The description of prevailing cisnormative medical cultures attested to by participants in our study is not a novel finding, as it reproduces research on the experiences of TGNC students in multiple higher education contexts.29,45,46 However, it is important to examine this culture in the light of the unique obligation of medical education institutions to consider how culture affects the care of vulnerable patients.
This was a small qualitative study focused primarily on an in-depth exploration of the experiences of TGNC medical students. Providing generalizable recommendations for programs seeking to improve the experiences of TGNC trainees, patients, and faculty is beyond the scope of this project, and we would direct readers to several recommendation documents29,45–49 for detailed suggestions and resources. However, given the paucity of literature regarding the experiences of this population, we thought it valuable to consider how our findings aligned with current recommendations for improving institutional cultures for SGM faculty, trainees, and patients. Table 2 outlines the alignment between the subthemes we have discussed and recommendations from major organizations regarding shifting institutional climate and culture to be inclusive of SGM learners, faculty, and patients. Synthesized recommendations from these sources were largely aligned with one another and are presented in Table 2.
Notably, none of the sources included in this synthesis commented on the strategies to address the challenges TGNC students face in gendered spaces other than washrooms. This absence contrasts with the experiences reported in this study with the challenges of frequently changing clinical environments and repeated inappropriate assignment to gendered spaces, including locker rooms. Further, though some participants were reassured by antidiscrimination policies inclusive of SGM individuals, there was also mistrust expressed of the value of these policies when institutions are not seen to enforce them. The enactment of antidiscrimination policies that include protection against discrimination for SGM people could perhaps be understood as a floor, rather than a ceiling, when it comes to shaping institutional cultures that are welcoming and inclusive for people from SGM communities.
Given the small and hidden nature of our population of interest, this was a small study, and purposive sampling was not possible. Initially, the use of respondent-driven sampling was proposed by the researchers and was approved by the Research Ethics Board but was disallowed by the Protocol Review Committee at our local institution because of concerns regarding participant confidentiality. The resultant convenience sample used is susceptible to sampling bias, as participants who were already members of an online group for SGM medical students or a research network focused on SGM health may have different experiences from those who are not part of these networks. As in any study that recruits participants, volunteer bias may also have affected our findings.
In designing and recruiting for the study, we used language including Two-Spirit people with the aim of hearing about the potential nuances in how Two-Spirit students navigated their experiences. The lack of Two-Spirit participants in our sample is another limitation, as these individuals may have different experiences from non-Indigenous students. Further, none of our participants identified as trans women, which may reflect the greater degree of discrimination faced by trans women in employment and educational settings in comparison with trans men and gender nonconforming people.8
Understanding the experiences of TGNC students who are being enculturated into a medical professional culture with persistent underlying cisnormative assumptions about patients, clinicians, and trainees is a first step in considering how to shift this culture and, ultimately, address the health disparities faced by TGNC people. Medical professionals and trainees are certainly not alone in facing cultural challenges to improving both professional culture and quality of care as they relate to TGNC people. However, the imperative to consider how we as medical learners, teachers, and professionals can improve health outcomes for these underserved communities should motivate us to consider how we can intervene both locally and on a broader scale. Moving forward, more in-depth knowledge of the experiences of TGNC medical trainees would be valuable, as would further research on quantifying the outcomes of implementing the published best practices in supporting TGNC learners, faculty, and patients in health professions educational environments.
Navigating Cisnormative Medical Culture: Subthemes and Focused Codes, From a Qualitative Study of Trans and Gender Nonconforming Medical Student Experiences in Canadian Training Programs, 2017–2018
Culture and context
- Larger cultural discourse about transness
- Medical culture as slow to change
- Trans people as target of cruel jokes
- “Med school is difficult for everyone”
- “I just have a different perspective”
Interactions with classmates
- Not feeling like you belong
- Supportive classmates
- Shifting classmate competency
- Role of racialization, gender, and sexuality in social belonging
- Context: rapidly changing curriculum
- Wide curricular variation
- Erasure of trans patients
- Gaps in teaching: “Overall, inadequate”
- Poorly integrated curricular change
- Appreciating the little things
- Transphobic lecture content
Policy and administration
- Name change policies
- Awaiting nonbinary options
- Dis/trust and awareness of antidiscrimination policies
- Fear of discrimination
- Disclosure choices to administration
- Experiences of rejection and support
- Context of physical vulnerability and frequent change in environment
- Gender-neutral washrooms
- Misgendering in gendered spaces
- Inappropriate assignment despite disclosure
- Realization of need for self-advocacy
- Inflexibility of administrators
The authors wish to thank the participants who shared their time, energy, and stories, as well as Dr. Meredith Vanstone (McMaster University), Dr. Natasha Johnson (McMaster University), Dr. Claire Bodkin (McMaster University), and Dr. Kira Abelsohn (University of Toronto) for their helpful edits and feedback on the manuscript.
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