TABLE 2.

Themes, Subthemes and Representative Quotes From Adolescent and Caregiver Interview Participants

Caregivers	Adolescents
Theme 1: Barriers to receiving services in primary care
Subtheme 1: Difficulties accessing gender-affirming care services in the primary care setting
We haven’t had good experiences so far, [my child] has actually not been to their primary care doctor, since they came out as trans. [Mother of a nonbinary adolescent]	I don’t go to my primary care doctor super often… and I I have nothing against them, but I feel a little bit uncomfortable because I don’t I don’t know them super well… and also because it… feels uncomfortable because… it’s an environment where it’s not something that’s already talked about… it feels like maybe it might bring up confusion, and then you have to explain it, and then that’s the whole thing, that’s a big deal and not fun to talk about. [14-y-old trans male, nonbinary, genderqueer, genderfluid, gender nonconforming, demi-gender adolescent]
Subtheme 2: Inadequate psychosocial support from PCP
I am not entirely sure that our physician, as supporting as they are, would be knowledgeable enough to answer many of the questions that we have. [Mother of trans male adolescent]	I wouldn’t want any primary care doctors to say that you have to be in therapy, to make sure you’re not just trans because of trauma. [14-y-old trans male adolescent]
Subtheme 3: Discrimination and microaggressions in PCP environments
I felt like the provider kind of clicked into this … anxious state of, “Okay don’t say anything wrong, don’t say anything wrong.” [Mother of a trans male adolescent]	[My PCP office] is a bit of a smaller clinic though I feel a bit more subjected to people being biased or being influenced by other sources. So that’s I guess a little bit of a worry about going to a primary. [16-y-old trans male adolescent]
	I don’t really remember how it came up because I think they figured that [me being transgender] was a possibility, but they didn’t really want to bring it up and so after a while of them typing out [the wrong pronouns], I was just like, “Hey, I’m not really comfortable with you using those pronouns”. [14-y-old trans male adolescent]
Theme 2: Benefits of gender-affirming care provision in the primary care setting
Subtheme 1: Established ongoing relationships with PCPs facilitates trust
For us, obviously the comfort that my kid has talked to their [PCP], that is a great benefit, instead of having to go see somebody they’ve never met. [Mother of a demi-gender adolescent]	I had an old doctor that I was with … for a really long time. And she was my mom’s doctor and my dad’s doctor… I would have felt totally comfortable talking with her [17-y-old trans male adolescent]
Subtheme 2: PCP has a more comprehensive view of health
Ideally… I could take my child to talk to the PCP about emotional social concerns, biochemical, physical, and mental concerns. Yeah, all the whole body, the whole person. [Father of a trans male]	For me, I think it would be better, because I already have a relationship with them and I’m already comfortable talking to them about pretty much anything. [14-y-old trans male adolescent]
Well, I mean the continuity of care would be awesome to get it all in one place. Be a one-stop shop. [Father of a trans male adolescent]	It would certainly be easier to have everything in one place. [15-y-old, nonbinary adolescent]
Subtheme 3: PCP accessibility and convenience
It’s closer and I think it’s easier to get in. I mean, if we make an appointment [with] his primary care physician, you can generally get an appointment that following week. I think it would be easier. [Mother of a nonbinary adolescent]	I think I might prefer [to see my PCP] because i’ll be honest, [they are] literally just down the street from us, so I think it’d be easier to have in-person visits. To just, be able to just walk down there. [16-y-old trans male adolescent]
When it’s closer to home, it takes less time so I can find a babysitter for the smallest kids. When it’s farther away, and you have to commit four hours with travel and doctors and travel home, I can’t usually go. [Mother of a nonbinary adolescent]
Theme 3: Strategies to improve access to gender-affirming primary care
Subtheme 1: Training and education specific to serving TGD youth for PCPs and their staff
If you’re doing advising and training with primary care providers, I would also want to make sure their entire clinic staff also has some kind of training. [Mother of a trans female, nonbinary, gender nonconforming adolescent]	There’s been a lot of advancement in recent years, like we [are] progressing quite a bit, but that doesn’t mean that everybody’s been catching up on stuff I just wish that more places would put more efforts into educating themselves and their staff [17-y-old trans male adolescent]
Subtheme 2: Interdisciplinary collaboration and care coordination between PCP and gender care specialists
I want to reiterate how good of an idea it seems to me to have very open communication and collaboration between the gender clinic and the child’s PCP [Father of a nonbinary adolescent]	It would make a difference, because at least the doctor would know what to do if they consulted the gender clinic doctor. [17-y-old trans male, nonbinary, genderfluid adolescent]
Subtheme 3: Removing logistical barriers for PCPs to provide gender-affirming services
Our primary care doctor that we see is very, very busy It’s even hard to get an appointment and it’s very hard to get her to follow up with anything like prescriptions or blood work orders or anything, so I just feel like that’s going to be a big problem. [Mother of a trans male adolescent]	It would probably take longer for my insurance to approve [my hormones] and send it off without my dad having to pay like $80. [17-y-old trans male adolescent]
Theme 4: Opportunities to integrate primary and specialty care to support TGD adolescents
Subtheme 1: Services that can be provided in the primary care setting
It’d be nice if we could even go to the primary care doctor to administer the injections once a week. [Mother of a nonbinary adolescent]	I do have to go through the gender clinic to get refills on hormones. So, if I could do that through my primary care provider, it would probably be easier [15-y-old, nonbinary adolescent]
Subtheme 2: Services that should continue to be provided by a gender clinic
The specialized knowledge that the gender clinic has about future questions that we may have, the directions we might go, or what we want to do next. I’m a little leery of how much the general PCP knows about those specialized questions. [Mother of a trans male adolescent]	I mean, I definitely feel more comfortable talking about trans stuff with my main doctor, but I think I still would prefer any big changes to be done through the gender clinic. [15-y-old trans male adolescent]
	I personally feel a little iffy about getting surgery recommendations in general, let alone from someone who doesn’t know much about gender [17-y-old trans male, nonbinary, genderfluid adolescent]
Subtheme 3: Positive impact of receiving services from a gender clinic
There was something in the just feeling affirmed about going to the gender clinic, that I think is important to acknowledge. [Mother of a trans male adolescent]	In the gender clinic I can trust that they already know what I’m talking about. [17-y-old trans female, nonbinary, genderqueer, gender nonconforming adolescent]