Table 3.

Summary of the 16 included studies.

Author, year, country	Study type	Participant characteristics	Experiences and perceptions of primary care	Expectations from a primary care service/healthcare providers	Key findings
Wright et al. 2021, UK, [24]	Qualitative study, interview	Transgender people who had also taken part in the HIV Self-Testing Public Health Intervention (SELPHI) randomised control trial Total participants − 20 Gender − 7 trans women, 12 trans men, 1 nonbinary trans masculine person Ages − 21–57	Examination of the pathway from primary care to specialist gender identity services in the UK	NR	GPs are poorly informed about TNB identities and care pathways Cisnormative views enforcing the gender binary may alter how patients present to primary care in order to access care Positive interactions with GPs are when they prioritise treating the patient holistically as a whole person and have a willingness to learn and take responsibility
Haire BG et al. 2021, Australia, [25]	Qualitative study, interview	TNB people living in Australia, recruitment facilitated by the Gender Centre Total participants − 12 Gender − 9 trans women, 1 trans man, 2 nonbinary people Ages − 19 to 59 Race/Ethnicity − 5 participants were Indigenous	Experiences of healthcare access in trans and gender diverse people with complex health needs	NR	TNB people have to navigate multiple HCPs and HCS and HCPs act as gatekeepers Perceived erasure of nonbinary identities and a need to conform to gender stereotypes to access care Perceived ignorance and stigma from HCPs common A welcome physical environment and supportive peer community seen as vital
Ker et al. 2020, New Zealand, [26]	Qualitative, interview	TNB people accessing a primary care pilot clinic providing HRT Total participants − 4 TNB people and 4 HCPs Gender – of the service users: 3 female, 1 nonbinary and neutrois Ages − 18-26	Exploring the experiences of a primary care-based pilot clinic providing gender-affirming hormone therapy in New Zealand	NR	Primary care led clinics were perceived as more accessible, with less waiting times and less gatekeeping HCPs emphasised partnership with service users and that the service provided was adaptable Perception it depathologised gender diversity Efforts to centralise care seen as minimising the power dynamic
Willis et al. 2020, Wales, [27]	Qualitative, interview	Older TNB people who were trying to medically transition later in life Total participants − 19 Gender − 15 trans women, 4 trans men Ages − 50 to 74	Examining supportive and obstructive points of interaction with health-care professionals	NR	GPs were inconsistent allies Participants often forced into the role of patient educators as GPs lacked knowledge of trans needs, available treatments and care pathways Perception HRT could be GP managed but seen as too specialist Some GPs would act as individual gatekeepers
Allory et al. 2020, France, [28]	Qualitative interview	TNB adults in France recruited through local trans or LGBTI (lesbian, gay, bisexual, trans, and/or intersex) associations, primary care providers, and social networks Total participants − 27 Gender − 14 trans men, 12 trans women, 1 nonbinary person Ages − 18 to 60	Exploring the difficulties experienced by transgender people in accessing primary health-care services	Exploring expectations towards primary care providers to improve their health-care access.	Nano, micro, meso and macro levels of difficult accessing primary care services Anxiety in anticipating GP responses and being “outed” in waiting rooms TNB people form peer community networks and refer on trusted HCPs Healthcare systems not adapted to TNB people Expectations of gender normativity common and pressure to conform to gender stereotypes to access care Expectations included self-determination and reducing the need for psychiatric assessment TNB people want primary care led services for initiating and following up treatments, perceived to be more holistic and accessible
Bell et al. 2019, Canada, (29)	Qualitative, interview	TNB people in Ontario recruited through family medicine clinics and community agencies Total participants − 11 Gender − 4 trans men, 6 trans women, 1 GNC	Exploring past experiences of TNB people in primary care	Describing expectations of members of the trans community regarding the delivery of primary care by their family physicians	Perceived HCP knowledge of TNB identities found lacking overall and limited knowledge about hormones Patient self-advocacy beyond what would be expected, e.g. bringing in guidelines or referring GPs to local events Discrimination by HCPs common Primary care led treatment preferred as perceived to be more holistic though more education is needed More research into the systemic oppression of trans people which has led to an intersectionality with poverty, mental illness and substance abuse
Zwickl et al. 2019, Australia, [30]	Qualitative, survey	TNB adults in Australia recruited through the trans medical research Facebook group Total participants − 928 Gender − 37% trans women or trans femme, 36% trans men or trans masc, 27% nonbinary identities	Exploring health needs of trans and gender diverse people in Australia	NR	80% have a regular HCP Mainstreaming services to primary care will likely improve accessibility TNB people should guide research priorities and health service delivery 44.8% said HCP knowledge lacking Positive interactions including respecting names, pronouns, not asking invasive questions and knowing about care pathways Need for more research about HRT risks long term and about improving care
Vermeir et al. 2017, Canada, [31]	Qualitative, interview	TNB adults living in Nova Scotia who wanted to experience, or had tried to experience, primary and/or emergency care within the last two years Total participants − 8 people Gender − 3 trans women, 1 trans man, 1 trans masc guy, 1 transsexual man, 1 genderqueer and nonbinary person, 1 dude/guy/demi-guy/person Ages − 18 to 44	Exploring the barriers trans adults encounter when pursuing primary and emergency care in Nova Scotia, Canada		Interpersonal barriers to care included HCP knowledge and patients having to educate HCPs Reasons as to why patients seeking care taking a backseat Perceived uncomfortable attitudes by HCPs, including deadnaming, being “outed”, “gendering” care, invasive questioning Lack of welcome physical spaces e.g. gender neutral bathrooms, exclusion of TNB inclusive information on posters and forms Extensive wait times for specialist care
Westerbotn et al. 2017, Sweden, [32]	Qualitative interview	TNB people living in Stockholm with experience of the Swedish healthcare system Total participants − 14 Ages − 20 to 50	Experiences of TNB people meeting with healthcare professionals	Exploring expectations TNB have before and upon meeting HCPs	Clear knowledge gap among HCPs TNB people wanted to be treated like anyone else TNB people often expected ignorance or discrimination Many participants felt anxious before meeting with HCPs which led to avoidance of services of fear of being exposed / questioned by HCP and reception staff
Melendez et al. 2009, USA, [33]	Qualitative, interview	Trans women who took part in a study around their ideas of best practice for HIV prevention and primary care in a specific community-based clinic in New York City. Total participants − 20 Gender - all trans women Ages − 18 to 53 Race/ethnicity − 16 were Latina (14 Puerto Ricans, 1 Central American, one South American), 4 were African American	Exploring the experience of trans women at this particular primary care and HIV prevention clinic, which was not an LGBT-specific clinic.	Exploring what trans women think best practice looks like for providing primary care and HIV prevention support to trans women in a community clinic.	Some participants preferred using a general health clinic to an LGBT specific clinic because they saw themselves as women, rather than transgender women, and because of tensions within the LGBT community. The participants reported feeling safe at the clinic and many had been recommended the clinic by friends as it had been reported to be safe. Factors influencing their feelings of safety included being called by their preferred names, feeling cared for, and understood their community, including the intersection of their (primarily Latinx) racial/ethnic identity and their identity as trans women. They also reported feeling like the clinic could provide a ‘one stop shop’ for medical care, sexual healthcare and gender affirming care.
Treharne et al. 2022, New Zealand, [34]	Quantitative, survey	TNB people living in New Zealand with a primary care doctor or GP Recruited through social networks and within local trans and queer communities Total participants − 948 Gender − 29% trans women, 29% trans men, 42% nonbinary identities Ages − 14 to 83	Experiences of the most common positive and negative experiences with primary care doctors for TNB people	NR	Supportive experiences include equitable treatment from doctors and cultural competence Negative healthcare experiences associated with distress and non-suicidal self-injury and suicidality 47% had to educate healthcare providers, 28% were told gender-affirming care could not be provided on account of lack of knowledge 48% had primary care doctors supportive of their healthcare needs Nonbinary people more likely to have negative healthcare experiences in accessing gender affirming care
Kattari et al. 2021, USA, [35]	Quantitative, cross-sectional survey	Transgender Adults (18+) in the US, recruited online. Total participants − 27,715 Gender − 28.6% man/ trans man, 33.85% woman / trans woman, 34.15% nonbinary/genderqueer, 2.62% cross-dresser = 2.62% Age: M = 31.23 Ethnicity − 80.76% white/European American, 5.24% Latinx/Hispanic, 4.65% Biracial/Multiracial, 2.79% Black/African American, 2.52% Asian/Asian American, 1.07% American Indian, 2.96% Other	To assess how many TNB individuals see a physician on a yearly basis; how many TNB individuals have a regular primary care provider (PCP); and how many of these individuals have a PCP who they would consider to be knowledgeable about transgender health	NR	17.8% reported that their PCP knew almost nothing about TNB health, 17.7% that their PCP knew some things, 12.6% that their PCP knew most things, and 15.2% that their PCP knew almost everything. The remaining 36.7% did not know how much their PCP knew about TNB health. Being nonbinary/genderqueer or a crossdresser was associated with lower levels of PCP knowledge, being a trans woman was associated with higher levels of PCP knowledge.
Bauer et al. 2015, Canada, (7)	Quantitative, cross-sectional survey	Transgender people in Canada, recruited online using respondant-driven sampling. Total participants − 433 Gender − 184 (52%) were assigned female at birth (AFAB), 172 (48%) were assigned male at birth (AMAB) Ages − 16 to 25 = 41% TM 20.9% TF; 25-45 = 48.8% TM, 47.6% TF; 45 + 10.2% TM, 31.5% TF. Race/ethnicity − 68.1% were white, 31.9% were racialised or Aboriginal.	To assess how comfortable participants are to discuss trans healthcare with their PCP (Discomfort/Comfort). Checklist of 9 trans-specific negative experiences with GPs. Provider knowledge of trans issues, 4-point Likert scale.	NR	47.7% AFAB trans people and 54.5% AMAB trans people were not comfortable discussing trans issues with their doctor. This discomfort was present despite accounting for factors such as access to a regular family physician and having universal healthcare insurance. Having a provider perceived as knowledgeable was associated with more comfort, and previous negative experiences were associated with more discomfort. Higher levels of transphobia were independently and negatively associated with discomfort among transfeminine participants.
Tan et al. 2022, New Zealand, [36]	Mixed methods, cross-sectional survey with quantitative and qualitative outcome variables	Trans people (aged 14+) living in New Zealand who are accessing primary care. Total participants – Quantitative n = 871, qualitative n = 153 Gender – Quantitative: 29.1% trans women, 29% trans men, 41.9% nonbinary Qualitative: 12.3% trans women, 20.1% trans men, 33.3% nonbinary Ages – Quantitative: 15.3% aged 14–18, 28.1% aged 19–24, 34.6% aged 25–39, 13.4% aged 40–54, 8.3% aged 55+. Qualitative: 7.5% aged 14–18, 10.1% aged 19–24, 21.3% aged 25–39, 19.8% aged 40–54, 27.3% aged 55+. Race/ethnicity – Quantitative: 84.3% New Zealand/European, 12.9% Maori, 1.5% Samoan, 1.4% Chinese. Qualitative: 18.3% Maori, 16.6% NZ European, 10.3% other.	To assess participants confidence in their GP in explaining information, involving them in decision-making and consideration of financial factors To explore broader experiences in primary care	NR	Transgender participants had greater risk of feeling no confidence in their GPs (Cohen’s d = 0.39), reporting barriers accessing primary care due to cost (38.4% vs 17.4%; RR = 2.21), and transport issues (13.5% vs 3.0%; RR = 4.58) compared to the general population Enabling resources relating to affordability of care and transport were key factors in accessing primary care, with regional variability comparing suburban to rural areas.
Goldenberg et al. 2021, USA, [37]	Mixed methods, cross-sectional survey and individual in-depth interviews	Trans youth of colour living in 14 US cities who had experienced using healthcare. Survey, total N = 79 Interviews, total N = 33 Gender – Trans femme = 20, Trans masc = 13. Ages − 16 to 24 Race – Non-Hispanic Black = 14, Asian/Pacific Islander = 4, Latinx/Hispanic = 11, Multiracial = 4.	To explore quantitatively the need for, and access to, gender affirmation within healthcare To qualitatively explore healthcare experiences, and barriers and facilitators to accessing care.	NR	Finding a provider was described as challenging, although some had positive experiences due to being referred to specific affirmative providers via other services or through recommendations from within the trans community. They described barriers in making an appointment and being in the waiting room. Participants reported positive and negative healthcare experiences, according to provider knowledge, whether they were treated with respect, and how much support they were given to navigate the healthcare system. They reported more negative experiences as being linked to healthcare avoidance Healthcare avoidance was associated with providers using inappropriate words for body parts, not having gender neutral bathrooms, and not being able to access referrals
Hinrichs, 2018, USA, [38]	Mixed methods	TNB participants who have accessed TNB-related and/or primary care at Smiley’s family medicine clinic in Minnesota Total participants − 22 Gender − 4 transgender man, 4 transgender man/male, 3 transgender women/female, 3 female, 1 transgender woman, 1 transgender male, 1 transgender man/other, 1 trans man/genderqueer/GNC, 1 trans woman/other, 1 GNC transmasc bigender, 1 GNC/other Ages − 18 to 65	To explore how primary care clinics can improve care for TNB patients	NR	Negative experiences of misgendering, stereotypes, stigma and/or rejection of services from HCPs TNB people need time to build trust and HCPs need to be willing to learn Need for sensitive and inclusive HCPs where patients can seek care for non-transition related care as well where their identity isn’t the focus Patients would prefer HRT to be primary care led and wanted more research into the long-term impact of HRT Challenges of mainstreaming TNB competent primary care services included inconsistency of HCP education, reluctance to adapt and struggles to ensure clinic wide consistency

NR: not relevant; TNB: transgender and nonbinary; GP: General practitioner; HCP: healthcare provider; HCS: healthcare system(s); GNC: gender non-conforming; LGBTQ+: lesbian, gay, bisexual, transgender, queer and plus; HRT: hormone replacement therapy; PCP: primary care provider; AFAB: assigned female at birth; AMAB: assigned male at birth.