Suggestions for improving healthcare for transgender and gender diverse people in the United States

Abstract

Introduction: Transgender and gender diverse (TGD) individuals face disproportionate barriers to accessing affirming healthcare, ranging from individual practitioners’ biases to financial constraints and societal-level cisnormativity. Method: This study identified suggestions for improving healthcare from 420 TGD individuals in the United States. Participants responded to an open-ended question about their suggestions for improving healthcare for TGD people. These responses were then coded using thematic analysis, resulting in 22 specific codes under 6 themes. Results: Results indicated a need for eliminating cisnormativity, taking a holistic approach with clients, adjusting conceptual frameworks for care, eliminating accessibility barriers, promoting affirmative interactions with TGD clients, and providing TGD-affirmative training for providers. Notably, these suggestions spanned from the broader, cultural level regarding general understandings of TGD people and gender to micro-level interactions. Conclusions: This study provides important tools for improving TGD care via a reduction of barriers and an increase in competency and affirmation.

Transgender and gender diverse (TGD) people may seek medical or mental healthcare for a variety of needs, including general healthcare services not specific to their identity or for gender affirming medical care (e.g., hormones or surgeries to affirm a person’s gender). Although accessing healthcare is a basic need, there are significant challenges that impact TGD people’s access to care. Barriers to care for TGD individuals exist at multiple levels, from institutional and structural barriers to provider and patient-level barriers (Hernandez & Fultz, 2006). These barriers to care include ignorance and lack of education about TGD health, stigma and minority stress within healthcare (Brooks, 1981; Testa et al., 2015), and insurance or financial matters. In light of these common barriers and exposure to minority stress (Testa et al., 2015), we sought to understand TGD peoples’ views about potential improvements for their healthcare experiences within the United States (U.S.).

Common barriers to affirming experiences in healthcare for TGD people in the U.S

TGD individuals often find that healthcare providers lack knowledge about TGD-specific healthcare (e.g., hormones and/or surgeries to affirm one’s gender) and TGD people in general. Medical professionals self-report knowledge deficits in this area (Lurie, 2005; Poteat et al., 2013; Snelgrove et al., 2012) and there is a lack of coverage on these topics within medical training (Obedin-Maliver et al., 2011). In qualitative studies, TGD people often express frustration with their healthcare providers’ lack of knowledge about their needs (Poteat et al., 2013). Providers often not only lack knowledge about the specifics of gender affirming medical care (e.g., surgeries or hormones to affirm someone’s gender), but also basic knowledge about transgender identities. For instance, many TGD people report that providers are unaware of nonbinary identities, which can negatively impact interactions with providers (Puckett et al., 2018). Research on the experiences of TGD individuals in psychotherapy, a specific healthcare context, has found that therapists often lack experience with TGD clients, have a limited view of gender, make assumptions that all TGD people’s experiences are the same, and either place an exaggerated focus on gender or avoid gender as a topic altogether (Mizock & Lundquist, 2016; Xavier et al., 2013). These same experiences are often reported in medical care (Puckett et al., 2018; Sperber et al., 2005; Xavier et al., 2013). To meet their healthcare needs, TGD individuals often carry the burden of educating their providers about TGD-specific healthcare needs and TGD identities (Bradford et al., 2013; James et al., 2016; Puckett et al., 2018).

TGD people also face harassment and discrimination by medical providers and staff (Bradford et al., 2013; Grant et al., 2011; James et al., 2016; Lambda Legal, 2010; Puckett et al., 2018). TGD people often report being denied healthcare services due to being trans (James et al., 2016; Lambda Legal, 2010; Puckett et al., 2018; Sperber et al., 2005; Xavier et al., 2013), including for transition related medical care and general medical services (Kosenko et al., 2013). Being denied services also disproportionately impacts TGD people of color (Grant et al., 2011). TGD individuals also report hostility, insensitivity, and disrespect from providers (Kosenko et al., 2013; Xavier et al., 2013). TGD people often report stigma and discrimination from therapists as well, especially instances of providers attempting to dissuade them from affirming their gender or equating their TGD identity with mental illness (Carroll & Gilroy, 2002; James et al., 2016; Mizock & Lundquist, 2016). Though less frequent than harassment and discrimination, TGD people may also experience verbal and physical abuse from healthcare providers (Grant et al., 2011; Kosenko et al., 2013; Lambda Legal, 2010; Puckett et al., 2018). Even TGD people who have not had personal experiences with discrimination report knowing someone who has (Shipherd et al., 2010).

Insurance and financial issues also pose significant barriers to care for many TGD individuals, especially for gender affirming healthcare (Xavier et al., 2013). Research has shown that TGD people are less likely than cisgender individuals to have health insurance, and TGD people of color have even higher rates of being uninsured (Dickey et al., 2016; Grant et al., 2011; Xavier et al., 2013). Additionally, TGD individuals are less likely to be insured through their employer and more likely to be covered under state programs such as Medicare or Medicaid (Grant et al., 2011). Even when TGD people have access to health insurance, there are often exclusions or limitations that inhibit coverage of gender affirming medical services (Gorton, 2007; James et al., 2016; Puckett et al., 2018; Xavier et al., 2013). Some TGD individuals also report difficulty getting routine medical care covered. For example, many transgender men report difficulty getting their insurance to cover gynecological care once they have legally changed their sex or gender marker on record because insurance companies do not cover gynecology for patients designated as male (Xavier et al., 2013).

Ongoing disagreement about best practices in medical and mental health services further complicates healthcare for TGD individuals and creates barriers to healthcare. Many healthcare providers advocate for the use of the World Professional Association for Transgender Health’s (WPATH), Standards of Care (SOC) recommendations as best practice. TGD individuals have historically reported that the SOC were restrictive and imposed barriers to accessing care (Lombardi, 2001; Puckett et al., 2018). A widespread critique that TGD people have had about the WPATH SOC is that they often resulted in providers, particularly mental health providers, acting as gatekeepers which can be a barrier to securing gender affirming care (Bockting et al., 2004; Lev, 2009; Mizock & Lundquist, 2016; Puckett et al., 2018). Many have also contended that, in the past, the WPATH SOC have also increased financial burdens by requiring letters from mental health professionals (Lev, 2009; Lombardi, 2001; Puckett et al., 2018; Schulz, 2018). In addition, many TGD individuals believe that the requirement of a mental health diagnosis related to gender dysphoria to access gender affirming care, which often may be the case with insurance companies, is stigmatizing (Bockting et al., 2004; Puckett et al., 2018; Schulz, 2018; Xavier et al., 2013). Hale (2007) also argues that removing the bodily autonomy of adults capable of providing informed consent may cause harm to TGD patients and violates medical ethics.

Importantly, the WPATH SOC were recently updated with the release of Version 8 of the SOC in 2022 (Version 7 was published in 2012) and this most recent version includes greater emphasis on autonomy for TGD people and attempts to remove some of these barriers (Coleman et al., 2022). For instance, the latest SOC call for education of all personnel working with TGD people at all stages of training and across the duration of their career, explicitly states that therapy is not a requirement for receiving gender affirming medical care, and emphasizes that a diagnosis is not needed to pursue gender affirming medical care. In addition, the updated guidelines more specifically addresses the importance of respecting individuals with nonbinary identities and suggests that, at most, only one letter of support be needed for any gender affirming medical care which can be provided by any healthcare providers who meets the suggested educational and licensing requirements (Coleman et al., 2022). Ultimately, providers will need to update their practices to be in line with these latest SOC, which can be an issue with some providers operating on outdated standards for some time even when these standards have been updated. Furthermore, there will need to be notable shifts with insurance company requirements in the U.S. to come in line with these latest SOC.

Implications of barriers to healthcare

TGD individuals often report fear, anxiety, and worry about stigma and discrimination in healthcare, often anticipating that they will be denied necessary medical care (Lambda Legal, 2010; Puckett et al., 2018). Experiences of harassment and discrimination by medical providers and fear and anxiety about the possibility of these experiences have detrimental effects for TGD people, such as delayed medical care (James et al., 2016). For example, in a large national survey of TGD individuals, Grant et al. (2011) found that 33% reported that they postponed preventative medical care due to fear of discrimination by providers and 28% continued to postpone care even when they were sick or injured due to fear of discrimination. These barriers are of great concern given that TGD people may not be able to access services that would improve their health and wellbeing, particularly in light of documented medical and mental health disparities (Brown & Jones, 2016; Downing & Przedworski, 2018).

Current study

Barriers to healthcare for TGD individuals are well-documented yet continue to persist. TGD individuals have difficulty finding providers knowledgeable about TGD healthcare, experience high rates of discrimination and minority stress within healthcare settings (Testa et al., 2015), and have difficulty accessing insurance and paying for healthcare services. Additionally, there is debate regarding best practices within medical and mental health fields, which further contributes to these barriers. Suggestions for improving the healthcare experiences of TGD individuals often come from people outside of the TGD community, which may overlook important needs within the community. The aim of this study was to supplement the existing literature with suggestions from TGD people on how to improve their healthcare experiences in the U.S.

Methods

This study entailed a branched enrollment into two separate sections of the overall project. Our main project was a daily diary study focused on the associations between minority stress, substance use, mental health, and sexual behaviors. The specific inclusion criteria for the daily diary portion of the study were: being between ages 16-40 years old, identifying as a trans man, trans woman, genderqueer, or nonbinary person, living in the U.S., having had sex in the past 30 days, and either binge drinking or using substances in the past 30 days. The eligibility requirements related to sex and drinking or substance use were included to ensure that our sample was engaged in activities that were the primary focus of the daily diary data collection efforts. Any participants who did not meet these criteria but who were at least 16 years old, TGD identified, and living in the U.S. were invited to participate in a one-time survey instead of the daily diary study and did not have to meet any requirements related to sex or drinking and substance use. The one-time survey was more broadly aimed at exploring minority stress, mental health, and coping. The findings presented here come from participants in both sections of the study and thus both are described here in more detail.

Participants in the daily diary study first completed a baseline questionnaire and then surveys daily for 56 days (i.e., 8 weeks). These daily surveys measured experiences of stress, mood, substance use, sexual behaviors, and other related constructs. At the end of the 8 weeks, participants completed a brief survey to follow up on some of the experiences reported at baseline. The one-time survey included questions about mental health, minority stress, coping, resilience, and related areas. Many of the specific measures varied across the daily diary and one-time survey but both completed the open-ended question about suggestions to improve healthcare (daily diary participants completed this at baseline).

Participants who completed at least 85% of the daily diary surveys were paid $50-60 (range reflects additional funding that was acquired after the study began) and those who completed less than this, but at least half of the days received $20. Participants in the one-time survey received $5 for completing the survey, except for the first 200 participants as funding was not available at that time. These participant payments were delivered via online gift cards. More details about each study are available in Puckett et al. (2020, 2021), including additional details about data screening, the involvement of a community advisory board, and data quality assurance. All procedures were approved by the institutional review boards of the primary investigator’s institutional affiliations. Participants provided consent to participate via the online survey, with a waiver of parental consent for those under 18.

When these studies began, we inquired about the barriers participants experienced in receiving gender affirming medical care. Given that these were open-ended text responses, we obtained enough data on this question before concluding the overall recruitment. These findings have been published in Puckett et al. (2018). This initial question was then replaced with a question about suggestions for improving healthcare services, which is the specific data we are reporting on in this current analysis. Responses to this question came from both the daily diary participants and individuals who took part in the one-time survey and thus more broadly represent TGD people’s experiences beyond the limited recruitment in each subsection.

Participants

Given that not all participants answered this specific question about suggestions for improving healthcare (either because they did not receive this question due to being asked about barriers to care instead or they chose not to respond), we report the demographics specifically for individuals who were included in this publication’s data analysis to more accurately reflect the sample. There were 112 participants from the daily diary sample and 308 participants from the one-time survey who responded to this item in the study (total N = 420). Participants in the daily diary study were on average 25.29 years old (SD = 5.56) and those in the one-time survey were on average 24.67 years old (SD = 7.96). Participants had a range of TGD gender identities, mostly identified as sexual minorities, and most participants were white (87.5% in the daily diary study and 76% in the one-time survey). Additional demographic information about participants is available in Table 1.

Table 1.

Sample demographics.

	Daily Diary Sample (N = 112)	One-Time Survey Sample (N = 308)	Total (N = 420)
Characteristic	N (%)	N (%)	N (%)
Gender Identity
Transgender Man	48 (42.9%)	69 (22.4%)	117 (27.9%)
Transgender Woman	15 (13.4%)	36 (11.7%)	51 (12.1%)
Genderqueer	14 (12.5%)	37 (12%)	51 (12.1%)
Nonbinary	35 (31.3%)	66 (21.4%)	101 (24%)
Agender	N/A	40 (13%)	40 (9.5%)
Androgyne	N/A	4 (1.3%)	4 (1%)
Woman	N/A	7 (2.3%)	7 (1.7%)
Man	N/A	17 (5.5%)	17 (4%)
Bigender	N/A	3 (1%)	3 (0.7%)
Not Listed	N/A	29 (9.4%)	29 (6.9%)
Sexual Orientation
Queer	55 (49.1%)	77 (25%)	132 (31.4%)
Pansexual	20 (17.9%)	55 (17.9%)	75 (17.9%)
Bisexual	21 (18.8%)	45 (14.6%)	66 (15.7%)
Gay	5 (4.5%)	30 (9.7%)	35 (8.3%)
Asexual	1 (0.9%)	48 (15.6%)	49 (11.7%)
Heterosexual	4 (3.6%)	14 (4.5%)	18 (4.3%)
Lesbian	4 (3.6%)	18 (5.8%)	22 (5.2%)
Not Listed	2 (1.8%)	21 (6.8%)	23 (5.5%)
Race/Ethnicity
White	98 (87.5%)	234 (76%)	332 (79%)
Black/African American	1 (0.9%)	5 (1.6%)	6 (1.4%)
American Indian or Alaska Native	1 (0.9%)	0	1 (0.2%)
Native Hawaiian/Other Pacific Islander	0	0	0
Asian	0	7 (2.3%)	7 (1.7%)
Latino/a	2 (1.8%)	13 (4.2%)	15 (3.6%)
Not Listed	3 (2.7%)	5 (1.6%)	8 (1.9%)
Multiracial/Multiethnic	7 (6.3%)	43 (14%)	50 (11.9%)
Missing Reponses	0	1 (0.3%)	1 (0.2%)
Education
Less than high school diploma	1 (0.9%)	41 (13.3%)	42 (10%)
High school graduate or equivalent	15 (13.4%)	38 (12.3%)	53 (12.6%)
Some college, but have not graduated	34 (30.4%)	97 (31.5%)	131 (31.2%)
Associates/technical school degree	6 (5.4%)	21 (6.8%)	27 (6.4%)
Bachelor’s degree	44 (39.3%)	68 (22.1%)	112 (26.7%)
Master’s degree	7 (6.3%)	38 (12.3%)	45 (10.7%)
Doctorate or professional degree	5 (4.5%)	5 (1.6%)	10 (2.4%)
Income
Less than $10,000	45 (40.2%)	163 (52.9%)	208 (49.5%)
$10-19,999	26 (23.2%)	44 (14.3%)	70 (16.7%)
$20-29,999	14 (12.5%)	34 (11%)	48 (11.4%)
$30-39,999	9 (8%)	23 (7.5%)	32 (7.6%)
$40-49,999	9 (8%)	15 (4.9%)	24 (5.7%)
$50-69,999	4 (3.6%)	11 (3.6%)	15 (3.6%)
$70-99,999	4 (3.6%)	13 (4.2%)	17 (4%)
Over $100,000	0	5 (1.6%)	5 (1.2%)
Missing	1 (0.9%)	0	1 (0.2%)

Note. Demographic questions about gender varied across the two sections of the study due to eligibility criteria. Thus, some of the response options were not available in the daily diary study, as noted by N/A (not applicable).

Measures

Demographics

Participants provided basic demographic information, including age, gender, sex assigned at birth, sexual orientation, race/ethnicity, income, and education. Table 1 includes the response options for these items.

Suggestions for care

Participants were asked the following question: “We were wondering if you have any recommendations for medical and mental health providers or staff to improve experiences of trans individuals within healthcare or mental health settings? If so, please describe your recommendations below.” This prompt was followed by a text response box where participants could enter their suggestions.

Analyses

SPSS was used to calculate descriptive information about demographic variables. A thematic analysis was conducted for the qualitative responses (Braun & Clark, 2006, 2022a, 2022b). As noted by Braun and Clarke (2022a, 2022b), there are a variety of approaches to thematic analysis (e.g., codebook thematic analysis and reflexive thematic analysis), making it important for researchers to clarify the specific steps taken in their work. We approached the data and analyses with an experiential orientation to prioritize participant voice and experiences. Our specific approach to thematic analysis involved a small group of coders with adjustments to facilitate team involvement, as follows: 1) We familiarized ourselves with the data by reviewing all data and creating notes about common experiences that were represented. Through collaboration and an iterative process, we developed a codebook with labels and definitions of each code. Although a codebook is not necessary for all types of thematic analysis, we used this to facilitate the involvement of multiple individuals at this stage of analysis. The codes tended to be descriptive in nature and we took an inductive approach to developing the codes. Following this, the second and third authors coded responses using Dedoose software for approximately 10% of the data. This coding was reviewed by the first author for consistency in the coding and to ensure that it aligned with the codebook. The codebook was refined throughout this process for greater clarity. These processes of using a codebook and reliability coding reflect a descriptive approach to the analyses. 2) The team then used the codebook to guide our coding of the data using Dedoose software. We reviewed the coding multiple times to ensure consistency throughout the coding. 3) This was followed by the initial generation of themes, which entailed examining the relationships between codes and how codes clustered together around a central concept or idea. 4) Next we reviewed the themes and continued to develop these by active reflection on the content within each theme and reviewing the themes in relation to the overall data. 5) We then further refined the themes, including naming and developing descriptive definitions of each theme. 6) Lastly, we produced written descriptions of the findings, including quotes to exemplify participants’ experiences.

Author positionality

All members of the research team had experience working with TGD communities. The lead researcher of the project who supervised the qualitative coding was a white clinical psychologist who identified as genderqueer/trans. The other two members of the coding team were also white and identified as a disabled queer nonbinary trans man and a nonbinary/trans person. We used memos throughout the coding process to note our interpretation of data and to reflect on how our own positionality may have influenced interpretation. We also met regularly to discuss coding, reflect on interpretations of the data, and to develop consistency in our approach.

Results

There were 420 participants who provided written responses about suggestions for how to improve healthcare for TGD people. These responses were grouped into 22 specific codes that were grouped into 6 broader themes (see Table 2). Here each theme is described and further information about the individual codes within the theme are noted in Table 2. Quotes are provided throughout to illustrate the findings.

Table 2.

Qualitative analyses findings and implications.

Themes, Codes, and Exemplar Quotes	Examples of Actionable Steps to Improve Care
Eliminate Cisnormativity (n = 110, 26.19%)
Recognize and Respond Appropriately to Cissexism and Heterosexism (e.g., “Implement pro-active policies to reduce harassment and demonstrate/build trustworthiness in medical settings. Ensure accountability for providers who mistreat patients and/or propagate harmful misconceptions.”)	Recognize when terms are offensive and refrain from using these Avoid intrusive questions Acknowledge biased behaviors from self or other staff and take steps to remedy these issues Become more educated about TGD communities to reduce future problematic behaviors Develop anti-discrimination policies for the setting Establish a safe method for patients to report mistreatment to an office administrator
Uncouple Gender from Bodies (e.g., “Have the medical stuff, [the info posters, etc.] stop making assumptions about what peoples bodies are like in regards to their gender. My planned parenthood uses my correct pronouns, but all of the ‘women’s health’ ‘women’s bodies’ ‘women on her period’ etc. stuff still makes me dysphoric.”)	Do not describe patients’ bodies as “male” or “female” Use medical terminology for organs rather than gendered terms Ask patients their preferred terminology for their body and use this terminology Ask about sex assigned at birth and gender on forms Consider using an “organ inventory” rather than assuming what type of care applies to a patient Name specific hormones (e.g., testosterone or estrogen) rather than gendering hormones (e.g., “male hormones”)
Individual and Holistic Approaches Improve Care (n = 134, 31.90%)
Recognize Nonbinary Identities as Legitimate (e.g., “Some of my doctors misgendered me and assumed I was a transgender man, so I would like all doctors, but especially those who focus on trans healthcare, to be more educated on nonbinary identities.”)	Treat all TGD people with respect, including people who are nonbinary Educate self about stereotypes related to gender-affirming medical care for nonbinary people
Use Neutral Language (e.g., “Also avoiding gender specific vocabulary (ie. Mr./Mrs., referring to reproductive organs as ‘lady parts,’ etc.”)	Ask about pronouns Default to neutral pronouns (they/them) rather than gendered terms when pronouns unknown Use neutral terms for honorifics Use medical terms or client preferred terms for anatomy or bodily functions Review medical forms and adapt language to be neutral instead of gendered (e.g., removing “he/she” language and other examples, like replacing “mother” and “father” in medical history sections with “parent 1” and “parent 2”)
Minimally Invasive Protocols (e.g., “Allow people who are dysphoric to cover themselves and take breaks as needed”)	Seek client consent prior to any physical contact Inquire about client comfort disrobing for medical examinations Minimize time disrobed for medical examinations Tailor the approach of a visit to client-specific needs
Reevaluate Underlying Conceptual Framework for TGD Healthcare (n = 69, 16.43%)
Remove Gatekeeping and Negative Influence of Standards (e.g., “I have been lucky to not have encountered any forms of gatekeeping where I need to ‘prove’ my transness but I have heard horror stories.”)	Use the most up to date version of the Standards of Care rather than relying on outdated expectations Remove gatekeeping practices that require TGD people to attend multiple sessions of evaluations or therapy prior to gender-affirming medical care
Informed Consent (e.g., “Work with informed consent. Requiring letters for these things provides significant barriers, and it’s not good.”)	Use an informed consent model to gender-affirming medical care
Reduce Accessibility Issues (n = 151, 35.95%)
Clearly Identify Practice as Trans-Affirming and Level of Training (e.g., “Begin by clarifying your standards of care [informed consent, whatever], remember that you have a huge amount of power over whether we get medication that we need to live, be sensitive about that.”)	Advertisements and provider descriptions should clearly name whether knowledgeable in TGD care Claims to competency should be backed by education and training rather than subjective opinions Clinic staff should be aware of whether the office provides TGD-affirming care and be prepared to discuss this with patients who inquire Utilize transparent descriptions about expectations related to gender-affirming medical care, such as whether a letter from a therapist is required
Elucidating and Dismantling Financial Barriers (e.g., “Do not require a therapists’ letter. It creates both economic and psychological barriers.”)	Make clear to patients early on the costs of procedures Accept health insurance Develop a sliding scale to reduce financial burden Reduce costs by not requiring a letter of support from a mental health provider prior to gender-affirming medical care
More Locations/Providers (e.g., “I live in a rural area so I have to travel three hours to the nearest clinic that has knowledge about transgender people. The travel time and associated costs have been the biggest barrier for me personally.”)	Train more providers in gender-affirming medical care Ensure that rural areas have affirming and knowledgeable providers Provide gender-affirming medical care at primary care providers’ offices
Provide Gender Neutral Restrooms (e.g., “make sure there are neutral bathrooms”)	Convert restrooms to be gender inclusive Make clear where gender-inclusive restrooms are located
Staff TGD People (e.g., “more trans people need to be working in these fields themselves.”)	Create employment opportunities for TGD people to join a practice or be on staff
Improving Interactions with Patients is Critical to Affirming Care (n = 231, 55.0%)
Affirming Language (e.g., “obviously using correct pronouns, if legal name doesn’t match real name then using real name [out loud and on paper] as much as possible”)	Inquire about affirming language and always use these terms Be transparent about when a legal name may be needed, such as for billing Record patient’s gender identity accurately in their medical record
Confidentiality and Privacy (e.g., “I was outed in his office waiting room twice -- even after calling in and discussing my name and pronouns”)	Ask patients what name and pronouns to use when communicating with others about their care to protect their privacy Ask youth if they would like to discuss their experiences without parents or guardians in the room Refrain from sharing information in unprofessional ways, such as gossiping about other TGD people
Focus on Immediate Medical Issues (e.g., “Do not turn something like an ER visit into a genital examination…”)	Do not shift attention inappropriately to a client’s gender when not relevant to their healthcare needs Do not equate being TGD with a mental illness
Special Regard for Trans Minors and Dependents (e.g., “have more professionals recognize and validate trans young people as being trans, like being a support instead of someone you have to be afraid of”)	Engage families who are unsupportive of TGD youth to support their learning and growth Advocate for TGD youth Respect and validate the gender identities of TGD youth
The Necessity of Improved Training  (n = 196, 46.67%)
Inclusion Training for Staff (e.g., “train your staff [even your receptionists] on trans 101 issues”)	Ensure that all staff are trained in creating an affirming healthcare environment, including front desk staff Provide training when onboarding and on an ongoing basis
Provide Information about being TGD, Resources, and Referrals (e.g., “Knowing of trans-friendly places to send clients who they themselves are not qualified to treat”)	Establish a resource list for the local area Become knowledgeable about referral options for patients when needed
Remove Burden of Education from Clients (e.g., “It get’s exhausting trying to explain my gender (or lack thereof) to professionals, particularly in mental health. I shouldn’t have to educate my therapist about my gender for them to be able to help me.”)	Be mindful of power dynamics and do not rely on patients to educate providers about TGD experiences Take initiative to seek out additional training on a continual basis
Standardization of Trans Health Education (e.g., “It’s hard to know where to even begin beyond just, like, ‘actually know things about trans lives and experiences’? There’s so much that’s just low-level to high-level shitty.”)	Make training about TGD healthcare a routine part of graduate and professional training Properly vet speakers to ensure that they can provide appropriate and affirming training

Note. TGD = transgender and gender diverse.

Eliminate cisnormativity

Cisnormativity describes the societal expectation and assumption that a person’s gender identity aligns with the sex they were assigned at birth. Cisnormative beliefs can lead to prejudice against TGD people who do not adhere to these expectations. It takes intentional effort for providers to pay attention to, witness, and make efforts to address cisnormativity given how pervasive and insidious these belief systems are. The examples participants provided of mistreatment within healthcare settings ranged from subtle to blatant bias, from assuming a TGD client’s pronouns to denying them care. For instance, sometimes these acts were likely a product of implicit biases (e.g., the suggestion of “Don’t stereotype”), whereas other times, participants noted that these acts were understood as deliberate. For instance, one participant reported:

My local hospital also has a preferred name system in place, and my preferred name is within my files. I’ve seen my files myself, my preferred name is the first name that shows up. I couldn’t even begin to tell you how many times nurses have overlooked the preferred name listed on my files and called me by my birth name. It’s a deliberate thing they do, considering the very first name that shows up is my preferred name

In many responses, cissexism led providers to question participants’ identities and their autonomy. Many participants had their gender criticized (e.g., “Do not say it is fake or … mental illness”) or treated as a joke (e.g., “Teach your staff not to laugh about us while on the work site. Many of us are not deaf and we can hear your staff in the hallway even with the examination room door closed”). Participants also reported that these types of beliefs led to them being denied care, such as this participant’s experience: “I had horrible experiences with multiple doctors trying to prevent me from accessing care because they don’t support trans rights.” An extreme example of how these biases influenced care was through providers assuming they had the right to be invasive or even to assault their patients, such as this participant’s experience:

Unfortunately, it is also vitally important for providers and staff to be well-educated about issues of sexual consent. I later found out that at least one other doctor at that clinic was known among trans women for sexually assaulting them, coercing them because he held their futures in their hands. The woman who told me this had experienced this herself, and had tried to report him, only to find that other providers and staff at the clinic closed ranks around him.

Participants also recognized that the space or setting influenced their experiences of cisnormativity. For instance, a participant talked about being in gender segregated spaces: “I occasionally go in-patient at mental health facilities, and there have been instances where I have been bunked with females. It doesn’t happen often, and it has not happened since I started testosterone, but it has happened since I’ve been out as trans.” Providers in these types of settings may need to work with clients to identify in which gendered space they feel the most comfortable and to address the mistreatment of TGD people within such spaces. These gendered spaces may be especially marginalizing for nonbinary TGD people. Gynecological care was also commonly mentioned as a gendered space.

In the face of these experiences of bias and cisnormativity within healthcare settings, participants suggested that providers must learn to recognize when cisnormativity is playing a role in their care and actively take steps to reduce these prejudices. As one participant said, “if you are uncomfortable around gender-nonconforming folks or people who are not straight, then please fix that. Go to P-FLAG, go to therapy, talk to other docs who are not straight\non-gender conforming…” Participants also recognized that providers’ investments in making such changes may vary and encouraged policy and procedure level changes to help ensure better care. An essential part of changing structures to reduce harassment is, as one participant suggested, “making sure that trans folks are able to communicate if they’re being harassed/discriminated against.” Having a system for reporting mistreatment helps to protect TGD clients and provides a mechanism to reinforce anti-discrimination policies.

Many participants’ suggestions also strongly emphasized disentangling gender from one’s sex assigned at birth or from their body. Describing participants’ bodies as male or female was a source of dysphoria. Several participants recommended referring to reproductive organs by medical terminology rather than gendered colloquialisms. Participants noted the assumptions made when using terms like “women’s health” or “lady parts” and stressed that not all women have the reproductive organs associated with these terms, nor do all people with these reproductive organs identify as women. To address this, participants encouraged use of medical terminology for bodily processes (e.g., “‘feminine hygiene’ is significantly less comfortable than ‘menstrual hygiene’ for many trans folks.”). Likewise, participants suggested using medical terminology for hormones rather than gendering them as “female” hormones for instance. Participants also indicated that practitioners should ask clients how they would like to talk about their anatomy. Providers can also decouple gender and bodies in their paperwork, such as providing options for both sex assigned at birth and gender or via an “organ inventory” instead of asking about solely a person’s sex assigned at birth. Allowing TGD people to indicate the type of care that specifically applies to them eliminates the need to rely on cisnormative assumptions.

Individual and holistic approaches improve care

Many participants’ suggestions aligned with an individual and holistic approach to TGD healthcare. This includes recognition of possible concurrent and/or chronic health conditions and refraining from using the existence of these conditions as a justification to deny care when unwarranted, such as the experience of the following participant: “I do have a strong and probably justified [if the horror stories I’ve heard are true] fear that my autism diagnosis will prevent me from accessing any sort of gender-affirming care, more so because I’m nonbinary.” This approach also includes believing clients, acknowledging their autonomy and lived experiences, and recognizing that clients are the experts on their lives and experiences.

The approach providers take should emphasize respect for nonbinary people and their identities, particularly concerning TGD-specific healthcare. Some providers refuse to treat TGD people who do not meet the providers’ strict and arbitrary conceptions of how TGD individuals “should” feel, look, and act in order to merit access to gender affirming care. Because nonbinary identities do not fit exactly into either binary gender, many providers deny nonbinary people care and label their identities illegitimate. This participant’s quote exemplified this sentiment:

Education on nonbinary identity is vital to ensure quality of care. many providers are only aware of binary trans people and will not treat patients who do not rigidly conform to binary gender roles “opposite” to their assigned sex. this is harmful to all trans people, as these standards are unrealistic and forces patients to lie or put on an act in order to receive care. nonbinary people are frequently thought by providers to not be “dedicated” enough to the process because of their refusal to conform to binary gender roles, or to be fakers. this must change.

To facilitate taking an individual approach to care, providers can use neutral language if they have not been informed by the patient what types of terms they would like them to use, which communicates an openness to a diverse range of identities and gender experiences. Use of neutral language applies to pronouns, honorifics, terms for one’s body, bodily functions, and so forth.

Participants also emphasized that inclusive care meant that their personal boundaries were respected and they suggested that providers require only consensual and necessary physical contact, examination, and disrobing. Physical contact and disrobing can cause severe discomfort for many TGD individuals, especially those who experience dysphoria. As such, weighing the necessity of disrobing and physical contact against the issues it may cause for the client can be helpful, as well as communicating details about the procedures at hand. One participant summarized, “Don’t make someone fully undress and get into a gown if you just need to take their pulse and make them say ah. Only make people undress as far as is strictly necessary.” Awareness of clients’ needs and gender identities can be especially significant during invasive medical examinations, such as gynecological care. Taking a tailored, individual approach to healthcare rather than expecting a uniform protocol for all office visits empowers TGD people to make health decisions that honor their needs and autonomy.

Reevaluate underlying conceptual framework for TGD healthcare

Participants commented on the restrictive frameworks that often guide approaches to TGD healthcare. These frameworks often emphasized provider presumption of knowledge and the questioning of TGD people’s ability to make their own choices regarding gender affirming healthcare. These responses emphasized removing gatekeeping practices commonplace in the field and shifting toward an informed consent model of care.

In TGD healthcare, gatekeeping is the process by which TGD clients are limited in or prevented from getting access to gender affirming care. This denial of care sometimes occurs because they do not fit outdated and/or misinformed narratives about what it means to be TGD. Some participants commented explicitly on the outdated expectation that clients must have a specific amount of “real-life experience” in their affirmed gender to access gender affirming surgeries (a product of past versions of the SOC). As one participant said, “Do not require trans people to follow outdated guidelines–for example, don’t require them to have months or years of real-life experience before they can access medical transition.”

In addition, participants commented about experiences where providers asked questions in interrogating ways that left them feeling they had to “prove” their gender to the provider to receive a letter of support from a therapist or to receive care from medical providers more broadly. These were a few experiences noted as barriers to care: misconceptions about gender, outdated narratives that emphasized identifying as trans from an early age, and requiring extensive numbers of sessions before being willing to provide a letter of support to clients. This participant’s experience was typical of others:

The requirements for gender-affirming surgery are hard to come by, especially if they require something like a therapist’s letter that requires the therapist to have known you for a given amount of time. If I’m not seeing a therapist for any other reason, why would I go to one for [an] extended period of time and use money just to “prove” to you that I’m transgender? I can understand meeting with the same therapist twice, and having it affirmed by another in one visit, but expecting to have consistent “evidence” of being transgender “enough” for surgery or hormones is ridiculous and impractical.

Participants suggested using an informed consent model in providing care. Participants emphasized that not following this approach created undue stress and imposed barriers, such as the amount of time and money spent on therapy prior to accessing medical care. Participants felt that the informed consent approach better respected TGD people’s autonomy and decision making. As one participant put it:

I am an advocate for the concept of Informed Consent Clinics which can offer same day prescription of hormones. The psychological evaluation currently required to begin hormone replacement therapy takes anywhere from twelve weeks to several years, based on nothing other than the whims of the counselor. It shouldn’t take more than an hour.

Reduce accessibility issues

This theme included all barriers to care which can be improved to make the process of obtaining care more accessible and safer for TGD individuals. These suggestions ranged from issues with locating providers to addressing accessibility at the providers’ practices, such as inclusive restroom access. To start, participants desired for providers to acknowledge being TGD affirming via their online presence, clinic signs, available literature, brochures, and other methods. However, the availability of such information is only helpful if it is accurate. One participant lamented, “I wish mental health providers would only say [they] specialize in gender therapy if they really do and not because they’ve seen one transgender person one time.” Providers who, for the sake of appearing inclusive, claim TGD-competence but do not live out such practices often do more harm than good. This behavior often results in patients feeling misled and forces them to spend more time without care before finding a provider who is informed and knowledgeable about their needs (e.g., “I had to see a plethora of ‘LGBT friendly’ counselors before finding one who actually knew how to help me obtain gender related care”). Providers should also be transparent about their expectations related to psychological evaluations for gender-affirming medical care. Multiple participants reported reliance on word of mouth to discover affirming providers given that otherwise they may be shuffled from one ill-suited provider to the next, experiencing discrimination and wasting time and money.

The cost of healthcare is also a significant barrier for TGD populations. Participants suggested that providers make healthcare costs clear and work to reduce financial barriers such as out-of-pocket expenses and high insurance deductibles. As one participant said,

When it came to insurance coverage I am still unsure if my insurance will cover any future procedures I will have in the future, so clearly stating if they do or do not. For medical procedures I was never shown or told the amount these expenses are so being clearer on the price would help.

Some participants reported difficulty paying for their insurance due to high deductibles and the fact that the majority of medical services necessary for many TGD people are classified as “elective” or specialized or were otherwise excluded from coverage. Many also explained that it was difficult to find providers covered by their insurance and suggested that insurance companies provide incentives for providers to take insurance. Some participants suggested implementing flexible payment options or a sliding scale. Many participants also viewed the requirement of a therapist’s letter as an unnecessary economic barrier.

To further reduce accessibility issues, participants suggested increasing the number and diversity of locations where TGD people may access TGD healthcare, including general practitioner offices. Several participants reported having to travel long distances to receive appropriate healthcare services due to a lack of providers in their areas, especially in rural locations. This participant’s experience highlighted some challenges and suggestions in this area: “I was able to get some care through my primary care provider, which was great because the waiting lists for trans specific care in my area were 10 months. So if more PCPs would be comfortable discussing it with patients that would be helpful.”

Having access to a restroom is a basic need when receiving services at a provider’s office. When providers do not have gender inclusive restrooms, this poses a barrier to TGD people receiving services. If there are single stall restrooms, these can be converted to ungendered spaces (e.g., “…there were only women’s restrooms…and really they were single-person so there was no reason not to make them all-gender”). According to participants, when there are multi-stall restrooms, this should also be addressed by either making these inclusive or providing access to a single stall restroom that is not gendered.

Finally, given that most providers are cisgender, participants also suggested that offices employ TGD providers and staff. One participant also called for “more trans people involved in leadership within health centers and trans health departments.” Having TGD individuals on staff may help to identify shortcomings or ways to improve the practice before TGD patients have marginalizing experiences. Seeing a provider or staff member who shares their identity may also allow clients to feel more comfortable.

Improving interactions with patients is critical to affirming care

Some of the suggestions participants provided explicitly revolved around interactions between themselves and providers. Participants suggested that providers ask for and reliably use affirming language, including gender terms, honorifics, pronouns, name, terminology for body parts and functions, and so forth. Inquiring about this language can be done via conversation with patients, intake forms or a standard questionnaire in routine care. When providers use affirming language, this ensures experiences that are more positive and builds trust with providers. As one participant said, “Healthcare providers and staff need to be aware of gender pronouns and the need to be respectful of other people’s pronouns. Misgendering someone does not foster trust or create an environment where trans people want to seek care.”

Participants also suggested that providers record TGD people’s gender accurately rather than simply recording their assumed sex or their assigned sex at birth. Accurately recording a person’s gender is affirming and also prevents dangerous medical consequences. As one participant stated,

Don’t start listing me as female in records once you know I am trans. I have already changed my gender markers and have been on hormones for years. It would be much more sensible to ask me what procedures I’ve had and not had, and record my pronouns. If you record me as female in my records, you are putting me at risk as my hormone levels are not female-standard…. Sex hormones have tremendous effects throughout the whole human body, and listing me as female implies things about my physiology that are not true and would put me in physical danger

Other suggestions included the need to be sensitive around situations in which legal name or one’s sex assigned at birth must be used, such as billing.

Participants expressed a need for privacy in situations where people may be present who do not need to know their TGD identity, such as waiting rooms or during phone conversations (e.g., “being sensitive to what names and information is revealed in less private ways like voicemail [might be the home phone]”). Participants also noted a need for “decline to say” options on intake forms regarding questions about sex assignment and gender. The safety of TGD dependents and minors was also noted as a privacy concern: “Ask them if they would like to talk to you separately from their parent/guardian and if they have anything they would like to notify you of, and don’t judge them.” Providers should also be mindful about sharing private medical information about other patients, such as in this scenario: “Case in point: for my revision my anesthesiologist made ‘small talk’ with me immediately before surgery by asking me if I ‘had it all done’ (i.e. bottom surgery) and recounting another transman’s surgery to me. So unprofessional!”

Interactions with providers can also be improved by focusing on relevant medical issues rather than focusing inappropriately on a patient’s gender (e.g., “If I come in for something unrelated to my genitalia, it is none of the doctor’s business what type of genitalia I have”). Furthermore, providers should not conflate concurrent or chronic conditions with a patient’s gender (e.g., “My doctor saw that I was transgender and assumed that my symptoms of psychosis were a byproduct of my gender identity.”) and should not blame an unrelated medical issue on a client’s TGD identity (e.g., “To understand that not every medical condition is due to being trans”). A client’s TGD identity is irrelevant to many healthcare needs and should not be treated as a medical issue or mental disorder. Symptoms should not be automatically assumed to be due to hormone therapy or dysphoria, like this participant suggested: “Honestly, that should only be important to know if there’s a medical problem that involves hormones in some way. Stop blaming all symptoms on dysphoria/hormones.”

Lastly, before reaching age 18, many dependents are unable to access care without parental approval. Participants expressed the need for parents and providers to believe TGD minors and dependents when they express their identities rather than dismissing and invalidating their lived experiences due to their status as a minor or dependent. Also, guardians often lack knowledge surrounding TGD issues. To remedy this, it was suggested that providers “talk to the family of the individual… Family tends to listen to people who are certified professionals, so I think that hearing an explanation from them can help them understand a lot and it’ll help them come to terms.” Given this suggestion, providers should try to educate and engage with the families of TGD minors or dependents, given their consent. Family rejection of a TGD minor or dependent ultimately often results in necessary medical care being inaccessible. This causes harm and should not be accepted unchallenged by providers committed to improving access to TGD-affirming healthcare.

The necessity of improved training

A few suggestions centered on training needs that can decrease barriers and increase affirmation of TGD people within medical contexts. Notably, all individuals within a given practice should receive training in how to be affirming given that patients interact with many people throughout a visit. Non-provider staff, such as receptionists, are often the first staff members a person meets when entering a clinic; thus, they set the tone for the entire clinic. If staff engage in microaggressions, patients may expect the providers will be uneducated as well. As one participant stated, there are

numerous reports of bad experiences with intake staff, even where the physicians or other healthcare providers are affirming. This includes rude treatment, refusal to process insurance paperwork, misgendering, and outing persons as trans to others in sometimes crowded waiting rooms. Providers need to be aware of the impact their front desk staff have on patients, and hold them accountable to mistreatment.

It also is helpful when providers take the initiative to pursue education and improve their own knowledge about resources. Participants expressed that it would be helpful for providers to create and maintain an updated list of trained and affirming providers for referral purposes (e.g., “I would ask that healthcare providers have a list of local resources for receiving trans-specific healthcare”). Another suggestion was for providers to develop outreach programs for community education on TGD identities; this could be particularly helpful for younger people:

I would like to see more outreach programs to help younger people know that there is such a thing as being transgender and have people that they can talk to about possibly being transgender, be it volunteers or professionals or, preferably, even both.

TGD clients should never be burdened with educating providers. As one participant stated, “There really has to be more education for medical health professionals - I’ve had to teach every one of my doctors about even the most basic realities of being GNC [gender non-conforming], which isn’t how it should be.” Some participants expressed feeling like test cases for inexperienced providers (e.g., “physicians that view us as the token patient to treat as a guinea pig. I apologize for the bluntness of my previous statement, but we are not your test subjects”). Because education about affirming care is relatively absent from medical and mental health training, providers will need to take the initiative to develop this competency.

It also is critical that education about TGD-specific healthcare be standardized and become a routine part of graduate level and professional training. One participant expressed, “I feel so much like an intrepid explorer entering a medical setting. Never know what to expect. From affirmation to being misgendered to complete lack of knowledge of gender dysphoria in a medical setting.” Many participants called for “adequate training and education to all healthcare/mental health professionals starting in medical/graduate school and continuing in the workplace.” In addition, when providers are inviting trainers, they should be appropriately screened to ensure that the education is affirming. Some participants mentioned the experience of educators being perceived as knowledgeable when they actually perpetuated problematic or outdated understandings of TGD people (e.g., “make sure ‘experts’ in healthcare for trans persons are actually knowledgeable. One ‘expert’ who I agreed to let present at a healthcare workshop, recommended by persons with whom we had done training in trans-affirming healthcare, was not properly vetted.”).

Integration of findings

Figure 1 provides an overview of the study findings. Participants’ responses emphasized the shortcomings of the healthcare system and the flaws of the care they received. This inadequate care represents the status quo in most of the U.S. healthcare system. Many participants felt that healthcare settings and the broader field enforced cisnormative beliefs about gender and stereotypes about TGD people that resulted in compromised care and mistreatment. The status quo relies on an enforcement of a top-down power hierarchy in which TGD people’s needs are minimized, dismissed, and pathologized. In order to transform care to center the needs of TGD people, there are a variety of actionable steps that providers can take—such as reducing barriers to care, developing accountability systems, and standardizing routine education about TGD-inclusive healthcare. Through such changes, healthcare can become TGD-inclusive and the relationship to power can shift to fostering an awareness of power, privilege, and oppression while empowering TGD people in their care. When healthcare is TGD-inclusive and affirming, there are shifts in the individual interactions of providers, as well as the setting and broader field that communicate respect for TGD identities and autonomy.

Figure 1.

Transforming care to be TGD-inclusive and affirming.

Discussion

Significant strides must be made in healthcare to improve the experiences of TGD individuals in the U.S. and to work toward cultural humility (Tervalon & Murray-García, 1998). Participants highlighted the need to eliminate the cisnormative assumptions that permeate healthcare, including correcting cissexist and heterosexist beliefs. This study found that an essential part of working with TGD clients is listening to their input and concerns. TGD individuals reported that, when seeking care unrelated to their gender identity, providers tend to have an exaggerated focus on their gender instead of the problem at hand (Sperber et al., 2005; Xavier et al., 2013). This experience, which is commonly referred to as “trans broken arm syndrome” within TGD communities (Dietz & Halem, 2016; Payton, 2015), highlights the deterministic view of TGD individuals that some medical health professionals may hold. Rather than affirming the experiences of TGD clients, this approach can alienate TGD individuals and make them feel that their concerns are not being addressed or heard.

This study also found that healthcare settings should use individual and holistic approaches that understand that gender affirming care will look different for each individual. Our participants emphasized that healthcare settings need to radically amend how they approach TGD healthcare, specifically pivoting to an informed consent model and dismantling the system of medical gatekeeping. Providers also need to clearly indicate if they are affirming and be transparent about their education and preparation for working with TGD clients. In a survey of websites of providers that purported to be TGD-affirming, Holt et al. (2021) found that only 36% listed any TGD specific resources for clients, 53.5% employed affirming terminology, 32.1% gave clients the option to provide their affirmed name, and 18.4% gave clients the option to provide their pronouns. This finding highlights not only the importance of ensuring that providers are affirming in more than name, but also the difficulties TGD individuals face in finding supportive healthcare. Consistent with Meyer et al. (2020), providers should be transparent about the steps and timeline for gender-affirming services at their practice, use inclusive language on forms, and ensure that staff interacting with TGD patients are aware of and respectful of their identities.

Furthermore, affirming care needs to be more accessible and the individual interactions with providers and staff need improvement. Participants reflected on the importance of increasing the number of affirming providers and care agencies, which aligns with the difficulty TGD individuals currently have in accessing care (Puckett et al., 2018; Sanchez et al., 2009; Xavier et al., 2013). Consistent with other literature, our study also found financial barriers to healthcare for TGD people (Grant et al., 2011; James et al., 2016; Xavier et al., 2013). Furthermore, acquiring letters of support for gender affirming medical care is a financially costly endeavor, especially considering that many TGD individuals already struggle to cover the costs of their medical care (Lev, 2009; Lombardi, 2001; Puckett et al., 2018). Therefore, medical professionals must be transparent with their patients about their procedures for acquiring letters, and add as little additional financial burden as possible, including offering information about the time and steps required for gender affirming care upfront so that patients can make informed decisions about their care (Meyer et al., 2020). In addition, the current model of requiring TGD individuals to obtain a letter from a mental health provider to receive gender affirming medical care not only reinforces medical gatekeeping and denies individuals agency to define their own gender experiences, but places additional financial burdens on TGD clients wishing to obtain medical gender affirmation procedures (Nordmarken & Kelly, 2014).

Finally, participants identified several areas of improvement in terms of training. Healthcare providers frequently lack knowledge about TGD identities and TGD-affirming healthcare (Lurie, 2005; Puckett et al., 2018; Snelgrove et al., 2012), and this can negatively influence rapport (Poteat et al., 2013). Often providers attempt to rectify this lack of knowledge by turning to their patients for education (Grant et al., 2011; Mizock & Lundquist, 2016). Addressing this knowledge gap involves not only mandating and providing training on working with TGD individuals, but also addressing stigma against TGD individuals within the institution of medicine, as this stigma contributes to ignorance and misinformation about TGD individuals and their health needs (Poteat et al., 2013).

Overall, these findings can serve as a guide for professionals in the field (Table 2 includes a variety of specific steps providers can take to improve their practice). Perhaps the most notable finding across these suggestions is the importance of listening to TGD individuals. Many of the suggestions put forward in this study center on respecting the experience and knowledge of TGD clients, and the understanding that while providers may have expertise in their clinical specialty, they need to honor their client’s expertise in their own identity and lived experiences. Providers need to defer to clients’ emphases on the importance, or lack thereof, of their gender identity in relation to their presenting problems. However, providers should be careful to not burden their clients to educate them about the basics of TGD-inclusive care. As healthcare providers, the onus to provide care falls on them, rather than the client. Asking the client to provide the emotional labor of educating the provider is in direct conflict with that aim. Finally, providers can be proactive in assessing how inclusive their practice is for TGD individuals, rather than responding to client complaints or concerns afterwards. By examining procedures, practices, and accommodations and how they may act as barriers to care or stressors for TGD individuals, providers can help prevent clients from experiencing additional stress and create an affirming environment.

These findings are particularly important in light of the legislative efforts in the U.S. that seek to restrict access to gender-affirming healthcare, particularly for youth, and that seek to criminalize this care. For instance, according to the Movement Advancement Project (2021), over half of the states in the U.S. have considered banning gender-affirming medical care for TGD youth specifically. These efforts have intensified with some states even considering making it a felony for medical providers to offer gender-affirming healthcare for youth. There are many steps needed to improve TGD healthcare and we must also consider the broader sociopolitical context that may influence whether TGD people have access to this care. It is imperative that these legislative efforts be challenged as access to gender-affirming care is critical to the health and wellbeing of TGD communities.

Limitations

This study has several limitations that are important to consider. The sample was predominantly white (79%), possibly due to the online method of recruitment. Because the sample consists mainly of white participants, it does not adequately account for the experiences of TGD people of color, who may relate to the healthcare system with additional and differing barriers due to intersecting minority stressors. Because this study relied on responses to open-ended questions, participants were not asked to expand further about how their race or ethnicity may have impacted their experiences or suggestions. As such, this study is unable to elaborate on this area. Similarly, the age of the sample (M = 25) limits the study in terms of representation of other age demographics. Furthermore, the sample was specific to individuals in the U.S. Healthcare experiences can vary substantially across countries in terms of access and expectations for care. Given this, our findings should be viewed in light of the geographical location of participants and may not apply to all healthcare settings in all countries. In addition, we did not examine whether the source of participants, specifically whether they participated in the daily diary study or the one-time survey, influenced their responses. Anecdotally, reviewing a selection of responses across these sources, we did not find notable variations and expect that the source of data collection did not meaningfully influence responses to this particular question.

Conclusion

The study expands upon past research concerning barriers to care, adding pertinent recommendations for action. These suggestions included eliminating cisnormativity, maintaining a holistic approach, adjusting conceptual frameworks for TGD care, eliminating accessibility barriers, improving interactions between providers/clinics and clients, and training related issues. These findings reveal some of the steps needed to address documented inadequacies in TGD care, aiding the development of affirming and knowledgeable providers. Implementing these suggestions could lead to an increase in the availability and quality of TGD care, benefitting the overall health of TGD populations.

Author note

Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number F32DA038557 (Puckett). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

We thank the members of the Trans Health Community Advisory Board in Chicago who assisted with this project for their time, feedback, and dedicated involvement. We also would like to thank the participants who took part in this research for their time and effort.

Declaration of conflicting interests

The authors declare that there is no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Funding

Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number F32DA038557 (Puckett).