Navigating access to medical gender affirmation in Tasmania, Australia: an exploratory study

Abstract

Background: Gender affirmation through hormone replacement therapies and surgery can significantly improve the health and wellbeing of some transgender, nonbinary, and gender diverse people. Despite the well-documented benefits of gender affirming care, barriers persist for many trans and gender diverse people, particularly those in rural areas.

Aims: This exploratory study aimed to identify the barriers trans and gender diverse people faced when seeking to medically affirm their gender in the rural state of Tasmania, Australia.

Methods: This article draws on qualitative data from a mixed-methods online survey of 84 trans and gender diverse Tasmanians aged 18-70.

Results: Participants identified financial and geographical barriers, discrimination, and medical gatekeeping as the three key factors that prevented or delayed their gender affirmation.

Conclusion: Costly services that require multiple referrals to access limit trans and gender diverse patients’ options, impacting their mental health and wellbeing. Gender affirmation on the basis of informed consent would reduce unnecessary medical gatekeeping and improve trans and gender diverse health and wellbeing.

Introduction

Transgender (hereafter ‘trans’) and gender diverse people continue to experience significant stigma, discrimination, harassment, and violence, leading to high rates of psychological distress and suicidality (Hill et al., 2023). In Australia, despite universal public health care and anti-discrimination laws at the State and Federal level, trans people face high levels of discrimination and are significantly more likely than the general population to experience mental ill-health (Zwickl et al., 2021, p 82). Due in part to prevailing cisnormativity, or the assumption that it is normal to be cisgender (Worthen, 2016), some trans and gender diverse people may experience gender dysphoria. Gender dysphoria refers to acute physical and emotional distress related to the incongruence between one’s gender identity and sex assigned at birth (Atkinson & Russell, 2015). Affirming one’s gender, socially (e.g. changing names and pronouns, clothes, or hairstyle), legally (e.g. gender/sex and/or name change on official documents), and, for some, medically (e.g. hormone therapies, surgeries), has been shown to reduce gender dysphoria and improve mental health and wellbeing for trans people of all ages (De Vries et al., 2014; Gorin-Lazard et al., 2012; Russell et al., 2018). However, it is important to note that not all trans and gender diverse people experience distress or dysphoria, and not all seek medical intervention on the basis of their gender identity. Some trans people have highlighted the importance of shifting the focus toward gender euphoria: the positive feelings related to aspects of one’s gender presentation aligning with one’s gender identity (Beischel et al., 2022).

Navigating access to gender affirming care poses challenges, yet trans and gender diverse people have long developed strategies to overcome these barriers (Bartholomaeus et al., 2021; Pullen Sansfaçon et al., 2023). Medicine has systematically marginalized trans and gender diverse people through pathologising diagnoses, dehumanizing treatment, and complex referral processes that seek to reduce trans agency and complexity (Spade, 2003). Because trans healthcare has largely focussed on the treatment of gender dysphoria, medicine and psychology, in particular, have prioritized certain narratives of trans experience that emphasize and necessitate suffering before gender affirming treatments are provided (Garrison, 2018; Latham, 2017). Thus, trans experiences have been commonly framed around being ‘born in the wrong body,’ with medical intervention necessary to ‘fix’ or ‘realign’ trans people (Engdahl, 2014; Stryker, 1994). In this cisnormative context, experiences of discrimination, inappropriate questioning, and refusal of care, remain common for many trans and gender diverse people in Australia and elsewhere (Lett et al., 2022). Such instances of discrimination within health services underscore the need for improved cultural competence. Despite gaps in medical training leading to issues like offensive language and insufficient knowledge (Bretherton et al., 2021; Loo et al., 2021), the trans community’s resilience is evident as they navigate and persist within an imperfect system. For example, trans and gender diverse people often take an active role in educating healthcare providers, drawing on their own lived experience to guide innovation in treatment (Shepherd & Hanckel, 2021).

While there is a growing body of work exploring trans and gender diverse health and access to gender affirming care in Australia, less is known about access to and experiences of medical gender affirmation in regional and rural settings. Internationally, research indicates that trans and gender diverse people living in rural areas face high rates of stigma and discrimination, resulting in poor mental health, suicidality, increased substance use, and social isolation (Horvath et al., 2014; Johnson et al., 2020; Knutson et al., 2018). In addition to the well-documented dearth of health services in many rural areas, rural trans and gender diverse people may have limited options for trans-inclusive healthcare, reducing their ability to access medical gender affirmation locally (Renner et al., 2021). Previous Australian research has acknowledged that geographical location can act as a barrier to gender affirmation for rural and remote trans and gender diverse Australians, who may have to travel long distances to capital cities or interstate to access health services (Heng et al., 2019; Soh et al., 2022). In contrast, emerging trans mobilities scholarship highlights rural trans and gender diverse people’s dynamic agency and health entrepreneurialism through travel to access gender affirmation and social support (Aizura, 2018; Kerry, 2017). Much of this previous research on rural Australia is situated in the context of northern Australia, yet it is important to consider how rural spaces are complex and specific and the nuanced impacts this can have on healthcare access. In particular, the southern island state of Tasmania presents a very different version of rural Australia to that of previous work, making it a pertinent site to study trans and gender diverse health in that context.

Located off the southeast coast of the Australian mainland, Tasmania is a largely rural island with a population of 557,571 people (Australian Bureau of Statistics, 2022). Hobart is the capital city and most populous (pop. 247,086), located to the south (Australian Bureau of Statistics, 2022). Tasmania exhibits some of the nation’s lowest average incomes, poorest educational levels, highest unemployment and welfare dependency, and reduced health outcomes (Australian Bureau of Statistics, 2022). In addition, Tasmania was the last state to decriminalize homosexuality in 1997, prior to which, it had some of the nation’s harshest anti-gay and anti-cross dressing laws (Grant, 2021). Despite this history, over the last three decades Tasmania has led the way in Australian LGBTIQ law reform, becoming the first state to officially recognize same-gender relationships, to legalize same-gender parent adoption, and to introduce marriage equality legislation to parliament. In April 2019, the Tasmanian Government became the first in Australia to pass landmark reforms supporting trans and gender diverse people, voting to remove gender from birth certificates (Delaney, 2019). Yet LGBTIQ health outcomes remain poor in Tasmania, due to continuing discrimination, decreased LGBTIQ visibility, and limited access to LGBTIQ-inclusive services (Grant, 2021; Grant et al., 2020). Previous research has also found that Tasmanian health practitioners may have limited awareness of the gender affirmation needs of trans and gender diverse patients, reducing the availability and quality of care (Grant et al., 2021). While there is a growing body of research exploring LGBTIQ health and healthcare provision in Tasmania, to date no studies have focussed on trans and gender diverse people’s experiences of gender affirmation in the state. To address this gap in research, in this article we draw on qualitative data from a mixed-methods survey of trans and gender diverse Tasmanians to explore their experiences of accessing Tasmanian health services for medical gender affirmation.

Methods

Design

This project was conducted in 2022 on the lands of the muwinina and palawa peoples in lutruwita/Tasmania. This article draws on findings from a mixed methods survey administered to a convenience sample of 84 trans and gender diverse people aged 18 and over from Tasmania, Australia. The survey included questions about participants’ demographic details (age, gender, sexuality, ethnicity, income, geographic location), mental health (stress, life satisfaction), types and locations of services accessed, wait times, satisfaction with services, feelings of comfort when accessing services, and perceived level of respect from service providers. Questions included both established (e.g. Diener et al., 1985; Lovibond & Lovibond, 1995; Smith & Gray, 2009) and original measures. The study received approval from the [removed for peer review]’s Social Sciences Human Research Ethics Committee.

This article reports only on the qualitative data collected in response to the following original open-ended questions at the end of the survey:

1. What could Tasmanian services keep doing or start doing to improve gender affirming care?

2. What could Tasmanian services stop doing to improve their gender affirming care?

Participant recruitment

Participants were recruited for this study primarily through targeted social media advertising, with support of key LGBTIQ community organizations and private Facebook groups for trans and gender diverse communities in Tasmania. Physical flyers with a QR code linking to the survey were also distributed in health centers and community venues. The project was first advertised at the start of May 2022 and closed in August 2022, following a third round of advertising.

Eligibility criteria to complete the survey were: current residents of Tasmania; aged 18 years or older; identifying as trans, nonbinary, or otherwise gender diverse; having accessed or tried to access gender affirming care in Tasmania in the past 5 years. A total of 89 participants consented to participate and were eligible. Of this number, 84 began the main survey questions that followed the demographic items. Seven of these participants reported not receiving any type of gender affirming treatment in Tasmania in the past 5 years and provided data on why treatment was not accessed.

Analysis

Following data collection, qualitative responses to open-ended questions were analyzed thematically using QSR NVivo by Author 1 first by open coding or surface reading responses, taking note of any striking words or phrases arising from the data using the NVivo’s annotate function. Once common themes were identified, thematic categories, or nodes, were created in NVivo and relevant data were coded to those nodes. Authors 2 and 3 conducted additional analyses and provided critical feedback on the initial interpretation of the data. Key themes identified included the following experiences of accessing gender affirmation: (1) Navigating financial and geographical challenges, (2) Attitudes of Health Professionals, (3) Medical gatekeeping.

Results

Participants

Of the total sample of 84 participants, 32.1% (n = 27) described themselves as “man or male”, 22.6% (n = 19) “woman or female”, 29.8% (n = 25) “nonbinary” and 15.5% (n = 13) “other”, including gender identities such as genderqueer, bigender, demigender and agender. Age groups ranged from 18-20 to 60+, with 53.6% (n = 45) of participants under the age of 30. Most participants identified as white Australians (89.2% n = 75), while a smaller portion identified as Aboriginal and/or Torres Strait Islander (4.8% n = 4), Asian and other ethnicities. Of those who provided their income (82.1% n = 69), most (56.5% n = 47) reported a household income under $60,000.

Going to the mainland: Navigating financial and geographical challenges when accessing medical gender affirmation

A common barrier to gender affirmation for our Tasmanian participants was affordability. Many participants called for gender affirming surgeries, in particular, to be covered or subsidized under Australia’s universal public health system (Medicare), or more comprehensively by private health insurance:

Top surgery for us female-to-males is expensive. Mine, which I had to cancel due to the cost, was $15,600. For someone that has a small chest, I think that amount is too much. (Trans man, 20s)

I’m on a single income with a mortgage and even though I won’t let money get in the way of my transition, it’s not easy coming up with the cost. (Trans man, 40s)

In an ideal world it would be great if more services and procedures that gender diverse people access as a part of their transition were covered by private health insurance, because, in my opinion, a lot of so-called cosmetic procedures can improve the quality of life for a gender diverse individual. (Trans woman, 30s)

Although the cost of gender affirming surgeries is often prohibitive for trans and gender diverse people in Tasmania, many are determined to find a way to access treatment regardless of cost. Some forms of medical gender affirmation are available at low cost to low income Australians, as one participant points out, yet gender affirming surgeries and other procedures often framed as ‘cosmetic,’ are rarely covered by health insurance, despite their well-documented health benefits for many trans and gender diverse people (Defreyne et al., 2017). In acknowledging this, these participants are critical of health systems and income supports that often fail to meet the needs of trans and gender diverse people (Spade, 2008). One participant emphasized the benefits of having access to gender affirming surgical procedures unexpectedly due to a change in their financial situation:

Surgery has made a MASSIVE DIFFERENCE [to my wellbeing]. It’s awesome, I love it. Even though it was $10k+, it was worth it. I am very poor and a student. I managed to save money ONLY due to the Coronavirus supplement. I expected to receive this surgery maybe around age 30, after graduating and finding a stable job. Just got lucky I guess. (Trans man, 20s)

Following the initial outbreak of COVID-19 in 2020, the Australian Government increased welfare payments for those on low incomes and provided additional financial support to those who were no longer able to work due to lockdowns and business closures associated with the pandemic. This participant’s experience highlights the importance of affordable healthcare, while also reflecting inequalities of access. In line with Defreyne et al. (2017), this participant describes the cost-effectiveness of surgery (‘Even though it was $10K, it was worth it.), given the significant impact it can have on trans and gender diverse people’s sense of self and wellbeing. Nevertheless, participants felt that the cumulative costs associated with medical gender affirmation placed them under financial stress and in some cases deterred or delayed them from pursuing treatment (‘I had to cancel due to the cost’).

While the cost of gender affirmation was experienced as prohibitive for participants in general, some felt that Tasmanians face specific financial barriers because of their geographical location. There is a small range of services available in Tasmania for gender affirmation. Tasmania’s public health system offers gender affirmation treatment through the Sexual Health Service. These services are located in three clinics around the state, providing assessments and some prescriptions, as well as referrals for further services, such as surgeries. Additionally, any general practitioner in Tasmania can provide gender affirming healthcare. However, some surgical and cosmetic procedures are not widely available in Tasmania. Participants reported waiting an average of three months, and in some cases up to six months, to access the Sexual Health Service for gender affirmation, which some perceived as lengthy:

Moving to Hobart from [major Australian city] in 2019 resulted in a reduction of the gender affirming medical support available to me. Today our current health service has not caught up to where mainland services were back then. (Nonbinary person, 20s)

[We need] more surgeries available here in Tasmania and they should be affordable. It’s hard for someone on a disability support pension to have money to even go over to the mainland let alone afford the life-saving surgery as it is. (Trans man, 30s)

The wait times almost killed me and treatments are too expensive. It’s far more expensive to get surgery here than the mainland: ∼$6000 more. Treatment options are also severely limited which adds to the cost and pushes people to seek it out on the mainland or in other countries with more resources and qualified surgeons with accessible results. (Trans man, 20s)

These accounts reflect many trans and gender diverse Tasmanians’ frustrations about perceived inequitable access to gender affirmation because of where they live. Echoing their concerns about the cost of gender affirmation, participants also found their options limited or postponed due the dearth of available services in Tasmania. In this context, the choice to travel to access more timely treatment arguably demonstrates trans people’s agency in navigating health systems that may not always accommodate them locally. While these participants express desire for more local services, many trans and gender diverse people travel to access gender affirming treatments as a form of self-preservation and care (Aizura, 2018). Though personal choice is a common factor in travel to access gender affirming medical care, trans and gender diverse people in regional and rural areas may have to consider whether to endure a long wait to access a local service or face a costly interstate or even international trip to access gender affirming procedures elsewhere. Either option compounds costs and time involved in accessing care, reducing trans and gender diverse Tasmanians’ wellbeing (‘the wait times almost killed me’).

Attitudes of health professionals

When our participants did access health services for gender affirmation in Tasmania, they reported a range of experiences of treatment by health professionals. Some participants shared positive experiences of supportive practitioners, for example:

My experience in general has been very positive. I was already seeing a psychologist for depression when I realised I was trans, and they were incredibly supportive and helped get the ball rolling. Their support meant that my first appointment went smoothly and I was on an HRT regime within two months from that first appointment. (Trans man, 30s)

My journey officially medically started last year and I have found everyone that has been involved in my change so far have been amazing. It’s been a very positive experience for me and I’m so thankful for how easy they have made this process for me. (Trans man, 40s)

I have been lucky with my GP. I managed to get the right people very quickly and I started transitioning well over a decade ago. They are extremely supportive, understanding and a blessing to be around. (Trans man, 50s)

These experiences underscore how supportive and understanding healthcare professionals can help facilitate a smoother and more affirming transition process, fostering a sense of wellbeing. In contrast, other participants shared experiences of explicit discrimination in health services. For example:

I have found that some doctors just look at me and say that there is something wrong with me. In that, they do not believe that there are more than two genders. I have had one doctor refuse to treat me because they "don’t deal with problems like yours." I have had a foreign doctor tell me that I needed to find Christ. This kind of thing is NOT helpful and is insulting and rude. (Trans man, 50s)

I have had experiences where psychologists have basically told me "it’s all in my head" when trying to explain the nuances that come with socialising as a transgender person. I’m now seeing a different psychologist who has a much better understanding of trans people but still automatically assumes all my problems are in relation to my trans identity (which they aren’t). (Trans man, 20s)

These experiences demonstrate how healthcare providers can take a problematizing approach to trans health, viewing gender diversity as a pathology to be treated. Participating in our research and highlighting these experiences was arguably a form of activism for our participants. Many who wrote in responses to our survey were passionate about improving trans healthcare and wanted to use their experiences to advocate for others. While many had experienced discrimination in health settings, most were able to identify mistreatment and overcome this by seeking out better care, as the participant above had done.

While trans and gender diverse people have a right to high quality healthcare free from discrimination, some participants did describe enduring poor treatment without complaint lest they be denied care. For example:

I wasn’t given any options. I was told this is what I am doing, not asked much more about who and what I am. I am non-binary, and I was forced onto testosterone and wasn’t given any other advice. I wasn’t even asked for permission for them to touch parts of my body either, they just went ahead and did that, and I felt very uncomfortable. I felt like I wasn’t given proper care nor support to find ways to understand what was just told to me. (Nonbinary person, 30s)

[Practitioners need to] give context for why certain questions are asked. For example, don’t just say “tell me about your periods” followed by “and how do you feel about your breasts?” Was it some sort of form you were ticking boxes on? Was it morbid curiosity? Were you trying to determine if I experienced gender dysphoria? Were you trying to trigger dysphoria to see what would happen? It was never made clear, especially as the first question seemed at first to be about establishing some sort of baseline before starting HRT while the second had nothing to do with my purpose for being there. (Nonbinary trans person, 30s)

In these accounts, nonbinary participants were asked intrusive questions or subjected to non-consensual physical examinations that they did not perceive as relevant to their treatment (see also Vermeir et al., 2018). These instances of discrimination arguably reflect doctor-patient relationships where there is a significant power imbalance that is heightened by a system that leaves trans and gender diverse patients desperate to medically affirm their gender even if they must undergo dehumanizing treatment. In contrast, these participants’ accounts show critical reflection on their treatment and an astute ability to identify more appropriate and collaborative approaches to gender affirming care that could inform improved treatment. For example, both participants above show a preference for an informed consent approach to gender affirmation, where trans and gender diverse people’s lived experiences are trusted and practitioners work together with trans patients to determine the desired course and outcomes of their affirmation. The following section expands on this by considering the role that healthcare providers play in gatekeeping gender affirmation.

Hurdle after hurdle: Medical gatekeeping delaying gender affirmation

In addition to discrimination and structural barriers to accessing medical gender affirmation in Tasmania, another significant challenge participants faced was a sense that medical gatekeeping was delaying their gender affirmation. Under earlier versions of the WPATH standards of care (Coleman et al., 2012), trans and gender diverse patients were required to gain at least one referral from a psychologist in order to access hormone replacement therapy (HRT). While this has since been updated (see Coleman et al., 2022), at the time of our survey, many participants experienced healthcare providers’ adherence to these previously recommended standards as establishing seemingly arbitrary “hurdles” to prevent or delay gender affirmation. For example:

I felt that [health professionals] were always forcing a specific pathway with specific providers and longer waiting times, which makes patients feel ‘bad’ or that they’ve done wrong by taking things into their own hands and getting private referrals. (Trans man, 20s)

Overall, the system has long wait times and too much gatekeeping. [The clinic] presented hurdle after hurdle instead of just giving me the treatment I wanted. I would really like to see a proper informed consent system, where we are able to access hormones the day we decide we want them - instead of having doctors stand in the way for months to years. (Trans woman, 30s)

Literature on medical gatekeeping highlights health professionals’, particularly doctors’, status as experts with the power to determine patients’ healthcare options at their own discretion (Tomson, 2018). While clinicians are often well-placed to make such decisions (Coleman et al., 2022), which can have vital implications for individuals’ health and broader health system capacity, some scholars have been critical of the underlying assumption of medical objectivity informing such judgements (Spencer et al., 2023). In the context of trans and gender diverse health, a growing body of research suggests that health professionals act as powerful gatekeepers to medical gender affirmation, sometimes despite having limited knowledge in this area (Ashley, 2019; Stryker, 1994). Although trans and gender diverse people often have a wealth of their own knowledge of best practices in gender affirming care drawn from lived experience (see also Noonan et al., 2018), our participants felt that this knowledge was seldom trusted, taken seriously, or followed up by practitioners, who were perceived as rigid and discouraging of trans and gender diverse people actively engaging in their own care. As one participant mentioned, this is in contrast to informed consent models of care which emphasize a shared decision making approach to gender affirmation, drawing on the ability and agency of patients to determine their own care pathways (Australian Professional Association for Trans Health [AusPATH], 2021). By referring to current standards of care and calling for updated informed consent approaches to trans healthcare in Tasmania, participants demonstrated a high level of knowledge and awareness of best practice—a key strength of trans communities.

Participants felt that practitioners’ mistrust of trans and gender diverse patients was especially reflected in their understandings of gender. In line with previous research (Ashley, 2019), many of our participants shared experiences of feeling like they had to perform or express their gender or share a particular kind of trans narrative in order to affirm their gender based on practitioners’ perceptions of gender norms (Spade, 2003). For example:

So much of the early process at [the clinic] feels like you have to prove you deserve the treatment, and then that the doctors have goals for your transition, rather than facilitating the goals of the patient. For example: “we like to have you at [hormone level]” when it should be “hormone levels for people taking [x] range from [y] to [z]. Different bodies react to them differently. Does where you’re at feel right to you?” (Trans woman, 30s)

They should stop putting such a focus on getting people to ‘prove’ their transness, particularly in regard to consenting adults seeking gender-related medical treatment. It is degrading and feels like you have to live up to some unrealistic standards just to prove you’re ‘trans-enough’ to get the medical treatments you want and deserve. (Trans man, 20s)

The amount of gatekeeping that happens along the way led me to be in constant fear that something would stop me from being able to get top surgery. Up until the moment I woke up after the surgery I was sure something would come up, the psychiatrist would write and say I wasn’t fit for surgery, I didn’t meet the standards to be “trans enough” or my dysphoria wasn’t enough, or my funds wouldn’t come through. (Nonbinary person, 30s)

[Practitioners need an] understanding that not everyone needs to follow the same transition pathway, that it’s not just a magical escalator to "passing" Talk with each person about what they want to achieve, what their goals are, to help them assess their choices rather than prescribing a certain treatment pathway. (Nonbinary person, 40s)

Here, participants highlight how dominant medicalised narratives of what it means to be “authentically” trans are often privileged over trans and gender diverse people’s varied lived experiences (Garrison, 2018; Riggs et al., 2019). Notably, by preferencing a binary understanding of gender and assuming trans experiences center on the dysphoria of being “born in the wrong body,” the practitioners our participants describe ‘flatten out the complexities of trans people’s experiences of sex-gender and sexuality’ (Latham, 2019, p. 14). While this level of gatekeeping is harmful, trans and gender diverse people developed strategies to access care within these systems, identifying dominant trans narratives and gendered expectations held by transnormative practitioners and either performing accordingly or actively critiquing such standards.

Such standards or assumptions of what it means to be “authentically” trans were perhaps the most insidious barriers to gender affirmation that our participants faced because these not only deterred or delayed access to care, but they also impacted their sense of self. For example, these participants shared experiences of reduced wellbeing due to delays in medical gender affirmation:

It was a difficult process of needing to wait many months for a psychiatrist/psychologist to approve etc. This took a large toll on my mental health because I had already internalised the concept for months beforehand, coming to my own decision that HRT is what I want. So it became a waiting game instead of an exploration of options. (Trans man, 20s)

[After long delays in accessing mental health support which impacted access to HRT], basically my transition has been delayed and impacted breast development. I have lost faith in who I am and considering de-transitioning. It’s becoming too painful and pointless to continue further. (Trans woman, 50s)

While some trans and gender diverse people may choose to reschedule or delay aspects of their gender affirmation for a variety of reasons, delayed access due to medical gatekeeping is damaging to trans and gender diverse people’s mental and physical health (Ashley, 2019). These participants’ comments are especially concerning given that timely access to gender affirming care has been shown to improve mental health and wellbeing, while reducing suicidal ideation, with very low rates of regret or de-transition (De Vries et al., 2014). In line with the comment above, when de-transition occurs it is usually due to external pressures, such as discrimination and delayed access to care (Turban et al., 2021). These findings demonstrate how medical gatekeeping can prevent trans and gender diverse people from accessing care and delay their gender affirmation, which, when compounded with experiences of discrimination, financial strain, and geographical isolation, significantly reduces their wellbeing in regional and rural locations like Tasmania.

In contrast, participants’ positive experiences with healthcare providers highlight the importance of an informed consent approach to gender affirmation:

I was lucky and found a GP who specialises in LGBTQI + health and has greatly helped me start my transition, she is great support and explains everything in detail. I have started HRT and have an appointment to see an endocrinologist, the psychiatrist I see was a psychiatrist I was already seeing for ADHD, when I came out to him, he was very supportive and provided a number of resources. (Trans woman, 30s)

The first GP I saw was knowledgeable but more importantly respected my autonomy to make decisions for myself and allowed me to select my HRT regime. I am only in this position however, because I am privileged. I know what medications work for me, both through education and through trial and error. Furthermore, I am a very confident individual, and am not afraid to ask for what I need. (Trans woman, 20s)

Here, practitioners who provide whole-person care, by actively engaging their patients in developing their gender affirmation strategies, are valued highly by trans and gender diverse people. By recognizing trans and gender diverse people as active decision-makers in their gender affirmation journey, informed consent empowers them to make choices aligned with their identity. These narratives highlight that such an approach not only respects the agency and expertise of trans people but also contributes to a more affirming, supportive, and efficient healthcare environment. One participant above reflects that her relative privilege has contributed to her ability to effectively navigate health systems and advocate for herself with confidence. This suggests that those with less privilege, such as trans and gender diverse people with disabilities, people of color, and those with lower education and incomes may face greater barriers to care. Recognizing the intersectionality of privilege and adversity within trans and gender diverse communities underscores the importance of creating a healthcare system that caters to diverse needs. By prioritizing inclusive healthcare policies, fostering cultural competence, and providing targeted support, communities with intersecting marginalized identities can be empowered to navigate health systems, ensuring equitable access to gender affirming care.

Discussion

This exploratory study aimed to develop a deeper understanding of trans and gender diverse people’s experiences of medical gender affirmation in Tasmania, Australia. We found that cost, prolonged wait times, discrimination, and medical gatekeeping act as key barriers to medical gender affirmation for trans and gender diverse Tasmanians. This article makes a novel contribution to existing research by considering how these barriers are connected and how such barriers are exacerbated in rural and regional environments. We found that living in Tasmania presented specific geographical and financial barriers to gender affirmation for our participants. Many recounted the need for intra- and interstate travel to access gender affirming treatments unavailable locally. Traveling from rural areas to capital cities or interstate to access LGBTQ-inclusive healthcare and community services has been well-documented (Grant, 2021), however, few have acknowledged the financial and mental strain this causes trans and gender diverse people seeking gender affirming treatment. Traveling regularly to access HRT may not be physically or financially possible for many rural trans and gender diverse people, while traveling further afield for surgery significantly increases the cost and reduces access to familial or social supports for aftercare. Subsequently, our Tasmanian participants were especially concerned about the cost of surgeries, to the point where some did not pursue treatments they wanted. These findings likely reflect the fact that many of our participants had low incomes, with many living below the poverty line (earning less than $400 per week). Given the health and socio-economic benefits of gender affirming surgery for those who seek it, we argue that reducing the cost of surgery by increasing government subsidies (including for travel associated with care) would improve the wellbeing of this population, particularly those in regional and rural areas.

Given the negative experiences that many of our participants shared, we suggest the need for gender affirming care that prioritizes informed consent, centers trans and gender diverse knowledge and lived experience, and meaningfully engages local trans and gender diverse communities. Our findings show that persistent, systemic barriers to gender affirming care can create an environment where trans and gender diverse people are desperate to access treatment even if they are dehumanized and discriminated against in the process. Left unchecked, this environment produces unequal power dynamics between healthcare providers and trans and gender diverse patients, where medical gatekeeping becomes especially salient. We found that gatekeeping gender affirmation due to clinicians’ personal views on gender binarism, normative expression/performance, or transnormativity, is especially harmful to trans and gender diverse people. Overall, we argue that such gatekeeping furthers trans precarity, exacerbating the impacts of other barriers by deterring or delaying treatment while also undermining trans and gender diverse people’s sense of self.

Nevertheless, our findings importantly demonstrate trans and gender diverse Tasmanians’ knowledge, agency, and resilience in navigating access to gender affirming care. While many had faced frustrating and harmful barriers, our participants used a range of strategies to access care, including travel, evaluating different local practitioners, crowd-sourcing information within their communities, educating practitioners, and through self-advocacy. Participating in this study was often a form of activism, with the goal of improving local services and raising awareness about trans and gender diverse experiences of healthcare in Tasmania. Throughout this process, participants emphasized the importance of informed consent models of gender affirmation that honor trans and gender diverse people’s lived experiences.

Limitations

This article draws on a small, localized convenience sample of trans and gender diverse people responding to two open-ended survey questions and is thus limited in its scope and generalizability. We note that many of our findings are not unique to Tasmania specifically, yet speak to challenges that trans and gender diverse people face throughout Australia and internationally. In particular, trans women were under-represented in our sample, as were Aboriginal and Torres Strait Islander people. While issues around medical gatekeeping and discrimination in healthcare settings are pertinent for these groups, their lower representation in this study is a limitation likely resulting from both our recruitment strategies and the increased stigma these groups face in the community which can deter some from participating in research. Similarly, perhaps as a result of our recruitment strategy, the majority of our participants were under 30, which may have influenced some of our key findings regarding financial and geographical barriers to gender affirmation. This article analyses qualitative responses from a mixed-methods survey. As the open-ended questions were optional and situated at the end of the survey it is possible that those who took the time to write in responses were those with stronger views on the topic, which may not reflect the experiences of the broader trans and gender diverse population. However, the fact that that vast majority of participants were motivated enough to carry on until the end of the survey, suggests that some may have simply felt their views were sufficiently expressed through their quantitative responses presented earlier. Furthermore, the framing of the open-ended questions may have influenced the kinds of experiences and perspectives that participants chose to share. For example, asking what services should ‘keep or start’ doing rather than asking two separate questions may have led participants to focus more on a deficit approach (i.e. what the services do not yet do), rather than highlighting more positive examples. Nonetheless, due to the nature of the method, qualitative survey data does not allow for further exploration or context beyond what participants choose to write, limiting how we might interpret the data. Thus, we encourage further in-depth qualitative research using a range of methods to continue exploring trans and gender diverse people’s experiences of healthcare access in Australia.

Recommendations

Despite these limitations, this study has implications for and can inform the ongoing development of gender affirming care in Australia and internationally. First, our findings suggest that healthcare providers should adopt and prioritize informed consent approaches to gender affirming care, aligning with the AusPATH recommendations. This patient-centred approach respects individual autonomy and expedites access to necessary care. Second, both State and Federal Governments should consider providing financial support or rebates to alleviate the financial and geographic barriers that impede access to gender affirming care, particularly for those with low incomes. Third, healthcare services offering gender affirming treatments should establish lived experience advisory boards, actively involving trans and gender diverse voices in the development, promotion, and evaluation of these services. This would acknowledge and build upon the strengths of the trans communities. Finally, it is imperative to streamline referral processes within healthcare systems to reduce wait times and the complexity of accessing comprehensive gender affirming care, particularly in rural settings. These recommendations collectively aim to enhance the quality and accessibility of gender affirming care while fostering a more inclusive and equitable healthcare landscape for trans and gender diverse populations.

Funding Statement

The author(s) reported there is no funding associated with the work featured in this article.

Disclosure Statement

No potential conflict of interest was reported by the author(s).