Barriers to sexual and reproductive health care faced by transgender and gender diverse people: a systematic review

Abstract

Background

Transgender (trans) and gender diverse people face significant obstacles when accessing sexual and reproductive health (SRH) services. This review aims to systematically identify and characterise the specific barriers to SRH barriers across a range of service domains.

Methods

A systematic literature search was carried across MEDLINE, CINAHL, Embase, PsycInfo and Global Index Medicus for studies published up until Aug 17, 2023. We included qualitative, quantitative and mixed-methods studies that illustrated which barriers to SRH services trans and gender diverse people face. Relevant data were extracted and examined using an inductive approach by which organic themes emerged across the SRH service domains. Quality assessment was carried out using the Critical Appraisal Skill Programme (CASP) checklists.

Findings

A total of 53 studies examining barriers to SRH services were deemed eligible for inclusion. This consisted of 20 studies relating to fertility care, two to abortion care, four to contraception, 15 to reproductive cancer screening, nine to antenatal, intrapartum and postnatal care and three spanning multiple domains of SRH. Eight studies were deemed to be moderate quality, the remaining 45 were high quality. 49 of the included studies were conducted exclusively in high-income countries. 40 studies were conducted from the perspectives of trans and gender diverse people, 10 from that of health providers whilst three incorporated both. Participants included for analysis ranged in age from 18 to 78 years. Domain specific and cross-cutting barriers were described throughout the included studies, including financial accessibility, lack of provider knowledge and education, limited information availability, systemic and interpersonal discrimination, cis-normative and gender biased health system practices and dysphoria associated with treatments and procedures.

Interpretation

Trans and gender diverse people face substantial barriers to SRH services that prohibit them from fully exercising their reproductive rights. The evidence collated by this review demonstrates that whilst some barriers are shared with cisgender women, trans and gender diverse people face unique barriers to accessing SRH services. Both systems- and individual-level reform is necessary to improve not only gender responsiveness but also gender-inclusivity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-025-02038-6.

Background

Health is a fundamental right of every human being, as recognised by the World Health Organization (WHO) in its 1948 constitution and since then in several international human rights treaties and national constitutions [1]. Sexual and reproductive health (SRH) refers to “a state of physical, emotional, mental, and social wellbeing in relation to all aspects of sexuality and reproduction, not merely the absence of disease, dysfunction, or infirmity” [2]. SRH services include those related to safe abortion care, fertility care, prevention and control of sexually transmitted infections (STIs), reproductive cancer screening, contraception, antenatal, intrapartum and postnatal care [2]. The goal of ensuring universal access to SRH services without discrimination was reaffirmed in the 2030 Agenda for Sustainable Development for both health and gender equality in recognition of its significance for health and broader social outcomes [3].

Notwithstanding human rights and political commitments to leave no one behind, transgender (trans) and gender diverse people continue to face barriers to SRH services around the world [4, 5]. It is well recognised that significant social, economic and political barriers, including harmful gender norms, prevent many cisgender women from accessing services that would enable the fulfilment of their SRH. These barriers are not only shared but amplified for trans and gender diverse people as a consequence of heteronormative1dimensions of gender-based discrimination at both interpersonal and structural levels.

Negative health outcomes faced by trans and gender diverse people have been documented across a wide range of SRH disciplines. A 2019 systematic review of 88 studies estimated the prevalence of human immunodeficiency virus (HIV) among trans women and trans men in the United States (US) at 14.1% and 3.2% respectively, demonstrating a substantially higher burden of HIV among trans and gender diverse people in comparison to cisgender people [6]. Significant disparities in SRH service access between trans and gender diverse people and cisgender women have also been documented in previous research. An analysis of Medicaid databases in the US between 2014 and 2018 identified that compared to cisgender women, trans men were less likely to be prescribed any form of contraception and received significantly fewer prescriptions of oral contraceptive pills and long-acting reversible contraception [7]. Trans and gender diverse individuals also face barriers to various elements of fertility care. A 2024 Council of Europe report found that only 16 of 47 Member States allow for couples to access assisted reproductive technology (ART) regardless of sexual orientation and/or gender identity [8]. Additionally, this report found that even in countries where access is permitted, trans and gender diverse people continue to face extensive legal, economic and health system barriers to ART [8]. Reflective of these barriers, a 2020 review found that despite high reproductive desire among transgender individuals, few accessed fertility care due to anticipated bias, poor provider awareness and costs [9]. Access to abortion care is an integral component of SRH yet in many jurisdictions, even in those where abortion has been decriminalised, access remains limited for trans and gender diverse people. A 2019 survey of 1,694 trans and gender diverse people in the US found that that structural barriers, including refusals and mistreatment by service providers and institutions, frequently dissuaded them from seeking out abortion care [10]. Trans and gender diverse people also continue to face barriers to reproductive cancer screening. The American College of Obstetricians and Gynecologists recommends cervical cancer screening for “all individuals who have a cervix”, despite this, there are disparities in cervical cancer screening rates between cisgender women and trans and gender diverse people [11]. A 2024 survey of 100,000 lesbian, gay, bisexual, transgender, intersex, queer (LGBTIQ +) people across the European Union showed that the proportion of cisgender women who reported undergoing cervical cancer screening in the past 12 months was low at only 29%, but even lower for non-binary and gender-diverse people with cervixes and transgender men at only 20% and 11% respectively [12]. Similarly, a retrospective chart review of more than 5,000 patients, including 350 transgender men, identified that transgender men were 37% less likely to be up to date with cervical cancer screening than cisgender women [13].

The disparities in SRH health outcomes faced by trans and gender diverse people necessitates a further exploration of the barriers faced by this community, to better understand why they occur. This review aims to systematically assess the specific barriers faced by trans and gender diverse people accessing SRH services, specifically those relating to: contraception, fertility care, abortion care, antenatal, intrapartum, and postnatal care, and reproductive cancer screening. These domains have been selected in response to calls by the trans and gender diverse community for a greater focus on holistic care within SRH. This review excludes services related to the provision care for HIV and STIs, which have already been the focus of considerable research.

This review seeks to raise attention to the perspectives of trans and gender diverse people in future policy and guideline making processes relating to SRH services. This includes complementing the ongoing development of a WHO guideline which is considering evidence around the provision of and access to gender affirming care2 services for trans and gender diverse adults as well as mechanisms to ensure access to all forms of gender-inclusive care3 [14, 15].

Methods

Search strategy and selection criteria

Our review adhered to PRISMA Reporting Guidelines [16] (Additional Material 1) and is registered with PROSPERO (CRD42023465552).

A search strategy was developed by selecting MeSH terms and key words aimed at identifying articles across our three focus domains: (1) barriers to care, (2) trans and gender diverse people, and (3) SRH services. This search was executed across MEDLINE, CINAHL, Embase, PsycInfo and Global Index Medicus on 17 August 2023. The search strategies used for each database are included as Additional Material 2.

This review included qualitative, quantitative and mixed-methods studies. To be eligible, studies were required to explicitly identify that the population they were investigating was trans and gender diverse people. Studies were required to illustrate barriers faced by trans and gender diverse persons articulated either by trans and gender diverse persons engaging with care or the providers of such care in the following SRH service domains: contraception, abortion care, fertility care, antenatal, intrapartum, and postnatal care, and/or reproductive cancer screening. Studies that related to other SRH services, including HIV and STI care, or which did not disaggregate by domain of SRH service were not included. Also excluded were studies that did not disaggregate the experiences of trans and gender diverse people from the wider LGBTIQ + community. Studies with trans and gender diverse participants under 18 were excluded unless data were delineated by age, in which case only data pertaining to adult participants were included. Review articles, research protocols, conference abstracts, editorials, and commentaries were not eligible for inclusion.

All stages of screening were performed in Covidence [17] by two authors independently (CLA and LM), conflicts were resolved through discussion. The step-by-step breakdown of the screening process is outlined in the PRISMA flowchart (Fig. 1). After automated deduplication in Covidence, a total of 7,292 articles were identified to be screened at title and abstract level. Of these, 266 progressed to full text screening, which yielded 53 studies for inclusion in this review. A comprehensive list of articles excluded at full text screening with rationale is available in Additional Material 3.

Fig. 1.

PRISMA flowchart

Data extraction and data analysis

A data extraction table in Excel was developed to capture key information from the included studies. The primary author (CLA) extracted data from all studies, a total of 25% were double author extracted by a second author (LM) to ensure consensus and accuracy of the extraction approach. Disagreements were resolved through discussion. Extracted bibliographic data included: study author(s), year of publication, country, income level, study aims, sample size, participant gender identities and sex assigned at birth, age range, and other relevant subgroups/characteristics. Data relating to the SRH service were also collected, including service domain of SRH and specific intervention(s) described. Methodological data including study design, quantitative/qualitative method(s) applied and theoretical framework adopted in analysis were also extracted. Qualitative data (quotes and verbatim transcripts) were extracted alongside quantitative data relating to barriers and/or their association with health outcomes. Throughout this process we adopted an inductive coding approach, enabling barriers to emerge organically both within and across the various service domains.

Quality assessment of the included studies was performed by two authors (CLA and LM) independently with consensus reached through discussion. Qualitative studies were assessed using the CASP Qualitative Studies Checklist [18] whilst quantitative and mixed-methods studies were assessed using the CASP Cross-Sectional Studies Checklist [19] (Additional Material 4). Studies were deemed to be low, moderate or high quality if they scored ≤ 49%, 50%-74% or ≥ 75% respectively.

Results

A total of 53 studies [20–72] were deemed eligible for inclusion in this review; detailed characteristics of the included studies are described in Table 1. There were 15 quantitative [23, 25, 30, 34, 36, 49, 52, 54, 55, 57, 60, 62–64, 68], 31 qualitative [20–22, 24, 26, 28, 29, 33, 35, 37–45, 47, 51, 53, 58, 59, 61, 65–67, 69–72] and seven mixed-methods [27, 31, 32, 46, 48, 50, 56] studies included in this review. Included studies were found to be either moderate (n = 8) [23, 25, 27, 34, 48, 56, 57, 63] or high (n = 45) [20–22, 24, 26, 28–33, 35–48, 50–55, 58–62, 64–72] quality. 49 studies [20–51, 54–57, 60–72] were conducted in high-income countries, two [52, 53] in upper middle-income countries, one [59] in both high- and upper middle-income countries and one [58] in a lower middle-income country. Studies spanned 17 countries in total; the largest proportion were conducted in the Region of the Americas (n = 28) [20, 21, 28–30, 33, 34, 37, 39, 40, 42–46, 50, 53–55, 57, 61–64, 68, 70–72] consisting mostly of studies from the United States (n = 26) [20, 21, 28–30, 33, 34, 37, 39, 40, 42, 43, 45, 46, 50, 54, 55, 57, 61–64, 68, 71, 72]. Other studies were conducted in the European (n = 14) [22–25, 27, 36, 38, 47, 51, 56, 60, 65, 67, 69], Western Pacific (n = 8) [26, 31, 32, 35, 41, 48, 49, 66], and South-East Asia Regions (n = 2) [52, 58] whilst one study [59] was conducted across multiple regions.

Table 1.

Characteristics of included studies

Author (Year)	Country	WHO Region	Study aims	Domain of SRH	Participant group	Relevant sample size	Sex assigned at birth	Participant age	Study design	Results summary	Quality assessment tool	Overall quality
Agenor et al., (2020) [20]	United States	Americas	To gather information on the barriers and facilitators to contraceptive use among transmasculine individuals	Contraception	Patients	21 Men or male (n = 5) Transgender men or male (n = 9) Transmasculine (n = 5) Nonbinary (n = 23)	AFAB	18–29	In-depth interviews	• Many participants incorrectly assumed testosterone used for purposes of gender transition was sufficient alone for contraception • Participants struggled to locate accurate information relating to contraception specific to trans and gender diverse people • Provider knowledge and training on this topic was frequently poor • Many trans and gender diverse people were concerned about dysphoria associated with taking hormonal contraception incongruent with their gender identities	CASP Qualitative Checklist	High
Agenor et al., (2016) [21]	United States	Americas	To investigate how transmasculine people and healthcare providers perceive HPV and cervical cancer risks, and how these perceptions impact cervical cancer screening delivery and uptake	Reproductive cancer screening	Patients and providers	49 Patients (n = 32): Transmasculine (n = 32) Providers (n = 17)	AFAB	21–64	Semi-structured patient interviews and provider focus-group	• Participants recognised the need for cervical cancer screening for individuals with a cervix regardless of gender identity • Participants were unclear on the role that testosterone plays in cervical cancer risk • Perspectives varied on whether trans men with cervixes should be screened for cervical cancer if they had not engaged in penetrative sex	CASP Qualitative Checklist	High
Almvik et al., (2023) [22]	Norway	Europe	To examine midwives' perspectives on providing prenatal care to pregnant trans men	Antenatal, intrapartum and postnatal care	Providers	14 Providers: Midwives (n = 14)	-	37–64	Semi-structured provider interviews	• Midwives expressed that they would find engaging with pregnant transgender men ‘unusual’ • Midwives described a need for more knowledge and training on delivering pregnancy care to transgender men	CASP Qualitative Checklist	High
Alpern et al., (2022) [23]	Israel	Europe	To evaluate fertility aspirations and preservation rates among transgender individuals of reproductive age and identify factors influencing their fertility preservation decisions	Fertility care	Patients	188 Transgender women (n = 97) Transgender men (n = 91)	AMAB and AFAB	19–57	Questionnaire survey	• Transgender women more significantly more likely to have pursued fertility preservation compared to transgender men • The main reasons for not pursuing fertility preservation were unwillingness to postpone gender-affirming treatment, preference to adopt a child and cost • Factors described as reasons for not pursuing fertility preservation included distress caused by the fertility preservation technique, fear of gender dysphoria caused by hormonal treatment and concern over the attitude of medical staff	CASP Cross-Sectional Checklist	Moderate
Armuand et al., (2017) [24]	Sweden	Europe	To assess the experiences of transgender men with a fertility preservation program focused on oocyte cryopreservation at a university hospital	Fertility care	Patients	15 Transgender men (n = 15)	AFAB	19–35	In-depth interviews	• Participants reported that clinic documentation seldom accommodated for trans identities • Cis and heterormative assumptions were commonplace • On some occasions, participants were refused services	CASP Qualitative Checklist	High
Auer et al., (2018) [25]	Germany	Europe	To analyse how the desire for children and the use of fertility preservation options vary among trans women and trans men at different stages of transitioning in Germany	Fertility care	Patients	189 Transgender women (n = 99) Transgender men (n = 90)	AMAB and AFAB	20–51	Cross-sectional study, self-constructed, self-report questionnaire	• Financial issues were a key barrier to fertility preservation • Participants expressed a desire for fertility preservation to be covered by public insurance	CASP Cross-Sectional Checklist	Moderate
Bartholomaeus et al., (2020) [26]	Australia	Western Pacific	To explore the experiences of participants regarding their interactions with healthcare professionals about fertility preservation	Fertility care	Patients	295 Transgender men (n = 100) Transgender women (n = 72) Non-binary (n = 102) Agender (n = 21)	AMAB and AFAB	Not specified (median age = 25)	Questionnaire survey	• Participants described professionals were lacking in knowledge on the impact of transitioning on fertility • A portion of participants were not informed about fertility preservation at all • Language and environment of fertility preservation clinics was rarely accommodating to trans and gender diverse patients	CASP Cross-Sectional Checklist	High
Berner et al., (2021) [27]	UK	Europe	To understand the attitudes and preferences of UK-based transmasculine and non-binary individuals towards cervical screening	Reproductive cancer screening	Patients	137 Transmasculine (n = 109) Non-binary (n = 24) Other non-cis identities (n = 12)	AFAB	18–64	Cross-sectional survey	• Participants describe difficulty in accessing cervical cancer screening if their gender was male on documentation • Some participants reported incidences of transphobia from health professionals, in some instances being refused treatment • Gender dysphoria related to the procedure was common	CASP Cross-Sectional Checklist	Moderate
Birenbaum-Carmeli et al., (2021) [28]	United States	Americas	Not specified	Fertility care	Patients	4	AMAB	19–29	In-depth ethnographic interviews	• Costs were a significant barrier to fertility preservation, some participants were required to loan money to access the service. • Misgendering occurred as late as in the operating room	CASP Qualitative Checklist	High
Carpenter et al., (2021) [29]	United States	Americas	To investigate the reproductive health strategies used by queer cisgender women and gender-expansive individuals	Abortion care	Patients	7 Non-binary (n = 3) Genderqueer (n = 2) Other (n- = 2)	AFAB	20–40	Semi-structured interviews	• Due to a lack of information on trans specific abortion care, participants sought their own information online • Participants describe a lack of queer-informed/affirming care	CASP Qualitative Checklist	High
Carroll E et al., (2023) [30]	United States	Americas	To assess the familiarity and knowledge of primary care providers with breast cancer screening recommendations for transgender and gender-diverse patients	Reproductive cancer screening	Providers	95 Primary care providers (n = 95)	-	21–60 +	Cross-sectional survey	• trans and gender diverse knowledge and education received varied significantly among practitioners • A minority of providers were aware of breast cancer screening guidelines for trans and gender diverse patients • Barriers to trans and gender diverse specific training included poor exposure during clinical training and a lack of faculty experience	CASP Cross-Sectional Checklist	High
Carroll R et al., (2023) [31]	New Zealand	Western Pacific	To identify the uptake, barriers, and reasons for delaying cervical cancer screening among transgender and gender non-binary people in New Zealand	Reproductive cancer screening	Patients	318 Transgender men (n = 129) Non-binary (n = 189)	AFAB	20–69	Community-based survey	• Participants delayed accessing cervical cancer screening due to fears of mistreatment • Material barriers such as costs, anxiety about the procedure itself and information deficits were common	CASP Cross-Sectional Checklist	High
Charter et al., (2018) [32]	Australia	Western Pacific	To understand how Australian trans men experience and develop their desire for parenthood and gestational pregnancy	Fertility care	Patients	25	AFAB	25–46	Semi-structured interviews and online survey	• Discontinuing hormone therapy to conceive triggered fears relating to body changes and gender dysphoria • Many trans men describe feeling more comfortable with performing their own insemination with known donor due to fears of misgendering in fertility services	CASP Qualitative Checklist	High
Chen et al., (2019) [33]	United States	Americas	To identify factors affecting transgender adolescents’ and young adults’ decisions to pursue fertility preservation	Fertility care	Patients	12	AMAB and AFAB	15–24	Semi-structured interviews	• Participants describe emotional and psychological challenges of accessing fertility preservation, particularly when it conflicted with their gender identity • Financial barriers were significant for many participants • A lack of awareness among clinicians on the impact of fertility preservation on hormone therapy was reported	CASP Qualitative Checklist	High
Chen et al., (2017) [34]	United States	Americas	To describe fertility preservation utilisation by transgender adolescents at a paediatric gender clinic	Fertility care	Patients	1 Transgender woman (n = 1)	AMAB and AFAB	14–20	Retrospective chart review	• A participant described being misgendered by a staff member at the sperm bank they attended	CASP Cross-Sectional Checklist	Moderate
Copeland et al., (2023) [35]	Australia	Western Pacific	To gain a deeper understanding of the pregnancy and birth experiences of transgender and non-binary individuals, and to suggest ways to provide inclusive care	Antenatal, intrapartum and postnatal care	Patients	2 Trans/non-binary (n = 1) Agender/gender-fluid (n = 1)	AFAB	Not specified	Semi-structured interviews	• Participants described the cisgender focus of the antenatal, intrapartum and postnatal care environments • Anticipated misgendering was a source of anxiety	CASP Qualitative Checklist	High
Defreyne et al., (2020) [36]	Belgium	Europe	To explore the considerations and concerns of transgender individuals regarding fertility preservation and the desire for parenthood in a large nonclinical sample	Fertility care	Patients	172 Transgender men (n = 116) Gender non-binary (n = 56)	AFAB	19–29	Web-based survey	• Participants feared encountering discrimination • A significant portion of participants report not receiving information on fertility preservation • Key reasons for not proceeding with fertility preservation were cost, not placing a high value on genetic relation to children and wanting to avoid an interruption in gender-affirming hormone therapy		High
Ellis et al., (2015) [37]	United States	Americas	To investigate the perspectives on conception, pregnancy, and childbirth among male and gender-variant gestational parents who transitioned before pregnancy	Antenatal, intrapartum and postnatal care	Patients	8 Multiple genders (n = 6): Male-identified (n = 4) Transgender men (n = 4) Genderqueer (n = 3) Female-to-male (n = 3) Gender variant (n = 2) Two-spirit (n = 1) Androgynous (n = 1) One gender (n = 2): Male-identified (n = 2)	AFAB	29–41	In-depth individual interviews	• Participants describe internal conflict between their gender identity and societal norms of traditional gender roles in parenthood • There was a lack of support and trans and gender diverse-specific information from care providers • Anticipatory discrimination was common	CASP Qualitative Checklist	High
Falck et al., (2021) [38]	Sweden	Europe	To examine how trans masculine individuals experience healthcare encounters related to pregnancy, delivery, and nursing after the removal of mandatory sterilization to change legal gender	Antenatal, intrapartum and postnatal care	Patients	12 Man (n = 4) Trans man (n = 6) Transgender (n = 3) Gender fluid on the male spectrum (n = 1) Non-binary and/or trans-man (n = 4) Exclusively non-binary (n = 1)	AFAB	Not specified	In-depth face to face interviews	• Participants felt marginalised in antenatal, intrapartum and postnatal care settings due to cisgender focused forms and language • Health care providers demonstrated a lack of knowledge about trans and gender diverse issues in antenatal, intrapartum and postnatal care settings • There was significant fear around bias and discrimination during delivery	CASP Qualitative Checklist	High
Fischer et al., (2021) [70]	Canada	Americas	To capture the unique reproductive narratives of non-binary individuals assigned female at birth	Antenatal, intrapartum and postnatal care	Patients	5 Non-binary (n = 5)	AFAB	31–44	In-depth unstructured interviews	• Transphobia was reported throughout engagement with providers in antenatal, intrapartum and postnatal care settings • Participants report experiencing frequent gendered and heteronormative assumptions from providers • Participants felt that providers were lacking in training and education on trans and gender diverse health	CASP Qualitative Checklist	High
Fix et al., (2020) [39]	United States	Americas	To gather diverse stakeholder perspectives on barriers and facilitators to contraception and abortion for transgender and gender-expansive individuals assigned female at birth	Contraception, abortion care	Patients and providers	27 Patients (n = 5): Gender expansive individuals (n = 5) Providers (n = 22): Clinician (n = 13) Advocate (n = 5) Researcher (n = 4)	AFAB	18–45 +	In-depth interviews	• Participants described several contraceptive methods as triggering gender dysphoria • trans and gender diverse people were concerned about potential interactions between gender affirming hormone therapy and hormonal contraception • Participants describe feeling that stigma and discrimination accessing abortion care were exacerbated by their gender identity • Inclusive, affirming and adequately trained health care providers were scarce • Many participants feared re-traumatisation due to previous negative experiences in health care	CASP Qualitative Checklist	High
Forsberg et al., (2022) [40]	United States	Americas	To identify best practices for pregnancy prevention care through interviews with healthcare providers experienced in pregnancy counselling for this group	Contraception	Providers	20 Nurse practitioner (n = 8) Doctor (n = 6) Health educator (n = 2) Midwife (n = 1) Naturopathic physician (n = 1) Case manager (n = 1) Registered nurse (n = 1)	-	Not specified	Open ended interviews	• Many providers describe a lack of training in discussing contraception and pregnancy prevention with trans and gender diverse patients • The lack of inclusive resources and overt gendered language in health care settings was recognised as a barrier to care by providers • Some providers acknowledged the risk of triggering gender dysphoria when prescribing certain contraceptives	CASP Qualitative Checklist	High
Gibson et al., (2022) [41]	Australia	Western Pacific	Not specified	Reproductive cancer screening	Providers	12 Trans health advocates (n = 3) Sexual and reproductive health providers (n = 5) Professionals involved in cancer policy (n = 4)	-	Not specified	Semi-structured interviews	• Several providers acknowledged that trans people had been largely overlooked in cervical screening policies and guidelines • Many providers were not aware of the cervical cancer screening needs of trans men • Providers recognised the need for trauma-informed care and the risk of dysphoria associated with cervical cancer screening	CASP Qualitative Checklist
Gomez et al., (2020) [42]	United States	Americas	To capture diverse professional perspectives on cervical cancer screening for transgender individuals with a cervix	Contraception	Patients	20 Trans men (n = 13) Genderqueer/nonbinary (n = 4) Men (n = 4) Another gender identity (n = 2)	AFAB	22–29	Semi-structured interviews	• Participants report difficulties associated with billing due to his legal gender marker being male • There was a reported lack of research and clear information available on the role of testosterone as contraception • Providers were frequently described as lacking in knowledge about trans and gender diverse reproductive needs	CASP Qualitative Checklist	High
Hoffkling et al., (2017) [43]	United States	Americas	To understand the needs of transgender men who have given birth through a qualitative study	Antenatal, intrapartum and postnatal care	Patients	10 Transgender (n = 10)	AFAB	Not specified	Semi-structured interviews	• Many patients describe a lack of cultural competence from providers when engaging with trans and gender diverse patients • Some participants describe outright transphobia and the pathologisation of their gender identity • Administrative and information systems barriers were also described	CASP Qualitative Checklist	High
James-Abra et al., (2015) [44]	Canada	Americas	To address the gap in knowledge regarding transgender people’s experiences with assisted reproduction services through interviews with those who have accessed or attempted to access these services in Ontario, Canada	Fertility care	Patients	9 Transgender women (n = 1) Transgender men (n = 5) Other trans identities (n = 2) Female (n = 1) Male (n = 1)	AMAB and AFAB	26–45	Semi-structured interviews	• Participants were frequently misgendered by staff even after adjusting intake forms • Cisnormative assumptions about patients’ identities and reproductive options were common • Participants were denied services based on their gender identity	CASP Qualitative Checklist	High
Johnson et al., (2016) [46]	United States	Americas	To examine the cervical cancer screening behaviours of lesbian, bisexual, and queer women and transgender men using American Cancer Society guidelines, and to identify factors influencing participation	Reproductive cancer screening	Patients	25 FTM transgender (n = 4) Genderqueer (n = 21)	AFAB	21–65	In-depth telephone interviews and online questionnaire	• There was a lack of research on cervical screening needs of AFAB trans and gender diverse people • Many participants avoided Pap smears due to discomfort and dysphoria associated with the procedure	CASP Qualitative Checklist	High
Johnson et al., (2020) [45]	United States	Americas	To identify the determinants of cervical cancer screening from the perspective of transgender men through exploratory qualitative research	Reproductive cancer screening	Patients	20 Transgender men (n = 20)	AFAB	21–65	Semi-structured interviews	• Previous experiences of discrimination in health care settings prompted some participants to avoid accessing services • Dysphoria associated with cervical cancer screening was described • Financial and insurance barriers were significant barriers to accessing screening	CASP Qualitative Checklist	High
Kawsar et al., (2022) [47]	Sweden	Europe	To analyse how healthcare professionals experience encounters with transgender individuals in obstetrics and gynaecology, and to suggest improvements	Reproductive cancer screening	Providers	6 Physician (n = 3) Midwife (n = 2) Nurse (n = 1)	-	Not specified	Semi-structured interviews	• Providers describe that whilst national guidelines on transgender health care exist, these are unclear and difficult for providers and patients to follow • There were several administrative and systems issues that saw some patients miss out on screening • Providers lacked knowledge on trans and gender diverse specific health issues	CASP Qualitative Checklist	High
Ker et al., (2022) [48]	New Zealand	Western Pacific	To contribute empirical data from New Zealand, examine access to cryopreservation, and promote better fertility information and services for transgender and non-binary individuals regarding reproductive decision-making	Fertility care	Patients	1175 Non-binary individuals (AFAB) (n = 397) Trans women (n = 328) Trans men (n = 324) Non-binary individuals (AMAB) (n = 126)	AMAB and AFAB	Not specified	Community-based survey with free text options available	• Cost was a key barrier to fertility preservation • Participants stated a desire for financial support or subsidies to be able to access fertility preservation • Fertility clinics were frequently described as being heavily gendered environments	CASP Cross-Sectional Checklist	High
Kerr et al., (2022) [49]	Australia	Western Pacific	To explore issues with cervical cancer screening participation, awareness, and healthcare provider recommendations for transgender and gender-diverse individuals	Reproductive cancer screening	Patients	196	AFAB	20–35 +	Community-based survey	• A significant portion of participants report never having undergone cervical cancer screening • Trans men were less likely than other gender-diverse identities with cervixes to undergo screening • The commonest reason for never undergoing screening was that the procedure itself is traumatic and that patients had not been able to find a provider with whom they would feel comfortable	CASP Cross-Sectional Checklist	Moderate
Kyweluk et al., (2018) [50]	United States	Americas	To investigate trans adolescents’ initial reactions to fertility preservation technologies and their importance in medical decision-making	Fertility care	Patients	11	AMAB and AFAB	15–24	Semi-structured interviews	• The high costs associated with fertility preservation were a key barrier • Participants weighed up whether delaying gender affirming hormone therapy was worth undergoing fertility preservation	CASP Qualitative Checklist	High
Marinho et al., (2021) [51]	Portugal	Europe	To examine the parenthood intentions and experiences with health services of transgender and non-binary individuals	Fertility care	Patients	14 Transgender men (n = 7) Transgender women (n = 6) Non-binary (n = 1)	AMAB and AFAB	19–43	Focus groups	• Participants describe not being informed about fertility preservation options • Some participants felt that the focus on fertility preservation was disproportionate compared to other aspects of the gender transition	CASP Qualitative Checklist	High
Mattawanon et al., (2022) [52]	Thailand	Asia	To explore the desires and barriers to fertility preservation among transgender women and gender-diverse individuals assigned male at birth in Thailand	Fertility care	Patients	303 Trans women (n = 199) Gender diverse (AMAB) (n = 104)	AMAB	21–30	Cross-sectional study; questionnaire	• The majority of participants never received any information on fertility preservation • Only a minority of participants would be willing to delay gender affirming hormone therapy for the purposes of undergoing fertility preservation	CASP Cross-Sectional Checklist	High
Mendieta et al., (2021) [53]	Argentina	Americas	To illustrate the challenges Argentinean trans men face with the medical and healthcare system when seeking pregnancy, prenatal care, or abortion	Abortion care, antenatal, intrapartum and postnatal care	Patients	3 Transgender men (n = 3)	AFAB	32–34	Examination of newspaper articles	• Participants report engaging with providers who did not understand or respect their gender identity • Many participants describe anticipating disrespect or discrimination due to previous negative experiences in health care settings • Administrative obstacles such as difficulties registering names and gender were reported	CASP Qualitative Checklist	High
Morong et al., (2022) [54]	United States	Americas	To assess parenting intentions, knowledge and attitudes regarding fertility preservation, and barriers to achieving parenthood in an adult transgender population	Fertility care	Patients	80 Transgender men (n = 29) Transgender woman (n = 11) Other (n = 40)	AMAB and AFAB	18–65	Cross-sectional study, survey	• The largest barriers to fertility preservation were cost and a desire to continue gender affirming hormone therapy uninterrupted	CASP Cross-Sectional Checklist	High
Moseson et al., (2021) [55]	United States	Americas	To fill evidence gaps on the abortion experiences and preferences of transgender, non-binary, and gender-expansive individuals in the United States, and to inform policies and practices to improve abortion care access and quality for this population	Abortion care	Patients	1694	AFAB	18–78	Online quantitative survey	• Participants preferred medical over procedural or surgical abortions due to wanting to avoid interactions with medical providers where they might be misgendered or traumatised	CASP Cross-Sectional Checklist	High
Peitzmeier et al., (2017) [71]	United States	Americas	To examine factors influencing Pap test utilization among transmasculine individuals to inform evidence-based interventions promoting regular cervical cancer screening	Reproductive cancer screening	Patients	32	AFAB	Not specified (mean age = 33)	In-depth interviews	• Many participants describe undergoing Pap smears emotionally difficult due to the emphasis the procedure places on their assigned sex at birth • Participants found providers lacked cultural competency in dealing with trans and gender diverse patients • Dysphoria and a desire to avoid discomfort associated with Pap smears was common	CASP Qualitative Checklist	High
Peitzmeier et al., (2020) [72]	United States	Americas	To understand barriers and facilitators to cervical cancer screening as part of a larger study	Reproductive cancer screening	Patients and providers	49 Patients (n = 32)*: Male-identifying (n = 11) FTM/transgender/trans man/trans masculine (n = 22) Genderqueer (n = 6) Providers (n = 17): Physician (n = 11) Nurse practitioner (n = 4) Physician assistant (n = 2)	AFAB	21–56	In-depth interview and focus groups	• Participants report that some providers rejected the idea of adapting Pap smears for trans patients, as they saw it as inherently female • Providers dismissed the idea of making Pap smears and gynaecological exams more trans friendly	CASP Qualitative Checklist	High
Pezaro et al., (2023) [56]	UK	Europe	To explore the educational needs of perinatal staff regarding the needs of trans and non-binary individuals in perinatal care settings	Antenatal, intrapartum and postnatal care	Providers	108 Midwife (66%) Senior midwife (16%) Student midwife (8%) Consultant midwife (4%) Lecturer ( 4%) Maternity support worker (2%) Physiotherapist (2%) Nurse midwife (1%) Junior obstetrician (1%) Consultant obstetrician (1%) Specialist midwife (1%) Independent midwife (1%) Volunteer birth support worker (1%) Lactation consultant (1%) Neonatal nurse (1%) Medical and renal registrar (1%)	-	Not specified	Surveys	• Providers report lacking understanding and training of trans and gender diverse issues in perinatal care settings • Systemic issues relating to legal and administrative procedures were described as barriers to accessing perinatal care • Heteronormativity is commonplace in perinatal care environments	CASP Cross-Sectional Checklist	Moderate
Ramos-Pibernus et al., (2021) [57]	United States	Americas	To examine cervical cancer preventive behaviours in clinical interactions between medical students and a low-income transgender man	Reproductive cancer screening	Providers	37 Medical students (n = 37)	-	Not specified (mean age = 36)	Standardised Patient Simulations (SPS)	• Medical students lacked training and skills around the provision of cervical cancer screening to trans patients	CASP Cross-Sectional Checklist	Moderate
Restar et al., (2020) [58]	Philippines	South-East Asia	To investigate socio-ecological factors contributing to low condom use among Filipino transgender women and cisgender men who have sex with men in Manila	Contraception	Patients	23 Transgender women (n = 23)	AMAB	18–29	Semi-structured interviews	• Significant barriers to accessing contraception were described including lack of awareness around free availability and requirements for HIV testing before access • Use of certain contraceptives was stigmatised • The cost of contraception was reported as a significant barrier	CASP Qualitative Checklist	High
Riggs et al., (2021) [59]	USA, UK, Australia, Germany, Canada, Bulgaria	Multiple: Americas, Europe, Western Pacific	To examine the pregnancy experiences, including conception, of men, transmasculine, and non-binary individuals	Fertility care	Patients	51 Transgender man/transmasculine (n = 21) Man (n = 11) Non-binary (n = 11) Genderqueer/androgyne/fluid/greygender (n = 8)	AFAB	Not specified	In-depth interviews	• Cost was reported as a significant barrier to fertility preservation • Patients felt marginalised by the lack of inclusivity in clinical environments	CASP Qualitative Checklist	High
Rogers et al., (2021) [60]	UK	Europe	To categorize the reasons transgender and gender-diverse individuals choose to store or not store gametes before hormonal treatments	Fertility care	Patients	2942	AMAB and AFAB	10–85	Electronic medical records	• Participants felt that providers lacked formal training and education on trans and gender diverse specific care • Instances of discrimination and stigmatisation were common • Administrative procedures were cisnormative and exclusionary	CASP Cross-Sectional Checklist	High
Ruderman et al., (2021) [61]	United States	Americas	To understand the topics and considerations explored by prenatal and preconception genetic counsellors with transgender patients or partners	Antenatal, intrapartum and postnatal care	Providers	9 Genetic counsellors (n = 9)	-	Not specified	Semi-structured interviews	• Providers frequently defaulted to using cisnormative terminology and language • Administrative forms and procedures were not designed to accommodate trans and gender diverse identities • There were deficits in training and guidelines relating to the provision of trans and gender diverse specific care	CASP Qualitative Checklist	High
Shires et al., (2019) [62]	United States	Americas	To assess gynaecologic healthcare providers' willingness to provide routine care and Pap tests to transmasculine individuals, and to examine the influence of personal, clinical, and professional factors	Reproductive cancer screening	Providers	60 Advanced practitioner (n = 19) Attending physician (n = 30) Resident (n = 11)	-	Not specified	Survey	• The majority of providers describe a lack of familiarity with transgender guidelines which limited their ability to deliver informed care • Political views significantly influenced the willingness of providers to provide cervical cancer screening to trans patients • Providers who had met a trans person were more likely to be willing to provide screening to trans patients compared to those who had not	CASP Cross-Sectional Checklist	High
Sonnenblick et al., (2022) [63]	United States	Americas	To investigate breast radiologists' practices related to recording sex and gender in medical records, knowledge and attitudes about breast cancer screening recommendations for transgender individuals, and willingness to include transgender patients' data in screening mammography databases	Reproductive cancer screening	Providers	401 Breast radiologists (n = 401)	-	Not specified	Survey	• The majority of providers agreed that there is an insufficient body of evidence providing guidance on the screening of trans patients • Providers report lacking trans and gender diverse specific training • There was significant variability and poor overall adherence to breast cancer screening for trans women	CASP Cross-Sectional Checklist	High
Stewart et al., (2020) [64]	United States	Americas	To compare utilization rates of gynaecologic screening services by transgender individuals in a rural setting to national rates among cisgender individuals	Reproductive cancer screening, contraception	Patients	255 Transgender men (n = 145) Transgender women (n = 87) GNB/GNC/Genderqueer (n = 10) Gender diverse (n = 10)	AMAB and AFAB	18 +	Retrospective chart review	• Many eligible patients did not receive appropriate breast and cervical cancer screening • Some participants were not using contraception and had not received education from providers about contraception	CASP Cross-Sectional Checklist	High
van Amesfoort et al., (2023) [65]	Netherlands	Europe	To improve perinatal care for transgender individuals by exploring their needs and barriers in family planning, pregnancy, childbirth, postpartum, and perinatal care through interviews	Antenatal, intrapartum and postnatal care	Patients	5	AFAB	23–35	Semi-structured interviews	• Many participants chose to prioritise pregnancy over continuing gender affirming hormone therapy • Insemination was perceived as stressful and a trigger for gender dysphoria • Participants described significant variability in provider comfort and experience in delivering antenatal, intrapartum and postnatal care to trans and gender diverse patients	CASP Qualitative Checklist	High
von Doussa et al., (2015) [66]	Australia	Western Pacific	To understand how transgender individuals overcome barriers imposed by restrictive laws, medical practices, and cultural attitudes to achieve parenthood	Fertility care	Patients	13 Transgender women (n = 4) Transgender (n = 3) Transgender men (n = 2) Transsexual (n = 2) Female-to-male (n = 1) Gender diverse (n = 1)	AMAB and AFAB	23–67	Semi-structured interviews	• Participants report fears of discrimination and mistreatment by staff in fertility preservation settings • Legal frameworks and significant financial costs were described as barriers to fertility preservation • The process of fertility preservation conflicted with gender identity and was described as dysphoric by many participants	CASP Qualitative Checklist	High
Voultsos et al., (2021) [67]	Greece	Europe	To investigate the attitudes of transgender individuals in Greece towards having genetically related children and pursuing fertility treatments	Fertility care	Patients	12 Transgender men (n = 8) Transgender women (n = 4)	AMAB and AFAB	23–60	In-depth interviews	• Participants describe a lack of education around fertility preservation options • Participants expressed regret at rushing into transitioning without being adequately counselled about the potential for biological parenthood or fertility preservation	CASP Qualitative Checklist	High
Vyas et al., (2021) [68]	United States	Americas	To query transgender and gender-diverse individuals on their desire for fertility preservation, perceived barriers to accessing care, and decisional regret	Fertility care	Patients	70 Female (n = 9) Male (n = 13) Transgender female (n = 24) Transgender male (n = 8) Gender queer (n = 1) Gender non-binary (n = 9) Gender fluid (n = 2) Not disclosed (n = 4)	AMAB and AFAB	18–50 +	Cross-sectional study	• Key barriers to fertility preservation were cost, a lack of desire to pause gender affirming hormone therapy and worsening gender dysphoria associated with treatment and pregnancy	CASP Cross-Sectional Checklist	High
Wentling et al., (2021) [69]	UK	Europe	To examine how transgender embodiment shapes perceived needs for and experiences with sex-specific cancer screenings in the North American healthcare system, in response to a call for studies on embodied experiences of stigma	Reproductive cancer screening	Patients	35 Transgender men (n = 19) Transgender women (n = 15) Transgender-identified genderqueer (n = 1)	AMAB and AFAB	19–70	Semi-structured interviews	• Discrimination in SRH settings was prevalent • Many participants reported discomfort and dysphoria associated with undergoing Pap smears and mammograms • Providers were described as lacking in cultural competence	CASP Qualitative Checklist	High

Gender is as written in the study. Participants could identify as multiple genders; these were not mutually exclusive

Overall, there were 40 studies [20, 23–29, 31–38, 42–46, 48–55, 58–60, 64–71] whose participants were only trans and gender diverse patients, ten studies [22, 30, 40, 41, 47, 56, 57, 61–63] whose participants were providers delivering care to trans and gender diverse patients whilst three studies [21, 39, 72] included both trans and gender diverse patients and their providers. Of the 43 studies [20, 21, 23–29, 31–39, 42–46, 48–55, 58–60, 64–72] whose participants included trans and gender diverse patients; 24 studies [20, 21, 24, 27, 29, 31, 32, 35–39, 42, 43, 45, 46, 49, 53, 55, 59, 65, 70–72] were composed exclusively of participants assigned female at birth (AFAB), three studies [28, 52, 58] were composed exclusively of participants assigned male at birth (AMAB) whilst 16 studies [23, 25, 26, 33, 34, 44, 48, 50, 51, 54, 60, 64, 66–69] included both AFAB and AMAB participants. The ages of the participants who were included for analysis in this review ranged from 18 to 78 years.

By domain of SRH, 20 studies [23–26, 28, 32–34, 36, 44, 48, 50–52, 54, 59, 60, 66–68] related to fertility care, two studies [29, 55] to abortion care, four studies [20, 40, 42, 58] to contraception, 15 studies [21, 27, 30, 31, 41, 45–47, 49, 57, 62, 63, 69, 71, 72] to reproductive cancer screening and nine studies [22, 35, 37, 38, 43, 56, 61, 65, 70] to antenatal, intrapartum and postnatal care. Three studies [39, 53, 64] related to multiple service domains; their findings are incorporated into corresponding service domains below.

Fertility care

A total of 20 studies [23–26, 28, 32–34, 36, 44, 48, 50–52, 54, 59, 60, 66–68] addressed barriers to fertility care. These studies focused on barriers to fertility preservation, in particular assisted reproductive therapies (e.g., gamete (sperm/oocyte) cryopreservation).

Financial barriers were frequently cited as a barrier by both AMAB and AFAB trans and gender diverse persons [23, 25, 28, 33, 36, 48, 50, 54, 59, 60, 67, 68]. This barrier was particularly prominent among younger trans and gender diverse people [28, 33, 48, 50, 60, 67] in one study [60] financial inaccessibility was cited by 39.7% of those in the 18–45 age group as the most common reason for not storing gametes. Reflecting on this, a participant in one study [48] expressed, “[storing gametes is] expensive for young people (specifically students) but essential so you don’t ruin your future. I wish there was a subsidy for sperm/egg storing”. In one instance [59] the cost of fertility preservation was higher for trans and gender diverse individuals compared to same-sex cisgender couples, a participant describing, “There are a lot of places that were offering really, really cheap fertility treatments, but only if you had a partner—specifically if you were a male–female couple.”

Participants also reflected on the urgency of fertility preservation and mutual exclusivity with transitioning, which in many instances amplified frustration surrounding financial barriers [33, 36, 48, 50, 66, 67]. The requirement to pause/delay gender-affirming hormone treatment to undergo fertility preservation was described by participants; in one study [36] this was cited as a barrier to fertility preservation by 60.9% of participants.

Certain barriers to fertility preservation affected transgender men and women differently [23, 36, 52]. For example, in one study [23] barriers reported more commonly by transgender men compared to transgender women were distress caused by the fertility preservation technique (60.3% versus 29.3%, p = 0.006), fear of gender dysphoria i.e., the distress that can be experienced as a result of gender incongruence, both experienced and anticipated, caused by hormonal treatment (63.5% versus 28.3%, p = 0.002) and concern about the attitude of medical staff (44% versus 19%, p = 0.027).

There were significant deficits in the availability and/or provision of information to trans and gender diverse patients seeking fertility preservation services [36, 51, 52, 66, 67]. In some studies, this also appeared to affect specific groups of trans and gender diverse individuals differently [36, 52]. For example, in one study [36] transgender men were found to have been more likely to receive information on fertility preservation compared to gender non-binary (AFAB) participants (74.2% versus 40.7% respectively, p < 0.001). In another study [52] 75.3% of transgender women and 95.2% of other AMAB gender diverse people never received any information on fertility preservation. Deficits in provider education and training around fertility preservation for trans and gender diverse people were commonly described both in relation to information provision and as a standalone barrier to care [26, 36, 44, 53, 59, 60, 66]. In one study [26] a participant interpreted the state of provider training, “the lack of clinical knowledge about how transition affects trans masculine people is a little frightening… No doctor was able to tell me what impact hormones would actually have on my ovaries or eggs.”

Discrimination, both anticipated and experienced, was reported as a barrier to accessing fertility care [24, 26, 28, 32, 34, 36, 44, 51, 53, 59, 60, 66, 67]. Interpersonal discrimination in the forms of overt bullying by health and care providers or deliberate and repeated misgendering of trans and gender diverse patients was common; [23, 24, 26, 28, 32, 34, 44, 53, 59, 60, 67] occurring as late in the clinical encounter as the operating room [28]. A lack of gender-inclusive care and language in clinical documentation were also frequently reported [24, 34, 36, 44, 48, 53, 60]. In one study [24] a participant reported, “There were tons of factual inaccuracies in all our documentation and everything. I mean, I had a health card that lists me as female, correctly, and on their charts they always had me listed as male.”

Abortion care

Four studies [29, 39, 53, 55] contained data relating to barriers faced by trans and gender diverse people accessing abortion care.

A lack of gender-inclusive care as a barrier to abortion care was described in multiple studies [29, 39, 53]. In one instance [39], a participant who received an abortion stated they had “never had anybody even acknowledge that trans people have abortions” and that ultimately they “didn’t mention the gender part [identity]” to their clinician.

A lack of provider knowledge sometimes drove participants to seek their own information regarding the provision of abortion care to trans and gender diverse persons, a participant in one study [29] stating, “I feel like it can feel really isolating… when the internet doesn’t have answers for you, that’s when you know you are in some deep territory”. Limitations in the availability of information and trans and gender diverse specific information, especially information specific to trans and gender diverse individuals, was also described in this study [29].

The role that stigma plays as a barrier to abortion care at broader societal level was addressed in one study [39]. One participant described this, “Even within transgender expansive communities, like any marginalized communities, we don’t want to draw attention to what is considered bad by society. Right? So we don’t want to draw attention to something like abortion because of the stigma around it”.

Discriminatory clinical practices were also discussed as a barrier to abortion care [39, 53]. In one study [53] a participant seeking an abortion described an incident of gender based discrimination, “Once in a public hospital in the city of Rosario they refused to see me because they did not understand the trans body, even after the [gender identity] law was sanctioned, a gynecologist abstained from treating me by using as reason his ‘freedom of conscience’”.

Finally, cost as a barrier to abortion care was described in one study in the United States [39] wherein a participant stated that they borrowed money “from everybody” to be able to afford an abortion, which in this instance was completely self-funded.

Contraception

Six studies [20, 39, 40, 42, 58, 64] addressed barriers to contraception and/or contraceptive care faced by trans and gender diverse individuals.

Multiple studies discussed a lack of provider knowledge and education as a barrier in this domain [20, 39, 40, 42]. In some instances, providers were aware of their lack of training, with a clinician from one study [40] stating, “There’s a lack of formalized training on the subject, even among our staff. So, even the in-house knowledge isn’t transferred well, particularly to staff who aren’t expressly interested in this subject. Like, if it’s something you want to do and you care about, then there’s people to talk to and trainings, but if it’s not something that you specifically... want education in, you won’t get it”. Transgender men frequently described receiving conflicting or inaccurate information regarding the efficacy of testosterone as a contraceptive [20, 39, 40, 42]. In one study [20], several transmasculine participants reported different understandings of the requirement to continue using another contraceptive whilst on testosterone, one saying, “I heard it from some friends and groups, and sometimes even providers who are less informed will say, ‘Oh, you’re on testosterone, you shouldn’t be able to get pregnant.’ It’s kind of a myth that’s been going around.”

The lack of comprehensive research and data pertaining to contraception for trans and gender diverse people was also a factor in preventing clinicians from being able to accurately advise trans and gender diverse patients on contraception [39, 40, 42]. A provider in one study [40] emphasised, “Yeah, a lot of [pregnancy prevention counseling for TNB [trans and non-binary] AFAB people is like, “I’m really sorry there’s very little research on [the risks of unintended pregnancy for AFAB people on testosterone], some of it is like a guess and we don’t really know.”

Care provided solely through the lens of binary conceptualisations of gender identity and sex directly prohibited trans and gender diverse patients from accessing the correct type of contraception [39, 40, 42]. A respondent in one study [40] illustrated this point, “a lot of trans men are not going to get birth control counseling because they [providers] are under the assumption that... a man is going to sleep with a woman... there’s a lot of assumptions around body parts and preferences... which are just not true”. Coupled with this, language used in clinical spaces, educational materials and by providers often expressed harmful gender and heteronormative norms that associated contraceptive responsibility exclusively with cisgender women. This was described as alienating for trans and gender diverse people seeking contraception [40, 42], in one study [40] a patient remarked, “…there’s a lot of dissonance when everything, all the language we hear about pregnancy and contraception is just like ‘women, women, women’”. These heteronormative presumptions drove fears among trans and gender diverse patients of being misgendered [20, 39]; a participant from one study [39] describing, “as someone who’s at risk of unintended pregnancy, just being misgendered is one of my biggest things…”.

Lack of gender-inclusive insurance provisions were also a barrier to contraception reported by both participants and providers [39, 40]; in one study [40] 35% of providers reported it as an obstacle to providing care, with one primary care provider commenting, “Like trying to bill for an IUD [intrauterine device]... if someone’s insurance says M [male] is like going to be a clusterfuck”.

The dysphoria, both experienced and anticipated, associated with certain contraceptive methods such as placement of an intrauterine device, was a common deterrent for trans and gender diverse people seeking contraception [20, 39, 40, 42]. Approximately half of the participants in one study [39] reported dysphoria associated with examinations/procedures required to provide contraception as a barrier to care. In all studies where dysphoria related to contraception was described, dysphoria associated with taking hormonal contraception incongruent with gender identity was emphasised [20, 39, 40, 42]. One participant [20] articulated the distress of this, “Honestly, part of the reason why [I] wouldn’t want to go on hormonal birth control is because I don’t want to take estrogen [considered a “female” hormone]. And I think that’s related to dysphoria, and I just wouldn’t feel great, as somebody who doesn’t identify as a woman, taking estrogen.” This barrier often intersected with or was compounded by poor availability of information on contraception for trans and gender diverse people [20, 39, 42]. One participant [20] described this phenomena, “I would love to see it laid out where you have the pill you have the IUD and information about how it works. But also how might this interact with masculinizing hormones. I would love to see that tied in. I feel like that’s a stopping point for so many people; like how is it going to affect my transition?”.

These specific barriers faced by trans and gender diverse people are further exacerbated by many of the barriers that are faced by other people accessing contraceptive care. For example, the stigma associated with accessing contraception was also an issue faced by trans and gender diverse participants [20, 39, 58]. In one study [58] a transgender woman reported that she “never encountered talking about condoms with my doctor [and nurses] … because it’s like a taboo thing to talk about.”

One study [39] touched on the scarcity of providers in rural areas as a barrier for people, including trans and gender diverse, seeking contraception. One provider articulated, “People don’t go to the doctor. People don’t have PCPs [primary care providers]. People don’t go for yearly checkups or anything like that. People don’t use birth control at all…”.

Finally, the role that organisations and institutions played in directly prohibiting people, including trans and gender diverse people, from accessing contraception was described [58]. A study [58] conducted in the Philippines spoke of the role that the church played in preventing education around contraception, with one participant stating, “[The] church [fears] that when you introduce condoms…you are giving [the students] the signal that they can do sex everywhere.”

Reproductive cancer screening

16 studies [21, 27, 30, 31, 41, 45–47, 49, 57, 62–64, 69, 71, 72] examined barriers to reproductive cancer screening, specifically breast and cervical cancer screening, faced by trans and gender diverse people. No studies relating to prostate cancer screening were identified.

The degree to which financial barriers to reproductive cancer screening were exacerbated by certain insurance policies was represented in a number of studies [31, 45, 47, 71]. In one study [71], participants were reportedly denied insurance coverage for ‘Pap’ smears (i.e., a swab of cervical cells for cervical cancer screening) if their legal gender had been changed to male, resulting in some patients opting to miss their ‘Pap’ smears altogether.

In many studies, providers were unable to understand how the provision of cervical cancer screening might be modified to suit the needs of trans and gender diverse people [21, 27, 41, 62, 64, 69, 71, 72]. In one instance [72], upon being asked how the gynaecological exam might be made a more gender-neutral test, a clinician remarked, “I don’t even think I understand what that means to make it more male-friendly.”

Interpersonal discrimination was mentioned in multiple studies by trans and gender diverse patients and was often a significant deterrent to engaging with reproductive cancer screening services. In one study [27] a participant recounted, “I had met two health professionals … who expressed strong moral objections to the existence of transgender people, and refused to treat me and recommended religion as conversion treatment.” Anticipated discriminatory treatment was a common barrier [27, 30, 31, 71], with one study [31] identifying that 30% of transgender men delayed or had not had cervical screening due to concerns about how they would be treated as a trans and gender diverse person.

Poor provider knowledge was frequently cited as a barrier to reproductive cancer screening [21, 27, 30, 41, 47, 49, 57, 62–64, 71]. In one study [30] only 35% of practitioners were aware that breast cancer screening recommendations for transgender patients existed. As a consequence, the availability and provision of information to trans and gender diverse patients pertaining to reproductive cancer screening was frequently described as poor, a participant from one study [21] remarking, “I know that I still need to be concerned about breast cancer, I know that. But I’m not sure that I know … I’m not sure whether any of my doctors are the ones talking to me about any of these things.” There were also calls by trans and gender diverse patients for greater availability of trans and gender diverse specific resources and information sources in reproductive cancer screening [21, 27, 30].

A lack of consistent, standardised guidelines for the provision of reproductive cancer screening for trans and gender diverse people was discussed as a factor in preventing trans and gender diverse people from accessing appropriate care [30, 41, 47, 63]. Relating specifically to cervical screening, one study found that trans and gender diverse participants had been “largely invisible” in screening policies, with a patient in one study [41] describing, “Even [ …] a couple of years ago trans people with a cervix were not at all considered in health policy related to HPV [human papillomavirus] screening […] And really, still aren’t.”

In one study [62], political views were associated with differences in provider willingness to provide cervical cancer screening to transgender men. In this study [62], 86.7% and 100% of clinicians who identified as politically moderate and liberal respectively were willing to provide Pap smears to transgender men compared to only 44.4% of those who identified as conservative (p = 0.025).

Finally, dysphoria associated with reproductive cancer screening, especially cervical, was common [27, 31, 41, 45–47, 49, 69]. In one study [27] 82% of participants undergoing cervical cancer screening reported dysphoria related to the procedure. In some instances, anticipatory dysphoria was distressing enough for people to avoid screening altogether. One participant [45] summarised their dismay with the cervical cancer screening process, “…it is hard to undergo a procedure that reminds me of the body part I hate the most.”

Antenatal, intrapartum and postnatal care

A total of ten studies [22, 35, 37, 38, 43, 53, 56, 61, 65, 70] illustrated barriers to antenatal, intrapartum and postpartum care faced by trans and gender diverse people.

Discrimination in medical institutions was frequently cited as a barrier to receiving antenatal, intrapartum and postpartum care faced by trans and gender diverse people [37, 38, 43, 53, 56, 61, 65]. One way this manifested was through exclusionary administrative practices. Information systems were often reported as being unable to accommodate trans and gender diverse who needed obstetric or gynaecological care due to the inability of record systems to accommodate patients’ preferred name and gender identity, therefore, disallowing providers from providing gender-inclusive care regardless of their intentions [22, 38, 43, 53, 56, 61]. One study [56] examining the experiences of midwives working with trans and gender diverse people articulated this, “Traditionally we refer to our clients as ‘women.’ Maternity IT [information technology] systems are built to only process female records. No space to document gender or pronouns.” Alongside systemic discrimination, instances of interpersonal discrimination and prejudice were also documented [37, 38, 43, 53, 56, 61, 65, 70]. In one study [53] a participant recounted, “When I found out I was pregnant, the female Doctor at all times treated me as a woman even though I identified myself to her as a man. When I told her I was a trans man, she said, “well, that’s all right, girl.””

Cisnormative behaviours were often imbedded in language and clinical environments and were frequently described as a barrier to care for trans and gender diverse people in maternity settings [22, 35, 37, 38, 43, 53, 56, 61, 65, 70]. Participants in one study [35] found the cisnormative nature of the pregnancy care environment “alienating” and the prospect of being misgendered “a source of anxiety.” The awareness of cisnormative attitudes and behaviours in maternity settings was not isolated to patients; providers were also able to recognise the gendered nature of language in clinical spaces [56, 61], with a provider from one study [56] summarising, “Heteronormativity prevails within maternity departments.”

Many trans and gender diverse patients were unable to locate content and information pertaining to pregnancy specific to trans and gender diverse people [37, 38, 43]. Deficits in provider knowledge were also a key barrier in this domain [22, 35, 37, 38, 43, 56, 61, 65, 70]; in one study [70] a patient described this, “They were very eager to show how supportive they were, but none of them were really educated on the subject …I was in the position of knowing more than them about a subject … meaning that they were not wholly qualified to handle me as a patient.” Knowledge gaps were acknowledged by providers as well as patients; a study [22] examining the experiences of midwives providing care to transgender men described, “although most midwives thought that it would be exciting and instructive to meet a pregnant man, they also commented that the greatest challenge in this situation would be a lack of knowledge which might result in making mistakes.”

Finally, in one study [56], providers expressed lower confidence in their ability to provide safe antenatal, intrapartum and postnatal care to trans and gender diverse people. In this instance, midwifery and other staff demonstrated mean scores of 3.30 and 2.50 on a seven-point scale measuring their confidence in being able to provide effective care to childbearing transgender individuals and their confidence in their colleagues' ability to do the same, respectively.

Discussion

Main findings

The International Covenant on Economic, Social and Cultural Rights recognises, “the right of everyone to the highest attainable standard of physical and mental health” [73]. Four dimensions of the human rights approach to health are essential to achieving this: availability, accessibility, acceptability and quality (AAAQ) [1]. Thus, in this section, we briefly outline how our principal findings across the different SRH services examined relate to four dimensions of the ‘AAAQ’ framework, and thus how the identified barriers constitute limitations to the exercise of the rights of trans and gender diverse people.

Availability

A rights-based approach to health requires that functioning health services are available and in sufficient quantity [73]. The limited availability of SRH services and/or service providers was an especially pertinent issue for trans and gender diverse individuals living in rural and remote settings.

Accessibility

Accessibility encompasses non-discrimination, physical, economic and informational barriers and hence relates to a number of barriers identified across services [73]. In particular, the cost of SRH services was often described by trans and gender diverse individuals as a barrier to care and was particularly prominent in studies addressing ART and fertility care wherein cost discouraged or completely disallowed trans and gender diverse individuals from accessing services. The financial inaccessibility of services rooted in high costs was often compounded by exclusionary insurance practices that restricted or outright forbade trans and gender diverse people from obtaining coverage for SRH services.

Alongside cost, the inaccessibility of SRH services was consequent to certain discriminatory health system practices. Trans and gender diverse participants frequently described medical administrative systems that failed to accommodate non-cisgender identities at various stages along the continuum of care. Accessibility of SRH services was also impeded by deficits in information availability and provision to trans and gender diverse patients seeking care. In multiple instances, a paucity of patient information limited awareness of and subsequently access to SRH services. Finally, interpersonal discrimination experienced by trans and gender diverse individuals accessing SRH services was a frequent driver of service inaccessibility across multiple domains.

Acceptability

The concept of acceptability refers to health services that are medically and culturally appropriate, confidential and respectful of all [73]. Implicit in the latter is the gender responsiveness and inclusiveness of services that challenge both harmful gender norms and cis/heteronormativity to fully meet the specific needs of trans and gender diverse people. Factors concerning the acceptability of SRH services were often cited as barriers to care in included studies. Many trans and gender diverse patients described deficits in provider competence relating to the provision of care to trans and gender diverse patients and/or respectful engagement with trans and gender diverse identities. In several instances, these factors were enough to discourage further engagement in care. There were many instances where the services themselves were unacceptable to trans and gender diverse patients. For example, the potential for gender dysphoria associated with reproductive cancer screening was a significant deterrent in representation.

Quality

Rights based health services are those that are of good quality, scientifically and medically appropriate and delivered by skilled health workers [73]. This review found that the quality of SRH services was often undermined by a lack of adequate provider training. In many instances, providers reported having received minimal to no trans and gender diverse specific training or education. Concurrently, trans and gender diverse participants frequently recounted instances of inadequate care provision. A paucity of guidance on the provision of trans and gender diverse specific SRH was described and often reported as a detriment to the quality of care.

Shared and unique barriers faced by trans and gender diverse and cisgender patients

In many instances, the barriers to SRH services identified in this review were not unique to trans and gender diverse people. This finding echoes that of Morgan et al. who note that ‘gender-related stigma, bias and discrimination manifest within sexual health services for cisgender women, girls and transgender individuals’ and constitute limitations to their ‘bodily autonomy’ [74]. For example, the acceptability of certain SRH services, such as abortion care, is frequently impaired by stigma associated with accessing such services [75]. Structural gender-based discrimination also manifests in the accessibility of SRH services, especially cost, which is also frequently reported as a barrier to fertility care for both cisgender women and trans and gender diverse people [76]. Further, issues with the quality of SRH, such as deficits in adequately educated and trained SRH providers is also a barrier described across multiple settings and populations and reflects institutionalised gender bias in health systems towards the quality of services generally perceived to be related to ‘women’s health’ [77, 78].

The ways in which harmful and restrictive gender and other socio-cultural norms surrounding sexuality create additional challenges to accessing services for specific groups due to the perceived (in)appropriateness of sexual activity for young people, unmarried individuals, older persons, amongst others has been widely examined in the literature [79, 80]. However, the ways in which the heteronormative dimensions of gender-based discrimination constitute additional and specific barriers for trans and gender diverse populations has received less attention.

Our findings illustrate that although barriers experienced by trans and gender diverse people relate to the lack of gender responsive services – i.e. services that tackle harmful gender norms—additional reported barriers to SRH services frequently stemmed from or were exacerbated by deficits in gender-inclusive care. Specifically, discrimination against these populations by health systems and health and care providers formed the basis of and/or perpetuated several barriers identified in this review. This was commonplace among the included studies and were observed in every SRH domain except contraception. These barriers demonstrate that both health systems and providers are presently underprepared to deliver SRH outside a binary conceptualisation of gender identity.

Several barriers to SRH identified in this review are also unique to the experiences of trans and gender diverse patients, because they grapple with the capacity of health services to adequately address the intersections between SRH and gender-affirming care. For example, trans and gender diverse participants reported having to delay gender-affirming care whilst waiting to access fertility preservation. There were also multiple instances where gender dysphoria arose as a consequence of interventions used in both fertility care and reproductive cancer screening. These underly the importance of considering both how, and to what extent, SRH services align with gender-affirming care.

Comparison to existing literature

Data from other clinical contexts underscore how some barriers that trans and gender diverse highlighted in this review were not limited to SRH services. The results of a 2024 survey of more than 100,000 sexual and gender minority (LGBTIQ +) people in the EU identified that discrimination faced by trans and gender diverse people in health care was commonplace, exemplifying a key finding of our review [12]. In this survey, 40% of transgender men and 39% of transgender women reported experiencing discrimination in a health care setting [12].

One 2023 Australian survey on mental health service use by trans and gender diverse people reported some key barriers to accessing mental health services were financial costs (41.4%) and shortages of trained or competent practitioners (42.8%) [81]. Echoing the phenomena of insurance denials as a barrier to care for trans and gender diverse people found in our review, a 2021 systematic review investigating health-related needs of trans and gender diverse populations across a range of health care specialisations similarly identified that a lack of comprehensive insurance coverage severely impeded access to several health services [82]. The recurring barrier of inadequate provider education in transgender health was well described elsewhere in the literature. This was particularly salient in medical education, with one review finding that 74% of medical students reported receiving less than two hours of teaching dedicated to transgender health [83].

Practice and policy implications

Several of the barriers faced by trans and gender diverse people, particularly those related to the ways in which harmful gender norms manifest as structural discrimination and negatively impact upon acceptability and accessibility are shared by cisgender women (and amplified for specific population groups facing discrimination). Therefore, efforts to address these common barriers by seeking to dismantle these norms and make health systems more gender responsive would be beneficial to all people seeking these services, including trans and gender diverse people. To address the additional barriers faced by trans and gender diverse people identified in this review, these efforts must include specific measures to make health systems more gender-inclusive. For example, health insurance non-discrimination laws can ensure that SRH services are covered for all service users, regardless of gender identity, which could help to mitigate barriers stemming from service unaffordability. Similarly, where SRH services are funded and/or provided by national health systems, governments should ensure this extends to trans and gender diverse people. Health information management systems should ensure that logistics and information systems are accommodating of trans and gender diverse identities, as well as gender identity markers which may change. Relating to clinical guidance, SRH protocols and services should account for ways in which services can be inclusive of trans and gender diverse persons and adapted to needs which may be specific within this community. Examples of the former may include adapting health information management systems in pregnancy care settings to enable for the recording of multiple gender identities and pronouns, while examples of the latter may include systematic counselling to reduce potential gender dysphoria as part of gamete extraction when accessing fertility services. Additionally, civil society organisations representing the interests of trans and gender diverse persons are important resources and allies in tailoring SRH services to be more gender-inclusive and aligned with community needs.

Several barriers identified in this review stemmed from issues relating to health worker delivery of SRH. Equipping health workers with the skills and competencies to be able to deliver gender-inclusive SRH to trans and gender diverse people will be important in overcoming these barriers. Tangibly, this could include modifications to health care worker training and education. In formal training settings, such as medical and nursing schools, modifying curricula to ensure the incorporation of education specifically for trans and gender diverse people could be effective [83]. Delivering teaching through a long term and varied pedagogical approach that incorporates multiple methods of learning has been proven to be beneficial in improving educational outcomes [84]. For instance, case-based learning and simulated clinical environments represent evidence-based opportunities for students and trainees to improve competencies in engaging with trans and gender diverse identities prior to joining the workforce [83, 84]. Integrating this teaching organically and in a non-siloed manner enables for the delivery of relevant content without being resource or time intensive for education providers [85]. Providing future health care workers with opportunities to engage with trans and gender diverse persons in SRH settings may also be useful in combatting biases or misconceptions [86]. To achieve this, training organisations should invest in opportunities that facilitate interactions between students and trans and gender diverse persons in education and/or clinical settings [87]. Adapting these strategies to train/re-train existing health care workers will undoubtedly be beneficial in improving their abilities and confidence in delivering respectful care to trans and gender diverse patients in SRH settings. Finally, creating assessment mechanisms to evaluate health care students' and workers' competencies will be crucial for measuring the effectiveness of training and education, as well as elucidating which approaches yield tangible, long-term improvements in overall proficiency [83].

To mitigate distress associated with certain procedures that fall within SRH, health care workers should strive to uphold and maximise patient autonomy. For example, relating to cervical cancer screening, health care providers should actively explore and account for each patient’s experiences, needs and expectations prior to the procedure [88]. Further, health care workers should provide information on all screening options, including options for self-collection, if available [89]. Efforts to give patients control over the procedure should also be made, for example, enabling patients to insert the speculum themselves [88]. Importantly, all of these recommendations need to be delivered in close collaboration with community groups to ensure services are delivered in a way that is reflective of peoples’ desires.

Strengths and limitations

A key strength of this review was the diversity of SRH domains, services and clinical contexts in which barriers were examined. This breadth facilitated useful comparisons within and between each domain of SRH, ultimately allowing for the identification of both domain-specific and overarching barriers. The inclusion of multiple methodologies was beneficial in facilitating a comprehensive understanding of the barriers faced by trans and gender diverse people in SRH settings, from both lived experiences and quantitative evidence. The predominantly high quality of included studies was another strength of this review and strengthened the certainty of our findings. Further, the inclusion of evidence from both trans and gender diverse patients as well as care providers, who occupied a variety of different roles, was useful in appreciating barriers from multiple rather than a single perspective, and in contrasting the experiences of trans and gender diverse patients and providers. Our use of an inductive coding approach enabled for an organic development of themes wherein our analysis was guided by evidence that emerged throughout data extraction/synthesis. This approach prioritised the capturing of authentic experiences of trans and gender diverse patients and their providers rather than using preconceived categories. Finally, identifying barriers for a diverse range of SRH services, including those concerning reproductive health, enables for a more holistic approach to trans health rather than a narrow focus on disease (HIV/STI) prevention and treatment alone.

In conducting this review, we encountered several limitations. Firstly, only one study from a lower-middle income country and none from low-income countries were identified for inclusion. The scarcity of data from these settings may limit the generalisability of our findings. It must be anticipated that the barriers that trans and gender diverse people face in low- and middle-income settings are different to those in the high-income settings that composed this review. At the time of submission our search strategy was executed more than 12 months ago meaning recently published, eligible articles may not have been included. In many instances, data in certain domains were skewed to one group within the trans and gender diverse umbrella. In these examples, it is likely that these findings relate exclusively/more strongly to this group than to the entire trans and gender diverse community; this limitation is best reflected by the identification of only three AMAB-only studies.

Areas for future research

Despite the breadth of SRH domains and services included in this review, there were significant knowledge gaps that require further research. Firstly, no studies from low/middle income settings were identified for inclusion in this review. The limited representation of AMAB participants was encountered when conducting this review. More evidence capturing the experiences of AMAB individuals will be required to understand how barriers to SRH services affect this community. Greater investment in conducting trans and gender diverse-specific health research can help with this and better enable providers to deliver gender-inclusive care. Investment in clinical and medical research specific to this population can also help to generate important data to inform how gender-affirming care interacts with relevant aspects of sexual and reproductive health (e.g. reproductive tract cancers or use of hormonal contraception). Further, future research should prioritise understanding how intersectional considerations, such as participants’ ethnic identity, impact access to SRH services for trans and gender diverse people. Additionally, not all research needs to be community specific, SRH research can endeavour to recruit relevant trans and gender diverse persons who meet inclusion criteria (e.g. a contraception trial including trans men or gender diverse persons with similar reproductive capacity), and present data by both sex and gender identity to be able to better distinguish trans and gender diverse persons’ experiences.

Conclusion

Trans and gender diverse people face various, substantial barriers to SRH services globally. This review illustrated the extent to which these barriers persist throughout heterogenous domains of SRH and their significant impacts on the lives of trans and gender diverse people. These barriers unequivocally prevent trans and gender diverse people from fully exercising their right to health. These barriers and their implications necessitate urgent systems- and individual-level change to ensure that SRH is both gender responsive and gender-inclusive and thus attainable for all persons.

Abbreviations

SRH

Sexual and reproductive health

CASP

Critical Appraisal Skill Programme

WHO

World Health Organization

STI

Sexually transmitted infection

HIV

Human immunodeficiency virus

US

United States

ART

Assisted reproductive technology

LGBTIQ

Lesbian, gay, bisexual, intersex, queer

AFAB

Assigned female at birth

AMAB

Assigned male at birth

TNB

Trans and non-binary

IUD

Intrauterine device

PCP

Primary care provider

HPV

Human papillomavirus

IT

Information technology

AAAQ

Availability, accessibility, acceptability, quality

HRP

Human Reproduction Program

Authors’ contributions

AC and AN conceptualised this review. CLA and LM performed screening, data extraction and quality assessment. LG provided supervision and technical expertise throughout this research. CLA wrote the original draft manuscript with input and revisions made by all authors. All authors contributed to and approved the final manuscript.

Funding

This review was conducted with the financial support of the UNDP-UNFPA-UNICEFWHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization to CLA, LM, AN, AC and LG. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on request.

Declarations

Disclaimer

The named authors alone are responsible for the views expressed in this publication and do not necessarily represent the decisions or the policies of the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) or the World Health Organization (WHO).

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.