Abstract
Purpose:
This study aimed to explore potential factors impacting parental consent for gender-affirming medical care (GAMC) among transgender and nonbinary (TNB) young adults who desired GAMC as minors but were unable to receive it due to the lack of parental consent.
Methods:
Participants were recruited in 2023 from patients age 18–20 years old receiving care through Plume, a virtual GAMC provider, and completed a single online survey about their experiences. Post hoc pairwise comparisons were used to test for differences in potential facilitators of parental consent and the characteristics of doctors, other parents, and support groups by demographic characteristics.
Results:
Respondents (N = 224) indicated that parental interaction with supportive medical providers, other parents, and support groups may have aided in parental consent; meeting with a doctor supportive of GAMC was rated as most helpful. Desired characteristics of doctors, parents, and support groups varied by race, ethnicity, and rurality.
Conclusion:
Critical in addressing barriers to GAMC, these data aid in our understanding of the support needs of parents of TNB adolescents and how these needs vary by race, ethnicity, and rurality. These data support a need for GAMC education and support for a diverse workforce in subspecialist and primary care settings.
Keywords: adolescence, informed consent, nonbinary gender identity, parenting, transgender
Introduction
Transgender and nonbinary (TNB) youth face many barriers to receiving gender-affirming care, especially gender-affirming medical care (GAMC).1 These barriers include a dearth of medical providers with specialized training in the provision of this care, geographic challenges, legislative restrictions, and lack of parental consent.1,2 In nearly all U.S. states, parental consent is required for adolescents to receive GAMC under the age of 18.3 Thus, without parental consent, TNB adolescents are largely unable to receive this care.
Although parents play an important role in access to care for TNB youth, limited research has explored parents’ experiences of understanding and supporting their TNB child’s gender identity.4–6 The data available suggest that parents are often confused about their child’s experience and unsure of how to best support them, including decisions related to consenting to GAMC.4–6 Parents have expressed interest in having opportunities to meet with medical and mental health experts as well as other parents of TNB youth to better understand the potential risks and benefits of medical interventions and receive information on how other parents have navigated these decisions.4–6
Minimal prior research has been conducted exploring the experiences of TNB individuals who desired GAMC as minors but were unable to receive it. Insights from this group may aid in the development of tailored interventions to support TNB youth and their families. This study surveyed TNB individuals who sought GAMC but were unable to receive it prior to age 18 due to lack of parental consent. It aimed to explore TNB young adults’ perceptions regarding factors they felt may have impacted their parents’ willingness to consent for them to receive GAMC.
Methods
As described previously,7 we distributed an online survey to TNB young adults ages 18–20 who were seeking care through Plume, the largest virtual provider of GAMC for adults in the United States. The survey was developed in concert with advisory boards of TNB youth, TNB young adults, and parents and caregivers of TNB youth. Participants were recruited via email link sent to all Plume patients who opted to receive email communications in July 2023. Eligibility criteria included (i) seeking GAMC between the ages of 18 and 20 and (ii) having not received GAMC from a licensed provider prior to 18 years of age. After consenting, participants completed a 42-item survey in REDCap. Those who completed the survey received a $10 e-gift card. This study was approved by the Seattle Children’s Hospital Institutional Review Board.
The current article focuses on the results from survey items related to perceived facilitators of parental consent for GAMC (Supplementary Appendix SA1). Respondents were only included in this analysis if they (i) indicated a desire to receive GAMC prior to age 18 but had not received it, and (ii) indicated that lack of parental consent was a barrier to receiving this care.
Participant characteristics
Demographics included gender identity, race and ethnicity, and rural status. Gender identity was asked using two items, both developed in partnership with a TNB youth advisory board. The first asked, “Which of the following terms best describes your gender identity? We understand there are many different ways people identify, so please pick the one that best describes you.” Response choices included man, woman, nonbinary, or none of these. The second question allowed respondents to write in any additional terms used to describe their gender identity. Race/ethnicity was assessed with the question “What is your race/ethnicity?” with options of “First Nations/Indigenous/Native American/American Indian,” “Asian,” “Black and/or African American,” “Latine and/or Hispanic,” “Native Hawaiian or Other Pacific Islander,” “White,” and “Race, ethnicity or origin not listed above” with the option to fill in a response and to select all that apply.
Rural status was determined using the zip code in which the respondent spent the longest time during their adolescent years (ages 13–17). Zip codes were categorized as rural or nonrural based on designations from the Federal Office of Rural Health Policy.8
TNB-perceived facilitators of parental consent
Respondents were asked “How likely would each of the following have been to increase your parent’s/guardian’s willingness to provide consent for you to start gender-affirming medications before you turned 18” on a Likert scale from 0 to 5 (0 = very unlikely, 5 = very likely) with options including “Meeting a trans or gender diverse adult who has been taking gender-affirming medications for years,” “Attending a support group with other parents of trans or gender diverse adolescents,” “Meeting with another parent of a trans or gender diverse adolescent who is supportive of their child receiving gender-affirming medical care,” “Meeting with a faith leader who is supportive of gender-affirming medical care for adolescents,” “Meeting with a therapist who is supportive of gender-affirming medical care for adolescents,” “Meeting with a doctor who is supportive of gender-affirming medical care for adolescents,” “Being provided with accurate information through handouts or videos about gender-affirming medical care for adolescents,” and “Something else” with the option to write in another answer.
Those who selected “very likely” or “likely” for options related to meeting with a doctor, meeting with another parent, or attending a support group, were provided with additional questions about the characteristics of these doctors, other parents, or support groups, such as alignment with the TNB’s parent’s faith practice, race/ethnicity, and geography.
Data analysis
Descriptive statistics were used to characterize the sample and t-tests with post hoc pairwise comparisons were used to test for differences in potential facilitators of parental consent and the characteristics of doctors, other parents, and support groups by demographic characteristics. All comparisons used the Bonferroni correction to account for the family-wise error rate when conducting multiple tests, with the p level set to 0.05. Respondents were only included in this analysis if they had complete data on all variables of interest. All analyses were conducted in Stata 14.2 (StataCorp LP, College Station, TX).
Results
A total of 224 TNB respondents met study inclusion criteria and had complete data on all variables of interest, 42.4% of whom identified as men, 41.1% as women, and 16.5% as nonbinary (Table 1). The majority identified as White (66.5%). Nearly half of respondents lived in the South during adolescence (49.6%). Approximately 18% lived in a rural zip code during adolescence.
Table 1.
Sample Demographics
|
N = 224 n (%) |
|
|---|---|
| Gender identity | |
| Man | 95 (42.4) |
| Woman | 92 (41.1) |
| Nonbinary | 37 (16.5) |
| Race and ethnicity | |
| Asian | 5 (2.2) |
| Black/African American | 10 (4.5) |
| Latino/a/x/e or Hispanic | 24 (10.7) |
| White | 149 (66.5) |
| Multiracial | 36 (16.1) |
| U.S. region | |
| Northeast | 21 (9.4) |
| Midwest | 33 (14.7) |
| South | 111 (49.6) |
| West | 59 (26.3) |
| Rural status | |
| Nonrural | 184 (82.1) |
| Rural | 40 (17.9) |
TNB-perceived facilitators of parental consent
Overall, respondents (n = 224) indicated that “meeting with a doctor who is supportive of gender-affirming medical care for adolescents” was the most likely (mean = 3.17 ± 1.78) and “meeting with a faith leader who is supportive of gender-affirming medical care for adolescents” was the least likely (2.28 ± 2.00) to increase their parent/guardian’s willingness to consent to GAMC.
Among those who indicated that meeting with a doctor who is supportive of GAMC for adolescents would make their parents/guardians more likely to consent (n = 193), respondents indicated that “The provider had specific training in caring for trans and gender diverse youth” would be most helpful (3.92 ± 1.32) and “The provider shared the same ethnic or racial background as my parent” would be least helpful (1.63 ± 1.72) of all doctor characteristics.
Among those who indicated that meeting with another parent of a trans or gender diverse adolescent who is supportive of their child receiving GAMC would make their parents/guardians more likely to consent (n = 188), respondents indicated that “Had a child that was already receiving gender-affirming medical care” was the most important (3.63 ± 1.41) and “Race or ethnicity” was the least important (1.71 ± 1.83) of all parent characteristics.
Among those who indicated that a support group would make their parent more likely to consent (n = 186), respondents indicated that support groups that “Included other participants who were parents/guardians of adolescents who were already receiving gender-affirming medications” was most important (3.58 ± 1.40) and support groups that “Included other participants that shared my parent/guardian’s ethnic or racial background” was the least important (2.04 ± 1.91).
Differences by race/ethnicity
There were no statistically significant differences in the overall facilitators of parental consent by race and ethnicity; however, there were significant differences related to specific characteristics of the doctors, other parents, and support groups (Table 2). Among those who indicated that talking to a doctor would make their parent/guardian more likely to consent, Asian (mean = 3.25; t = 2.90, p < 0.05), Black/African American (3.80; t = 5.60, p < 0.001), Latino/a/x/e or Hispanic (2.86; t = 5.14, p < 0.001), and multiracial (2.30; t = 4.13, p < 0.01) respondents indicated that meeting a doctor who “shared the same ethnic or racial background as my parent” would be significantly more helpful than for White respondents (mean = 1.05).
Table 2.
Facilitators of Parental Consent by Race and Ethnicity
| Overall | Asiana | Black/African Americanb | Hispanic/Latino/a/x/ec | Whited | Multiraciale | |
|---|---|---|---|---|---|---|
| Mean (SD) | Mean (SD) | Mean (SD) | Mean (SD) | Mean (SD) | Mean (SD) | |
| Facilitators of parental consent | (n = 224) | (n = 5, 2.2%) | (n = 10, 4.5%) | (n = 24, 10.7%) | (n = 149, 66.5%) | (n = 36, 16.1%) |
| Meeting with a doctor who is supportive of gender-affirming medical care for adolescents | 3.17 (1.78) | 3.00 (2.00) | 4.40 (0.84) | 3.08 (1.77) | 3.11 (1.78) | 3.14 (1.88) |
| Doctor characteristics (n = 193) | ||||||
| Had specific training in caring for trans and gender diverse youth | 3.92 (1.32) | 4.00 (1.41) | 4.60 (0.70) | 3.81 (1.60) | 3.91 (1.28) | 3.83 (1.44) |
| Was providing my routine care (e.g., PCP) or ongoing mental health support | 3.80 (1.19) | 4.00 (0.82) | 4.60 (0.70) | 3.67 (1.39) | 3.76 (1.21) | 3.77 (1.10) |
| Shared the same religious or spiritual beliefs as my parent | 2.38 (2.01) | 3.25 (2.36) | 3.80 (1.87) | 2.52 (1.81) | 2.08 (1.99) | 3.00 (2.00) |
| Was trans or gender diverse | 1.94 (1.75) | 0.50 (1.00) | 2.70 (1.64) | 2.48 (1.89) | 1.80 (1.73) | 2.07 (1.78) |
| Was lesbian, gay, bisexual, or queer | 1.67 (1.64) | 0.00 (0.00) | 2.20 (1.55) | 1.90 (1.55) | 1.65 (1.67) | 1.67 (1.60) |
| Shared the same ethnic or racial background as my parent | 1.63 (1.72) | 3.25 (2.36)d | 3.80 (1.23)d | 2.86 (1.56)d | 1.05 (1.39)a,b,c,e | 2.30 (1.82)d |
| Meeting with another parent of a trans or gender diverse adolescent who is supportive of their child receiving gender-affirming medical care | 3.08 (1.79) | 2.00 (1.58) | 4.30 (0.95) | 3.33 (2.01) | 3.01 (1.78) | 3.00 (1.77) |
| Parent characteristics (n = 188) | ||||||
| Had a child that was already receiving gender-affirming medical care | 3.63 (1.41) | 4.50 (0.58) | 4.30 (0.82) | 3.95 (1.54) | 3.52 (1.40) | 3.52 (1.52) |
| Same gender identity as me | 3.48 (1.56) | 4.25 (0.50) | 4.00 (1.05) | 3.95 (1.61) | 3.37 (1.55) | 3.39 (1.71) |
| Political affiliation | 3.15 (1.72) | 3.25 (1.71) | 3.10 (1.85) | 2.47 (1.58) | 3.22 (1.69) | 3.29 (1.88) |
| Geographic area | 2.72 (1.78) | 3.25 (1.71) | 3.30 (1.83) | 3.32 (1.60) | 2.67 (1.77) | 2.32 (1.85) |
| Religious/spiritual beliefs | 2.58 (1.98) | 3.75 (1.50) | 3.80 (1.48) | 2.95 (1.72) | 2.20 (2.01)e | 3.32 (1.83)d |
| Socioeconomic status | 2.49 (1.67) | 3.00 (2.45) | 3.60 (1.58) | 2.84 (1.50) | 2.24 (1.66) | 2.84 (1.57) |
| Gender identity | 2.46 (1.73) | 2.25 (2.22) | 2.30 (1.57) | 2.63 (1.67) | 2.40 (1.76) | 2.68 (1.74) |
| Race or ethnicity | 1.71 (1.83) | 4.50 (1.00)d,e | 4.40 (0.84)d,e | 3.74 (1.15)d,e | 0.96 (1.34)a,b,c,e | 2.23 (1.91)a,b,c,d |
| Being provided with accurate information through handouts or videos about gender-affirming medical care for adolescents | 2.99 (1.90) | 1.60 (1.52) | 4.30 (1.06) | 2.88 (2.19) | 2.99 (1.85) | 2.92 (2.03) |
| Meeting with a therapist who is supportive of gender-affirming medical care for adolescents | 2.86 (1.71) | 2.00 (1.58) | 4.20 (0.92) | 2.83 (1.79) | 2.77 (1.71) | 3.03 (1.76) |
| Attending a support group with other parents of trans or gender diverse adolescents | 2.73 (1.69) | 1.60 (1.52) | 3.80 (0.92) | 2.79 (1.72) | 2.66 (1.71) | 2.83 (1.70) |
| Support group characteristics (n = 186) | ||||||
| Included other participants who were parents/guardians of adolescents who were already receiving gender-affirming medications | 3.58 (1.40) | 3.25 (1.71) | 3.70 (1.49) | 3.62 (1.60) | 3.53 (1.37) | 3.73 (1.41) |
| Run by a therapist who was supportive of medical care for trans and gender diverse adolescents | 3.41 (1.39) | 3.25 (1.50) | 4.10 (0.88) | 3.05 (1.40) | 3.44 (1.35) | 3.37 (1.65) |
| Run by another parent who was supportive of medical care for trans and gender diverse adolescents | 3.37 (1.34) | 2.75 (2.06) | 3.60 (0.97) | 3.43 (1.50) | 3.39 (1.31) | 3.27 (1.41) |
| Included other participants that shared my parent/guardian’s religious or spiritual beliefs | 2.80 (1.93) | 4.00 (0.82) | 3.80 (1.69) | 3.24 (1.79) | 2.50 (1.98) | 3.20 (1.77) |
| Run by a faith leader who was supportive of medical care for trans and gender diverse adolescents | 2.34 (1.95) | 2.75 (2.22) | 3.10 (1.66) | 2.86 (1.53) | 2.07 (1.97) | 2.80 (2.06) |
| Included other participants that shared my parent/guardian’s ethnic or racial background | 2.04 (1.91) | 4.00 (2.00)d | 4.40 (0.84)d,e | 3.67 (1.53)d | 1.36 (1.58)a,b,c,e | 2.57 (2.03)b,d |
| Meeting a trans or gender diverse adult who has been taking gender-affirming medications for years | 2.56 (1.66) | 2.20 (1.79) | 3.30 (0.82) | 3.04 (1.85) | 2.46 (1.65) | 2.47 (1.68) |
| Meeting with a faith leader who is supportive of gender-affirming medical care for adolescents | 2.28 (2.00) | 3.00 (2.12) | 3.50 (2.01) | 2.96 (1.90) | 1.98 (1.92) | 2.61 (2.19) |
Significantly different from those who identified as Asian.
Significantly different from those who identified as Black/African American.
Significantly different from those who identified as Hispanic/Latino/a/e/x.
Significantly different from those who identified as White.
Significantly different from those who selected 2+ races.
PCP, primary care provider; SD, standard deviation.
Regarding meeting with a parent of a TNB adolescent, Asian (4.50; t = 4.95, p < 0.001), Black/African American (4.40; t = 7.43, p < 0.001), Latino/a/x/e or Hispanic (3.74; t = 8.00, p < 0.001), and multiracial (2.23; t = 4.48, p < 0.001) participants indicated that the race and/or ethnicity of the parent was significantly more important than did White respondents (0.96). Similarly, this was also the case for Asian (t = 3.04, p < 0.05), Black/African American (t = 4.24, p < 0.001), and Latino/a/x/e or Hispanic (t = 3.68, p < 0.01) respondents compared with multiracial respondents. Notably, although this parent characteristic was rated lowest for the overall sample, it was among the highest-rated characteristics for meeting with another parent among Asian, Black, and Latino/a/x/e or Hispanic respondents.
Finally, Asian (4.00; t = 3.18, p < 0.05), Black/African American (4.40; t = 5.65, p < 0.001), Latino/a/x/e or Hispanic (3.67; t = 5.97, p < 0.001), and multiracial (2.57; t = 3.61, p < 0.01) respondents also indicated that support groups that “Included other participants that shared my parent/guardian’s ethnic or racial background” were more important than did White respondents (1.36). Black/African American respondents also indicated that support groups with participants sharing their parent/guardians ethnic or racial background were significantly more important than did multiracial respondents (4.40 vs. 2.57; t = 3.08, p < 0.05). Again, although this support group characteristic was scored as least important for the overall sample, it was among the most important characteristics among Asian, Black, and Latino/a/x/e or Hispanic respondents.
Differences by rurality
Respondents who lived in nonrural areas during adolescence indicated that “Meeting with a faith leader who is supportive of gender-affirming medical care for adolescents” would be more likely to facilitate parental consent than did respondents who lived in rural areas (2.40 vs. 1.70; t = −2.02, p < 0.05, Table 3). Among those who indicated that meeting with a doctor who is supportive of GAMC for adolescents would make their parents/guardians more likely to consent (n = 193), respondents who lived in rural areas during adolescence indicated that “The provider was providing my routine care (e.g., PCP) or ongoing mental health support” was significantly more helpful than respondents who lived in nonrural areas (4.26 vs. 3.72; t = 2.19, p < 0.05). There were no statistically significant differences in the importance of parent characteristics or support group characteristics by rural status.
Table 3.
Facilitators of Parental Consent by Rural Status
| Overall | Nonrural | Rural | t-Test, p | |
|---|---|---|---|---|
| Mean (SD) | n = 224 | n = 184, 82.1% | n = 40, 17.9% | |
| Meeting with a doctor who is supportive of gender-affirming medical care for adolescents | 3.17 (1.78) | 3.26 (1.70) | 2.77 (2.07) | t = −1.56, p = 0.12 |
| Doctor characteristics (n = 193) | ||||
| Had specific training in caring for trans and gender diverse youth | 3.92 (1.32) | 3.88 (1.37) | 4.19 (1.00) | t = 1.11, p = 0.27 |
| Was providing my routine care (e.g., PCP) or ongoing mental health support | 3.80 (1.19) | 3.72 (1.22) | 4.26 (0.86) | t = 2.19, p = 0.03* |
| Shared the same religious or spiritual beliefs as my parent | 2.38 (2.01) | 2.41 (2.00) | 2.22 (2.10) | t = −0.45, p = 0.66 |
| Was trans or gender diverse | 1.94 (1.75) | 1.92 (1.79) | 2.04 (1.53) | t = 0.32, p = 0.75 |
| Was lesbian, gay, bisexual, or queer | 1.67 (1.64) | 1.67 (1.63) | 1.70 (1.68) | t = 0.10, p = 0.92 |
| Shared the same ethnic or racial background as my parent | 1.63 (1.72) | 1.70 (1.75) | 1.15 (1.46) | t = −1.57, p = 0.12 |
| Meeting with another parent of a trans or gender diverse adolescent who is supportive of their child receiving gender-affirming medical care | 3.08 (1.79) | 3.12 (1.77) | 2.90 (1.88) | t = −0.70, p = 0.48 |
| Parent characteristics (n = 188) | ||||
| Had a child that was already receiving gender-affirming medical care | 3.63 (1.41) | 3.63 (1.40) | 3.61 (1.50) | t = −0.06, p = 0.95 |
| Same gender identity as me | 3.48 (1.56) | 3.49 (1.55) | 3.45 (1.63) | t = −0.13, p = 0.90 |
| Political affiliation | 3.15 (1.72) | 3.15 (1.73) | 3.16 (1.71) | t = 0.04, p = 0.97 |
| Geographic area | 2.72 (1.78) | 2.64 (1.77) | 3.16 (1.79) | t = 1.51, p = 0.13 |
| Religious/spiritual beliefs | 2.58 (1.98) | 2.59 (1.95) | 2.55 (2.17) | t = −0.10, p = 0.92 |
| Socioeconomic status | 2.49 (1.67) | 2.53 (1.67) | 2.29 (1.72) | t = −0.72, p = 0.47 |
| Gender identity | 2.46 (1.73) | 2.39 (1.74) | 2.81 (1.68) | t = 1.21, p = 0.23 |
| Race or ethnicity | 1.71 (1.83) | 1.75 (1.84) | 1.48 (1.77) | t = −0.75, p = 0.46 |
| Being provided with accurate information through handouts or videos about gender-affirming medical care for adolescents | 2.99 (1.90) | 3.01 (1.88) | 2.90 (2.01) | t = −0.33, p = 0.74 |
| Meeting with a therapist who is supportive of gender-affirming medical care for adolescents | 2.86 (1.71) | 2.95 (1.63) | 2.45 (2.01) | t = −1.68, p = 0.09 |
| Attending a support group with other parents of trans or gender diverse adolescents | 2.73 (1.69) | 2.78 (1.65) | 2.50 (1.85) | t = −0.96, p = 0.34 |
| Support group characteristics (n = 186) | ||||
| Included other participants who were parents/guardians of adolescents who were already receiving gender-affirming medications | 3.58 (1.40) | 3.53 (1.46) | 3.83 (1.02) | t = 1.10, p = 0.27 |
| Run by a therapist who was supportive of medical care for trans and gender diverse adolescents | 3.41 (1.39) | 3.39 (1.41) | 3.53 (1.28) | t = 0.51, p = 0.61 |
| Run by another parent who was supportive of medical care for trans and gender diverse adolescents | 3.37 (1.34) | 3.33 (1.39) | 3.57 (1.04) | t = 0.87, p = 0.39 |
| Included other participants that shared my parent/guardian’s religious or spiritual beliefs | 2.80 (1.93) | 2.72 (1.94) | 3.17 (1.86) | t = 1.15, p = 0.25 |
| Run by a faith leader who was supportive of medical care for trans and gender diverse adolescents | 2.34 (1.95) | 2.38 (1.92) | 2.17 (2.12) | t = −0.54, p = 0.59 |
| Included other participants that shared my parent/guardian’s ethnic or racial background | 2.04 (1.91) | 2.07 (1.95) | 1.87 (1.70) | t = −0.54, p = 0.59 |
| Meeting a trans or gender diverse adult who has been taking gender-affirming medications for years | 2.56 (1.66) | 2.64 (1.64) | 2.17 (1.72) | t = −1.62, p = 0.11 |
| Meeting with a faith leader who is supportive of gender-affirming medical care for adolescents | 2.28 (2.00) | 2.40 (2.00) | 1.70 (1.92) | t = −2.02, p = 0.04* |
p < 0.05.
Discussion
Although there is a growing body of literature exploring experiences and perceptions of both TNB youth and their parents seeking GAMC,9,10 less is known about TNB youth whose parents are not supportive of them receiving GAMC as adolescents. Due in part to a sampling self-selection bias, parents unwilling to consent to GAMC for TNB youth are hard to reach, making it challenging to involve them in research. Thus, perspectives shared in this study from TNB young adults who were unable to access care prior to age 18 due to lack of parental consent offer unique insight into ways to support this group.
These findings suggest that information and experiential support from medical providers supportive of GAMC could facilitate access to this care. This finding aligns with prior studies emphasizing the importance of medical provider expertise in GAMC while also highlighting the challenge of finding medical providers with this training and experience.11 One recent study suggested that while lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority community-relevant (LGBTQ+) curricular content in the U.S. medical schools has grown, it continues to remain inadequate to meet patient needs.12
Our findings suggest that Asian, Black/African American, Latino/a/x/e or Hispanic, and multiracial TNB young adults felt that meeting with doctors, other parents, and attending support groups with a shared racial or ethnic background would have been helpful for their parents and is an important step toward developing interventions to support TNB youth and their families. The perspectives of young adults in our study are also consistent with prior studies exploring parents’ experiences with support groups, wherein Black/African American and Latino/a/x/e or Hispanic parents noted that they often did not see others who looked like them or who understood the specific challenges they faced related to stigma and discrimination separate from their child’s TNB identity.5,13
It is also possible that parents who experience race or ethnicity-based stigma and discrimination need inclusive and culturally responsive support to process the likelihood that their child’s gender identity may compound the harms they experience through added transphobia. Although racial or ethnic background was rated of lowest importance in the full sample, it was among the highest for Asian, Black, and Latino/a/x/e or Hispanic participants, highlighting the unique support needs of those with multiple marginalized identities. As published previously, participants in this sample who identified as Indigenous, Black, and Latino/a/e/x shared that prior negative experiences related to race or ethnicity in health care served as a barrier to accessing GAMC, and prior research has highlighted the impact of Black primary care providers (PCPs) on improved life expectancy and reduced all-cause mortality for Black patients.14,15
For rural participants, it was especially important that the knowledgeable and supportive provider was their PCP. This adds to the small but growing body of literature highlighting unique challenges associated with being TNB and living in areas where geographical access to affirming specialty clinics is lacking.16–18 In addition, many individuals, especially those living in rural areas and/or from marginalized communities, have mistrust of medical spaces19–21 and reaching them through more trusted providers in their community may improve the likelihood that they are willing to learn more about the potential role of GAMC.
Limitations
This research should be considered in the context of the following limitations. Participants in this study were young adults receiving care online through Plume and, although similar demographically to others in their age group who have accessed care via Plume,22 their experiences and those of their parents may not be reflective of all TNB young adults and parents. This is also a study of young adult perceptions of facilitators related to parental consent and may not reflect the experiences and needs of the parents themselves.
In addition, this was a survey asking young adults to retrospectively consider what may have been impactful for their parents which may have biased responses. Although we did see differences by race, ethnicity, and rurality, we may have lacked sufficient diversity in our sample to detect some differences. Despite these limitations, this is one of few studies exploring perceptions related to parental needs of TNB young adults who were interested in GAMC, but unable to access it due to lack of parental consent.
Conclusion
Understanding potential facilitators of care for TNB youth is critical. For parents of color, having support from others of a shared race or ethnicity may be an important means to reduce barriers to TNB adolescents receiving care. Participants also identified the critical role of knowledgeable and supportive medical providers, and for rural participants, the importance of the medical provider being their PCP. The data support the need for continued efforts to provide education on GAMC in both subspecialist and primary care settings.
Acknowledgments
The authors would like to thank the Gender Research Stakeholder Program for their assistance in designing the survey and the participants who provided the data for this analysis.
Abbreviations Used
- GAMC
Gender-affirming medical care
- PCP
Primary care provider
- TNB
Transgender and nonbinary
Authors’ Contributions
P.G.A., M.A.K., R.S., D.A.C., W.P., and L.P.R. provided substantial contributions to writing the original draft, review, and editing. N.F.K. conceptualized the study, completed formal analysis and original draft writing, reviewing, and editing. M.A.K. and K.M.K. conceptualized and designed the study, drafted the original article, and reviewed the article. G.M.S. provided supervision as well as writing, reviewing, and editing. All authors approved the final article as submitted and agreed to be accountable for all aspects of the work.
Author Disclosure Statement
G.M.S. is a consultant for Pivotal Ventures. The authors have no other conflicts of interest to disclose relevant to this article.
Disclaimer
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Funding Information
This work was supported by grants from the Agency for Healthcare Research and Quality (K08HS0229028), the Seattle Children’s Research Institute Center for Diversity and Health Equity (HE-FY23-SG-19-SequeiraKahn), the Seattle Children’s Research Institute Career Development Award, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health (1K23HD109376).
Cite this article as: Kidd KM, Kahn NF, Asante PG, Kyweluk MA, Salyer R, Christakis DA, Pratt W, Richardson LP, Sequeira GM (2025) Transgender and nonbinary young adult-perceived facilitators of parental consent for gender-affirming medical care as a minor, Transgender Health 10:4, 386–393, DOI: 10.1089/trgh.2024.0230.
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