Gender-affirming health care needs, barriers to care, and health and wellbeing in a broad nationwide sample of transgender people in Norway

Silje-Håvard Bolstad; Norman Anderssen; Bjørge H Hansen; Ilan H Meyer

doi:10.1186/s12889-025-25243-1

. 2025 Dec 5;25:4218. doi: 10.1186/s12889-025-25243-1

Gender-affirming health care needs, barriers to care, and health and wellbeing in a broad nationwide sample of transgender people in Norway

Silje-Håvard Bolstad ^1,^✉, Norman Anderssen ^1,², Bjørge H Hansen ¹, Ilan H Meyer ³

PMCID: PMC12681104 PMID: 41350873

Abstract

Background

Transgender people report increased prevalence of mental distress and suicide attempts compared to the general population. Gender-based minority stressors such as discrimination and victimization are positively associated with mental health problems while social and medical gender transition is inversely associated with mental health problems. Barriers to accessing gender-affirming health care is reported by transgender people in many countries, including Norway which has a state-funded public health care system. The aim of the current study was to examine gender-affirming health care needs, barriers to care and health and wellbeing in a broad nationwide sample of transgender people in Norway.

Methods

A nationwide sample with 579 transgender participants completed an anonymous online survey during June-September 2023. Chi-square tests and ANOVA were used to examine differences between gender identity groups.

Results

Having obtained gender-affirming health care was more common among trans men and trans women as compared to nonbinary people. Participants generally reported being satisfied with the outcomes of gender-affirming hormonal and surgical treatments. Having obtained treatment entirely through private funding was reported by 32.5% of those using hormones and 49.5% of those who had obtained surgery. Not being able to afford hormones or surgery was reported by 45.9% and 65.5% among those with unmet treatment needs. Compared to trans men and trans women with unmet needs, nonbinary people with unmet needs were less likely to be under assessment or on a waiting list to obtain treatments. Of the total sample, 36.7% reported suicide attempts, 74.8% reported mental distress above clinical cut-off and 12.5% reported being satisfied with life.

Conclusions

Transgender people in Norway reported high levels of mental distress and suicidality. Despite being young and with low income, a large proportion had obtained gender-affirming medical treatments entirely through private funding. Transgender people in need of gender-affirming health care could benefit from increased access to care through the state-funded public health care system in Norway.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-025-25243-1.

Keywords: Transgender, Nonbinary, Gender incongruence, Gender-affirming, Health care, Barriers, Health

Background

Transgender people are individuals whose gender identity differs from their sex assigned at birth. This population includes people with diverse gender identities including trans men, trans women, and nonbinary people who identify as neither man nor woman, or as both, or in other ways that depart from the traditional gender binary [1, 2]. Recent population estimates based on studies in the U.S., Sweden, The Netherlands, Belgium, Taiwan and New Zealand vary from 0.3% to 4.5% among adults and from 1.2% to 8.4% among children and adolescents [3].

Research from various countries has documented mental health disparities in young [4], adult [5–7], older [8] as well as ethnic minority [9] transgender populations as compared to the general population. Studies find reduced quality of life [10] and increased prevalence of depression [11], anxiety [12] and suicide attempts [13–15] among transgender people. Furthermore, studies from many countries have shown that transgender people face prejudice [16–18]. Transgender people are more often victims of violence and other discrimination and harassment behaviors [6, 19–22]. The minority stress model suggests that prejudice towards transgender people causes health disparities [23, 24]. Gender-based minority stress such as victimization, family rejection, internalized transphobia and gender identity non-disclosure is positively associated with mental health problems [25–29].

Gender transition refers to the process of making changes, to express and affirm one’s gender identity rather than the sex assigned at birth. Specific transition milestones are common to many transgender people, such as first identifying as a gender other than the sex assigned at birth, telling others about their transgender status, living part- or full time in line with their gender identity, and seeking out transition-related health care such as counselling, hormonal treatment or surgical procedures [30–32]. Completing social and medical transition steps is inversely associated with mental health problems [33–36]. Gender-affirming hormone treatment is associated with improved quality of life and reduced mental health problems such as depression and anxiety [37–43]. Gender-affirming surgeries are associated with improved quality of life and reduced psychological distress and suicidality [44–47], and patients are generally satisfied with surgical outcomes [48–52]. Common limitations of the existing research are small sample sizes, recruitment only in clinical settings, samples based on narrow diagnostic criteria, and not differentiating between gender identity groups [53].

Transgender people in many countries experience barriers to accessing health care [54, 55], including primary health [56], mental health [57–59], and gender-affirming health care [60–65]. Barriers include financial burden when gender-affirming care is not covered by health insurance policies and policies of state-funded health care systems [66–68], lack of competency in transgender-specific issues among clinicians [69–71], long waiting times or assessment periods [72, 73], discrimination in health care settings [74, 75], and transgender people’s healthcare avoidance based on lived or anticipated discrimination [76, 77]. Furthermore, nonbinary people may experience additional barriers such as pressure to conform to a binary gender identity, lack of available information on gender-affirming treatment options specifically for nonbinary people, and insurance policies not covering gender-affirming care for nonbinary people [78, 79].

The Norwegian context

In Norway, transgender people are included in the Equality and Anti-Discrimination Act [80], which aims to “promote equality and prevent discrimination on the basis of gender, pregnancy. disability, sexual orientation, gender identity, gender expression or age”. Compared to other countries, Norway scores high on indexes of legal rights and public attitudes towards transgender and LGBTQ + people [81, 82]. Yet, 12–18% of the general population in Norway report negative attitudes toward transgender people [18]. In a nationwide study from 2020, 20–27% of transgender people had experienced discrimination or harassment over a year because of their gender identity, and 26–30% were victims of violence over five years, compared to 9% of cisgender people [6]. Compared to cisgender students, binary and nonbinary transgender students have increased odds of poor life satisfaction (3.78 and 3.12), mental health problems (2.48 and 4.07) and lifetime suicide attempt (5.56 and 6.12) [13].

Norway has universal health coverage [83]. Although private clinics are available, residents generally do not need to privately fund medically necessary health care, such as consultations, expensive prescription drugs and surgery. Publicly funded gender-affirming medical treatment is currently provided through one national clinic, which is divided into a section for adults and a section for children and youth. The clinic usually requires an assessment period of minimum one year, often including a psychiatric evaluation, and patients are expected to live in line with their gender identity in all life contexts throughout the assessment period [84]. Publicly funded hormone treatment, breast surgery, genital surgery, puberty blockers, permanent hair removal and voice training can be obtained by patients found eligible by the national clinic. In 2022, the section for adults received 647 referrals and started hormone treatment for 216 patients [85]. Recently established regional centers for gender incongruence provide non-medical care such as counselling.

Qualitative studies have documented that transgender people report extensive barriers to accessing gender-affirming medical treatments through the public health care system in Norway [61, 71, 86, 87]. In a study from 2023 with 24 interviews and a focus group, informants reported that they experienced the health care system to lack a general recognition of gender diversity, rejecting nonbinary people seeking gender-affirming care, and providing gender-affirming care based on a predefined transition pathway instead of individual treatment needs [61]. Some informants had sought private clinics despite having low income, and some could not afford private funding of their gender-affirming care.

Privately funded gender-affirming hormone treatment and breast surgery are offered by a very small number of physicians and surgeons in Norway. Gender-affirming facial surgery and privately funded genital surgery can only be obtained abroad.

Norwegian authorities are obliged to provide equal access to adequate transgender-specific health care to those who need it [88–90]. To improve access to and quality of health care, more research is needed on this heterogenous population.

Aim

The aim of the current study was to describe a broad nationwide sample of Norwegian transgender people and investigate differences between gender identity groups within the sample, in terms of sociodemographic characteristics, transition pathways, gender-affirming health care needs, experiences with care, and health and wellbeing.

Methods

Study design and recruitment

This study use data from TransNor, an anonymous online survey among transgender people in Norway, conducted from June 7th to September 3rd, 2023. Inclusion criteria were residing in Norway, being 16-year-old or older, and having a gender identity different from sex assigned at birth.

A range of recruitment strategies were employed (Fig. 1): posts in relevant social media channels (e.g., “Transgender in Scandinavia”, “Nonbinary and fluid Norway”); advertising through transgender and LGBT organizations; posters at transgender health clinics; posters at three large pride festivals (Oslo, Bergen and Kristiansand); and survey participants were encouraged to tell others about the survey.

Qualtrics was used as the survey tool. Participants could leave and come back within 72 h to complete the survey. The Qualtrics software had a CAPTCHA (completely automated public Turing test to tell computers and humans apart) to inhibit programmed responses.

The project had a transgender community advisory board of three representatives with extensive community participation and accumulated experience-based knowledge beyond their own personal experiences. Advisory board members had a high degree of involvement in general study design, development of the questionnaire, recruitment, and interpretation of findings. They were compensated for the time they worked on the project.

The study questionnaire was developed as an assembly of carefully considered validated instruments, and some items developed specifically for this study. Where Norwegian translations did not already exist, a forwards-backwards translation procedure was used. Only four questions were mandatory to answer. The questionnaire was piloted in terms of receiving extensive feedback from the advisory board and additional five transgender people regarding phrasing of items and response categories, meaningful and respectful introductions, and survey length.

Measures

Sociodemographic characteristics

To ensure participant anonymity and avoid the risk of indirect identification through compilation of variables, only a limited set of carefully considered sociodemographic variables was collected: age (assessed through 5-year-categories and reported as three age categories), having changed legal gender in the national registry (yes/no), size of residence (four categories), highest completed education level (two categories), annual income (three categories), currently in a relationship (no; yes with one person; yes with several persons), having own biological children (yes/no), and currently having care responsibilities for children (yes/no).

Gender identity

Based on considerations of power estimates, gender identity was assessed with three response options: man/trans man; woman/trans woman; and nonbinary. The nonbinary group was later stratified into two groups based on assigned sex at birth. It was explained to participants that for statistical purposes, only a limited number of gender identity categories were available. Gender identity was also assessed with an open question and with a continuous measure (not reported in this publication).

Gender-affirming health care

Transition-related counselling was assessed by two questions: have you ever wanted counselling or psychotherapy for your gender identity or transition (yes/no), and have you ever had such counselling (yes/no). Among those having obtained counselling, perceived therapist knowledge about transgender issues was assessed by a 4-point scale from “a lot” to “nothing”, or “I don’t know”, and perceived therapist supportiveness of transgender needs was assessed by a 5-point scale from “very supportive” to “very unsupportive” [21].

Gender-affirming medical treatments, i.e., hormone treatment and various types of surgery, were assessed by several questions (Figure A1 in Appendix A) and later combined into four options for each treatment type: obtained; unmet need; don’t know if they want; don’t want. Participants who had obtained hormones reported their current use of prescription and non-prescription sources. Participants who had obtained hormones or surgery indicated their outcome satisfaction on a 5-point scale from “very satisfied” to “very dissatisfied” and indicated the extent treatment had been obtained through state-funded public health care (all; most; some; none). Participants who had unmet needs for a treatment selected from a list of reasons for not yet having obtained the treatment.

A small number (n = 15) had obtained only “other” surgery (Figure A1), and because the type of procedure was unknown, these were excluded from the “obtained surgery” group (Table A6 and Table A7).

Transition progress

Participants’ transition progress was assessed by asking participants to rate on a horizontal visual 5-point scale how far they had come in a process of transition or change, from 1 (“I have thought about it, but not made any changes”) to 5 (“I have made most of the changes I want”). This was a slightly modified version of the approach developed by Budge and colleagues [91]. The score was analyzed as a continuous scale variable.

A small number (n = 11) responded that they did not want to make any changes, and a small number (n = 29) responded that they didn’t know, and these were excluded from analysis of transition progress.

General health

General health was assessed by an item with response options ranging from 1 (very good) to 5 (very bad) [92]. Responses were reported as three categories.

Life satisfaction

Life satisfaction was assessed by the Satisfaction With Life Scale (SWLS), a 5-item scale designed to measure global cognitive judgments of one’s life satisfaction, and not related constructs such as positive affect or loneliness [93]. Participants indicated to what extent they agreed with each item using a 7-point scale from 1 (strongly disagree) to 7 (strongly agree). The values of all items were summed, and the total score was analyzed as three categories: dissatisfied (5–19), neutral (20–25) and satisfied (26–35) [94]. The Cronbach’s alpha of the SWLS in the current study was 0.891.

Mental distress

Mental distress was assessed by the 10-item version of the Hopkins Symptom Checklist (HSCL-10). Participants indicated to what extent they had experienced symptoms of anxiety and depression during the last week, using a 4-point scale from 1 (not affected at all) to 4 (affected a lot). The values of all items were averaged, and the total score was analyzed dichotomously with a score of 1.85 as the clinical cut-off value (i.e., a predictor of a diagnosable mental disorder as assessed by clinical interview) [95]. The Cronbach’s alpha of the HSCL-10 in the current study was 0.895.

Social anxiety symptoms

Social anxiety symptoms were assessed by the shortened version of the Social Phobia Inventory (Mini-SPIN), a 3-item scale developed as a brief screening instrument for social anxiety disorder [96]. Participants indicated to what extent they had experienced typical symptoms of social anxiety during the last week, using a 5-point scale from 0 (not affected at all) to 4 (affected a lot). The values of all items were summed, and the total score was analyzed dichotomously with a score of 6 as the clinical cut-off value [96]. The Cronbach’s alpha of the Mini-SPIN in the current study was 0.822.

Suicide attempts

Suicide attempts were assessed by both lifetime occurrence and during the last 12 months (yes/no).

Statistical analysis

SPSS version 29.0 was used for statistical analysis. Chi-Square Test for Independence was used, with Cramer’s v as estimate of effect size (0.06 is considered a small effect, 0.17 a medium effect and 0.29 a large effect) [97]. Z-tests with Bonferroni correction were used for post hoc analyses, reported as subscript letters in table rows where each subscript letter denotes a subset of groups that do not differ significantly from each other at the 0.05 level. One-way analysis of variance (ANOVA) was used, with eta squared (η²) as estimate of effect size (0.01 is a small effect, 0.06 a medium effect and 0.14 a large effect) [97].

Results

Sociodemographic characteristics

Of the total sample, 37.0% identified as man or trans man, 33.7% as woman or trans woman, and 29.4% as nonbinary. Among participants assigned female at birth (AFAB), 38.9% identified as nonbinary, and among participants assigned male at birth (AMAB), 14.8% identified as nonbinary. Trans men and trans women were more likely to have changed legal gender, compared to nonbinary people (Table 1). The majority (74.8%) of the total sample were below 35 years of age, and trans men and nonbinary AFAB people were younger, had lower income and were less likely to have own biological children, compared to trans women and nonbinary AMAB people.

Table 1.

Sociodemographic characteristics by gender identity group

	Total		Man/trans man		Woman/trans woman		Nonbinary AFAB		Nonbinary AMAB		p-value
	n	(%)	n	(%)	n	(%)	n	(%)	n	(%)	p-value
Assigned sex at birth
AFAB	350	(60.4)	214				136
AMAB	229	(39.6)			195				34
Have changed legal gender	275	(47.6)	135	(63.1)^a	118	(60.8)^a	19	(14.0)^b	3	(8.8)^b	<.001
Age
16–24	202	(34.9)	93	(43.5)^a	45	(23.1)^b	58	(42.6)^a	6	(17.6)^b	<.001
25–34	231	(39.9)	85	(39.7)	79	(40.5)	52	(38.2)	15	(44.1)	.931
>34	146	(25.2)	36	(16.8)^a	71	(36.4)^b	26	(19.1)^a,c	13	(38.2)^b,c	<.001
Urban-rural
Oslo (capital; 709k)	142	(24.9)	49	(23.4)	52	(26.7)	33	(24.8)	8	(23.5)	.897
Large city (>100k)	159	(27.8)	49	(23.4)	55	(28.2)	44	(33.1)	11	(32.4)	.242
Medium city (20k-100k)	162	(28.4)	65	(31.1)	53	(27.2)	34	(25.6)	10	(29.4)	.697
Rural area	108	(18.9)	46	(22.0)	35	(17.9)	22	(16.5)	5	(14.7)	.512
Education level
Primary or high school	284	(49.8)	114	(54.3)	89	(46.1)	68	(51.1)	13	(38.2)	.199
College or university	286	(50.2)	96	(45.7)	104	(53.9)	65	(48.9)	21	(61.8)	.199
Annual income¹
NOK <300k	321	(60.2)	124	(66.0)^a	94	(49.2)^b	86	(71.7)^a	17	(50.0)^a,b	<.001
NOK 300k-500k	91	(17.1)	35	(18.6)	35	(18.3)	18	(15.0)	3	(8.8)	.471
NOK >500k	121	(22.7)	29	(15.4)^a	62	(32.5)^b	16	(13.3)^a	14	(41.2)^b	<.001
In a long-term relationship	261	(46.2)	92	(44.2)	93	(48.4)	58	(44.3)	18	(52.9)	.676
Biological children	69	(12.2)	9	(4.4)^a	39	(20.2)^b	12	(9.1)^a	9	(26.5)^b	<.001
Care resp. for children	65	(11.4)	14	(6.7)^a	26	(13.3)^a,b	15	(11.4)^a,b	10	(29.4)^b	.001

Open in a new tab

Each subscript letter denotes a subset of groups that do not differ significantly from each other at the .05 level

¹Median annual income in the general population of Norway was NOK 572k in 2022

Transition progress

Of the total sample, 82.6% were currently living as their self-identified gender always or almost always, and this was more common among transmen (93.5%), followed by transwomen (80.5%), nonbinary AFAB people (75.7%) and nonbinary AMAB people (52.9%) (p <.001) (Table A1). Similarly, the groups differed significantly in their transition progress. The proportion who had made most of the changes they wanted (socially, medically, or other) was higher among transmen (35.4%), followed by trans women (17.6%), nonbinary AFAB people (16.1%) and nonbinary AMAB people (0.0%) (p <.001).

Older participants have had more time to make changes and might have moved further in their transition process than younger participants. Therefore, we stratified the total sample by three age groups (Fig. 2 and Table A2). Higher age was associated with higher transition progress only among trans men (p <.001; η² = 0.07) and trans women (p <.001; η² = 0.12), while among nonbinary people, age was not significantly associated with transition progress.

Fig. 2 — Mean score on the transition progress scale (range 1–5) by gender identity group, stratified by age. 95% CI

Gender-affirming health care

The gender identity groups differed significantly in relation to gender-affirming health care, and effect sizes indicated large differences between the groups (Table 2). Having obtained gender-affirming health care was generally more common among trans men and trans women, as compared to nonbinary people. Unmet treatment needs for all different types of treatments were observed in every gender identity group. The proportion of respondents that did not want or did not know if they wanted a specific treatment differed among treatments.

Table 2.

Gender-affirming health care by gender identity group

	Total		Man/trans man		Woman/trans woman		Nonbinary AFAB		Nonbinary AMAB		p-value	Cramer’s v ¹
	n	(%)	n	(%)	n	(%)	n	(%)	n	(%)	p-value	Cramer’s v ¹
Transition-related counselling
Wanted and obtained	281	(49.6)	119	(57.2)^a	108	(56.0)^a	39	(29.3)^b	15	(45.5)^a,b	<.001	.23
Wanted but unmet need	161	(28.4)	40	(19.2)^a	41	(21.2)^a	69	(51.9)^b	11	(33.3)^a,b	<.001	.30
Did not want, but had	57	(10.1)	32	(15.4)^a	20	(10.4)^a,b	4	(3.0)^b	1	(3.0)^a,b	.001	.17
Did not want, did not have	68	(12.0)	17	(8.2)	24	(12.4)	21	(15.8)	6	(18.2)	.115	.10
Hormones
Obtained	341	(59.1)	158	(73.8)^a	135	(69.9)^a	36	(26.5)^b	12	(35.3)^b	<.001	.41
Unmet need	135	(23.4)	48	(22.4)	54	(28.0)	27	(19.9)	6	(17.6)	.267	.08
Don’t know if they want	74	(12.8)	7	(3.3)^a	1	(0.5)^a	55	(40.4)^b	11	(32.4)^b	<.001	.51
Don’t want	27	(4.7)	1	(0.5)^a	3	(1.6)^a	18	(13.2)^b	5	(14.7)^b	<.001	.27
Chest/breast surgery
Obtained	164	(28.4)	111	(51.9)^a	23	(11.8)^b,c	30	(22.4)^c	0	(0.0)^b	<.001	.42
Unmet need	237	(41.1)	96	(44.9)^a	77	(39.5)^a	59	(44.0)^a	5	(14.7)^b	.008	.14
Don’t know if they want	104	(18.0)	6	(2.8)^a	54	(27.7)^b	31	(23.1)^b	13	(38.2)^b	<.001	.32
Don’t want	72	(12.5)	1	(0.5)^a	41	(21.0)^b	14	(10.4)^b	16	(47.1)^c	<.001	.37
Internal genital surgery²
Obtained	93	(16.2)	49	(23.1)^a	30	(15.5)^a,b	14	(10.4)^b	0	(0.0)^c	<.001	.17
Unmet need	230	(40.1)	72	(34.0)^a	113	(58.2)^b	37	(27.6)^a	8	(23.5)^a	<.001	.27
Don’t know if they want	162	(28.2)	67	(31.6)^a	32	(16.5)^b	50	(37.3)^a	13	(38.2)^a	<.001	.19
Don’t want	89	(15.5)	24	(11.3)^a	19	(9.8)^a	33	(24.6)^b	13	(38.2)^b	<.001	.23
External genital surgery³
Obtained	44	(7.7)	13	(6.2)^a	28	(14.4)^b	3	(2.2)^a	0	(0.0)^a,b	<.001	.19
Unmet need	162	(28.3)	61	(29.0)^a	90	(46.2)^b	10	(7.5)^c	1	(2.9)^c	<.001	.35
Don't know if they want	192	(33.5)	90	(42.9)^a	47	(24.1)^b	40	(29.9)^a,b	15	(44.1)^a,b	<.001	.18
Don’t want	175	(30.5)	46	(21.9)^a	30	(15.4)^a	81	(60.4)^b	18	(52.9)^b	<.001	.40

Open in a new tab

Each subscript letter denotes a subset of groups that do not differ significantly from each other at the .05 level

¹Cramer’s v effect size: .06 is a small effect, .17 a medium effect and .29 a large effect

²Removal of testicles, ovaries and/or uterus

³Vaginoplasty, metoidioplasty or phalloplasty

Among trans women and nonbinary AMAB people, a proportion reported unmet needs for facial feminization surgery (44.1% and 29.4%), tracheal shave (28.7% and 14.7%) and voice feminization surgery (27.2% and 8.8%); only a small proportion of trans women had obtained such surgeries (5.6%, 5.1% and 1.5%) (Table A3).

Among participants who had obtained transition-related counselling, 39.5% perceived the therapist as having a high level of knowledge about transgender topics, and 76.3% perceived the therapist as supportive of their needs as a transgender person, and gender identity groups did not differ significantly (Table A4). Those who had counselling despite not wanting it did to a greater extent perceive the therapist as unsupportive, as compared to those who wanted the counselling (24.6% vs. 11.1%, p <.01, Table A5).

Participants who had obtained gender-affirming medical treatments generally reported high satisfaction with treatment outcomes (Table 3).

Table 3.

Experiences with gender-affirming treatments, and reasons for not yet having obtained treatments, by gender identity group¹

	Total		Man/trans man		Woman/trans woman		Nonbinary AFAB		Nonbinary AMAB		p-value
	n	(%)	n	(%)	n	(%)	n	(%)	n	(%)	p-value
Proportions among those who had obtained hormones (n=341)
Very or slightly satisfied with hormone treatment outcome	319	(93.3)	155	(98.1)^a	121	(89.0)^b	33	(91.7)^a,b	10	(83.3)^b	.008
Obtained hormones entirely through private funding	111	(32.5)	37	(23.4)^a	50	(36.8)^a,b	17	(47.2)^b	7	(58.3)^b	.003
Currently obtains hormones with prescription from a doctor	315	(94.6)	153	(97.5)^a	124	(93.2)^a	31	(96.9)^a	7	(63.6)^b	<.001
Currently obtains hormones from non-prescription sources	49	(14.7)	12	(7.6)^a	30	(22.6)^b,c	1	(3.1)^a,c	6	(54.5)^b	<.001
Proportions among those who had obtained surgery (n=186)
Very or slightly satisfied with surgery outcome	178	(95.7)	109	(95.6)	37	(94.9)	32	(97.0)			.907
Obtained surgery entirely through private funding	92	(49.5)	50	(43.9)	22	(56.4)	20	(60.6)			.148
Proportions among those who had unmet needs for hormones (n=135)
Unable to afford hormone treatment	56	(45.9)	18	(41.9)	20	(42.6)	15	(57.7)	3	(50.0)	.574
Currently under assessment for hormone treatment	73	(58.4)	30	(68.2)^a	36	(72.0)^a	5	(20.0)^b	2	(33.3)^a,b	<.001
Currently on a waiting list to start hormone treatment	27	(22.1)	11	(25.0)	12	(26.1)	3	(11.5)	1	(16.7)	.489
Consulted a health professional and was refused treatment	27	(22.3)	6	(13.6)	14	(31.1)	5	(19.2)	2	(33.3)	.214
Not obtained hormones because of fear of negative reactions from others	38	(31.4)	15	(34.1)	15	(33.3)	6	(23.1)	2	(33.3)	.784
Proportions among those who had unmet needs for surgery (n=397)
Unable to afford surgery	260	(65.5)	83	(58.0)^a	106	(67.1)^a,b	59	(77.6)^b	12	(60.0)^a,b	.030
Currently under assessment for surgery	147	(37.8)	60	(43.2)^a	70	(44.0)^a	16	(22.2)^b	1	(5.3)^b	<.001
Currently on a waiting list to obtain surgery	97	(25.7)	48	(35.3)^a	41	(27.5)^a	7	(9.6)^b	1	(5.3)^a,b	<.001
Consulted a health professional and was refused treatment	70	(18.5)	28	(20.4)	29	(19.3)	12	(16.4)	1	(5.3)	.419
Not obtained surgery because of fear of negative reactions from others	82	(21.5)	19	(14.0)^a	32	(21.1)^a,b	22	(29.7)^b	9	(45.0)^b	.003
The type of surgery needed is not available in Norway	165	(42.7)	49	(36.0)^a	88	(56.1)^b	19	(26.0)^a	9	(45.0)^a,b	<.001

Open in a new tab

Each subscript letter denotes a subset of groups that do not differ significantly from each other at the .05 level

¹Each table row represents a separate variable. Some variables had a small number of missing responses, and the table shows percentages of completed (non-missing) responses. See Table A6, A7, A8 and A9 for complete tables

More than half (58.4%) of the total sample had experienced discrimination related to their gender identity or expression when accessing health care and therefore had difficulties getting medical or mental health treatment (transition-related or other); gender identity groups did not differ significantly in their experience of discrimination (not shown in table). Barriers to care were evident both among people who had obtained gender-affirming treatments and among people who had unmet needs (Table 3). Among those having obtained hormones, one third had obtained it entirely through private funding, and this was more common among nonbinary people compared to trans men. Among those having obtained surgery, half had obtained it entirely through private funding. Among participants with unmet treatment needs, almost half could not afford hormones, more than half could not afford surgery, and one out of five had consulted a health professional but was refused treatment. Furthermore, compared to trans men and trans women with unmet needs, nonbinary people with unmet needs were less likely to be under assessment (i.e., having sought a medical/psychological evaluation of eligibility for treatment), less likely to be on a waiting list to obtain surgery (i.e., having been approved as eligible for treatment), and more likely to have not sought surgery because of fear of negative reactions from others. Currently obtaining hormones from non-prescription sources and having an unmet need for surgery that is not available in Norway were more common for feminizing than masculinizing treatments.

Health and wellbeing

Almost half of the participants reported good general health; almost two-thirds reported being dissatisfied with their life; three quarters reported clinical levels of mental distress, and more than one-third reported having attempted suicide (Table 4). Health and wellbeing mostly did not differ significantly between gender identity groups.

Table 4.

Health and wellbeing by gender identity group

	Total		Man/trans man		Woman/trans woman		Nonbinary AFAB		Nonbinary AMAB		p-value
	n	(%)	n	(%)	n	(%)	n	(%)	n	(%)	p-value
General health
Fairly bad or very bad	138	(23.9)	45	(21.1)	41	(21.0)	44	(32.6)	8	(23.5)	.060
Neither good nor bad	166	(28.8)	60	(28.2)	51	(26.2)	43	(31.9)	12	(35.3)	.568
Fairly good or very good	273	(47.3)	108	(50.7)^a	103	(52.8)^a	48	(35.6)^b	14	(41.2)^a,b	.010
Life satisfaction
Dissatisfied	354	(62.3)	120	(57.1)	124	(64.2)	86	(65.6)	24	(70.6)	.230
Neutral	143	(25.2)	58	(27.6)	47	(24.4)	30	(22.9)	8	(23.5)	.767
Satisfied	71	(12.5)	32	(15.2)	22	(11.4)	15	(11.5)	2	(5.9)	.370
Mental distress above clinical cut-off	431	(74.8)	162	(76.1)	141	(72.3)	104	(77.6)	24	(70.6)	.636
Social anxiety above clinical cut-off	302	(53.1)	119	(56.4)^a	86	(44.8)^a	78	(59.1)^a	19	(55.9)^a	.041
Suicide attempt
Ever	211	(36.7)	95	(44.6)^a	66	(34.0)^a	42	(31.3)^a	8	(23.5)^a	.015
Last 12 months	27	(4.7)	14	(6.6)	9	(4.6)	3	(2.3)	1	(2.9)	.298

Open in a new tab

Each subscript letter denotes a subset of groups that do not differ significantly from each other at the .05 level

Discussion

The aim of the study was to describe a broad national sample of Norwegian transgender people and investigate differences between gender identity groups within the sample. Roughly one third (37.0%) of the sample identified as man or trans man, one third (33.7%) as woman or trans woman, and one third (29.4%) as nonbinary, the latter being more common among AFAB (38.0%) than AMAB (14.8%) people. Having obtained gender-affirming health care was more common among trans men and trans women as compared to nonbinary people. Unmet needs for treatments were observed in every gender identity group. Having obtained treatment entirely through private funding was reported by one third (32.5%) of those who had obtained hormones and half (49.5%) of those who had obtained surgery. Approximately half (47.3%) of the total sample reported good general health, almost two-thirds (62.3%) reported low levels of life satisfaction, almost three quarters (74.8%) reported mental distress above clinical cut-off, and more than one third (36.7%) had ever attempted suicide.

Gender-affirming health care

Participants in our study generally reported being satisfied with the outcomes of gender-affirming hormonal and surgical treatments. This is in line with previous research [21, 48, 98].

As elaborated in the WPATH international standards for transgender health care (SOC8), treatment needs cannot be predicted for any individual based solely on their gender identity [32]. This was evident in the present study. We investigated five different types of gender-affirming health care: counselling, hormone treatment, chest/breast surgery, and internal and external genital surgery. Results clearly indicated differences in health care needs, not only between gender identity groups, but also within gender identity groups. Overall, the gender identity groups were internally heterogenous regarding treatment needs, i.e., a considerable proportion in every gender identity group did not want or did not know if they wanted specific treatments. Notable exceptions were that most trans men and trans women expressed a need for hormones, and most trans men expressed a need for chest surgery. One implication from these findings is that provision of gender-affirming health care should be tailored to individual treatment needs, and not solely be based on gender identity group membership.

Although the current study did not assess why participants did not know if they wanted specific treatments, several aspects may explain this. Lack of information about available treatment options, particularly for nonbinary people, could make treatment decisions more difficult [78]. More importantly, the need for a specific treatment, e.g., surgery, may be dependent on the outcome of a different treatment, e.g., hormones. Some may want to assess the bodily and psychological effects of hormone treatment, before making decisions about surgery. Decisions as well as uncertainty may also be dependent on other factors such as sexual needs, reproductive needs, relationship status and other life circumstances, and transgender people may consider benefits and risks related to treatment outcomes as well as social consequences of medical transition [99]. Thus, providers of health care must be attentive to the individual needs and life situations of patients.

Among participants who had obtained counselling or psychotherapy for their gender identity or transition, 39.5% perceived the therapist as having a high level of knowledge about transgender topics. Although the current study did not assess therapist level of knowledge directly, the results indicate a need for increased availability of therapists with adequate training in transgender topics. In Norway, this should be aimed for not only through regional or local transgender-specific health centers that are being established but also through public mental health services and school health services. Transition-related counselling can include affirmative exploration of gender identity and treatment needs, psychoeducation on the impact of minority stress and the internalization of prejudice, as well as promoting resilience such as identity pride and building supportive social networks.

Differences between trans men, trans women, and nonbinary people

Trans women, despite being older than trans men, reported lower transition progress and had to a lesser extent made the changes they wanted. For some trans women, feminization of body and gender expression might require a larger number of interventions or transition steps, such as permanent hair removal, voice training, facial feminization surgery and other surgical interventions, which may be less accessible, or simply too costly due to lack of coverage from the state-funded health care system. A growing body of research indicates that facial feminization surgeries are associated with improved quality of life and psychosocial outcomes [100–102].

Compared to trans men and trans women, nonbinary people reported lower transition progress and were to a lesser extent living as their self-identified gender. Nonbinary people may have a “less linear and more flexible transition pathway that may start at later stages in their lives and have a less specific end point” [31]. Nonbinary people may to a lesser extent desire gender-affirming medical interventions [103–105], and some research indicates that they to a lesser extent experience body discomfort [99, 106, 107], or their experiences are more diverse and differ from a traditional binary concept of gender dysphoria [108, 109]. However, some social and medical transition steps desired by nonbinary people might be unavailable to them. Nonbinary people may need a change of legal gender to affirm their gender identity, but the Norwegian government currently do not allow a third legal gender option in official identity documents [110], despite calls from The Norwegian Directorate for Children, Youth and Family Affairs for increased legal recognition of nonbinary people [111]. Traditionally, medical gender transition was based on a binary understanding of gender. Some nonbinary people may present with other treatment needs, such as tailored hormone treatment with lower dosage or duration [112–114] or masculinizing chest surgery to obtain a non-flat, androgynous-appearing chest instead of a flatter, masculine-appearing chest typically desired by trans men [115, 116]. Fear of negative reactions from others was a more common reason for not obtaining surgery among nonbinary people compared to trans men.

Barriers to care

Gender-affirming medical treatments are based on decades of clinical experience and research and has been found effective at reducing gender incongruence and gender dysphoria, and thus, are generally considered as medically necessary health care for transgender people in need of it [32]. This view is sometimes challenged, such as in discussions on appropriate care for transgender adolescents [117], nonbinary people, or for specific procedures such as facial feminization surgery [118]. In Norway, medically necessary health care is provided through the state-funded public health care system, and residents do not need private funding of such health care. Despite the existence of publicly funded gender-affirming care, a high proportion of participants in the sample, of which many were young and had low income, had obtained gender-affirming hormone treatment or surgery entirely through private funding. Among participants with unmet treatment needs, a high proportion reported that they could not afford treatment. This is particularly alarming given the high rates of mental distress reported by participants in our study, and evidence that gender-affirming health care is associated with reduced mental distress [36, 37, 40, 44, 45]. The findings indicate a need for increased access to medically necessary gender-affirming health care through the state-funded public health care system in Norway.

The current study did not directly assess reasons why participants chose privately funded care despite the existence of a publicly funded clinic. Multiple explanations can be hypothesized, such as long waiting times [61, 86], the one-year minimum assessment period currently required by the public clinic [84], concern that the psychiatric evaluation or readiness assessment could postpone or exclude access to treatment [119–121], the perception that providers lack recognition of gender diversity [61], experienced or anticipated exclusion of nonbinary people from care [61, 71, 78], and experienced or anticipated non-provision of individualized care such as tailored hormone treatment.

Some participants may have obtained treatment through private funding after being refused treatment from public health care. A limitation of the current study was that treatment refusal was only assessed among participants with unmet treatment needs, of which one out of five (18.5%−22.3%) had consulted a health professional and was refused treatment. Reasons for treatment refusals could be multitude and were not assessed in the current study. Important in this context, the WPATH Standards of Care have over time evolved from a gatekeeping model towards an informed consent model for gender-affirming care, with a shift in ethical considerations from “do no harm” to the core principle of patient autonomy, where expressed patient needs for gender-affirming care are given more weight [120].

Compared to trans men, nonbinary people were more likely to have obtained hormone treatment entirely through private funding. Compared to trans men and trans women with unmet needs for hormones or surgery, nonbinary people with unmet needs were less likely to be under assessment and less likely to be on a waiting list to obtain surgery. This may in part be due to public health care policies which implicitly or explicitly exclude nonbinary people from accessing gender-affirming medical treatments [61]. Some nonbinary people might feel pressure to present as more binary or conceal their nonbinary identity in clinical settings [78]. To reduce barriers to care, policies of state-funded health care should align with the WPATH Standards of Care (SOC8) which recommend that nonbinary people are provided individualized assessment and treatment that affirms their experience of gender [32].

Nonbinary AFAB people were less likely to have obtained transition-related counselling, and more likely to have unmet needs for counselling, as compared to trans men and trans women. Nonbinary people may avoid disclosing their gender identity because they anticipate or experience therapists and primary health care providers to lack specific knowledge about nonbinary identities and health care needs [122].

Having had transition-related counselling despite not wanting it was reported by 10.1% of the total sample, and these were less likely to perceive their therapist as supportive compared to those who wanted the counselling. Counselling or psychotherapy as a mandatory prerequisite for gender-affirming medical treatments is not recommended in the WPATH Standards of Care (SOC8) [32]. It can be a harmful barrier to care for those who do not need counselling or lack access to therapists with adequate training in transgender issues.

Of the total sample, 58.4% had experienced discrimination related to their gender identity or expression when accessing health care (transition-related or other). To prevent discrimination in health care settings, and make transgender people feel safe disclosing their transgender status, health service providers in general need up-to-date knowledge about transgender identities and health care needs [56, 123].

Health and wellbeing

In the current study of the transgender population in Norway, 36.7% of the total sample reported having ever attempted suicide. This is nearly 12 times compared to the general population of Norway (3.1%) [124]. In addition, 74.8% reported levels of mental distress above clinical cut-off, which is an almost fourfold prevalence compared to the general population (20%) [125]. Satisfaction with life was reported by 12.5%, which is lower than the general population (56.2%; results based on first author’s analysis of the Statistics Norway Quality of Life Survey 2023 dataset [126]). In terms of overall physical and mental health, 47.3% assessed their general health as very or fairly good, which is lower than the general population (68.0%) [125].

The health status of the total sample in the current study were generally in line with findings from previous studies on the transgender population in Norway. The 36.7% prevalence of suicide attempts resemble the 30–34% found in a nationwide transgender sample [6] but was higher than the 21.4–23.2% found in a sample of transgender students [13] and higher than the 27.0% found in a regional sample of transgender people [71]. The 74.8% prevalence of clinical mental distress found in the current study resembled the 71.4–74.6% reported by transgender students [13] but was higher than the 63.0–67.0% found in a nationwide transgender sample [6]. And the 47.3% proportion having good general health was lower than 56.0–57.0% found in a nationwide [6] and 56.0% found in a regional transgender sample [71].

It is important to note that the current study also documented positive outcomes and indicators of resilience. Approximately half (47.3%) of the study sample reported good general health, half (50.2%) had completed college- or university-level education, half (46.2%) were in a long-term relationship, and 11.4% had care responsibilities of children. The majority (82.6%) were living as their self-identified gender, and most participants had completed at least some of their desired transition steps. Among those having obtained gender-affirming medical treatments, a very large proportion (93.3% and 95.7%) were satisfied with the outcomes of hormone treatment and surgery. Obtaining gender-affirmation despite prejudice and structural barriers indicates agency and strength in the pursuit of good health and life satisfaction.

There were few significant differences between the gender identity groups on health and wellbeing. Previous research in various countries has been mixed on this issue, with some studies indicating better health and others worse health among nonbinary as compared to binary transgender people [127]. A meta-analysis of 21 studies from six countries found that nonbinary youth reported poorer general mental health than binary transgender youth, while no significant differences was found on depressive symptoms, anxiety, or lifetime or past year suicide attempts, with moderate heterogeneity among studies [128]. Transgender people face challenges that are shared by gender identity groups within this population, as well as challenges that are unique or more pronounced for specific gender identity groups, which may vary across culture and social context.

The study sample comprised participants that were currently at various stages of transition, i.e., pre-transition, mid-transition, and post-transition. Gender minority stress can be experienced regardless of transition status. Lifetime and past year suicide attempts as well as mental distress reported by participants can be influenced by factors unrelated to minority stress and gender transition. However, several empirical studies and reviews clearly indicate that minority stressors such as discrimination, victimization and non-affirmation of gender identity are positively associated with mental distress and suicidality [24, 25, 29]. Conversely, obtaining medically necessary gender-affirming health care is negatively associated with mental distress and suicidality [37, 43–45]. Thus, having unmet needs for gender-affirming care and experiencing barriers to such care could lead to prolonged mental health problems and reduced quality of life [47, 129–131]. This points to a need for increased access to medically necessary gender-affirming health care through the state-funded public health care system in Norway.

Strengths and limitations

The relatively large sample size, with a good distribution across gender identity groups within the study population, allowed for detailed descriptive statistics on variables of high relevance for the study population. Using non-probability sampling techniques is considered an appropriate method for recruiting hard-to-reach and stigmatized populations, but it carries a risk of selection bias. We used multiple parallel recruitment strategies to ensure diversity of survey participants. Although a large proportion of participants were of younger ages, the sample had a broad distribution on key variables such as gender identity, sociodemographic characteristics, transition progress, health care needs, treatment status and experiences with heath care. Since we do not know to what extent the sample is representative of the transgender population in Norway, generalizations should be made with caution.

An important strength of the current study was the high level of involvement of a transgender community advisory board in study design and implementation. This contribution strengthened the relevance and precision of research themes, survey questions and interpretation of findings.

Extensive questionnaire piloting regarding aspects such as phrasings, meaningfulness and length likely contributed to high survey participation and completion rates.

Conclusions

Supplementary Information

Supplementary Material 1.^{(299.4KB, pdf)}

Acknowledgements

The authors want to thank the transgender community advisory board (Luca Dalen Espseth, Christine Marie Jentoft and Aleksander Sørlie) for their significant contributions and efforts in the project. The authors also want to thank all participants who completed the survey and provided valuable information.

Abbreviations

AFAB: Assigned female at birth
AMAB: Assigned male at birth
NOK: Norwegian Krone
U.S.: United States
SWLS: Satisfaction With Life Scale
HSCL: Hopkins Symptom Checklist
SPIN: Social Phobia Inventory
ANOVA: Analysis of variance
SoMe: Social media
CAPTCHA: Completely automated public Turing test to tell computers and humans apart
WPATH: World Professional Association for Transgender Health
SOC8: Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Authors’ contributions

SHB was responsible for conceptualization and design of the study, and for acquisition, analysis and interpretation of data, and for drafting and revising all parts of the manuscript. NA contributed to the acquisition of data. NA, BHH and IHM contributed to conceptualization and reviewed the manuscript. All authors read and approved the final manuscript.

Funding

Open access funding provided by University of Agder. The project was funded by the University of Agder, Norway.

Data availability

The datasets generated and/or analyzed during the current study will be available in the Sikt public archive after the doctoral project is completed: https://sikt.no/en/tjenester/finn-data/survey-bank.

Declarations

Ethics approval and consent to participate

The project was approved by the Research Ethics Committee (FEK) at the Faculty of Health and Sport Sciences, University of Agder (RITM0216904). The study adhered to the Declaration of Helsinki. Participants provided electronic informed consent after having received detailed information about the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

1.Liszewski W, Peebles JK, Yeung H, Arron S. Persons of nonbinary Gender - Awareness, Visibility, and health disparities. N Engl J Med. 2018;379(25):2391–3. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Monro S. Non-binary and genderqueer: an overview of the field. Int J Transgend. 2019;20(2–3):126–31. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Zhang Q, Goodman M, Adams N, Corneil T, Hashemi L, Kreukels B, Motmans J, Snyder R, Coleman E. Epidemiological considerations in transgender health: A systematic review with focus on higher quality data. Int J Transgend Health. 2020;21(2):125–37. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Mezzalira S, Scandurra C, Mezza F, Miscioscia M, Innamorati M, Bochicchio V. Gender felt pressure, affective domains, and mental health outcomes among transgender and gender diverse (TGD) children and adolescents: a systematic review with developmental and clinical implications. Int J Environ Res Public Health. 2022;20(1):785. [DOI] [PMC free article] [PubMed]
5.Pinna F, Paribello P, Somaini G, Corona A, Ventriglio A, Corrias C, Frau I, Murgia R, El Kacemi S, Galeazzi GM, et al. Mental health in transgender individuals: a systematic review. Int Rev Psychiatry. 2022;34(3–4):292–359. [DOI] [PubMed] [Google Scholar]
6.Anderssen N, Eggebø H, Stubberud E, Holmelid Ø. Seksuell orientering, kjønnsmangfold og levekår. Resultater fra spørreundersøkelsen 2020 [Sexual orientation, gender diversity and living conditions. Results from the survey 2020]. Bergen: Institutt for samfunnspsykologi, Universitetet i Bergen; 2021.
7.Kidd JD, Tettamanti NA, Kaczmarkiewicz R, Corbeil TE, Dworkin JD, Jackman KB, Hughes TL, Bockting WO, Meyer IH. Prevalence of substance use and mental health problems among transgender and cisgender U.S. Adults: results from a National probability sample. Psychiatry Res. 2023;326:115339. [DOI] [PMC free article] [PubMed] [Google Scholar]
8.Lampe NM, Barbee H, Tran NM, Bastow S, McKay T. Health disparities among Lesbian, Gay, Bisexual, Transgender, and Queer older adults: a structural competency approach. Int J Aging Hum Dev. 2024;98(1):39–55. [DOI] [PMC free article] [PubMed] [Google Scholar]
9.Robertson L, Akre ER, Gonzales G. Mental health disparities at the intersections of gender identity, race, and ethnicity. LGBT Health. 2021;8(8):526–35. [DOI] [PubMed] [Google Scholar]
10.Nobili A, Glazebrook C, Arcelus J. Quality of life of treatment-seeking transgender adults: a systematic review and meta-analysis. Rev Endocr Metab Disord. 2018;19(3):199–220. [DOI] [PMC free article] [PubMed] [Google Scholar]
11.Borgogna NC, McDermott RC, Aita SL, Kridel MM. Anxiety and depression across gender and sexual minorities: implications for transgender, gender nonconforming, pansexual, demisexual, asexual, queer, and questioning individuals. Psychol Sex Orientat Gend Divers. 2019;6(1):54–63. [Google Scholar]
12.Millet N, Longworth J, Arcelus J. Prevalence of anxiety symptoms and disorders in the transgender population: A systematic review of the literature. Int J Transgenderism. 2016;18(1):27–38. [Google Scholar]
13.Anderssen N, Sivertsen B, Lønning KJ, Malterud K. Life satisfaction and mental health among transgender students in Norway. BMC Public Health. 2020;20(1):138. [DOI] [PMC free article] [PubMed] [Google Scholar]
14.Vigny-Pau M, Pang N, Alkhenaini H, Abramovich A. Suicidality and non-suicidal self-injury among transgender populations: a systematic review. J Gay Lesbian Ment Health. 2021;25(4):358–82. [Google Scholar]
15.Anderson AM, Mallory AB, Alston AD, Warren BJ, Morgan E, Bridge JA, Ford JL. Sociodemographic factors associated with suicide outcomes in transgender and gender diverse young adults. Arch Suicide Res. 2025;29(2):392–406. [DOI] [PubMed]
16.Ipsos. Ipsos LGBT+ Pride report 2024. Paris: Ipsos; 2024.
17.Hatch HA, Warner RH, Broussard KA, Harton HC. Predictors of transgender prejudice: a meta-analysis. Sex Roles. 2022;87(11–12):583–602. [Google Scholar]
18.Opinion. Befolkningens holdninger til lhbtiq personer. Rapport fra en spørreundersøkelse [The general population’s attitudes towards lhbtiq people. Report from a survey]. Oslo: Bufdir/Opinion; 2022.
19.Borgogna NC, Lathan EC, Aita SL. Sexual and gender minority victimization: base rates of assault in college students across sexual and gender identities. J Interpers Violence. 2023;38(7–8):5613–37. [DOI] [PubMed] [Google Scholar]
20.Lian Q, Li R, Liu Z, Li X, Su Q, Zheng D. Associations of nonconforming gender expression and gender identity with bullying victimization: an analysis of the 2017 youth risk behavior survey. BMC Public Health. 2022;22(1):650. [DOI] [PMC free article] [PubMed] [Google Scholar]
21.James SE, Herman JL, Durso LE, Heng-Lehtinen R. Early insights: A report of the 2022 U.S. Transgender survey. In. Washington, DC: National Center for Transgender Equality; 2024. [Google Scholar]
22.Flores AR, Meyer IH, Langton L, Herman JL. Gender identity disparities in criminal victimization: National crime victimization survey, 2017–2018. Am J Public Health. 2021;111(4):726–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
23.Testa RJ, Habarth J, Peta J, Balsam K, Bockting W. Development of the gender minority stress and resilience measure. Psychol Sex Orientat Gend Divers. 2015;2(1):65–77. [Google Scholar]
24.Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674–97. [DOI] [PMC free article] [PubMed] [Google Scholar]
25.Pellicane MJ, Ciesla JA. Associations between minority stress, depression, and suicidal ideation and attempts in transgender and gender diverse (TGD) individuals: systematic review and meta-analysis. Clin Psychol Rev. 2022;91:102113. [DOI] [PubMed] [Google Scholar]
26.Tan KKH, Treharne GJ, Ellis SJ, Schmidt JM, Veale JF. Gender minority stress: a critical review. J Homosex. 2020;67(10):1471–89. [DOI] [PubMed] [Google Scholar]
27.Testa RJ, Michaels MS, Bliss W, Rogers ML, Balsam KF, Joiner T. Suicidal ideation in transgender people: gender minority stress and interpersonal theory factors. J Abnorm Psychol. 2017;126(1):125–36. [DOI] [PubMed] [Google Scholar]
28.Klein A, Golub SA. Family rejection as a predictor of suicide attempts and substance misuse among transgender and gender nonconforming adults. LGBT Health. 2016;3(3):193–9. [DOI] [PubMed] [Google Scholar]
29.Wilson LC, Newins AR, Kassing F, Casanova T. Gender minority stress and resilience measure: a meta-analysis of the associations with mental health in transgender and gender diverse individuals. Trauma Violence Abuse. 2024;25(3):2552–64. [DOI] [PubMed] [Google Scholar]
30.Scandurra C, Carbone A, Baiocco R, Mezzalira S, Maldonato NM, Bochicchio V. Gender identity milestones, minority stress and mental health in three generational cohorts of Italian binary and nonbinary transgender people. Int J Environ Res Public Health. 2021;18(17):9057. [DOI] [PMC free article] [PubMed]
31.Tatum AK, Catalpa J, Bradford NJ, Kovic A, Berg DR. Examining identity development and transition differences among binary transgender and genderqueer nonbinary (GQNB) individuals. Psychol Sex Orientat Gend Divers. 2020;7(4):379–85. [Google Scholar]
32.Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, Ettner R, Fraser L, Goodman M, Green J, et al. Standards of care for the health of transgender and gender diverse People, version 8. Int J Transgender Health. 2022;23(sup1):S1–259. [DOI] [PMC free article] [PubMed] [Google Scholar]
33.Hughto JMW, Gunn HA, Rood BA, Pantalone DW. Social and medical gender affirmation experiences are inversely associated with mental health problems in a U.S. non-probability sample of transgender adults. Arch Sex Behav. 2020;49(7):2635–47. [DOI] [PMC free article] [PubMed] [Google Scholar]
34.Klein H, Washington TA. Transition milestones, psychological distress, and suicidal ideation among transgender adults: a structural equation analysis. Omega (Westport). 2023;8:302228231221308. [DOI] [PubMed]
35.Thoma BC, Jardas EJ, Choukas-Bradley S, Salk RH. Perceived gender transition progress, gender congruence, and mental health symptoms among transgender adolescents. J Adolesc Health. 2023;72(3):444–51. [DOI] [PMC free article] [PubMed] [Google Scholar]
36.Ireland K, Hughes M, Dean NR. Do hormones and surgery improve the health of adults with gender incongruence? A systematic review of patient reported outcomes. ANZ J Surg. 2025;95(5):864–77. [DOI] [PMC free article] [PubMed] [Google Scholar]
37.Baker KE, Wilson LM, Sharma R, Dukhanin V, McArthur K, Robinson KA. Hormone therapy, mental health, and quality of life among transgender people: a systematic review. J Endocr Soc. 2021;5(4):bvab011. [DOI] [PMC free article] [PubMed] [Google Scholar]
38.Doyle DM, Lewis TOG, Barreto M. A systematic review of psychosocial functioning changes after gender-affirming hormone therapy among transgender people. Nat Hum Behav. 2023;7(8):1320–31. [DOI] [PMC free article] [PubMed] [Google Scholar]
39.Fisher AD, Castellini G, Ristori J, Casale H, Cassioli E, Sensi C, et al. Cross-sex hormone treatment and psychobiological changes in transsexual persons: two-year follow-up data. J Clin Endocrinol Metab. 2016;101(11):4260–9. [DOI] [PubMed] [Google Scholar]
40.Tordoff DM, Wanta JW, Collin A, Stepney C, Inwards-Breland DJ, Ahrens K. Mental health outcomes in transgender and nonbinary youths receiving gender-affirming care. JAMA Netw Open. 2022;5(2):e220978. [DOI] [PMC free article] [PubMed] [Google Scholar]
41.Green AE, DeChants JP, Price MN, Davis CK. Association of gender-affirming hormone therapy with depression, thoughts of suicide, and attempted suicide among transgender and nonbinary youth. J Adolesc Health. 2022;70(4):643–9. [DOI] [PubMed] [Google Scholar]
42.Chen D, Berona J, Chan YM, Ehrensaft D, Garofalo R, Hidalgo MA, et al. Psychosocial functioning in transgender youth after 2 years of hormones. N Engl J Med. 2023;388(3):240–50. [DOI] [PMC free article] [PubMed] [Google Scholar]
43.Aldridge Z, Patel S, Guo B, Nixon E, Pierre Bouman W, Witcomb GL, et al. Long-term effect of gender-affirming hormone treatment on depression and anxiety symptoms in transgender people: a prospective cohort study. Andrology. 2021;9(6):1808–16. [DOI] [PubMed] [Google Scholar]
44.Almazan AN, Keuroghlian AS. Association between gender-affirming surgeries and mental health outcomes. JAMA Surg. 2021;156(7):611–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
45.Swan J, Phillips TM, Sanders T, Mullens AB, Debattista J, Brömdal A. Mental health and quality of life outcomes of gender-affirming surgery: a systematic literature review. J Gay Lesbian Ment Health. 2022;27(1):2–45. [Google Scholar]
46.Alcon A, Kennedy A, Wang E, Piper M, Loeliger K, Admassu N, et al. Quantifying the psychosocial benefits of masculinizing mastectomy in trans male patients with patient-reported outcomes: the university of California, San Francisco, gender quality of life survey. Plast Reconstr Surg. 2021;147(5):e731-40. [DOI] [PubMed] [Google Scholar]
47.Branstrom R, Pachankis JE. Reduction in mental health treatment utilization among transgender individuals after gender-affirming surgeries: a total population study. Am J Psychiatry. 2020;177(8):727–34. [DOI] [PubMed] [Google Scholar]
48.Javier C, Crimston CR, Barlow FK. Surgical satisfaction and quality of life outcomes reported by transgender men and women at least one year post gender-affirming surgery: a systematic literature review. Int J Transgender Health. 2022;23(3):255–73. [DOI] [PMC free article] [PubMed] [Google Scholar]
49.Olson-Kennedy J, Warus J, Okonta V, Belzer M, Clark LF. Chest reconstruction and chest dysphoria in transmasculine minors and young adults: comparisons of nonsurgical and postsurgical cohorts. JAMA Pediatr. 2018;172(5):431–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
50.Ascha M, Sasson DC, Sood R, Cornelius JW, Schauer JM, Runge A, et al. Top surgery and chest dysphoria among transmasculine and nonbinary adolescents and young adults. JAMA Pediatr. 2022;176(11):1115–22. [DOI] [PMC free article] [PubMed] [Google Scholar]
51.Park RH, Liu YT, Samuel A, Gurganus M, Gampper TJ, Corbett ST, et al. Long-term outcomes after gender-affirming surgery: 40-year follow-up study. Ann Plast Surg. 2022;89(4):431–6. [DOI] [PubMed] [Google Scholar]
52.Day DL, Klit A, Lang CL, Mejdahl MK, Holmgaard R. High self-reported satisfaction after top surgery in gender-affirming surgery: a single-center study. Transgender Health. 2023;8(2):124–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
53.van Leerdam TR, Zajac JD, Cheung AS. The effect of gender-affirming hormones on gender dysphoria, quality of life, and psychological functioning in transgender individuals: a systematic review. Transgender Health. 2023;8(1):6–21. [DOI] [PMC free article] [PubMed] [Google Scholar]
54.Goulding R, Goodwin J, O’Donovan A, Saab MM. Transgender and gender diverse youths’ experiences of healthcare: a systematic review of qualitative studies. J Child Health Care. 2025;29(2):523–45. [DOI] [PMC free article] [PubMed]
55.Costa D. Transgender health between barriers: a scoping review and integrated strategies. Societies. 2023;13(5):125.
56.Holland D, White LCJ, Pantelic M, Llewellyn C. The experiences of transgender and nonbinary adults in primary care: a systematic review. Eur J Gen Pract. 2024;30(1):2296571. [DOI] [PMC free article] [PubMed] [Google Scholar]
57.Lucas R, Geierstanger S, Soleimanpour S. Mental health needs, barriers, and receipt of care among transgender and nonbinary adolescents. J Adolesc Health. 2024;75(2):267–74. [DOI] [PubMed] [Google Scholar]
58.Snow A, Cerel J, Loeffler DN, Flaherty C. Barriers to mental health care for transgender and gender-nonconforming adults: a systematic literature review. Health Soc Work. 2019;44(3):149–55. [DOI] [PubMed] [Google Scholar]
59.Cronin TJ, Pepping CA, Lyons A. Mental health service use and barriers to accessing services in a cohort of transgender, gender diverse, and non-binary adults in Australia. Sex Res Soc Policy. 2023. 10.1007/s13178-023-00866-4. [Google Scholar]
60.Cicero EC, Reisner SL, Silva SG, Merwin EI, Humphreys JC. Health care experiences of transgender adults: an integrated mixed research literature review. ANS Adv Nurs Sci. 2019;42(2):123–38. [DOI] [PMC free article] [PubMed] [Google Scholar]
61.Langeland F, Gulli M, Rigtrup-Lindeman B. Likeverdig helsehjelp for personer med kjønnsinkongruens [Equal healthcare for people with gender incongruence]. Bodø: Nordlandsforskning; 2023.
62.Ebert MR, Guo MS, Klein SJ, Doren EL, Klement KA. Barriers of access to gender-affirming health care and surgery: a systematic review. Transgender Health. 2025;10(5):418–27. [DOI] [PMC free article] [PubMed]
63.Marano AA, Miller AS, Castillo W, Reisner SL, Schechter LS, Coon D. Social and systemic barriers to transition-related surgical procedures for transgender Americans. LGBT Health. 2024. 10.1089/lgbt.2023.0341. [DOI] [PubMed] [Google Scholar]
64.Redfield E, Conron KJ, Mallory C. The impact of 2024 Anti-Transgender legislation on youth. In. Los Angeles, CA: The Williams Institute, UCLA; 2024. [Google Scholar]
65.Gender-affirming care by country [https://www.equaldex.com/issue/gender-affirming-care].
66.Faletsky A, Han JJ, Lee KJ, Zhou G, Singer S, Talbot SG, et al. Crowdfunding for gender-affirming mastectomy: balancing fundraising with loss of privacy. Ann Plast Surg. 2022;88(4):372–4. [DOI] [PubMed] [Google Scholar]
67.Ngaage LM, Knighton BJ, Benzel CA, McGlone KL, Rada EM, Coon D, et al. A review of insurance coverage of gender-affirming genital surgery. Plast Reconstr Surg. 2020;145(3):803–12. [DOI] [PubMed] [Google Scholar]
68.Kiely E, Millet N, Baron A, Kreukels BPC, Doyle DM. Unequal geographies of gender-affirming care: a comparative typology of trans-specific healthcare systems across Europe. Soc Sci Med. 2024;356:117145. [DOI] [PubMed] [Google Scholar]
69.Ross MB, Jahouh H, Mullender MG, Kreukels BPC, van de Grift TC. Voices from a multidisciplinary healthcare center: understanding barriers in gender-affirming care-a qualitative exploration. Int J Environ Res Public Health. 2023;20(14):6367. [DOI] [PMC free article] [PubMed]
70.van Heesewijk J, Kent A, van de Grift TC, Harleman A, Muntinga M. Transgender health content in medical education: a theory-guided systematic review of current training practices and implementation barriers & facilitators. Adv Health Sci Educ Theory Pract. 2022;27(3):817–46. [DOI] [PMC free article] [PubMed] [Google Scholar]
71.Stokke M, Lundhaug K, Hammeren G, Solberg A, Steinland V. Skeives levekår i Agder. En kvantitativ og kvalitativ kartlegging [Queer people’s living conditions in Agder. A quantitative and qualitative survey]. Lillehammer: Østlandsforskning; 2018.
72.van de Grift TC, Martens C, van Ginneken L, Mullender MG. Waiting for transgender care and its effects on health and equality: a mixed-methods population study in the Netherlands. EClinicalMedicine. 2024;73:102657. [DOI] [PMC free article] [PubMed] [Google Scholar]
73.Carlile A, Butteriss E, Sansfacon AP. It’s like my kid came back overnight: experiences of trans and non-binary young people and their families seeking, finding and engaging with clinical care in England. Int J Transgender Health. 2021;22(4):412–24. [DOI] [PMC free article] [PubMed] [Google Scholar]
74.Shires DA, Jaffee K. Factors associated with health care discrimination experiences among a national sample of female-to-male transgender individuals. Health Soc Work. 2015;40(2):134–41. [DOI] [PubMed] [Google Scholar]
75.Alizaga NM, Aguayo-Romero RA, Glickman CP. Experiences of health care discrimination among transgender and gender nonconforming people of color: a latent class analysis. Psychol Sex Orientat Gend Divers. 2022;9(2):141–51. [Google Scholar]
76.Costa AB, da Rosa Filho HT, Pase PF, Fontanari AMV, Catelan RF, Mueller A, et al. Healthcare needs of and access barriers for Brazilian transgender and gender diverse people. J Immigr Minor Health. 2018;20(1):115–23. [DOI] [PubMed] [Google Scholar]
77.Falck F, Branstrom R. The significance of structural stigma towards transgender people in health care encounters across Europe: health care access, gender identity disclosure, and discrimination in health care as a function of national legislation and public attitudes. BMC Public Health. 2023;23(1):1031. [DOI] [PMC free article] [PubMed] [Google Scholar]
78.Javier C, Maxwell C, Atkin T, Crimston CR, Barlow FK. Barriers reported by nonbinary adults when accessing gender-affirming medical treatments: a systematic scoping literature review. Psychol Sex Orientat Gend Divers. 2024. Advance online publication. 10.1037/sgd0000702.
79.Bond SM, Fouche T, Smith JR, Garza RM. Review of health insurance policy inclusivity of gender nonconforming and nonbinary individuals seeking gender-affirming health care. Transgend Health. 2022;7(6):484–96. [DOI] [PMC free article] [PubMed] [Google Scholar]
80.Norway. Lov om likestilling og forbud mot diskriminering (likestillings- og diskrimineringsloven) [Equality and Anti-Discrimination Act]. LOV-2017-06-16-51. Oslo: ministry of culture and equality; 2017. Available from: https://lovdata.no/dokument/NLE/lov/2017-06-16-51. Cited 2025 June 11.
81.LGBT Equality Index by country. [https://www.equaldex.com/equality-index].
82.Trans Rights Map. [https://transrightsmap.tgeu.org/home/].
83.The Structure of the Healthcare System. [https://www.regjeringen.no/en/topics/health-and-care/innsikt/the-structure-of-the-healthcare-system/id227440/].
84.Kjønnsinkongruens [Gender incongruence]. [https://www.oslo-universitetssykehus.no/behandlinger/kjonnsinkongruens/].
85.Årsrapport. 2022. Nasjonal behandlingstjeneste for kjønnsinkongruens [Annual Report 2022. National Treatment Service for Gender Incongruence]. https://forskningsprosjekter.ihelse.net/senter/rapport/L-OUS-21/2022.
86.Moen V. Norske transkvinners Opplevelse av kjønnsbekreftende behandling [Norwegian trans women’s experiences with gender-affirming treatments]. Fontene Forskning. 2019;12(2):32–45. [Google Scholar]
87.van der Ros J. Alskens folk. Levekår, livssituasjon og livskvalitet til personer med kjønnsidentitetstematikk. [All kinds of people. Living conditions, life situation and quality of life for people with gender identity issues.]. Hamar: Likestillingssenteret; 2013.
88.Sørlie A. The right to Trans-specific healthcare in Norway: understanding the health needs of transgender people. Med Law Rev. 2019;27(2):295–317. [DOI] [PubMed] [Google Scholar]
89.Nasjonal faglig retningslinje for. helsetjenestetilbud til personer med kjønnsinkongruens [National professional guideline for healthcare services for people with gender incongruence] [https://www.helsedirektoratet.no/retningslinjer/kjonnsinkongruens]
90.Norwegian Directorate of Health. Rett Til Rett kjønn - helse Til alle kjønn. Utredning av vilkår for endring av juridisk kjønn Og organisering av Helsetjenester for personer Som opplever kjønnsinkongruens Og kjønnsdysfori [Right to the right gender - health for all genders. Report on conditions for changing legal gender and organization of health services for people who experience gender incongruence and gender dysphoria]. In. Oslo: Helsedirektoratet; 2015.
91.Budge SL, Adelson JL, Howard KAS. Anxiety and depression in transgender individuals: the roles of transition status, loss, social support, and coping. J Consult Clin Psychol. 2013;81(3):545–57. [DOI] [PubMed] [Google Scholar]
92.Cullati S, Bochatay N, Rossier C, Guessous I, Burton-Jeangros C, Courvoisier DS. Does the single-item self-rated health measure the same thing across different wordings? Construct validity study. Qual Life Res. 2020;29(9):2593–604. [DOI] [PMC free article] [PubMed] [Google Scholar]
93.Diener E, Emmons RA, Larsen RJ, Griffin S. The satisfaction with life scale. J Pers Assess. 1985;49(1):71–5. [DOI] [PubMed] [Google Scholar]
94.Pavot W, Diener E. Review of the satisfaction with life scale. Psychol Assess. 1993;5(2):164–72. [Google Scholar]
95.Strand BH, Dalgard OS, Tambs K. Measuring the mental health status of the Norwegian population: a comparison of the instruments SCL-25, SCL-10, SCL-5 and MHI-5 (SF-36). Nord J Psychiatry. 2003;57(2):113–8. [DOI] [PubMed] [Google Scholar]
96.Connor KM, Kobak KA, Churchill LE, Katzelnick D, Davidson JR. Mini-SPIN: a brief screening assessment for generalized social anxiety disorder. Depress Anxiety. 2001;14(2):137–40. [DOI] [PubMed] [Google Scholar]
97.Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates,; 1988. [Google Scholar]
98.Siira M, Getahun D, Silverberg MJ, Tangpricha V, Goodman M, Yeung H. Satisfaction with current hormone therapy and goals of additional gender-affirming care in transgender adults. J Sex Med. 2023;20(4):568–72. [DOI] [PMC free article] [PubMed] [Google Scholar]
99.Kennis M, Duecker F, T’Sjoen G, Sack AT, Dewitte M. Gender affirming medical treatment desire and treatment motives in binary and non-binary transgender individuals. J Sex Med. 2022;19(7):1173–84. [DOI] [PubMed] [Google Scholar]
100.Raner GA, Jaszkul KM, Bonapace-Potvin M, Al-Ghanim K, Bouhadana G, Roy AA, et al. Quality of life outcomes in patients undergoing facial gender affirming surgery: a systematic review and meta-analysis. Int J Transgender Health. 2024;25(4):653–62. [DOI] [PMC free article] [PubMed] [Google Scholar]
101.Caprini RM, Oberoi MK, Dejam D, Chan CH, Potemra HMK, Morgan KBJ, Weimer A, Litwin MS, Mendelsohn AH, Lee JC. Effect of Gender-affirming facial feminization surgery on psychosocial outcomes. Ann Surg. 2023;277(5):e1184–90. [DOI] [PubMed] [Google Scholar]
102.Morrison SD, Capitan-Canadas F, Sanchez-Garcia A, Ludwig DC, Massie JP, Nolan IT, et al. Prospective quality-of-life outcomes after facial feminization surgery: an international multicenter study. Plast Reconstr Surg. 2020;145(6):1499–509. [DOI] [PubMed] [Google Scholar]
103.Almås E, Bolstad S-H, Benestad EEP, Karlsen T-I, Giami A. Gender identities and affirmation pathways among transgender individuals in Norway. Sex Relat Ther. 2025;40(2):412–29. [Google Scholar]
104.James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The report of the 2015 U.S. Transgender survey. In. Washington, DC: National Center for Transgender Equality; 2016. [Google Scholar]
105.Koehler A, Eyssel J, Nieder TO. Genders and individual treatment progress in (Non-)binary trans individuals. J Sex Med. 2018;15(1):102–13. [DOI] [PubMed] [Google Scholar]
106.Huisman B, Verveen A, de Graaf NM, Steensma TD, Kreukels BPC. Body image and treatment desires at clinical entry in non-binary and genderqueer adults. Int J Transgend Health. 2023;24(2):234–46. [DOI] [PMC free article] [PubMed] [Google Scholar]
107.Jones BA, Pierre Bouman W, Haycraft E, Arcelus J. Gender congruence and body satisfaction in nonbinary transgender people: a case control study. International Journal of Transgenderism. 2019;20(2–3):263–74. [DOI] [PMC free article] [PubMed] [Google Scholar]
108.Murawsky S. The struggle with transnormativity: non-binary identity work, embodiment desires, and experience with gender dysphoria. Soc Sci Med. 2023;327:115953. [DOI] [PubMed] [Google Scholar]
109.Galupo MP, Pulice-Farrow L, Pehl E. There is nothing to do about it: nonbinary individuals’ experience of gender dysphoria. Transgend Health. 2021;6(2):101–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
110.Legal recognition of non-. binary gender by country [https://www.equaldex.com/issue/non-binary-gender-recognition]
111.The Norwegian Directorate for Children, Youth and Family Affairs. Utredning Om En Tredje juridisk kjønnskategori. [Report on a third legal gender category.]. Oslo: Barne-, ungdoms- og familiedirektoratet (Bufdir); 2023.
112.van Dijken JB, Steensma TD, Wensing-Kruger SA, den Heijer M, Dreijerink KMA. Tailored gender-affirming hormone treatment in nonbinary transgender individuals: a retrospective study in a referral center cohort. Transgend Health. 2023;8(3):220–5. [DOI] [PMC free article] [PubMed] [Google Scholar]
113.Hodax JK, DiVall S. Gender-affirming endocrine care for youth with a nonbinary gender identity. Ther Adv Endocrinol Metab. 2023;14:20420188231160405. [DOI] [PMC free article] [PubMed] [Google Scholar]
114.Cocchetti C, Ristori J, Romani A, Maggi M, Fisher AD. Hormonal treatment strategies tailored to non-binary transgender individuals. J Clin Med. 2020;9(6):1609. [DOI] [PMC free article] [PubMed]
115.Sayyed AA, Haffner ZK, Abu El Hawa AA, Ford A, Hill A, Chang B, Del Corral G. Mutual understanding in the field of gender affirmation surgery: a systematic review of techniques and preferences for top surgery in nonbinary patients. Health Sci Rev. 2022;3:100024.
116.Rahmani B, Park JB, Adebagbo OD, Raquepo TM, Tobin MJ, Fanning JE, et al. Along the spectrum from reduction to mastectomy: comparing the opinions of an online transmasculine and gender-diverse community on an algorithmic approach to gender-affirming top surgery. Aesthet Plast Surg. 2025. 10.1007/s00266-025-04884-y. [DOI] [PubMed] [Google Scholar]
117.Defant MJ. Reevaluating gender-affirming care: biological foundations, ethical dilemmas, and the complexities of gender dysphoria. J Sex Marital Ther. 2025;51(2):200–10. [DOI] [PubMed] [Google Scholar]
118.Dubov A, Fraenkel L. Facial feminization surgery: the ethics of gatekeeping in transgender health. Am J Bioeth. 2018;18(12):3–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
119.MacKinnon KR, Grace D, Ng SL, Sicchia SR, Ross LE. I don’t think they thought i was ready: how pre-transition assessments create care inequities for trans people with complex mental health in Canada. Int J Ment Health. 2020;49(1):56–80. [Google Scholar]
120.Amengual T, Kunstman K, Lloyd RB, Janssen A, Wescott AB. Readiness assessments for gender-affirming surgical treatments: a systematic scoping review of historical practices and changing ethical considerations. Front Psychiatry. 2022;13:1006024. [DOI] [PMC free article] [PubMed] [Google Scholar]
121.Ashley F, Parsa N, kus t, MacKinnon KR. Do gender assessments prevent regret in transgender healthcare? A narrative review. Psychol Sex Orientat Gend Divers. 2024;11(4):553–62. [Google Scholar]
122.Burchell D, Coleman T, Travers R, Aversa I, Schmid E, Coulombe S, et al. I don’t want to have to teach every medical provider’: barriers to care among non-binary people in the Canadian healthcare system. Cult Health Sex. 2024;26(1):61–76. [DOI] [PubMed] [Google Scholar]
123.Treharne GJ, Carroll R, Tan KKH, Veale JF. Supportive interactions with primary care doctors are associated with better mental health among transgender people: results of a nationwide survey in Aotearoa/New Zealand. Fam Pract. 2022;39(5):834–42. [DOI] [PMC free article] [PubMed] [Google Scholar]
124.Grimholt TK, Bonsaksen T, Heir T, Schou Bredal I, Skogstad L, Ekeberg O. Prevalence of suicide attempt and associations with deliberate self-harm, mental health problems, drug misuse and traumatic experiences - a cross sectional survey of the Norwegian population. BMC Psychiatry. 2024;24(1):164. [DOI] [PMC free article] [PubMed] [Google Scholar]
125.Støren KS, Rønning E. Livskvalitet i Norge 2021. [Quality of life in Norway 2021]. Oslo/Kongsvinger: Statistisk sentralbyrå; 2021.
126.Statistics Norway, Grimstad S, Støren KS. Livskvalitetsundersøkelsen 2023 (Versjon 1). [Quality of life survey 2023 (Version 1).] [Dataset]. Sikt - Kunnskapssektorens tjenesteleverandør; 2024. 10.18712/NSD-NSD3173-V1.
127.Scandurra C, Mezza F, Maldonato NM, Bottone M, Bochicchio V, Valerio P, Vitelli R. Health of Non-binary and genderqueer people: A systematic review. Front Psychol. 2019;10:1453. [DOI] [PMC free article] [PubMed] [Google Scholar]
128.Klinger D, Oehlke SM, Riedl S, Eschbaum K, Zesch HE, Karwautz A, Plener PL, Kothgassner OD. Mental health of non-binary youth: a systematic review and meta-analysis. Child Adolesc Psychiatry Ment Health. 2024;18(1):126. [DOI] [PMC free article] [PubMed] [Google Scholar]
129.Turban JL, King D, Kobe J, Reisner SL, Keuroghlian AS. Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. PLoS ONE. 2022;17(1):e0261039. [DOI] [PMC free article] [PubMed] [Google Scholar]
130.Witcomb GL, Bouman WP, Claes L, Brewin N, Crawford JR, Arcelus J. Levels of depression in transgender people and its predictors: results of a large matched control study with transgender people accessing clinical services. J Affect Disord. 2018;235:308–15. [DOI] [PubMed] [Google Scholar]
131.Tan KKH, Byrne JL, Treharne GJ, Veale JF. Unmet need for gender-affirming care as a social determinant of mental health inequities for transgender youth in Aotearoa/New Zealand. J Public Health (Oxf). 2023;45(2):e225–33. [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Material 1.^{(299.4KB, pdf)}

Data Availability Statement

[CR1] 1.Liszewski W, Peebles JK, Yeung H, Arron S. Persons of nonbinary Gender - Awareness, Visibility, and health disparities. N Engl J Med. 2018;379(25):2391–3. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR2] 2.Monro S. Non-binary and genderqueer: an overview of the field. Int J Transgend. 2019;20(2–3):126–31. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR3] 3.Zhang Q, Goodman M, Adams N, Corneil T, Hashemi L, Kreukels B, Motmans J, Snyder R, Coleman E. Epidemiological considerations in transgender health: A systematic review with focus on higher quality data. Int J Transgend Health. 2020;21(2):125–37. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR4] 4.Mezzalira S, Scandurra C, Mezza F, Miscioscia M, Innamorati M, Bochicchio V. Gender felt pressure, affective domains, and mental health outcomes among transgender and gender diverse (TGD) children and adolescents: a systematic review with developmental and clinical implications. Int J Environ Res Public Health. 2022;20(1):785. [DOI] [PMC free article] [PubMed]

[CR5] 5.Pinna F, Paribello P, Somaini G, Corona A, Ventriglio A, Corrias C, Frau I, Murgia R, El Kacemi S, Galeazzi GM, et al. Mental health in transgender individuals: a systematic review. Int Rev Psychiatry. 2022;34(3–4):292–359. [DOI] [PubMed] [Google Scholar]

[CR6] 6.Anderssen N, Eggebø H, Stubberud E, Holmelid Ø. Seksuell orientering, kjønnsmangfold og levekår. Resultater fra spørreundersøkelsen 2020 [Sexual orientation, gender diversity and living conditions. Results from the survey 2020]. Bergen: Institutt for samfunnspsykologi, Universitetet i Bergen; 2021.

[CR7] 7.Kidd JD, Tettamanti NA, Kaczmarkiewicz R, Corbeil TE, Dworkin JD, Jackman KB, Hughes TL, Bockting WO, Meyer IH. Prevalence of substance use and mental health problems among transgender and cisgender U.S. Adults: results from a National probability sample. Psychiatry Res. 2023;326:115339. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR8] 8.Lampe NM, Barbee H, Tran NM, Bastow S, McKay T. Health disparities among Lesbian, Gay, Bisexual, Transgender, and Queer older adults: a structural competency approach. Int J Aging Hum Dev. 2024;98(1):39–55. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR9] 9.Robertson L, Akre ER, Gonzales G. Mental health disparities at the intersections of gender identity, race, and ethnicity. LGBT Health. 2021;8(8):526–35. [DOI] [PubMed] [Google Scholar]

[CR10] 10.Nobili A, Glazebrook C, Arcelus J. Quality of life of treatment-seeking transgender adults: a systematic review and meta-analysis. Rev Endocr Metab Disord. 2018;19(3):199–220. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR11] 11.Borgogna NC, McDermott RC, Aita SL, Kridel MM. Anxiety and depression across gender and sexual minorities: implications for transgender, gender nonconforming, pansexual, demisexual, asexual, queer, and questioning individuals. Psychol Sex Orientat Gend Divers. 2019;6(1):54–63. [Google Scholar]

[CR12] 12.Millet N, Longworth J, Arcelus J. Prevalence of anxiety symptoms and disorders in the transgender population: A systematic review of the literature. Int J Transgenderism. 2016;18(1):27–38. [Google Scholar]

[CR13] 13.Anderssen N, Sivertsen B, Lønning KJ, Malterud K. Life satisfaction and mental health among transgender students in Norway. BMC Public Health. 2020;20(1):138. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR14] 14.Vigny-Pau M, Pang N, Alkhenaini H, Abramovich A. Suicidality and non-suicidal self-injury among transgender populations: a systematic review. J Gay Lesbian Ment Health. 2021;25(4):358–82. [Google Scholar]

[CR15] 15.Anderson AM, Mallory AB, Alston AD, Warren BJ, Morgan E, Bridge JA, Ford JL. Sociodemographic factors associated with suicide outcomes in transgender and gender diverse young adults. Arch Suicide Res. 2025;29(2):392–406. [DOI] [PubMed]

[CR16] 16.Ipsos. Ipsos LGBT+ Pride report 2024. Paris: Ipsos; 2024.

[CR17] 17.Hatch HA, Warner RH, Broussard KA, Harton HC. Predictors of transgender prejudice: a meta-analysis. Sex Roles. 2022;87(11–12):583–602. [Google Scholar]

[CR18] 18.Opinion. Befolkningens holdninger til lhbtiq personer. Rapport fra en spørreundersøkelse [The general population’s attitudes towards lhbtiq people. Report from a survey]. Oslo: Bufdir/Opinion; 2022.

[CR19] 19.Borgogna NC, Lathan EC, Aita SL. Sexual and gender minority victimization: base rates of assault in college students across sexual and gender identities. J Interpers Violence. 2023;38(7–8):5613–37. [DOI] [PubMed] [Google Scholar]

[CR20] 20.Lian Q, Li R, Liu Z, Li X, Su Q, Zheng D. Associations of nonconforming gender expression and gender identity with bullying victimization: an analysis of the 2017 youth risk behavior survey. BMC Public Health. 2022;22(1):650. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR21] 21.James SE, Herman JL, Durso LE, Heng-Lehtinen R. Early insights: A report of the 2022 U.S. Transgender survey. In. Washington, DC: National Center for Transgender Equality; 2024. [Google Scholar]

[CR22] 22.Flores AR, Meyer IH, Langton L, Herman JL. Gender identity disparities in criminal victimization: National crime victimization survey, 2017–2018. Am J Public Health. 2021;111(4):726–9. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR23] 23.Testa RJ, Habarth J, Peta J, Balsam K, Bockting W. Development of the gender minority stress and resilience measure. Psychol Sex Orientat Gend Divers. 2015;2(1):65–77. [Google Scholar]

[CR24] 24.Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674–97. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR25] 25.Pellicane MJ, Ciesla JA. Associations between minority stress, depression, and suicidal ideation and attempts in transgender and gender diverse (TGD) individuals: systematic review and meta-analysis. Clin Psychol Rev. 2022;91:102113. [DOI] [PubMed] [Google Scholar]

[CR26] 26.Tan KKH, Treharne GJ, Ellis SJ, Schmidt JM, Veale JF. Gender minority stress: a critical review. J Homosex. 2020;67(10):1471–89. [DOI] [PubMed] [Google Scholar]

[CR27] 27.Testa RJ, Michaels MS, Bliss W, Rogers ML, Balsam KF, Joiner T. Suicidal ideation in transgender people: gender minority stress and interpersonal theory factors. J Abnorm Psychol. 2017;126(1):125–36. [DOI] [PubMed] [Google Scholar]

[CR28] 28.Klein A, Golub SA. Family rejection as a predictor of suicide attempts and substance misuse among transgender and gender nonconforming adults. LGBT Health. 2016;3(3):193–9. [DOI] [PubMed] [Google Scholar]

[CR29] 29.Wilson LC, Newins AR, Kassing F, Casanova T. Gender minority stress and resilience measure: a meta-analysis of the associations with mental health in transgender and gender diverse individuals. Trauma Violence Abuse. 2024;25(3):2552–64. [DOI] [PubMed] [Google Scholar]

[CR30] 30.Scandurra C, Carbone A, Baiocco R, Mezzalira S, Maldonato NM, Bochicchio V. Gender identity milestones, minority stress and mental health in three generational cohorts of Italian binary and nonbinary transgender people. Int J Environ Res Public Health. 2021;18(17):9057. [DOI] [PMC free article] [PubMed]

[CR31] 31.Tatum AK, Catalpa J, Bradford NJ, Kovic A, Berg DR. Examining identity development and transition differences among binary transgender and genderqueer nonbinary (GQNB) individuals. Psychol Sex Orientat Gend Divers. 2020;7(4):379–85. [Google Scholar]

[CR32] 32.Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, Ettner R, Fraser L, Goodman M, Green J, et al. Standards of care for the health of transgender and gender diverse People, version 8. Int J Transgender Health. 2022;23(sup1):S1–259. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR33] 33.Hughto JMW, Gunn HA, Rood BA, Pantalone DW. Social and medical gender affirmation experiences are inversely associated with mental health problems in a U.S. non-probability sample of transgender adults. Arch Sex Behav. 2020;49(7):2635–47. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR34] 34.Klein H, Washington TA. Transition milestones, psychological distress, and suicidal ideation among transgender adults: a structural equation analysis. Omega (Westport). 2023;8:302228231221308. [DOI] [PubMed]

[CR35] 35.Thoma BC, Jardas EJ, Choukas-Bradley S, Salk RH. Perceived gender transition progress, gender congruence, and mental health symptoms among transgender adolescents. J Adolesc Health. 2023;72(3):444–51. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR36] 36.Ireland K, Hughes M, Dean NR. Do hormones and surgery improve the health of adults with gender incongruence? A systematic review of patient reported outcomes. ANZ J Surg. 2025;95(5):864–77. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR37] 37.Baker KE, Wilson LM, Sharma R, Dukhanin V, McArthur K, Robinson KA. Hormone therapy, mental health, and quality of life among transgender people: a systematic review. J Endocr Soc. 2021;5(4):bvab011. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR38] 38.Doyle DM, Lewis TOG, Barreto M. A systematic review of psychosocial functioning changes after gender-affirming hormone therapy among transgender people. Nat Hum Behav. 2023;7(8):1320–31. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR39] 39.Fisher AD, Castellini G, Ristori J, Casale H, Cassioli E, Sensi C, et al. Cross-sex hormone treatment and psychobiological changes in transsexual persons: two-year follow-up data. J Clin Endocrinol Metab. 2016;101(11):4260–9. [DOI] [PubMed] [Google Scholar]

[CR40] 40.Tordoff DM, Wanta JW, Collin A, Stepney C, Inwards-Breland DJ, Ahrens K. Mental health outcomes in transgender and nonbinary youths receiving gender-affirming care. JAMA Netw Open. 2022;5(2):e220978. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR41] 41.Green AE, DeChants JP, Price MN, Davis CK. Association of gender-affirming hormone therapy with depression, thoughts of suicide, and attempted suicide among transgender and nonbinary youth. J Adolesc Health. 2022;70(4):643–9. [DOI] [PubMed] [Google Scholar]

[CR42] 42.Chen D, Berona J, Chan YM, Ehrensaft D, Garofalo R, Hidalgo MA, et al. Psychosocial functioning in transgender youth after 2 years of hormones. N Engl J Med. 2023;388(3):240–50. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR43] 43.Aldridge Z, Patel S, Guo B, Nixon E, Pierre Bouman W, Witcomb GL, et al. Long-term effect of gender-affirming hormone treatment on depression and anxiety symptoms in transgender people: a prospective cohort study. Andrology. 2021;9(6):1808–16. [DOI] [PubMed] [Google Scholar]

[CR44] 44.Almazan AN, Keuroghlian AS. Association between gender-affirming surgeries and mental health outcomes. JAMA Surg. 2021;156(7):611–8. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR45] 45.Swan J, Phillips TM, Sanders T, Mullens AB, Debattista J, Brömdal A. Mental health and quality of life outcomes of gender-affirming surgery: a systematic literature review. J Gay Lesbian Ment Health. 2022;27(1):2–45. [Google Scholar]

[CR46] 46.Alcon A, Kennedy A, Wang E, Piper M, Loeliger K, Admassu N, et al. Quantifying the psychosocial benefits of masculinizing mastectomy in trans male patients with patient-reported outcomes: the university of California, San Francisco, gender quality of life survey. Plast Reconstr Surg. 2021;147(5):e731-40. [DOI] [PubMed] [Google Scholar]

[CR47] 47.Branstrom R, Pachankis JE. Reduction in mental health treatment utilization among transgender individuals after gender-affirming surgeries: a total population study. Am J Psychiatry. 2020;177(8):727–34. [DOI] [PubMed] [Google Scholar]

[CR48] 48.Javier C, Crimston CR, Barlow FK. Surgical satisfaction and quality of life outcomes reported by transgender men and women at least one year post gender-affirming surgery: a systematic literature review. Int J Transgender Health. 2022;23(3):255–73. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR49] 49.Olson-Kennedy J, Warus J, Okonta V, Belzer M, Clark LF. Chest reconstruction and chest dysphoria in transmasculine minors and young adults: comparisons of nonsurgical and postsurgical cohorts. JAMA Pediatr. 2018;172(5):431–6. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR50] 50.Ascha M, Sasson DC, Sood R, Cornelius JW, Schauer JM, Runge A, et al. Top surgery and chest dysphoria among transmasculine and nonbinary adolescents and young adults. JAMA Pediatr. 2022;176(11):1115–22. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR51] 51.Park RH, Liu YT, Samuel A, Gurganus M, Gampper TJ, Corbett ST, et al. Long-term outcomes after gender-affirming surgery: 40-year follow-up study. Ann Plast Surg. 2022;89(4):431–6. [DOI] [PubMed] [Google Scholar]

[CR52] 52.Day DL, Klit A, Lang CL, Mejdahl MK, Holmgaard R. High self-reported satisfaction after top surgery in gender-affirming surgery: a single-center study. Transgender Health. 2023;8(2):124–9. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR53] 53.van Leerdam TR, Zajac JD, Cheung AS. The effect of gender-affirming hormones on gender dysphoria, quality of life, and psychological functioning in transgender individuals: a systematic review. Transgender Health. 2023;8(1):6–21. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR54] 54.Goulding R, Goodwin J, O’Donovan A, Saab MM. Transgender and gender diverse youths’ experiences of healthcare: a systematic review of qualitative studies. J Child Health Care. 2025;29(2):523–45. [DOI] [PMC free article] [PubMed]

[CR55] 55.Costa D. Transgender health between barriers: a scoping review and integrated strategies. Societies. 2023;13(5):125.

[CR56] 56.Holland D, White LCJ, Pantelic M, Llewellyn C. The experiences of transgender and nonbinary adults in primary care: a systematic review. Eur J Gen Pract. 2024;30(1):2296571. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR57] 57.Lucas R, Geierstanger S, Soleimanpour S. Mental health needs, barriers, and receipt of care among transgender and nonbinary adolescents. J Adolesc Health. 2024;75(2):267–74. [DOI] [PubMed] [Google Scholar]

[CR58] 58.Snow A, Cerel J, Loeffler DN, Flaherty C. Barriers to mental health care for transgender and gender-nonconforming adults: a systematic literature review. Health Soc Work. 2019;44(3):149–55. [DOI] [PubMed] [Google Scholar]

[CR59] 59.Cronin TJ, Pepping CA, Lyons A. Mental health service use and barriers to accessing services in a cohort of transgender, gender diverse, and non-binary adults in Australia. Sex Res Soc Policy. 2023. 10.1007/s13178-023-00866-4. [Google Scholar]

[CR60] 60.Cicero EC, Reisner SL, Silva SG, Merwin EI, Humphreys JC. Health care experiences of transgender adults: an integrated mixed research literature review. ANS Adv Nurs Sci. 2019;42(2):123–38. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR61] 61.Langeland F, Gulli M, Rigtrup-Lindeman B. Likeverdig helsehjelp for personer med kjønnsinkongruens [Equal healthcare for people with gender incongruence]. Bodø: Nordlandsforskning; 2023.

[CR62] 62.Ebert MR, Guo MS, Klein SJ, Doren EL, Klement KA. Barriers of access to gender-affirming health care and surgery: a systematic review. Transgender Health. 2025;10(5):418–27. [DOI] [PMC free article] [PubMed]

[CR63] 63.Marano AA, Miller AS, Castillo W, Reisner SL, Schechter LS, Coon D. Social and systemic barriers to transition-related surgical procedures for transgender Americans. LGBT Health. 2024. 10.1089/lgbt.2023.0341. [DOI] [PubMed] [Google Scholar]

[CR64] 64.Redfield E, Conron KJ, Mallory C. The impact of 2024 Anti-Transgender legislation on youth. In. Los Angeles, CA: The Williams Institute, UCLA; 2024. [Google Scholar]

[CR65] 65.Gender-affirming care by country [https://www.equaldex.com/issue/gender-affirming-care].

[CR66] 66.Faletsky A, Han JJ, Lee KJ, Zhou G, Singer S, Talbot SG, et al. Crowdfunding for gender-affirming mastectomy: balancing fundraising with loss of privacy. Ann Plast Surg. 2022;88(4):372–4. [DOI] [PubMed] [Google Scholar]

[CR67] 67.Ngaage LM, Knighton BJ, Benzel CA, McGlone KL, Rada EM, Coon D, et al. A review of insurance coverage of gender-affirming genital surgery. Plast Reconstr Surg. 2020;145(3):803–12. [DOI] [PubMed] [Google Scholar]

[CR68] 68.Kiely E, Millet N, Baron A, Kreukels BPC, Doyle DM. Unequal geographies of gender-affirming care: a comparative typology of trans-specific healthcare systems across Europe. Soc Sci Med. 2024;356:117145. [DOI] [PubMed] [Google Scholar]

[CR69] 69.Ross MB, Jahouh H, Mullender MG, Kreukels BPC, van de Grift TC. Voices from a multidisciplinary healthcare center: understanding barriers in gender-affirming care-a qualitative exploration. Int J Environ Res Public Health. 2023;20(14):6367. [DOI] [PMC free article] [PubMed]

[CR70] 70.van Heesewijk J, Kent A, van de Grift TC, Harleman A, Muntinga M. Transgender health content in medical education: a theory-guided systematic review of current training practices and implementation barriers & facilitators. Adv Health Sci Educ Theory Pract. 2022;27(3):817–46. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR71] 71.Stokke M, Lundhaug K, Hammeren G, Solberg A, Steinland V. Skeives levekår i Agder. En kvantitativ og kvalitativ kartlegging [Queer people’s living conditions in Agder. A quantitative and qualitative survey]. Lillehammer: Østlandsforskning; 2018.

[CR72] 72.van de Grift TC, Martens C, van Ginneken L, Mullender MG. Waiting for transgender care and its effects on health and equality: a mixed-methods population study in the Netherlands. EClinicalMedicine. 2024;73:102657. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR73] 73.Carlile A, Butteriss E, Sansfacon AP. It’s like my kid came back overnight: experiences of trans and non-binary young people and their families seeking, finding and engaging with clinical care in England. Int J Transgender Health. 2021;22(4):412–24. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR74] 74.Shires DA, Jaffee K. Factors associated with health care discrimination experiences among a national sample of female-to-male transgender individuals. Health Soc Work. 2015;40(2):134–41. [DOI] [PubMed] [Google Scholar]

[CR75] 75.Alizaga NM, Aguayo-Romero RA, Glickman CP. Experiences of health care discrimination among transgender and gender nonconforming people of color: a latent class analysis. Psychol Sex Orientat Gend Divers. 2022;9(2):141–51. [Google Scholar]

[CR76] 76.Costa AB, da Rosa Filho HT, Pase PF, Fontanari AMV, Catelan RF, Mueller A, et al. Healthcare needs of and access barriers for Brazilian transgender and gender diverse people. J Immigr Minor Health. 2018;20(1):115–23. [DOI] [PubMed] [Google Scholar]

[CR77] 77.Falck F, Branstrom R. The significance of structural stigma towards transgender people in health care encounters across Europe: health care access, gender identity disclosure, and discrimination in health care as a function of national legislation and public attitudes. BMC Public Health. 2023;23(1):1031. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR78] 78.Javier C, Maxwell C, Atkin T, Crimston CR, Barlow FK. Barriers reported by nonbinary adults when accessing gender-affirming medical treatments: a systematic scoping literature review. Psychol Sex Orientat Gend Divers. 2024. Advance online publication. 10.1037/sgd0000702.

[CR79] 79.Bond SM, Fouche T, Smith JR, Garza RM. Review of health insurance policy inclusivity of gender nonconforming and nonbinary individuals seeking gender-affirming health care. Transgend Health. 2022;7(6):484–96. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR80] 80.Norway. Lov om likestilling og forbud mot diskriminering (likestillings- og diskrimineringsloven) [Equality and Anti-Discrimination Act]. LOV-2017-06-16-51. Oslo: ministry of culture and equality; 2017. Available from: https://lovdata.no/dokument/NLE/lov/2017-06-16-51. Cited 2025 June 11.

[CR81] 81.LGBT Equality Index by country. [https://www.equaldex.com/equality-index].

[CR82] 82.Trans Rights Map. [https://transrightsmap.tgeu.org/home/].

[CR83] 83.The Structure of the Healthcare System. [https://www.regjeringen.no/en/topics/health-and-care/innsikt/the-structure-of-the-healthcare-system/id227440/].

[CR84] 84.Kjønnsinkongruens [Gender incongruence]. [https://www.oslo-universitetssykehus.no/behandlinger/kjonnsinkongruens/].

[CR85] 85.Årsrapport. 2022. Nasjonal behandlingstjeneste for kjønnsinkongruens [Annual Report 2022. National Treatment Service for Gender Incongruence]. https://forskningsprosjekter.ihelse.net/senter/rapport/L-OUS-21/2022.

[CR86] 86.Moen V. Norske transkvinners Opplevelse av kjønnsbekreftende behandling [Norwegian trans women’s experiences with gender-affirming treatments]. Fontene Forskning. 2019;12(2):32–45. [Google Scholar]

[CR87] 87.van der Ros J. Alskens folk. Levekår, livssituasjon og livskvalitet til personer med kjønnsidentitetstematikk. [All kinds of people. Living conditions, life situation and quality of life for people with gender identity issues.]. Hamar: Likestillingssenteret; 2013.

[CR88] 88.Sørlie A. The right to Trans-specific healthcare in Norway: understanding the health needs of transgender people. Med Law Rev. 2019;27(2):295–317. [DOI] [PubMed] [Google Scholar]

[CR89] 89.Nasjonal faglig retningslinje for. helsetjenestetilbud til personer med kjønnsinkongruens [National professional guideline for healthcare services for people with gender incongruence] [https://www.helsedirektoratet.no/retningslinjer/kjonnsinkongruens]

[CR90] 90.Norwegian Directorate of Health. Rett Til Rett kjønn - helse Til alle kjønn. Utredning av vilkår for endring av juridisk kjønn Og organisering av Helsetjenester for personer Som opplever kjønnsinkongruens Og kjønnsdysfori [Right to the right gender - health for all genders. Report on conditions for changing legal gender and organization of health services for people who experience gender incongruence and gender dysphoria]. In. Oslo: Helsedirektoratet; 2015.

[CR91] 91.Budge SL, Adelson JL, Howard KAS. Anxiety and depression in transgender individuals: the roles of transition status, loss, social support, and coping. J Consult Clin Psychol. 2013;81(3):545–57. [DOI] [PubMed] [Google Scholar]

[CR92] 92.Cullati S, Bochatay N, Rossier C, Guessous I, Burton-Jeangros C, Courvoisier DS. Does the single-item self-rated health measure the same thing across different wordings? Construct validity study. Qual Life Res. 2020;29(9):2593–604. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR93] 93.Diener E, Emmons RA, Larsen RJ, Griffin S. The satisfaction with life scale. J Pers Assess. 1985;49(1):71–5. [DOI] [PubMed] [Google Scholar]

[CR94] 94.Pavot W, Diener E. Review of the satisfaction with life scale. Psychol Assess. 1993;5(2):164–72. [Google Scholar]

[CR95] 95.Strand BH, Dalgard OS, Tambs K. Measuring the mental health status of the Norwegian population: a comparison of the instruments SCL-25, SCL-10, SCL-5 and MHI-5 (SF-36). Nord J Psychiatry. 2003;57(2):113–8. [DOI] [PubMed] [Google Scholar]

[CR96] 96.Connor KM, Kobak KA, Churchill LE, Katzelnick D, Davidson JR. Mini-SPIN: a brief screening assessment for generalized social anxiety disorder. Depress Anxiety. 2001;14(2):137–40. [DOI] [PubMed] [Google Scholar]

[CR97] 97.Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates,; 1988. [Google Scholar]

[CR98] 98.Siira M, Getahun D, Silverberg MJ, Tangpricha V, Goodman M, Yeung H. Satisfaction with current hormone therapy and goals of additional gender-affirming care in transgender adults. J Sex Med. 2023;20(4):568–72. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR99] 99.Kennis M, Duecker F, T’Sjoen G, Sack AT, Dewitte M. Gender affirming medical treatment desire and treatment motives in binary and non-binary transgender individuals. J Sex Med. 2022;19(7):1173–84. [DOI] [PubMed] [Google Scholar]

[CR100] 100.Raner GA, Jaszkul KM, Bonapace-Potvin M, Al-Ghanim K, Bouhadana G, Roy AA, et al. Quality of life outcomes in patients undergoing facial gender affirming surgery: a systematic review and meta-analysis. Int J Transgender Health. 2024;25(4):653–62. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR101] 101.Caprini RM, Oberoi MK, Dejam D, Chan CH, Potemra HMK, Morgan KBJ, Weimer A, Litwin MS, Mendelsohn AH, Lee JC. Effect of Gender-affirming facial feminization surgery on psychosocial outcomes. Ann Surg. 2023;277(5):e1184–90. [DOI] [PubMed] [Google Scholar]

[CR102] 102.Morrison SD, Capitan-Canadas F, Sanchez-Garcia A, Ludwig DC, Massie JP, Nolan IT, et al. Prospective quality-of-life outcomes after facial feminization surgery: an international multicenter study. Plast Reconstr Surg. 2020;145(6):1499–509. [DOI] [PubMed] [Google Scholar]

[CR103] 103.Almås E, Bolstad S-H, Benestad EEP, Karlsen T-I, Giami A. Gender identities and affirmation pathways among transgender individuals in Norway. Sex Relat Ther. 2025;40(2):412–29. [Google Scholar]

[CR104] 104.James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The report of the 2015 U.S. Transgender survey. In. Washington, DC: National Center for Transgender Equality; 2016. [Google Scholar]

[CR105] 105.Koehler A, Eyssel J, Nieder TO. Genders and individual treatment progress in (Non-)binary trans individuals. J Sex Med. 2018;15(1):102–13. [DOI] [PubMed] [Google Scholar]

[CR106] 106.Huisman B, Verveen A, de Graaf NM, Steensma TD, Kreukels BPC. Body image and treatment desires at clinical entry in non-binary and genderqueer adults. Int J Transgend Health. 2023;24(2):234–46. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR107] 107.Jones BA, Pierre Bouman W, Haycraft E, Arcelus J. Gender congruence and body satisfaction in nonbinary transgender people: a case control study. International Journal of Transgenderism. 2019;20(2–3):263–74. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR108] 108.Murawsky S. The struggle with transnormativity: non-binary identity work, embodiment desires, and experience with gender dysphoria. Soc Sci Med. 2023;327:115953. [DOI] [PubMed] [Google Scholar]

[CR109] 109.Galupo MP, Pulice-Farrow L, Pehl E. There is nothing to do about it: nonbinary individuals’ experience of gender dysphoria. Transgend Health. 2021;6(2):101–10. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR110] 110.Legal recognition of non-. binary gender by country [https://www.equaldex.com/issue/non-binary-gender-recognition]

[CR111] 111.The Norwegian Directorate for Children, Youth and Family Affairs. Utredning Om En Tredje juridisk kjønnskategori. [Report on a third legal gender category.]. Oslo: Barne-, ungdoms- og familiedirektoratet (Bufdir); 2023.

[CR112] 112.van Dijken JB, Steensma TD, Wensing-Kruger SA, den Heijer M, Dreijerink KMA. Tailored gender-affirming hormone treatment in nonbinary transgender individuals: a retrospective study in a referral center cohort. Transgend Health. 2023;8(3):220–5. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR113] 113.Hodax JK, DiVall S. Gender-affirming endocrine care for youth with a nonbinary gender identity. Ther Adv Endocrinol Metab. 2023;14:20420188231160405. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR114] 114.Cocchetti C, Ristori J, Romani A, Maggi M, Fisher AD. Hormonal treatment strategies tailored to non-binary transgender individuals. J Clin Med. 2020;9(6):1609. [DOI] [PMC free article] [PubMed]

[CR115] 115.Sayyed AA, Haffner ZK, Abu El Hawa AA, Ford A, Hill A, Chang B, Del Corral G. Mutual understanding in the field of gender affirmation surgery: a systematic review of techniques and preferences for top surgery in nonbinary patients. Health Sci Rev. 2022;3:100024.

[CR116] 116.Rahmani B, Park JB, Adebagbo OD, Raquepo TM, Tobin MJ, Fanning JE, et al. Along the spectrum from reduction to mastectomy: comparing the opinions of an online transmasculine and gender-diverse community on an algorithmic approach to gender-affirming top surgery. Aesthet Plast Surg. 2025. 10.1007/s00266-025-04884-y. [DOI] [PubMed] [Google Scholar]

[CR117] 117.Defant MJ. Reevaluating gender-affirming care: biological foundations, ethical dilemmas, and the complexities of gender dysphoria. J Sex Marital Ther. 2025;51(2):200–10. [DOI] [PubMed] [Google Scholar]

[CR118] 118.Dubov A, Fraenkel L. Facial feminization surgery: the ethics of gatekeeping in transgender health. Am J Bioeth. 2018;18(12):3–9. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR119] 119.MacKinnon KR, Grace D, Ng SL, Sicchia SR, Ross LE. I don’t think they thought i was ready: how pre-transition assessments create care inequities for trans people with complex mental health in Canada. Int J Ment Health. 2020;49(1):56–80. [Google Scholar]

[CR120] 120.Amengual T, Kunstman K, Lloyd RB, Janssen A, Wescott AB. Readiness assessments for gender-affirming surgical treatments: a systematic scoping review of historical practices and changing ethical considerations. Front Psychiatry. 2022;13:1006024. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR121] 121.Ashley F, Parsa N, kus t, MacKinnon KR. Do gender assessments prevent regret in transgender healthcare? A narrative review. Psychol Sex Orientat Gend Divers. 2024;11(4):553–62. [Google Scholar]

[CR122] 122.Burchell D, Coleman T, Travers R, Aversa I, Schmid E, Coulombe S, et al. I don’t want to have to teach every medical provider’: barriers to care among non-binary people in the Canadian healthcare system. Cult Health Sex. 2024;26(1):61–76. [DOI] [PubMed] [Google Scholar]

[CR123] 123.Treharne GJ, Carroll R, Tan KKH, Veale JF. Supportive interactions with primary care doctors are associated with better mental health among transgender people: results of a nationwide survey in Aotearoa/New Zealand. Fam Pract. 2022;39(5):834–42. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR124] 124.Grimholt TK, Bonsaksen T, Heir T, Schou Bredal I, Skogstad L, Ekeberg O. Prevalence of suicide attempt and associations with deliberate self-harm, mental health problems, drug misuse and traumatic experiences - a cross sectional survey of the Norwegian population. BMC Psychiatry. 2024;24(1):164. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR125] 125.Støren KS, Rønning E. Livskvalitet i Norge 2021. [Quality of life in Norway 2021]. Oslo/Kongsvinger: Statistisk sentralbyrå; 2021.

[CR126] 126.Statistics Norway, Grimstad S, Støren KS. Livskvalitetsundersøkelsen 2023 (Versjon 1). [Quality of life survey 2023 (Version 1).] [Dataset]. Sikt - Kunnskapssektorens tjenesteleverandør; 2024. 10.18712/NSD-NSD3173-V1.

[CR127] 127.Scandurra C, Mezza F, Maldonato NM, Bottone M, Bochicchio V, Valerio P, Vitelli R. Health of Non-binary and genderqueer people: A systematic review. Front Psychol. 2019;10:1453. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR128] 128.Klinger D, Oehlke SM, Riedl S, Eschbaum K, Zesch HE, Karwautz A, Plener PL, Kothgassner OD. Mental health of non-binary youth: a systematic review and meta-analysis. Child Adolesc Psychiatry Ment Health. 2024;18(1):126. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR129] 129.Turban JL, King D, Kobe J, Reisner SL, Keuroghlian AS. Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. PLoS ONE. 2022;17(1):e0261039. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR130] 130.Witcomb GL, Bouman WP, Claes L, Brewin N, Crawford JR, Arcelus J. Levels of depression in transgender people and its predictors: results of a large matched control study with transgender people accessing clinical services. J Affect Disord. 2018;235:308–15. [DOI] [PubMed] [Google Scholar]

[CR131] 131.Tan KKH, Byrne JL, Treharne GJ, Veale JF. Unmet need for gender-affirming care as a social determinant of mental health inequities for transgender youth in Aotearoa/New Zealand. J Public Health (Oxf). 2023;45(2):e225–33. [DOI] [PMC free article] [PubMed] [Google Scholar]

PERMALINK

Gender-affirming health care needs, barriers to care, and health and wellbeing in a broad nationwide sample of transgender people in Norway

Silje-Håvard Bolstad

Norman Anderssen

Bjørge H Hansen

Ilan H Meyer

Abstract

Background

Methods

Results

Conclusions

Supplementary Information

Background

The Norwegian context

Aim

Methods

Study design and recruitment

Fig. 1.

Measures

Sociodemographic characteristics

Gender identity

Gender-affirming health care

Transition progress

General health

Life satisfaction

Mental distress

Social anxiety symptoms

Suicide attempts

Statistical analysis

Results

Sociodemographic characteristics

Table 1.

Transition progress

Fig. 2.

Gender-affirming health care

Table 2.

Table 3.

Health and wellbeing

Table 4.

Discussion

Gender-affirming health care

Differences between trans men, trans women, and nonbinary people

Barriers to care

Health and wellbeing

Strengths and limitations

Conclusions

Supplementary Information

Acknowledgements

Abbreviations

Authors’ contributions

Funding

Data availability

Declarations

Ethics approval and consent to participate

Consent for publication

Competing interests

Footnotes

References

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

Similar articles

Cited by other articles

Links to NCBI Databases