Barriers to Gender‐Affirming Care for Nonbinary People: A Systematic‐Narrative Hybrid Literature Review

ABSTRACT

Background

Nonbinary people can experience more barriers to accessing gender‐affirming care than binary transgender people, with impacts on health equity outcomes for this population. This systematic‐narrative hybrid review identifies and synthesises the barriers experienced by nonbinary people when accessing gender‐affirming care to inform future health promotion with this population.

Methods

A systematic‐narrative hybrid literature review was conducted in accordance with PRISMA guidelines, adapted for narrative reviews. Searches were performed on APA Psycinfo, EBSCOHost, PubMed, Scopus, Proquest and CINAHL Ultimate databases. The search used keywords related to nonbinary identity, gender‐affirming care, hormone therapy, surgery and experiences of care. Qualitative, quantitative and mixed‐methods studies were included, as well as systematic and scoping reviews. A quality appraisal of the studies was conducted using both MMAT and ROBIS checklist tools.

Results

Twenty‐seven studies were included. A total of four themes were identified: (1) A foot in the door: Access, (2) Medical gatekeeping, (3) Nowhere, invisible, and (4) The inconvenience of the complexity of gender. Each theme discusses the various barriers to gender‐affirming care that nonbinary people experience.

Discussion

This review expands understandings of the barriers faced by nonbinary people while accessing gender‐affirming care. The analysis highlights the determinants of health that lead to the unique barriers that nonbinary people experience when accessing gender‐affirming care. Most importantly, this paper provides insights for how to advance health equity outcomes for this population.

So What?

Identifying the barriers to gender‐affirming care for nonbinary people can inform health promotion strategies that address the health inequities experienced by this population and improve access to care.

1. Introduction

Gender‐affirming care is an important part of gender affirmation for many nonbinary people [1] and has been shown to improve health and wellbeing outcomes for this population [2]. Demand for gender‐affirming care from health professionals has increased significantly since 2020 [3], and access to care services has been identified as a key priority in the National Action Plan for the Health and Wellbeing of LGBTIQA+ People 2025–2035 [4]. Despite this, it is assumed that nonbinary people do not need or desire gender‐affirming care [5]. This belief has implications for both health promotion policy and the resulting health equity outcomes for this population.

In contrast to this common belief, an online survey of 271 nonbinary people in Australia conducted by Zwickl et al. [5] found that approximately 65% of respondents reported experiencing a need for gender‐affirming hormone therapy. Of this same cohort, approximately half of all participants reported a need for gender‐affirming surgery. Among this population, the rate of unmet need for oestrogen‐based gender‐affirming hormone therapy was approximately 9% and unmet need for testosterone‐based gender‐affirming hormone therapy was approximately 15%. Unmet need for gender‐affirming surgery is a slightly more complex area due to the multiple types of procedures that people can opt to undergo. However, 43%–82% of nonbinary people needing surgeries such as bilateral mastectomies, breast augmentation, metoidio/phalloplasty, vaginoplasty, orchiectomies and others report that they struggled to gain access to these surgeries [5].

Research has demonstrated that access to gender‐affirming care is a determinant of both health and mental health for this population [2, 6], with unmet need for gender‐affirming care resulting in poorer psychosocial outcomes [7, 8]. Despite the importance of gender‐affirming care, a scoping review conducted by Kearns et al. [9] found that nonbinary people are more likely to experience barriers to accessing gender‐affirming care compared to binary transgender people. This potential for inequity in access to gender‐affirming care has implications for health equity outcomes in this population. To address this health equity issue, there is an urgent need to document the barriers experienced by nonbinary people when accessing gender‐affirming care.

2. Methods

2.1. Design

This review utilised Turnbull et al.'s [10] systematic‐narrative hybrid approach to literature reviews. As a review method, it draws upon systematic review methods for search protocols and inclusion/exclusion criteria but applies a narrative approach to the synthesis and analysis of included literature. This includes six elements: (1) aims and research question; (2) justification; (3) literature sources; (4) search parameters; (5) data screening and (6) information synthesis. This approach combines the rigour of systematic review methods with the depth of narrative review methods [10]. Research about barriers to gender‐affirming care includes qualitative, quantitative and mixed‐method studies, as well as systematic and scoping reviews. A systematic‐narrative hybrid review ensures in‐depth analysis across multiple types of data. There are no human participants in this review article and as such ethical approval was not required.

2.2. Search Strategy

A systematic search was conducted across six databases which included APA Psycinfo, EBSCOHost, PubMed, Scopus, Proquest and CINAHL Ultimate. Due to the range of language used across the literature, the search terms required the use of a wide range of terms to adequately capture the existing research. Search terms ‘nonbinary’ ‘non‐binary’ ‘non binary’ ‘gender affirming care’ ‘medical transition’ ‘GAC’ ‘GAS’ ‘GAHT’ ‘affirm*’ ‘HRT’ ‘surgery’ ‘transition*’ ‘healthcare’ and operations ‘AND’ ‘OR’ were used to locate relevant literature.

2.3. Inclusion and Exclusion Criteria

Inclusion and exclusion criteria involved studies with a qualitative, quantitative or mixed‐methods research design as well as systematic and scoping reviews. Articles were included if published in English and between January 2015 to October 2025. Studies were included that contained a focus on nonbinary people's experiences of gender‐affirming hormone therapy and/or gender‐affirming surgery. Studies that focused on broad experiences of healthcare were included if they provided qualitative data on nonbinary people's experiences of gender‐affirming care. Studies that did not clearly report the inclusion of nonbinary people were excluded. Studies that did not include a discussion of the barriers experienced by nonbinary people were excluded.

2.4. Article Screening and Selection

Article selection followed the PRISMA 2020 guidelines, adapted for narrative review [11]. This process is illustrated in Figure 1. Study titles and abstracts were reviewed by the first author. Studies were screened for eligibility using PICO Portal software. Full‐text articles were reviewed by the first author, with consultation among the team when needed. Initially, 1257 research articles were identified as possibly relevant across the six databases that were searched. The use of PICO Portal immediately eliminated all duplicates (n = 471). After these duplicates were removed, 786 articles were then reviewed via title and abstract to ascertain eligibility as per the inclusion criteria. A total of 78 papers were identified as potentially suitable and were thus reviewed via full text.

FIGURE 1.

PRISMA flow diagram for literature search and inclusion.

2.5. Data Extraction and Analysis

Data was first extracted on 5 August 2025. The content and methodological quality were synthesised and analysed in three ways. Initially, the first author extracted key data into a Microsoft Excel template that was further reviewed by the second author. This template contained characteristics of each of the studies related to the country it was conducted in, the objectives of the study, the research design, the target population of the study, sample size, method and characteristics, data collection and analysis methods and the study findings and implications thereof. A quality appraisal of the studies utilised the Mixed Methods Appraisal Tool [12] for primary research design studies and the Risk of Bias in Systematic Reviews tool [13] was utilised to appraise the methodological quality of the included systematic and scoping reviews. A quality appraisal of the included studies is available in Table S1. To address the research question, a narrative synthesis using inductive analysis methods was performed to identify the barriers to gender‐affirming care discussed in the studies. The inductive analysis stage was completed by the first author, with consultation and review occurring among the wider team.

3. Results

Upon completion of the screening and selection process, 27 studies were selected to be included in this review [9, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39]. A summary of the characteristics of these studies is included in Table 1. An in‐depth summary is available in Table S1.

TABLE 1.

Study characteristics.

References	Country	Population	Method	Major findings
Burchell et al. [14]	Canada	Nonbinary people	Qualitative	Main themes included (1) erasure; (2) barriers to accessing health care and (3) assessing whether to come out. Sub‐themes included institutional erasure, informational erasure, general healthcare barriers, medical transition healthcare barriers, anticipated discrimination and assessing safety
Chang et al. [15]	USA	Transgender people who had previously accessed gender‐affirming surgery with the first author	Mixed‐methods	Experiences of misgendering using incorrect pronouns and/or preferred name. Misgendering typically occurred pre‐ and post‐surgical procedure by nurses, aides and administrative staff. Multiple experiences of being intentionally misgendered and called the wrong name. Staff members intrude into the patient's room to look at the patient's genitals and patients overhearing conversations about how “freaked out” staff are by the procedure
Clark et al. [16]	Canada	Trans and genderqueer youth	Quantitative	Nonbinary youth were twice as likely to experience barriers to accessing gender‐affirming hormone therapy than binary youth. Most common barrier identified was inability to find a doctor who could prescribe hormones. Other barriers identified included lack of family support, lack of health information about hormones, sports regulations and being pregnant
Cosgrove et al. [17]	USA	Nonbinary young adults	Qualitative	Study themes included the difficulty of accessing services that don't provide space for the nuances/uniqueness of nonbinary identity, the importance of feeling like one must manage various aspects of their identity to not overwhelm healthcare professionals, struggling with assumptions around binaries in clinical spaces and administrative forms and experiences of their gender being pathologised
Gillani et al. [18]	USA	Transgender and gender‐diverse people	Qualitative	Barriers to care included difficulties with private insurance, WPATH criteria, medical gatekeeping, negative experiences with medical personnel and a lack of representation
González and Veale [19]	New Zealand	Transgender people in New Zealand	Mixed‐methods	Barriers to care included availability, affordability, gatekeeping, lack of information, provider's lack of knowledge, gendered services. Facilitators of access included competent providers, healthcare providers that engaged in shared decision making and careful management of patient records
Grant et al. [20]	Australia	Transgender and gender‐diverse adults in Tasmania, AUS	Mixed‐methods	Main themes included (1) Financial/Geographical challenges, which referred to the financial outlay required to access gender‐affirming care and the distance required to travel to healthcare providers that offered trans health services. (2) Attitudes of health professionals; which ranged from positive experiences that were supportive and understanding to negative experiences such as direct discrimination, pathologisation of gender identity, needless and invasive physical examinations. (3) Medical gatekeeping; referring to the pathways to care and the feelings of having to perform transness appropriately for medical professionals to be willing to prescribe hormone therapy/surgical procedures
Haire et al. [21]	Australia	Transgender and gender diverse people with complex needs in Australia	Qualitative	Focused on experiences of healthcare settings more broadly, but gender‐affirming care was also discussed. Main themes included (1) Complexity of care; (2) economic hardship; (3) parameters of competent care and (4) community connection with other trans and gender diverse people. Nonbinary participant reported being prescribed hormone replacement therapy (HRT) dosages based on binary transgender affirmation and did not allow them to express their desires for HRT
Holland et al. [22]	Global	Transgender and nonbinary people in primary care settings	Systematic Review	Three key themes were identified in the study: (1) Primary care provider attitudes and knowledge; (2) the patient‐provider relationship and (3) healthcare settings. Trans people found experiencing insufficiently trained professionals and discrimination when accessing care. Study findings suggest a desire from trans and nonbinary people to have gender‐affirming care provided in primary‐care settings rather than specialised clinics
Ingraham et al. [23]	USA	Transgender and nonbinary adults who had received transition related care at a family planning clinic between 2019 and 2020	Qualitative	Mostly positive experiences of family planning clinics, particularly with regards to speed and ease of the informed consent process used in the clinics. Barriers occurred for nonbinary people with regards to embedded binaries in the medical system and insurance systems
Javier et al. [24]	Global	Nonbinary adults	Systematic Scoping Review	Study findings included seven barriers to accessing treatment: (1) Healthcare provider's lack of knowledge and understanding of nonbinary identity. These included experiences such as difficulty finding a doctor willing to prescribe them HRT. Doctors that refuse to assist due to assumptions that HRT should only be for people needing to transition to male or female. Denied due to religious/personal beliefs. Nonbinary people having to provide they are transgender to receive treatment. (2) Long waiting times to access treatments; (3) Expensive treatment costs; (4) Pressures to transition to a binary gender which involved nonbinary people feeling pressured to perform as a binary trans person to access treatment. Reported that nonbinary people would omit their nonbinary status for fear of being denied HRT. (5) Lack of social support; (6) Lack of information on gender‐affirming care for nonbinary people and (7) Personal circumstances which included pre‐existing medical conditions
Kearns et al. [25]	Global	Transgender and nonbinary youth	Systematic Review	Major themes included (1) Disclosure of gender identity; (2) the pursuit of care; (3) the cost of care; (4) complex family/caregiver dynamics and (5) patient‐provider relationships. These incorporated a wide range of issues such as financial impacts, geographic location, waiting times for services, the availability of knowledgeable healthcare professionals, Discriminatory healthcare professionals and the burden of having to prove a transgender identity
Kearns et al. [9]	Global	Transgender and nonbinary people	Scoping Review	Identified 41 different factors impacting access to healthcare. Key among these were difficulty accessing information regarding services, experiences of discrimination in healthcare settings, cost of accessing services and concerns around societal acceptance of gender identity
Kearns et al. [26]	UK	Trans and nonbinary youth, parents of trans and nonbinary youth and gender‐specific healthcare providers in Ireland	Qualitative	Study findings included 4 major themes: (1) Structural factors, (2) diagnostic factors, (3) personal factors and (4) interpersonal factors. Among them, key issues were related to lack of services for young people, lack of transparency around how the system works, waiting lists to access services, negative experiences of the assessment process and a lack of understanding of nonbinary desires around affirmation for healthcare professionals
Kimber et al. [27]	Australia	Transgender people and gender‐affirming healthcare providers in Australia	Mixed‐methods	Themes found involved the lack of appropriate services available. High costs. Long waiting times. Geographic location. Lack of available information leading to burden on patient to research. Healthcare providers with out‐of‐date professional knowledge about the informed consent process as well as best practice methods for administering HRT. healthcare providers with no knowledge and/or skill for working with trans and nonbinary people. Discrimination from healthcare providers. nonbinary people reporting being treated as a ‘child with no understanding of the self’. Nonbinary people reported being subjected to gendered biases while accessing gender‐affirming care and having to lie about their gender to fit these gendered ideals. Binary understandings of gender resulting in assumptions being made about their desires around hormone therapy and gender‐affirming care more broadly. Nonbinary people reported being treated as mentally ill. Findings suggest a strong need for care models that prioritise patient autonomy was identified, especially among nonbinary cohort
Lehmann et al. [28]	UK	Transgender people currently or not currently attending specialist gender services	Qualitative	Study findings included participants fears about needing to present their gender in a legible, binary manner. Nonbinary participants noted dressing more feminine or masculine than usual just to avoid being refused care and edited their experiences (omission, lying) in fear of being refused services during assessment and ongoing care. Healthcare professionals can have a binary understanding of gender identity, with nonbinary participants reporting being refused access to care unless they performed as a binary trans person
Lorusso et al. [29]	Italy	Transgender and nonbinary adults either currently accessing services in a gender clinic or are on the waitlist	Qualitative	Participants reported experiencing deadnaming/misgendering and invalidation of gender identity from healthcare professionals. All participants reported feeling as if they must conceal/edit their identity to fit normative ideals of binary gender identity to receive gender‐affirming care. Reports of participants being refused access to HRT because they did not align with the healthcare professional understanding of binary trans identity. Where binary trans people tend to experience invalidation from healthcare professionals if they express their gender in a non‐stereotypical manner, nonbinary people experience invalidation of their entire gender identity. Medical gatekeeping through actions such as refusing patient desires with regards to HRT dosages, accessing surgery at the ‘wrong time’ and so on. Participants highlighted having trouble with the ICD‐11 criteria of dysphoria due to a lack of resonance with how it is described not aligning with their own lived experience
Lykens et al. [30]	USA	Young genderqueer and nonbinary people who had accessed healthcare at least once in the previous 6 months	Qualitative	Included gender‐affirming care but this was reported along broader healthcare experiences. Participants reported: healthcare professionals who did not understand nonbinary identity and approached gender‐affirming care from a binary trans understanding. Healthcare professionals would regularly offer HRT dosages and referrals for gender‐affirming surgery that the person had not indicated any desire for. Participants struggled against assumptions of ordered methods of affirming their gender (start with HRT then Surgery 1, Surgery 2 and continue on.) or that they even desired certain surgeries in the first place. Additionally, healthcare professionals were noted as lacking knowledge of nonbinary specific gender‐affirming care requirements. Participants discussed feeling pressured to omit their nonbinary status while accessing gender‐affirming care and to perform more normative binary models of transgender identity to get easier care. Nonbinary people reported being referred to mental health services instead of gender‐affirming care when they previously tried to access HRT
Maine et al. [31]	Canada	Trans and nonbinary youth	Qualitative	Participants mentioned barriers such as long wait times. Lack of healthcare professionals' knowledge about the complexities of nonbinary identity. Participants discussed the burden of having to educate their providers. Being left unaware of available resources for gender‐affirming care, and the pathways to these services. Also discussed was that healthcare professionals did not often listen to or involve participants in their affirming care plan—there was a lack of discussion between the professionals and the person. Nonbinary people reported feeling ‘wrong’ and experiencing healthcare professionals dismissing their experience as their hormone numbers are ‘right’ but in accordance with binary trans guidelines
Marano et al. [32]	USA	Transgender adults	Quantitative	Quantitative analysis of responses from the 2015 US Trans Survey exploring barriers to surgery for transgender people. Barriers to care included: cost of accessing healthcare professionals and surgery, access to healthcare services overall and the limited availability of gender‐affirming surgeries
McGeough et al. [33]	USA	Trans and gender diverse youth in Kansas	Mixed‐methods	Participants reported experiences of discrimination from healthcare professionals and paternalism in approaches to care. Common experiences of being deadnamed and misgendered by healthcare professionals and clinical staff. A lack of knowledgeable healthcare providers resulting in experiences such as refusal to provide HRT due to out‐of‐date understanding of pathways to gender‐affirming care
Pastor Bravo and Linander [34]	Sweden, Spain	Trans and nonbinary youth in Sweden and Spain	Qualitative	Common reported barriers included wait times for gender clinics and services, financial barriers to accessing care and surgeries, lack of availability of gender‐affirming care providers, lack of inclusive facilities on‐site at clinics, widespread assumptions among healthcare professionals about the gender binary impacting care for nonbinary people
Puckett et al. [35]	USA	Trans and gender nonconforming individuals	Mixed‐methods	Findings included barriers because of a lack of information about gender‐affirming care for nonbinary people, limited availability of gender‐affirming care services and access issues due to financial and healthcare insurance limitations
Stewart et al. [36]	Australia	Trans, gender diverse and nonbinary patients accessing gender‐affirming care at one clinic in Sydney, Australia	Mixed‐methods	Study findings included most participants being appreciative of the gender‐affirming care clinic and its approaches to patient care. However, barriers discussed included: Financial barriers, a general lack of awareness of pathways to gender‐affirming care and gatekeeping by healthcare professionals
Stroumsa et al. [37]	USA	Trans and nonbinary adults	Qualitative	Participants reported feeling pathologised and doubtful of their own identity because of the assessment process. Mental health evaluation requirements left participants reporting feelings of stigmatisation due to the conflation of trans identity with mental illness. Participants felt the need to self‐edit, omit parts of their experiences and perform a certain type of normative gender ideal and of transness in order to ensure access to the required letters
Taylor et al. [38]	UK	Nonbinary adults currently accessing gender‐affirming care through a gender clinic in the UK	Qualitative	Participants reported feelings of being dismissed by clinic staff, leaving them feeling invisible and ignored. Discussions featured participant struggles with managing the influence and impact of binary models of trans identity in the gender clinic
Tristani‐Firouzi et al. [39]	USA	Trans and nonbinary adults who expressed desire for, or had previously undergone, a gender‐affirming surgery	Mixed‐methods	Barriers included the financial barrier to accessing gender‐affirming surgeries, feat of complications arising from surgery, the limited availability of gender‐affirming surgery services and employment related difficulties

Among the included studies, 63% were published in the last 3 years (n = 17), highlighting an increased interest in this topic in recent years. Most of the studies were conducted using qualitative research methods (n = 13), with mixed‐methods research design constituting the second largest proportion of the dataset (n = 8) and reviews (n = 4) and quantitative studies (n = 2) making up the rest of the studies. Despite all of the included studies featuring nonbinary participants, only 19% of the total included papers (n = 5) were exclusively focused on nonbinary people. Of this amount, approximately half were focused on nonbinary youth (n = 2). The reviewed studies include research conducted across Australia, Europe, New Zealand, North America and the United Kingdom. North America had the highest number of papers included (n = 13), followed by the United Kingdom (n = 3), Australia (n = 4), Europe (n = 2) and New Zealand (n = 1). Table 1 provides an overview of the characteristics of the articles included in this review and a detailed summary is available in Table S1. A total of four themes were developed based on the inductive analysis of the findings of these studies.

3.1. A Foot in the Door: Access

The first theme from the literature involves the myriad barriers that nonbinary people face in getting their ‘foot in the door’ of the medical system. These barriers are related to environmental factors such as geographical location, socioeconomic characteristics related to income and wealth, and rates of health literacy. They are typically experienced in the initial part of their journey to affirming their gender. Both individual health literacy and the broader health literacy environment is a key driver of health inequity as many nonbinary people have trouble locating resources for what, how, where and when to access gender‐affirming care [9, 16, 24, 31, 35, 36]. In the literature, even participants who reported a firm grasp of their desire for gender‐affirming care had their affirmation journey delayed due to uncertainty as to the pathways to access gender‐affirming services [31]. A dearth of informational materials about gender‐affirming care was identified as a common barrier. This suggests that the health literacy environment is failing to meet the needs of this population.

Determinants of health related to socioeconomic characteristics such as personal income and wealth were highlighted as a key factor in impacting health equity outcomes. For many individuals, financial constraints were frequently identified as a barrier to gender‐affirming hormone therapy [20, 21, 23, 24, 35]. Nonbinary people report difficulty with managing the financial burden of accessing gender‐affirming care due to out‐of‐pocket costs associated with accessing gender‐affirming care providers [36]. The ongoing cost of prescriptions for hormones such as oestrogen, androgen blockers and testosterone was also identified as a barrier to maintaining gender‐affirming care [20, 21, 23, 24, 35]. For nonbinary people in regional, rural and remote areas, health equity is complexified as environmental factors such as geographic location often intersect with socioeconomic characteristics to further impact upon health access. This is reflected in research that reports additional economic burdens due to the large distances nonbinary people must travel to access gender‐affirming care [14, 16, 20, 23, 25]. Additionally, the cost of accessing gender‐affirming surgery was also discussed as a common barrier [15, 18, 32, 35, 39]. Both the consultation costs of mental healthcare professionals for referral letters [35, 37] and the cost of surgery itself [15, 18, 32, 35, 39] were identified as particularly difficult to overcome for nonbinary people seeking gender‐affirming surgery. It is challenging to quantify what influence the high costs associated with privatised healthcare models have on exacerbating these barriers; however, studies conducted in Australia have had comparable findings. These Australian studies universally found the cost of surgeries (not covered by the public health system), medication and general practitioner visits as substantial barriers to care, even though Australia has a universal healthcare system in place [20, 21, 27, 36]. Consequently, socioeconomic characteristics related to financial income and wealth have a significant impact on health equity outcomes for this population.

A number of studies in the United States, Australia, Canada and the United Kingdom [9, 16, 18, 21, 23, 26, 29] have reported that nonbinary people commonly experienced difficulties locating healthcare professionals competent in the provision of gender‐affirming care. Surprisingly, participants who noted they were aware of a local gender‐affirming care provider still found it difficult to access care [9]. This was due to the provider experiencing high levels of patient demand thus impacting their capacity and resulting in limited availability and ever‐expanding waitlists [9, 16, 25, 32, 35, 39].

3.2. Medical Gatekeeping

For nonbinary people that manage to overcome the initial barriers and commence their affirmation journey, gender‐affirming care is controlled by medical professionals and dictated by the relevant standards of care associated with the region's professional association for trans healthcare, such as the World Professional Association for Transgender Health (WPATH) [1] and the Australian Professional Association for Trans Health (AusPATH) [40]. Consequently, medical gatekeeping is a common barrier for nonbinary people accessing gender‐affirming care. Despite the powerful implications of the impacts of this practice on people's wellbeing, much of the research on this has been descriptive in nature. However, research has found that nonbinary people are frequently left feeling vulnerable to the whims of healthcare professionals, pathologised and consequently powerless over their own affirmation because of these requirements and assessments [18, 29, 34, 37]. Professionals' narrow ideas of trans and nonbinary identity place pressure upon nonbinary people, with studies finding that nonbinary people will ‘self‐edit’ their gender to seek legibility, typically through performing a binary trans identity [24, 26, 28, 30, 37]. Studies found that nonbinary people reported fearing being refused access to gender‐affirming care if they did not participate in this behaviour [17, 20, 26, 29, 33, 37]. This is echoed throughout other studies that have reported nonbinary people experiencing being refused gender‐affirming care and instead being provided a referral on to mental healthcare services instead upon ‘coming out’ as nonbinary to healthcare professionals [30, 36]. Access to health services that are responsive to the needs of the consumer is a key social determinant of health [41], and there is a clear unmet need for this population regarding this determinant.

Nonbinary people frequently experience the dismissal of their lived experience in favour of healthcare professionals making decisions for them [21, 24, 29, 33]. Healthcare professionals can assert their medical authority over the person's gender‐affirming care plan, and consequently the person may be denied the chance to articulate their desires for affirmation [24, 30, 31, 33]. As a result, gender‐affirming hormone therapy can be provided to nonbinary people at doses intended for binary trans people with different affirmation goals [24, 29]. This conduct can also extend to discussions about gender‐affirming surgery, with recommendations for gender‐affirming surgery being at odds with the person's goals [20, 21, 24, 30], or provided at the wrong time [20, 29].

3.3. Nowhere, Invisible

An enduring theme throughout the literature was the invisibility of nonbinary identity and the barriers this creates to responsive care and health equity. Invisibilisation refers to the actions, processes and system that occur because of systemic inequity that actively erases the existence and needs of marginalised populations [42]. Rather than ‘hard to reach’, we use the concept of ‘invisibilisation’ here as it highlights how this is an active process that is done to marginalised people rather than a process where a community opts out of being included [42]. For nonbinary people, they are invisibilised through a process of social exclusion. In the context of gender‐affirming care, this process of invisibilisation manifests in gender‐inclusive clinics through clinical staff deadnaming, in other words using a person's name given at birth instead of the current, correct name [15, 17, 23, 29, 33] and misgendering people by using incorrect pronouns [15, 17, 29, 33]. The physical space of the clinic can also be a site of invisibilisation via multiple different methods. A lack of inclusive facilities on‐site, such as restrooms, is a common problem [33] that can create a sense of exclusion for nonbinary people. Nonbinary people can be further invisibilised by having to use clinic systems and intake forms that lack inclusive options for genders, pronouns and preferred names [14, 17, 23, 38]. This invisibilisation was also evident in other studies which found that nonbinary people faced barriers related to improving their health literacy level. This was due to an inability to locate information about gender‐affirmation for nonbinary people, and when information was accessible it was typically out of date and/or contradictory [24, 26, 31, 35].

Previous studies highlighted that the absence of nonbinary specific gender‐affirming care can continue into the healthcare professional's office, with nonbinary people frequently being exposed to unknowledgeable practitioners who are unaware of the nuances of nonbinary identity [14, 17, 18, 20, 22, 28, 30, 33]. Invisibilisation can have clear negative impacts on the experiences of gender‐affirming care. Consequently, this results in barriers to gender‐affirming care for nonbinary people and impacts upon health equity outcomes for this population. A study of the lived experiences of nonbinary people accessing a gender clinic in the United Kingdom by Taylor et al. [38] found that nonbinary people experienced barriers to ensuring their gender identity was recognised due to having to engage in a gender‐affirming care process that is primarily constructed for binary trans people.

3.4. The Inconvenience of the Complexity of Gender

The final theme refers to the tendency within the literature to decomplexify the experience of nonbinary gender, which has implications for evidence‐based practice and health policy for this population. Throughout the included studies, there is an overreliance on mixed‐method research methods and research that has been conducted on data collected from short‐answer questions [15, 16, 19, 32, 33, 36, 38]. This has a limiting effect on the information that can be collected and thus ignores the inherent complexity in, and experiences of, nonbinary people. Additionally, the voices of nonbinary people are further limited through researchers categorising their experiences in with binary trans people with the assumption that they are ‘similar enough’ [28]. Nonbinary people also risk having their identity erased as researchers will request their assumed gender at birth and analyse data through this lens [19, 28, 30, 38, 39]. Studies will use data visualisations that organise their participant data via assumed gender at birth [14, 19, 28, 39] and/or categorise participants as nonbinary when they have indicated they are a different gender instead [16, 23]. We include this discussion of problematic research practices here as healthcare and health promotion is evidence‐based and thus reliant on existing research. These studies may currently shape practice and health promotion efforts with nonbinary populations. Consequently, we argue that current research that informs practice can negatively impact the experiences of nonbinary people when accessing services or lead to barriers to care.

4. Discussion

To our knowledge, this is the first systematic‐narrative hybrid review focusing on barriers to gender‐affirming care for nonbinary youth and adults. The themes developed from the inductive analysis highlight the determinants of health such as health literacy, socioeconomic characteristics and geographic location of individuals that shape the barriers faced by nonbinary people when accessing gender‐affirming care. Many of these overlap and shape each other. The findings regarding people's lack of knowledge about gender‐affirming care and how to access it are consistent with existing research [9, 16, 24, 31, 35, 36], however, we argue that this is a health literacy issue and as such requires health promotion efforts to address [14, 16, 20, 23, 25]. Additionally, determinants related to socioeconomic characteristics and geographic location [14, 16, 20, 23, 25] were found to be key drivers of health equity outcomes as the financial burden of both gender‐affirming hormone therapy and gender‐affirming surgeries was found to impede access for many nonbinary people [20, 21, 23, 24, 35]. This finding is not novel as previous reviews exploring access to gender‐affirming care have also identified the financial cost of gender‐affirming care to be a key barrier to access [9, 22, 24, 25]. However, it is significant to note that it is also a key barrier for nonbinary people in Australia [20, 21, 27, 36] despite the existence of low‐to‐no cost general practitioners and government subsidised medication.

Reviews conducted by Javier et al. [24] and Kearns et al. [9] found that nonbinary individuals can experience additional barriers to accessing gender‐affirming care in comparison to binary trans people, and this review strengthens the evidence for this for both adults and nonbinary youth. Diverging from the themes discussed by Javier et al. [24], we identified additional barriers related to the invisibilisation of nonbinary identity in approaches to gender‐affirming care and barriers created by existing research practices. Research has identified that nonbinary people struggle with articulating their desires for gender‐affirming care [38]. This results in nonbinary people ‘self‐editing’ or omitting their nonbinary identity to perform more normative binary models of trans identity to avoid being refused access to gender‐affirming care [24, 26, 28, 30, 37]. We argue that this is a result of an active process of invisibilisation which erases nonbinary identity from gender‐affirming care spaces. As research informs evidence‐based practice, existing research practices that decomplexify nonbinary identities can negatively impact the experiences of nonbinary people and lead to barriers to gender‐affirming care.

4.1. Limitations and Future Directions

The number of included studies in this review was small due to the lack of research regarding the experiences of nonbinary people. The quality of the included studies varied, but all were deemed sufficient to be included. Sample sizes ranged from large to small, with purposive, snowball and convenience sampling commonly utilised. This could mean an over‐representation of people already engaged in gender‐affirming care spaces. Several studies conflated nonbinary identity with genderqueer, genderfluid and gender‐diverse identities, which impacts upon the reliability of study findings. Although all study samples included nonbinary participants, there was minimal discussion of the unique issues faced by this population. Future research should prioritise nonbinary voices [43] and specifically in exploring this topic.

Almost half (n = 10) of the included studies utilised data collected from online survey responses [16, 19, 20, 27, 33, 35, 36, 39], and/or participant data from broader studies [16, 19, 26, 31, 32] therefore creating a methodological gap. Future research should prioritise in‐depth qualitative research methods to avoid these methodological limitations. The themes developed in this review section suggest an approach to nonbinary identity from healthcare professionals and researchers that overlooks the complexity of lived experience in favour of more simplified, binary models. Future health promotion efforts should also seek to explore the complexity of nonbinary people's desires and needs for care. Finally, it is important to acknowledge the current political climate in both Australia and worldwide around gender‐affirming care. This has implications for health promotion and health equity outcomes. Existing research does not capture the impact of this worsening political climate on access to gender‐affirming care for nonbinary people. Future research directions should prioritise exploring the impacts of ongoing bans and restrictions on gender‐affirming care for nonbinary people. Health promotion efforts should also be mindful of the impacts of this climate.

5. Conclusion

This systematic‐narrative hybrid review expands upon understandings of the health inequities faced by nonbinary people accessing gender‐affirming care. Barriers related to structural and environmental factors as well as socioeconomic characteristics were discussed. Determinants of health related to people's geographic location, the cost of care and the availability of trained gender‐affirming healthcare professionals were identified as issues that impeded access to gender‐affirming care and health equity. For nonbinary people that were able to access gender‐affirming care, structural factors that produced barriers related to practices of medical gatekeeping were common. These included being refused access to gender‐affirming care due to being nonbinary and pressure from healthcare professionals to conform to binary gender norms to access care. We further identified the ways that nonbinary people are invisibilised in the field and how this perpetuates the existing barriers to health equity. Health promotion efforts must be informed by these findings and be informed and led by nonbinary needs for gender‐affirming care to ensure health equity.

Funding

The authors have nothing to report.

Ethics Statement

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Table S1: hpja70273‐sup‐0001‐TableS1.xlsx.

Danvers R., King J., Perich E., and Mullens A. B., “Barriers to Gender‐Affirming Care for Nonbinary People: A Systematic‐Narrative Hybrid Literature Review,” Health Promotion Journal of Australia 38, no. 1 (2027): e70273, 10.1002/hpja.70273.

Data Availability Statement

The data that supports the findings of this study are available in the Supporting Information of this article.