Transgender Youth’s Disclosure of Gender Identity to Providers Outside of Specialized Gender Centers

Abstract

Purpose

Transgender youth face significant health disparities and multiple barriers to receiving quality healthcare. Gender identity disclosure to healthcare providers (HCPs) is an important step in creating affirming relationships for transgender youth. The objectives of this study were to: (1) determine the prevalence of voluntary disclosure and intentional avoidance to HCPs outside of gender clinics; (2) identify factors associated with voluntary disclosure and intentional avoidance; and (3) elucidate strategies to increase comfort with disclosure.

Methods

A cross-sectional survey was administered to transgender youth ages 12–26. Bivariate analyses were conducted using chi-square or Fisher’s exact tests. Two logistic regression models for each outcome variable were used to examine factors associated with voluntary disclosure and intentional avoidance.

Results

Two-thirds (65%) of youth (N=153) identified as transmasculine and 57% were under 18. Three-quarters (78%) had voluntarily disclosed their gender identity to a HCP outside of gender clinic, while 46% had intentionally avoided disclosure. Odds of ever having disclosed were lower for participants 18 and over (OR=0.33; 95% CI: 0.11, 0.98), those out to fewer people (OR=0.12; 95%CI: 0.02, 0.81) and out for less than 1 year (OR=0.03; 95% CI: 0.004, 0.31). Odds of intentional avoidance were lower among youth with higher perceived parental support (OR=0.83; 95% CI: 0.70–0.98).

Conclusion

A majority of transgender youth reported having voluntarily disclosed their gender identity to a HCP outside of gender clinic, but almost half reported having intentionally avoided disclosure when they felt it was important. Parental support may play a protective role in mitigating avoidance.

Introduction

Transgender youth often face significant societal stigma and discrimination in addition to multiple barriers to receiving quality healthcare.^1–5 It is likely that a combination of these factors contributes to the development of the significant health disparities^6–12 and lower rates of healthcare utilization seen in this population.^13,14 Access to affirming environments^15,16 and gender affirming medical care^17–19 reduces these alarming health outcomes, but a limited number of transgender health specialists are available across the US.^1,7,20–22 Voluntary gender identity disclosure to healthcare providers (HCP’s) outside of specialized gender clinics is a crucial step in developing gender affirming relationships with a HCP and may facilitate access to transgender health specialists.^23,24 More broadly, voluntary disclosure of gender identity may be needed to maximize effectiveness, appropriateness, or safety of care (e.g., appropriate radiologic procedures, appropriate sexual health screening).

No prior studies have investigated the prevalence of voluntary disclosure- or its corollary, intentional avoidance- among transgender youth. Nor have studies explored the personal and system-level factors that influence youth comfort with gender identity disclosure in the healthcare setting. Prior studies have shown the majority of transgender adults feel identity disclosure to healthcare providers is important^23,25–30 and suggest that disclosure may differ based on gender identity, with binary transgender adults more likely to disclose (84%) than those who identify as nonbinary (52%).²⁶ Additionally, one-third (31%) of transgender adults indicated they had not disclosed their gender identity to any of their current healthcare providers (HCPs).²⁶ Unfortunately, no similar studies have been conducted in youth, but prior research investigating disclosure preferences of lesbian, gay and bisexual (LGB) youth suggests that despite feeling it is important that their HCP know their sexual orientation, most had not disclosed.³¹ LGB youth suggested providers initiate conversations about sexual orientation during clinical visits and provide opportunities to speak with youth confidentially to increase comfort with disclosure. Focused examination of these same questions among transgender youth is necessary to inform the creation of more welcoming healthcare spaces to support voluntary disclosure, reduce intentional avoidance and ultimately mitigate health disparities.

Thus, there is a knowledge gap regarding transgender youth’s experience with voluntary disclosure and intentional avoidance in health care settings, which is crucial to address to develop gender affirming environments for transgender youth. We aimed to fill this knowledge gap by conducting a cross-sectional survey with transgender youth about their health care experiences. The objectives of this study were threefold: (1) to determine the prevalence of voluntary gender identity disclosure and intentional avoidance in interactions with HCPs outside of specialized gender centers; (2) to identify factors associated with voluntary disclosure and intentional avoidance; and (3) to elucidate strategies to increase comfort with voluntary disclosure, thereby leveraging youth perspectives to create more inclusive health systems.

Methods

Study Design and Population

The study was conducted using a cross-sectional survey administered via electronic tablet. Transgender youth ages 12–26 were recruited from a multidisciplinary gender clinic in Southwestern Pennsylvania between July and November 2018. The first author reviewed the electronic health record of upcoming clinic schedules to identify potential study participants. Patients were approached by either their medical provider or a member of the research staff to introduce the study during a regularly scheduled clinic visit. With informed consent obtained, interested youth were screened based on their response to the following question ‘How do you describe your gender identity?’. Youth who identified their gender identity as only cisgender were excluded. In total, 211 youth were approached to participate, and 6 of these individuals were excluded due to identification as only cisgender. Of the remaining 205 participants, 204 completed the survey (99.5% participation rate). Approval, including a waiver of parental consent for participants younger than 18, was obtained from the Institutional Review Board (IRB).

Measures

The survey consisted of 78 items, with this analysis focusing on a subset of disclosure-related items. The majority of these disclosure related survey items were adapted from an existing survey tool designed to understand the factors influencing LGB youth’s choice to disclose their sexual orientation in the healthcare setting.³¹ Additional items were adapted from surveys used to understand health system factors important to LGB youth³² and transgender adults’ experiences accessing healthcare.^26,33 To ensure the survey language was appropriate for transgender adolescents and young adults, items underwent cognitive interviewing with two transgender young adults prior to content validation by seven transgender health content experts. Additional survey items asked participants to select from a list of options regarding why they avoided telling a healthcare provider about their identity, strategies HCPs could enlist to help them feel more comfortable talking about their gender identity and how they would want a conversation about their gender identity to start.

Outcome variables.

Our two primary outcome variables were voluntary disclosure and intentional avoidance. Voluntary disclosure was defined as a yes response to the following question “Have you ever chosen to tell a HCP outside of the gender clinic about your gender identity?”. Intentional avoidance was defined as a yes response to the following question “Have there been times you felt it could be important for your HCP to know your gender identity but you avoided telling them?”.

Demographic characteristics.

Gender identity was operationalized based on responses to the following question “How do you describe your gender identity?.” A range of 15 possible responses were provided as well as a free text option. For this analysis, we categorized responses into one of three categories ‘transmasculine’, ‘transfeminine’ and ‘nonbinary.’ Participants who selected only ‘transmasculine’ or only ‘transfeminine’ were included in these two respective groups. The remaining 29 participants, who identified outside of these two binary categories were coded to the umbrella term ‘nonbinary’. Of these 29 youth, 20 specifically selected the term ‘nonbinary’ to describe their identity. Of the remaining 9 participants, 3 selected the term ‘genderqueer’, 3 selected ‘androgyne’, 2 selected ‘agender’ and 1 selected ‘demiboy’. Among additional demographic questions, we categorized age into younger than 18 versus 18 or older, due to the impact of age on access to care and parental consent. Race/ethnicity was self-identified, and grouped into one of two categories for this analysis: ‘White’, or ‘Non-white’ due to small numbers of respondents selecting races other than white. Travel distance to clinic was assessed using the question “How long did it take you to get to clinic today?” and responses were grouped into ‘less than 30 minutes’, ‘30 minutes to 1 hour’ and ‘more than 1 hour’. Lastly, participants indicated the clinic site at which they were receiving their care as either ‘Endocrinology’ or ‘Adolescent Medicine’.

Gender-related characteristics.

In addition to self-described gender identity, the survey assessed other dimensions of gender presentation and the extent to which youth had discussed their gender identity with others. Gender expression was assessed using the following question “A person’s appearance, style, dress, or the way they walk or talk may affect how people describe them. How do you think other people who don’t know you would describe your appearance?” Responses were selected from a 5-point Likert scale. Youth responses were grouped into feminine (‘very or mostly feminine’ and ‘somewhat feminine’), neutral, or masculine (‘very or mostly masculine’ and ‘somewhat masculine’). To assess perception of passing, the following question was used: “Some people use the word passing to describe when most strangers perceive that they are the gender that they identify with. How well do you feel you pass as the gender you identify with?” and responses were recorded on a 4-point continuum from ‘don’t pass at all’ to ‘pass all of the time’. To assess the degree to which participants were out about their gender identity, the following question was used “Outside of healthcare, how out are you about your gender identity right now?” with a 5-point response continuum ranging from ‘not out to anyone’ to ‘out to everyone.’ The length of time out was assessed by asking how much time had passed since the first time participants disclosed their gender identity to someone else. Time out to parent was operationalized using the following question: “How long ago did you come out to your parent/guardian about your gender identity?.” Responses to both time out and time out to parent were grouped into ‘less than 1 year’, ‘1 to 2 years’, ‘2 to 3 years’ and ‘more than 3 years’. Finally, to assess each youth’s most supportive parental relationship, parental support was assessed as a continuous variable based on responses to the following question “On a scale of 1 to 10, how supportive would you say your most supportive parent/legal guardian is of your transition? (1 being not supportive at all and 10 being extremely supportive)”.

Factors influencing gender identity disclosure.

Two items were used to understand the clinic and provider level factors youth felt influenced their comfort with gender identity disclosure. Pre-determined response items were derived from existing survey measures assessing sexual orientation disclosure among LGB youth³¹ and prior studies exploring transgender youth’s experiences accessing healthcare.^32,34

Analyses

Descriptive statistics were used to report the prevalence of voluntary disclosure and intentional avoidance, as well as preferences for disclosure conversations and reasons for intentional avoidance. To identify factors associated with voluntary disclosure and intentional avoidance, we examined each of these two outcome variables separately. First, bivariate analyses were conducted using chi-square tests for categorical variables (or Fisher’s exact test when expected cell sizes were <5) and t-tests for continuous variables to identify whether demographic and gender-related characteristics were associated with either of our outcomes. We then examined the association between demographic and gender-related characteristics and each of our two primary outcome variables (voluntary disclosure and intentional avoidance) by running two separate logistic regression models for each outcome variable. The first model included only demographic variables and the second included demographic characteristics and any gender-related characteristics associated with the outcome at p<0.15 in the bivariate analysis. For multivariable models, we considered statistical significance to be p<0.05. Finally, descriptive statistics were used to report youth perspectives on how to create more inclusive healthcare environments. Data analysis was conducted using Stata version 14.2 (StataCorps, College Station, TX).

Of the 204 participants, 75% had complete data for all outcome variables, demographic characteristics and gender-related characteristics creating an analytic sample of 153 participants which was used for both bivariate and regression analyses. The proportion of missingness was minimal for our two primary outcome variables voluntary disclosure (0.4%) and intentional avoidance (1.5%). Missingness of the independent variables was highest for parental support (8.8%) and age (7.8%). Because missingness was largest for our independent variables and nearly complete for both primary outcome variables, we chose not to impute missing data. However we did conduct a sensitivity analysis using the missing indicator method.³⁵

Results

Sample Characteristics

Two-thirds (65%) of youth in our sample identified as transmasculine, almost one-fifth transfeminine (16%), and one-fifth nonbinary (19%; Table 1). The majority (84%) were seen in Adolescent Medicine clinic for their gender care, and over half (57%) were under the age of 18. Two-thirds (66%) traveled longer than 30 minutes to clinic, and 88% identified their race/ethnicity as ‘White’.

Table 1.

Bivariate Analysis of Factors Associated with Gender Identity Disclosure and Avoidance (n=153)

	Overall sample	Prevalence of Voluntary Disclosure Outside of Gender Clinic		Prevalence of Intentional Avoidance of Gender Identity Disclosure Outside of Gender Clinic
	n (%a)	n (%b)	p	n (% b)	p
Demographic characteristics
Gender identity
Transmasculine	100 (65)	83 (83)	0.101	50 (50)	0.084
Transfeminine	24 (16)	16 (67)		6 (25)
Nonbinary	29 (19)	20 (69)		14 (48)
Age
<18 years	87 (57)	71 (82)	0.191	37 (43)	0.358
≥18 years	66 (43)	48 (73)		33 (50)
Race
White	135 (88)	104 (77)	0.546	61 (45)	0.700
Non-white	18 (12)	15 (83)		9 (50)
Travel distance
<30 minutes	53 (35)	38 (72)	0.112	26 (49)	0.809
30 minutes-1hour	56 (37)	42 (75)		24 (43)
> 1 hour	44 (29)	39 (89)		20 (45)
Clinic site
Adolescent Medicine	128 (84)	97 (76)	0.179	64 (50)	0.017
Endocrinology	25 (16)	22 (88)		6 (24)
Gender-related characteristics (GRC)
Outness
Out to everyone	66 (43)	59 (89)	0.001	30 (45)	0.699
Out to most	55 (36)	42 (76)		23 (42)
Out to some	23 (15)	15 (65)		13 (57)
Out to few/none	9 (6)	3 (33)		4 (44)
Time since first gender identity disclosure to anyone
< 1 year	14 (9)	5 (36)	<0.0001	8 (57)	0.211
1–2 years	28 (18)	19 (68)		8 (29)
2–3 years	54 (35)	48 (89)		27 (50)
>3 years	57 (37)	47 (82)		27 (47)
Time since first gender identity disclosure to parent
<1year	32 (21)	20 (63)	0.048	15 (47)	0.789
1–2 years	37 (24)	27 (73)		16 (43)
2–3 years	47 (31)	40 (85)		24 (51)
>3 years	37 (24)	32 (86)		15 (41)
Perceived passing as gender
Pass all of the time	34 (22)	29 (85)	0.003	11 (32)	0.117
Pass most of the time	45 (29)	41 (91)		24 (53)
Pass some of the time	64 (42)	44 (69)		28 (44)
Donť pass at all	10 (7)	5 (50)		7 (70)
Gender Expression
Masculine	108 (71)	85 (79)	0.812	51 (47)	0.008
Feminine	24 (16)	19 (79)		5 (21)
Equally feminine/masculine	14 (9)	10 (71)		8 (57)
Neither feminine/masculine	7 (5)	5 (71)		6 (86)
Parental support, mean(SD)	8.13 (2.31)	8.25 (2.13)	0.250	7.60 (2.45)	0.008

^a=column percentage

^b=row percentage, OR=odds ratio, CI= confidence interval, SD= standard deviation, passing was defined as when most strangers perceive you as the gender you identify with

Voluntary Disclosure

The majority of youth (78%) reported telling a HCP outside of gender clinic about their gender identity at some point in their lifetime. Youth reported varying preferences with respect to how they would like to see a conversation about their gender identity start. Nearly half 47% indicated they would prefer the provider initiate the conversation and only 25% indicated they would prefer to bring it up themselves (with remaining youth indicating that either it made no difference (17%), that it depended on the situation (9%), or that they were unsure (3%)). Among those who preferred a provider-initiated discussion (n=71), 55% indicated they would prefer that the provider initiate this discussion during the confidential portion of the provider visit.

When examining respondent factors bivariately associated with voluntary disclosure (Table 1), a perception of passing most of the time was associated with an increased likelihood of voluntary disclosure (91% vs. 50%, p=0.003). Additionally, prevalence of voluntary disclosure was higher in youth who were out to more people about their gender identity (89% vs. 33%, p=0.001), had been out for longer periods of time (82% vs. 36%, p<0.0001), and youth who were out to a parent for a longer period of time (86% vs. 63%, p=0.048). Voluntary disclosure was not associated with youth’s race/ethnicity, travel distance, clinic site or perception of parental support in bivariate analysis.

In the first regression model (Table 2), participants who identified as transfeminine had 61% lower odds of voluntarily disclosing than participants who identified as transmasculine (OR=0.39; 95%CI: 0.13, 1.15), though this did not reach statistical significance. In the second regression model, participants who were out to few or no one had 88% lower odds of having voluntarily disclosed than those who were out to everyone (OR=0.12; 95%CI: 0.02, 0.81). Participants who had been out for less than 1 year (OR=0.03; 95% CI: 0.004, 0.31) had 97% lower odds of having voluntarily disclosed compared to those who were out for 2–3 years. Additionally, participants who were 18 or older (OR=0.33; 95% CI: 0.11, 0.98) had 67% lower odds of voluntarily disclosure when compared to youth under 18.

Table 2.

Factors Associated with Gender Identity Disclosure and Avoidance of Disclosure

	Voluntary Disclosure Outside of Gender Clinic		Avoidance of Gender Identity Disclosure Outside of Gender clinic
	Model 1	Model 2	Model 1	Model 2
	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)
Demographic characteristics
Gender identity
Transmasculine	1.00 (referent)	1.00 (referent)	1.00 (referent)	1.00 (referent)
Transfeminine	0.39 (0.13–1.15)†	1.05 (0.24–4.56)	0.35 (0.12–1.02)†	0.39 (0.08–1.89)
Nonbinary	0.53 (0.19–1.47)	0.76 (0.20–2.93)	0.91 (0.37–2.24)	0.77 (0.25–2.38)
Age
<18 years	1.00 (referent)	1.00 (referent)	1.00 (referent)	1.00 (referent)
≥18 years	0.72 (0.31–1.66)	0.33 (0.11–0.98)*	1.64 (0.81–3.32)	1.54 (0.72–3.30)
Race
White	1.00 (referent)	1.00 (referent)	1.00 (referent)	1.00 (referent)
Non-white	1.12 (0.28–4.42)	1.21 (0.24–6.10)	1.29 (0.45–3.64)	1.41 (0.48–4.15)
Travel distance
<30 minutes	0.92 (0.36–2.35)	1.04 (0.32–3.42)	0.89 (0.39–2.04)	0.86 (0.36–2.05)
30minutes-1hour	1.00 (referent)	1.00 (referent)	1.00 (referent)	1.00 (referent)
> 1 hour	2.23 (0.72–6.99)	2.23 (0.53–9.44)	1.02 (0.44–2.36)	0.85 (0.38–2.14)
Clinic site
Adolescent Medicine	1.00 (referent)	1.00 (referent)	1.00 (referent)	1.00 (referent)
Endocrinology	2.63 (0.69–10.04)	3.89 (0.70–21.48)	0.31 (0.11–0.89)*	0.44 (0.15–1.33)
Gender-related characteristics (GRC)
Outness
Out to everyone		1.00 (referent)
Out to most		0.53 (0.17–1.63)
Out to some		0.27 (0.06–1.14)
Out to few/none		0.12 (0.02–0.81)*
Time since first gender identity disclosure to anyone
< 1 years		0.03 (0.004–0.31)**
1–2 years		0.32 (0.06–1.75)
2–3 years		1.00 (referent)
>3 years		0.77 (0.20–2.91)
Time since first gender identity disclosure to parent
<1yr		3.17 (0.46–21.72)
1–2 years		1.15 (0.24–5.44)
2–3 years		1.00 (referent)
>3 years		1.75 (0.36–8.48)
Perceived passing as gender
Pass all the time		1.66 (0.42–6.55)		1.05 (0.36–3.00)
Pass most of the time		4.34 (1.07–17.65)		1.72 (0.72–4.12)
Pass some of the time		1.00 (referent)		1.00 (referent)
Don’t pass at all		0.50 (0.08–3.30)		2.55 (0.51–12.84)
Gender Expression
Masculine				1.00 (referent)
Feminine				0.60 (0.14–2.61)
Equally feminine/masculine				1.79 (0.43– 7.38)
Neither feminine/masculine				6.61 (0.67–65.43)
Parental support, mean(SD)				0.83 (0.70–0.98)*

SD= standard deviation, passing was defined as when most strangers perceive you as the gender you identify with

Model 1: demographics only; Model 2: demographics + GRC’s significant p<0.15 in bivariate analysis

^†p<0.10

^*p<0.05

^**p<0.01

Intentional Avoidance

Almost half (46%) of youth reported ever having intentionally avoided telling a healthcare provider about their gender identity when they thought it was important. Of those who indicated they had avoided (n=70), the most common reasons for avoidance were ‘I didn’t feel comfortable talking about it’ (66%) and ‘I didn’t know how to bring it up’ (65%; Table 3).

Table 3.

Youth Reported Factors that Influence Gender Identity Disclosure

What are some of the reasons you have avoided telling your health care provider about your gender identity?
	% indicated this response
I didnť feel comfortable talking about it	66
I didnť know how to bring up	65
The healthcare provider never asked me	53
I didnť think the healthcare provider would approve	50
I was worried about how office staff might react	49
I was worried about being denied services	44
My parent/guardian was in the room	29
I was scared the healthcare provider would tell parent	19
I didnť think it was important	19
I was worried about potential danger or harm	16
What can healthcare providers outside of the gender clinic do to make you feel more comfortable talking about your gender identity?
	% indicated this response
Use my name and pronouns in waiting room	85
Use forms that allow me to list my name/pronouns	81
Educate front desk staff about the importance of using name/pronouns	79
Use forms that allow me to list my gender identity	76
Put LGBT-friendly materials in the waiting room	66
Talk to me without my parents in the room	36
Ask if I would like to talk about my gender identity during routine visits	31
Assure me my healthcare provider will not tell parents	11
Assure me my healthcare provider will not write in my chart	9

LGBT= lesbian, gay, bisexual and transgender

In unadjusted analysis, intentional avoidance was associated with lower levels of parental support (7.6 vs. 8.1, p=0.008) and having a gender expression that was neither feminine nor masculine (86% ‘neither feminine nor masculine’ versus 57% ‘equally masculine and feminine’ versus 47% ‘somewhat/very masculine’ versus 21% ‘somewhat/very feminine’, p=0.008). With the exception of clinic site, no association was found between intentional avoidance and other demographic variables or aspects of outness.

In the first regression model, participants seen in the endocrine-based gender clinic had 69% lower odds of having intentionally avoided (OR=0.31; 95% CI: 0.11, 0.89) compared to those seen in the adolescent medicine-based gender clinic. In the second regression model, youth with higher perceived parental support had 17% lower odds of intentional avoidance (OR=0.83; 95% CI: 0.70–0.98).

In our sensitivity analyses using the missing indicator method, all of the significant findings from the first and second models remained significant with similar effect sizes and directions (data not shown).

Increasing Comfort with Voluntary Disclosure

One-third of youth surveyed (34%) indicated that they had both voluntarily disclosed and internationally avoided. When asked how settings outside of gender clinics can make youth more comfortable voluntarily disclosing their gender identity, the most commonly selected strategies were using their name and pronouns in the waiting room (85%), using forms that allow them to list their name/pronouns (81%) and gender identity (76%), and educating front desk staff members about the importance of using the correct name and pronouns (79%; Table 3). These were far more prevalent selections than ensuring gender identity would not be disclosed to their parents (11%) or would not be documented in the electronic health record (9%).

Discussion

To our knowledge, this is the first study investigating the health systems factors influencing transgender youth’s comfort with gender identity disclosure. Our findings indicate that a majority of transgender youth have voluntarily disclosed their gender identity to a healthcare provider outside of a multidisciplinary gender clinic, yet nearly a quarter reported they had never done so. Additionally, almost half of youth in our study had intentionally avoided disclosing when they felt it was important, highlighting the need to create more inclusive spaces for transgender youth in the healthcare setting. We suspect that transgender youth who are not yet receiving care in a multidisciplinary gender clinic may experience greater reluctance to disclosing their gender identity in health care settings due to the same barriers (personal, family or system) that have interfered with their ability to access care in the gender clinic. For this reason, voluntary disclosure in our sample is likely higher than might be found in a broader population of transgender youth. Despite this, our results remain notable for three reasons. First, these results offer a valuable estimate of voluntary disclosure and intentional avoidance. Even though we note above that the estimates may be more positive than the general population of transgender youth, these findings alone indicate nearly a quarter of youth refrained from ever voluntarily disclosing their gender identity in healthcare settings outside of gender clinic. This number alone is sobering, but is likely an underestimate of the true prevalence in a non-clinical sample.

Second, these data illuminate that there are important patient characteristics that may inform a more tailored discussion about how to improve comfort in healthcare settings for the most vulnerable subsets of the transgender youth. Youth older than 18 and those who were less out about their identities were less likely to have ever voluntarily disclosed, a finding likely due at least in part to the fact that this older group included youth presenting to care with limited parental support. These data highlight the need to recognize the heterogeneity of this patient population and importance of developing targeted strategies that embrace the intersectional nature of individual identities and experiences in both clinical care and research.^36,37 Clinically, as we work to create welcoming healthcare environments we must recognize the uniqueness of each individuals’ experience and include visual representations of youth with a wide range of ages, gender identities and gender expressions. With respect to research, future transgender health studies may benefit from continued assessment of additional dimensions of gender-related characteristics, such as gender expression, outness and passing.

Finally, these data highlight specific opportunities for health system interventions to improve access to care. The two primary reasons youth cited for intentional avoidance were related to discomfort initiating a conversation about gender identity during a clinical encounter. This aligns with Meckler’s³¹ work investigating sexual orientation disclosure in LGB youth that found youth were far more comfortable disclosing their sexual orientation if their provider ‘just asked’ them about their identity. However, transgender youth in our study were far more likely to have indicated they avoided disclosure out of concern their HCP would not approve. Transgender youth in our study were also more likely to select strategies to increase comfort with disclosure like forms, LGBT affirming visual cues and positive waiting room experiences.^31,32 Additionally, factors which LGB youth indicated were important to them in facilitating disclosure, like ensuring confidentiality, were much less important to our population of transgender youth. Finally, protective factors like parental support play a significant role in mitigating intentional avoidance and likely help facilitate access to gender affirming care, suggesting providers caring for transgender youth should consider opportunities to assist parents in supporting their transgender children. Our findings provide HCPs and health-system leadership with clear recommendations regarding strategies to make healthcare spaces safer for transgender youth to voluntarily disclose their gender identities.

The following limitations should be considered in interpreting the findings from this study. First, the study involves a convenience sample of transgender youth receiving care at a multidisciplinary gender clinic in one mid-sized city and lacked racial/ethnic diversity. Additionally, roughly a quarter of youth were excluded from our main analysis due to missing data; however these were included in our sensitivity analysis with similar results. Our findings must be interpreted narrowly as participants in this study have already overcome significant barriers to accessing care, and because of this, may differ in many aspects from individuals in a broader sample of transgender youth not currently accessing care. An investigation of disclosure in a broader sample of transgender youth is warranted to investigate experiences in populations not represented in our sample. Third, given the cross-sectional nature of the study, the results are subject to recall bias. In addition, the temporality with which disclosure or avoidance occurred with respect to presentation to the gender clinic was unable to be assessed. Finally, because our primary outcome variables were assessed as having “ever” disclosed or “ever” avoided, our results do not quantify the frequency with which these occurred.

Conclusion

Approximately three-quarters of transgender youth in our study reported ever having voluntarily disclosed their gender identity to a healthcare provider outside of gender clinic, but almost half reported having ever intentionally avoided disclosure when they felt it was important. Youth who were over 18 and less out about their identities were less likely to have voluntarily disclosed. Participants who reported higher perceived parental support were less likely to have intentionally avoided highlighting the protective role parental support may play in mitigating avoidance and facilitating access to care. Youth selected several health systems level strategies to increase comfort with disclosure, suggesting a continued need to facilitate change at the level of the health system to create affirming environments and mitigate health disparities.

Implications and Contribution:

This study highlights the importance of developing strategies to embrace the intersectional nature of individual identities and experiences. Future research may benefit from assessing gender-related characteristics like outness and parental support. To mitigate intentional avoidance, providers can develop opportunities for parents to learn how to support their transgender children.

Abbreviations:

HCP

healthcare provider

LGB

lesbian, gay, bisexual

IRB

Institutional Review Board