Abstract
Purpose:
To explore differences in healthcare experiences, healthcare avoidance, and well visit attendance between binary and nonbinary transgender adolescents; also, to explore the association between distinct healthcare experiences and healthcare avoidance and well visits.
Methods:
We surveyed transgender adolescents ages 12–26 (n=156) recruited from a multidisciplinary gender clinic from July through November 2018. Differences in distinct healthcare experiences by demographics were assessed using multivariable linear regression. Multivariable logistic regression was used to examine independent associations between demographics and lifetime healthcare avoidance and past-year well visit and, also, associations between distinct healthcare experiences and lifetime healthcare avoidance and past-year well visit.
Results:
Compared to transfeminine adolescents, more non-affirming healthcare experiences were reported by nonbinary (β=1.41, 95% confidence interval [CI]: 0.49, 2.33) and transmasculine adolescents (β=0.78, 95% CI: 0.02, 1.53). Gender-affirming healthcare experiences did not differ by demographics. Transmasculine adolescents had over three times the odds of lifetime healthcare avoidance (adjusted odds ratio [aOR]=3.58, 95% CI: 1.41, 9.08) than transfeminine peers. Only younger age was associated with past-year well visit (aOR=3.83, 95% CI: 1.44, 10.17). Non-affirming healthcare experiences were positively associated with healthcare avoidance (aOR=1.85, 95% CI: 1.47, 2.34). Gender-affirming healthcare experiences were not associated with healthcare avoidance or past-year well visit.
Conclusions:
Nonbinary and transmasculine adolescents experienced more non-affirming healthcare experiences than transfeminine adolescents. Non-affirming healthcare experiences were associated with healthcare avoidance, especially for transmasculine adolescents. Healthcare providers must be better equipped to provide inclusive and gender-affirming care to increase receipt of care for transgender adolescents beyond specialized gender clinics.
Keywords: adolescent, transgender, healthcare disparities
Introduction
Healthcare settings have been historically unwelcoming, stigmatizing, and discriminatory for transgender individuals[1] (i.e., those who identify as a gender different than their sex assigned at birth). Nevertheless, healthcare that is sensitive and affirming of transgender people (i.e., gender-affirming healthcare) is becoming increasingly more available, especially in urban, academic medical settings.[2] Gender-affirming healthcare is critical to the well-being of transgender individuals for several reasons. First, transgender individuals experience notable disparities in mental and physical health,[3] which can be mitigated through appropriate support and medical care.[4] For example, results from the 2014 Behavioral Risk Surveillance System data shows over 1 in 4 transgender individuals reported poor or fair general health—1.5 times higher than cisgender individuals. Transgender individuals also reported more poor physical (β=2.4) and mental health (β=1.7) days per month than cisgender individuals.[3] Second, across the life course, over 1 in 4 transgender individuals experience discrimination from a healthcare provider (HCP) due to their gender identity or expression.[5] Third, perceived and anticipated negative experiences in healthcare are associated with transgender individuals delaying or avoiding seeking acute and preventive care,[6,7] likely exacerbating health disparities among this population.[8] Prior research exploring transgender individuals receipt of healthcare has primarily focused on the experiences of transgender adults. Given adolescence is a unique and particularly important developmental stage in which care seeking patterns begin to develop, additional investigation into adolescents’ experiences receiving care is critically important.[9] In addition, some transgender adolescent’s parents or caregivers, who they rely on for support navigating the healthcare system, may be unaware of their gender identity.[10]
Transgender adolescents experience similar challenges as transgender adults in receiving healthcare as shown by existent research focusing on negative experiences with healthcare;[11] alternatively, data on transgender adolescents’ gender-affirming healthcare experiences are lacking. Examples of negative healthcare experiences include: transgender adolescents having to teach HCP about transgender health; incorrect use of names and pronouns; use of offensive/outdated language; and judgmental or hostile clinical interactions.[12,13] Contrastingly, gender-affirming care is characterized by acknowledging patients’ affirmed name and pronouns, using an organ-based approach to define anatomy and conduct screenings, and only asking questions relevant to the provision of care.[13,14] Adolescent gender-affirming care is generally concentrated to lesbian, gay, bisexual, queer, and transgender (LGBTQ)-specific health centers or pediatric gender-affirming care programs which are frequently housed within larger medical centers.[15] These clinics, are often referred to as ‘gender clinics,’ which are made up of multidisciplinary teams of providers dedicated to providing comprehensive gender-affirming care—this generally includes the provision of medically affirming interventions (e.g., puberty blockers, hormone therapy), mental health care, and other healthcare services in addition to the aforementioned interpersonal aspects of affirming care. Much of the existing research involving transgender adolescents has been conducted within gender clinics; consequently, little is known about this group’s experiences receiving care outside of gender clinics and even less is known about the impact these experiences have on care utilization.
Transgender adolescents’ healthcare experiences likely negatively influence their future use of preventive care and timely uptake of medical treatment. In the United States (US), transgender adolescents are more likely than their cisgender (i.e., non-transgender) peers to report underutilizing preventive care,[16] which is problematic given the degree to which preventive care (e.g., immunizations, routine screening for physical and mental health during well visits) has been shown to have many benefits.[17,18] In a nationwide Canadian study, 32.9% of transgender adolescents reported delaying physical health treatment and 42.6% of transgender adolescents reported delaying mental health treatment in the past year because of a prior negative healthcare experience.[19] US-based, quantitative studies of transgender adolescents have yet to assess how healthcare experiences—both positive and negative—are associated with healthcare utilization and healthcare avoidance.
Nonbinary adolescents—who do not identify exclusively as either boy/man or girl/woman—may be particularly vulnerable to negative healthcare experiences and, consequently, avoid seeking healthcare. In one US qualitative study, nonbinary young adults described how HCP approached them from a binary transgender perspective and, because of this perceived bias, these nonbinary patients reported borrowing a binary transgender label or foregoing healthcare altogether.[20] In a nationwide Canadian study, nonbinary young adults (ages 19–25) had nearly double the odds foregoing necessary medical care than similarly aged binary transgender peers.[21] Again, because research has focused mostly on adults, research studying nonbinary adolescents is needed to better understand their experiences with healthcare and use or avoidance of care.
The objectives of this study were three-fold. First, we examined differences in experiences with HCP outside of specialized gender clinics (e.g., in primary care, acute care, and mental health care settings) between binary and nonbinary transgender adolescents. We hypothesized nonbinary adolescents would report more negative and fewer positive healthcare experiences than binary transgender adolescents. Second, we examined differences in lifetime healthcare avoidance and past-year well visit. We hypothesized nonbinary adolescents would be more likely to report lifetime healthcare avoidance. Lastly, we examined the association between healthcare experiences and lifetime healthcare avoidance and explored the association between healthcare experiences and past-year well visit. We hypothesized negative healthcare experiences would be positively associated with lifetime healthcare avoidance.
Methods
Study design and population
This study analyzed a subset of data from a 78-item survey of transgender adolescents who received care from a multidisciplinary gender clinic within a large pediatric hospital in Southwestern Pennsylvania. The survey items used in this analysis were adapted from surveys used to understand transgender adults’ healthcare experiences [22,23] and informed by the findings from a survey of LGBTQ youth’s healthcare experiences and preferences.[24] The survey underwent cognitive interviewing with two transgender young adults. Afterwards, seven transgender health experts scored each item for relevance and clarity.
Transgender adolescents were identified using electronic health record clinic schedules, and invited to participate by research staff or a HCP during their clinic visit. To determine eligibility, potential participants were asked about their gender identity. Participants were given a wide range of gender identities to select as many as they would like to describe their gender including “other” with the opportunity to describe their gender in their own words (Table 1). Only adolescents 12–26 years old who did not identify as cisgender were included. Participants 18–26 years old were included because the gender clinic and its associated pediatric hospital provide care to patients up to 26 years old. Parental consent was waived for adolescents younger than 18 years old so they could provide their own assent to participate in the study. Overall, 204 adolescents completed the electronic survey (99.5% participation rate) between July and November 2018. This study was approved by the Institutional Review Board.
Table 1.
Survey questions by item, question, and response options
| Item | Question | Response Options |
|---|---|---|
|
| ||
| Gender Identity | How do you describe your gender identity? (Choose all that apply) | Transfeminine Transmasculine Nonbinary Genderqueer Genderfluid Gender nonconforming Agender Demi boy/man Demi girl/woman Gender variant Androgyne Two Spirit (or other identity of indigenous origin) Gender questioning Cisgender Other |
| Negative Healthcare Experiences | Have you ever felt you were disrespected by a healthcare provider because of your gender identity or expression? Has a healthcare provider ever... Discouraged you from exploring your gender? Inconsistently used or misused your name and preferred pronouns? Refused to care for you because of your gender? Refused to discuss or address gender related health concerns? Told you they didn’t know enough about gender related care to provide it? Hurtful or insulting language has been when discussing your gender? |
Yes/No |
| Positive Healthcare Experiences | Has a healthcare provider ever... Asked you what name and pronouns you would like to use Discussed that it is normal for people to explore their gender Asked if you wanted to talk about your gender Supported you in talking with your parent/guardian about your gender Asked you what terms you would like to use to describe parts of your body Connected you with a local organization or support group Connected you with an affirming mental health provider Connected you with another doctor or clinic where hormone blockers or puberty blockers are prescribed |
Yes/No |
| Lifetime Healthcare Avoidance | Have you ever avoided seeing a healthcare provider (even though you felt you needed to) because you were worried about how they might react to your gender identity? | Yes/No |
| Past-Year Well Visit | Is there a doctor or clinic where you have been seen in the last year for a physical or regular check-up? | Yes, I have been seen in a clinic other this one for a check-up Yes, I have been seen in this clinic for a check-up No Unsure Would rather not answer |
Measures
Based on the gender identity item, we coded participants as: transfeminine; transmasculine; or nonbinary. Those who selected only “transmasculine” or only “transfeminine” were coded into ‘transmasculine’ and ‘transfeminine’ groups, respectively. All other participants, who selected any of the following gender identities were coded as nonbinary: nonbinary, genderqueer, gender fluid, gender nonconforming, agender, demi boy/man, demi girl/woman, gender variant, androgyne, and two-spirit. Those who only wrote in a “other” gender identity were categorized based on their response. Participants who selected “gender questioning” were coded based on the other gender identities selected.
Participants’ age was coded as ‘under 18 years old’ and ‘18 years old and older’ due to differences in parental consent requirements for medical gender-affirming healthcare services for adolescents under 18 years old. Race/ethnicity was coded as ‘White’ and ‘Person of Color’ due to the limited diversity of the sample.
Adolescents’ interpersonal experiences with HCP in healthcare settings not associated with the gender clinic were measured using fifteen questions, seven of which measured negative experiences and eight which measured positive experiences (Table 1). HCP was broadly defined as, “anyone who delivers healthcare services to you. This includes doctors, nurses, therapists, social workers or anyone else you interact with as a part of your medical care.” For each question, participants could either respond “yes” or “no.”
Additionally, we measured participants’ lifetime healthcare avoidance and past-year well visit (Table 1). For past-year well visit, those who selected either “yes” options were coded as ‘yes’ regardless of the clinic specified.
Analytic procedures
Statistical analyses were conducted in Stata version 15.1 (College Station, Texas). Adolescents with any missing demographic data (n=20; 9.8%) and any missing healthcare experience, lifetime healthcare avoidance or past-year well visit values were excluded from the analysis (n=28; 13.7%). Our analytic sample contained 156 participants. Descriptive statistics described demographics, lifetime healthcare avoidance, and past-year well visit for the entire sample and by gender. Bivariate comparisons by gender were performed using a chi-square test (or Fisher’s exact tests when expected cell sizes were <5).
We used exploratory factor analysis (EFA) for the healthcare experiences questions to examine the dimensionality and factor loadings of transgender adolescents’ experiences in healthcare settings outside of the gender clinic. We used EFA because we did not have a strong a priori theory regarding the underlying structure of our data,[25] and EFA is recommended in such studies.[26]
Standard recommended EFA procedures and criteria guided this analysis.[27] We used a tetrachoric correlation matrix suited for binary variables[28] and rotated the factors using the varimax rotation. To select the number of existing factors, we used multiple criteria: eigenvalues values greater than 1, scree test, and parallel analysis. After deciding the number of factors, we retained items with factor loadings greater than or equal to 0.4. We assigned a qualitative label to the rotated factors that encompassed the overall construct of the loaded items. For each construct, we summed the loaded items and then calculated the mean and standard deviation for the total sample and by demographic characteristic. Finally, we conducted multivariable linear regression models to examine the independent associations between demographics and factors scores for each factor separately.
Next, we examined the associations of demographics and healthcare experiences factor scores on both lifetime healthcare avoidance and past-year well visit. We used multivariable logistic regression models first to explore the demographic differences in outcomes, then to assess the association of healthcare experiences on our outcomes, adjusting for demographics. Additionally, we conducted a sensitivity analysis for each of the multivariable analyses controlling for hormone therapy to identify if use of medically affirming interventions impacted study outcomes. Hormone therapy was categorized into three groups: not interested, interested but not currently taking, and currently taking puberty blockers or hormones. β and odds ratios (OR) include 95% confidence intervals. Significance was assessed at p<0.05.
Results
Our sample included 34 transfeminine (21.8%), 91 transmasculine (58.3%), and 31 nonbinary adolescents (19.9%). The transmasculine group was more likely to be under 18 years old (63.7%) than the transfeminine (41.2%) and nonbinary group (41.9%) (Table 2). Race/ethnicity did not differ by gender. Overall, most participants identified as White (n=135; 86.5%). Twenty-one (13.5%) participants were People of Color, which included adolescents who identified with the following racial/ethnic identities: multiracial (n=11; 7.05%), Black (n=6; 3.85%), and Hispanic/Latinx (n=3; 1.92%); in addition, one adolescent identified as both White and Latinx (0.6%). Lifetime healthcare avoidance was most prevalent among transmasculine adolescents (n=45, 49.5%). Past-year well visit attendance did not differ by gender. Most participants reported having attended a well visit in the past year (n=132; 84.6%), the majority of whom attended a well visit with a provider outside of the gender clinic (n=101; 64.7%) as opposed to a gender clinic provider (n=31; 19.9%).
Table 2.
Demographics, lifetime healthcare avoidance, and past-year well visit for the total sample and stratified by gender identity
| Gender Identity |
|||||||||
|---|---|---|---|---|---|---|---|---|---|
| Total (n=156) | Transfeminine (n=34) | Transmasculine (n=91) | Nonbinary (n=31) | ||||||
|
| |||||||||
| n | (%) | n | (%) | n | (%) | n | (%) | P | |
|
| |||||||||
| Age | |||||||||
| Under 18 years old | 85 | (54.5) | 14 | (41.2) | 58 | (63.7) | 13 | (41.9) | 0.02 |
| 18 years old and older | 71 | (45.5) | 20 | (58.8) | 33 | (36.3) | 18 | (58.1) | |
| Race/Ethnicity | |||||||||
| White | 135 | (86.5) | 31 | (91.2) | 79 | (86.8) | 25 | (80.7) | 0.50 |
| Person of Color | 21 | (13.5) | 3 | (8.8) | 12 | (13.2) | 6 | (19.4) | |
| Lifetime Healthcare Avoidance | |||||||||
| No | 93 | (59.6) | 26 | (76.5) | 46 | (50.5) | 21 | (67.7) | 0.02 |
| Yes | 63 | (40.4) | 8 | (23.5) | 45 | (49.5) | 10 | (32.3) | |
| Past-Year Well Visit | |||||||||
| No | 24 | (15.4) | 3 | (8.8) | 14 | (15.4) | 7 | (22.6) | 0.31 |
| Yes | 132 | (84.6) | 31 | (91.2) | 77 | (84.6) | 24 | (77.4) | |
Boldface indicates P<0.05
Healthcare experiences
The healthcare experiences items loaded onto two unique factors. Factor 1 named ‘non-affirming healthcare experiences’ contained seven items and contributed to 44.7% of variance. Factor 2 labeled ‘gender-affirming healthcare experiences’ included eight items and contributed to 55.3% of variance. All items and factor loadings are described in Table 3.
Table 3.
Factor loadings of healthcare experiences on final two-factor solution
| Item Description | Factor 1: Non-affirming Healthcare Experiences | Factor 2: Gender-Affirming Healthcare Experiences | |
|---|---|---|---|
|
| |||
| Have you ever... | Felt disrespected by a HCP because of your gender | 0.65 | |
| Has a health care provider ever... | Discouraged you from exploring your gender | 0.63 | |
| Inconsistently used or misused your name and preferred pronouns | 0.59 | ||
| Refused to care for you because of your gender | 0.41 | ||
| Refused to discuss or address gender related health concerns | 0.72 | ||
| Told you they didn’t know enough about gender related care to provide it | 0.50 | ||
| Hurtful or insulting language has been when discussing your gender | 0.58 | ||
| Asked you what name and pronouns you would like to use | 0.62 | ||
| Discussed that it is normal for people to explore their gender | 0.67 | ||
| Asked if you wanted to talk about your gender | 0.74 | ||
| Supported you in talking with your parent/guardian about your gender | 0.65 | ||
| Asked you what terms you would like to use to describe parts of your body | 0.52 | ||
| Connected you with a local organization or support group | 0.65 | ||
| Connected you with an affirming mental health provider | 0.52 | ||
| Connected you with another doctor or clinic where hormone blockers or puberty blockers are prescribed | 0.52 | ||
Table 4 shows the crude factor means generated for the total sample and by each demographic characteristic as well as the demographic-adjusted multivariable models. After adjusting for demographics, the average count of non-affirming experiences respondents reported ever experiencing were higher among transmasculine (β=0.78, 95% CI: 0.02, 1.53) and nonbinary (β=1.41, 95% CI: 0.49, 2.33) adolescents than transfeminine adolescents. There were no significant differences in number of gender-affirming healthcare experiences ever experienced by any demographic characteristic.
Table 4.
Unadjusted and adjusted demographic differences in healthcare experiences factor scores
| Crude Factor Means | Multivariable Models | |||||||
|---|---|---|---|---|---|---|---|---|
|
| ||||||||
| Factor 1: Non-affirming Healthcare Experiences | Factor 2: Gender-Affirming Healthcare Experiences | Factor 1: Non-affirming Healthcare Experiences | Factor 2: Gender-Affirming Healthcare Experiences | |||||
|
| ||||||||
| Mean | (SD) | Mean | (SD) | β | (95% CI) | β | (95% CI) | |
|
| ||||||||
| Total Sample | 2.10 | (1.90) | 2.79 | (2.49) | ||||
| Gender | ||||||||
| Transfeminine | 1.35 | (1.67) | 2.71 | (2.53) | Referent | Referent | ||
| Transmasculine | 2.15 | (1.82) | 2.66 | (2.34) | 0.78 | (0.02, 1.53) | 0.01 | (−1.00, 1.03) |
| Nonbinary | 2.77 | (2.12) | 3.29 | (2.88) | 1.41 | (0.49, 2.33) | 0.61 | (−0.62, 1.85) |
| Age | ||||||||
| Under 18 years old | 2.15 | (1.95) | 2.67 | (2.39) | 0.08 | (−0.52, 0.69) | −0.22 | (−1.03, 0.60) |
| 18 years old and older | 2.04 | (1.85) | 2.94 | (2.62) | Referent | Referent | ||
| Race/Ethnicity | ||||||||
| White | 2.07 | (1.88) | 2.82 | (2.45) | Referent | Referent | ||
| Person of Color | 2.29 | (2.03) | 2.62 | (2.80) | 0.08 | (−0.79, 0.95) | −0.27 | (−1.44, 0.90) |
Boldface indicates P<0.05; SD=standard deviation; CI=confidence interval.
Lifetime healthcare avoidance and past-year well visit
After adjusting for demographics, transmasculine adolescents had over three times the odds of reporting lifetime healthcare avoidance than transfeminine adolescents (adjusted OR [aOR]=3.58, 95% CI: 1.41, 9.08) (Table 5, Model 1). When including healthcare experience factor scores to the models (Table 5, Model 2), a one-point increase in non-affirming healthcare experiences nearly doubled the odds of reporting healthcare avoidance (aOR=1.85, 95% CI: 1.47, 2.34). We found no significant association between gender-affirming healthcare experiences and odds of healthcare avoidance.
Table 5.
Multivariable models of lifetime healthcare avoidance and past-year well visit
| Lifetime Healthcare Avoidance | Past-Year Well Visit | |||||||
|---|---|---|---|---|---|---|---|---|
| Model 1 | Model 2 | Model 3 | Model 4 | |||||
|
| ||||||||
| aOR | (95% CI) | aOR | (95% CI) | aOR | (95% CI) | aOR | (95% CI) | |
|
| ||||||||
| Gender | ||||||||
| Transfeminine | Ref | Ref | Ref | Ref | ||||
| Transmasculine | 3.58 | (1.41, 9.08) | 2.95 | (1.02, 8.55) | 0.39 | (0.10, 1.50) | 0.39 | (0.10, 1.55) |
| Nonbinary | 1.44 | (0.47, 4.40) | 0.62 | (0.16, 2.42) | 0.32 | (0.07, 1.42) | 0.33 | (0.07, 1.55) |
| Age | ||||||||
| Under 18 years old | 0.60 | (0.30, 1.21) | 0.47 | (0.21, 1.06) | 3.83 | (1.44, 10.17) | 3.98 | (1.48, 10.68) |
| 18 years old and older | Ref | Ref | Ref | Ref | ||||
| Race/Ethnicity | ||||||||
| White | Ref | Ref | Ref | Ref | ||||
| Person of Color | 2.25 | (0.86, 5.89) | 2.56 | (0.85, 7.69) | 0.79 | (0.23, 2.73) | 0.81 | (0.23, 2.83) |
| EFA Factor | ||||||||
| Factor 1: Non-affirming Healthcare Experiences | 1.85 | (1.47, 2.34) | 0.93 | (0.73, 1.19) | ||||
| Factor 2: Gender-Affirming Healthcare Experiences | 0.95 | (0.81, 1.11) | 1.07 | (0.89, 1.29) | ||||
Boldface indicates P<0.05; aOR=adjusted odds ratio; CI=confidence interval; Ref=reference group; EFA=exploratory factor analysis.
In the multivariable model for past-year well visit adjusting for demographics (Table 5, Model 3), only age was significantly associated with past-year well visit. Transgender adolescents under 18 years old had nearly four times the odds of receiving a well visit in the past year than transgender adolescents 18 and older (aOR=3.83, 95% CI: 1.44, 10.17). Upon including healthcare experience factors to the model (Table 5, Model 4), there were no significant associations between either gender-affirming or non-affirming healthcare experiences and odds of past-year well visit.
Sensitivity analyses
Most of the sensitivity analyses produced similar results as the primary analyses with two minor exceptions (Supplemental Tables 1 & 2). After controlling for demographics and hormone therapy, transmasculine adolescents had a higher count of non-affirming healthcare experiences than transfeminine adolescents but this was insignificant (β=0.66, 95% CI: −0.08, 1.39) (Supplemental Table 1). In addition, the number of gender-affirming healthcare experiences did not significantly differ by gender but the point estimate for transmasculine adolescents reversed direction after accounting for hormone therapy and other covariates (β=−0.03, 95% CI: −1.05, 0.98) (Supplemental Table 1).
Discussion
Nonbinary and transmasculine adolescents reported more non-affirming experiences with HCPs outside of gender clinics than transfeminine adolescents. Contrastingly, gender-affirming experiences with HCPs did not differ by gender. Inclusion of hormone therapy in the models minimally confounded the relationship between gender identity and gender-affirming and non-affirming healthcare experiences. Overall, greater reported adverse healthcare experiences among nonbinary and transmasculine adolescents is concerning because of the impact these adverse experiences have on care seeking and receipt of healthcare.
We found greater non-affirming healthcare experiences were associated with greater odds of lifetime healthcare avoidance, which supports previous findings that perceived discrimination was associated with healthcare avoidant behaviors.[29] In this sample, there was a high prevalence of healthcare avoidance reported (40% overall), especially for transmasculine (50%) and nonbinary adolescents (32%), similar to estimates from a nationwide survey of LGBTQ adults in which transgender adults reported the highest prevalence of avoidance (47%).[30] Transgender individuals’ healthcare avoidance may be explained by the stigma-based rejection sensitivity model.[31] This model posits that individuals who have experienced stigma may anxiously anticipate stigma, regularly perceive stigma, and strongly react to stigma.[31] Consequently, these transgender individuals may anticipate future mistreatment and, as a coping mechanism, delay seeking care[29,32] for preventable health conditions and delay accessing gender-affirming medical interventions which may improve mental health and quality of life.[33] For example, in a study of transmasculine adults, rejection sensitivity mediated the relationship between mistreatment in healthcare settings and healthcare avoidance.[32] Our findings showed that rejection sensitivity could be driving healthcare avoidance in our sample of transmasculine adolescents who reported greater non-affirming healthcare experiences and had increased odds of lifetime healthcare avoidance than transfeminine adolescents. Interestingly, this phenomenon was not present among nonbinary adolescents who also had greater odds of non-affirming healthcare experiences than transfeminine adolescents. Additionally, our study aimed to build on this theory and test whether non-stigmatizing/gender-affirming experiences impact this phenomenon and reduce healthcare avoidance. In this study, gender-affirming healthcare experiences were not associated with lifetime healthcare avoidance. Future research investigating the link between non-affirming healthcare experiences and avoidance is needed to identify how to mitigate healthcare avoidance among some (i.e., transmasculine) adolescents while also understanding potentially protective factors among other (i.e., nonbinary) adolescents who exhibit resilience.
Though prior research documents lower rates of preventive medical care among transgender adolescents,[16] our results showed high rates of completion of a past-year well visit. In our sample, the rates of past-year well visit exceeded the rates of adolescents nationally[34] and did not differ by gender. Rates of past-year well visits in our sample could be elevated for a number of reasons including that this data was self-reported, as opposed to measured via claims data,[34,35] and that this study recruited a clinic-based sample of adolescents already receiving care from a specialist[36] (i.e., gender clinic provider) who also provided preventative care for some of the sample (approximately 20%). Although, it is not well understood why receipt of care from a specialist would be a facilitator for adolescents’ completion of an annual well visit, it is notable that some gender-affirming care specialists may also provide preventative care services.[35] [37]On the other hand, our findings showed transgender adolescents under 18 years old were more likely than those18 years old and older to receive a well visit in the past year, which aligns with established literature showing higher rates of preventive care use among younger adolescents (particularly those under 16 years old).[34] Rates of preventative care for adolescents under 18 years old in this cohort and national samples are likely driven by parent or caregiver involvement.[10] Although not explored in this study, parent’s or caregiver’s awareness or knowledge of their adolescent’s gender identity may impact well visit attendance, which warrants further research. Overall, future research is needed to further explore barriers and facilitators to transgender adolescents’ receipt of preventative care, especially for older adolescents.
These data present a call to action to prevent adverse experiences with HCP and better equip HCPs to provide gender-affirming care to transgender adolescents, especially nonbinary and transmasculine adolescents. To start, future research is needed to investigate the specific aspects of healthcare encounters that are problematic for nonbinary and transmasculine adolescents.[20,37] For example, findings from a qualitative study of nonbinary young adults identify the need for diverse gender identity options on intake forms, increased opportunities for patients to define their identity, and medical gender affirmation (e.g., hormone therapy) that is tailored to one’s unique identity and gender affirmation goals.[20] Moreover, research that explores the degree of impact of various gender-affirming and non-affirming experiences on future utilization of care and whether that impact is moderated by frequency at the visit or provider-level is warranted. It is especially important that future research seek to understand and address the experiences of adolescents who are not connected to care, which was outside this study’s scope.
Ultimately, expanding access to training in transgender health is critical to reducing one of the commonly cited barriers to accessing care: limited number of HCPs trained to provide care to transgender adolescents.[12,21] Limited access to trained HCPs is, at least in part, a result of little to no medical training on transgender health topics in medical education.[38] Medical training on transgender health is only recently emerging and is often lumped together as a one-time, awareness-based LGBTQ health training session that fails to equip HCPs with sufficient knowledge and clinical training to provide care for transgender patients.[39] Universal provider education on transgender health and gender-affirming practices that is longitudinal and skills-based[39] is needed to increase the number of HCPs equipped to care for transgender patients. Education and trainings should be developed in collaboration with transgender adolescents and their caregivers. This may help build trusting relationships with the community as well as tailored education/training to the specific needs of transgender adolescents of various gender identities.[40]
We recognize several limitations. Although our survey items underwent cognitive interviewing and content validation, they were not part of a validated scale. Some nonbinary participants may have been misclassified because “transfeminine” or “transmasculine” could alone encompass nonbinary identities. Respondents only indicated if they “ever” experienced each of the healthcare experience items and healthcare avoidance, rather than indicating frequency or other dimensions of the experiences. Although the definition of HCP was broadly defined, adolescents’ experiences with some healthcare staff (e.g., front office staff) may not have been captured. In addition, the impact of the clinic space/environment on adolescents’ healthcare experience was not measured. Although our sample is representative of the population of patients seen at the gender clinic, the data reflect the experiences of a majority transmasculine, White adolescent population receiving healthcare in a specialized gender clinic. Our results should be interpreted cautiously as healthcare experiences and utilization may differ for a non-clinical sample of adolescents with a richer diversity of genders and race/ethnicities in addition to socioeconomic characteristics (e.g., health insurance, household income; which were unable to be accounted for in this analysis). Finally, this was a cross-sectional study; therefore, we could not assess temporality and our results were subject to recall bias.
In conclusion, nonbinary and transmasculine adolescents reported more non-affirming healthcare experiences with HCPs not associated with specialized gender clinics, in comparison to transfeminine adolescents. Particularly for transmasculine adolescents, non-affirming healthcare experiences were positively associated with lifetime healthcare avoidance. Further research is needed to understand the reasons for healthcare avoidance among transmasculine adolescents, but concerted efforts are needed to prevent non-affirming experiences with HCPs overall and increase access to gender-affirming healthcare beyond specialized gender clinics.
Supplementary Material
Implications and Contributions.
Transgender adolescents, particularly transmasculine and nonbinary adolescents, report adverse experiences with healthcare providers, which was associated with avoidance of healthcare. Creating more welcoming and inclusive healthcare environments may improve access to care and mitigate the health disparities transgender adolescents currently face.
Acknowledgements:
This research was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (TL1TR001858 to RWSC), the National Institute on Alcohol Abuse and Alcoholism (K01AA027564 to RWSC), and National Institute of Child Health and Human Development (T32HD087162 to GMS), Seattle Children’s Research Institute Career Development Award and the Agency for Healthcare Research and Quality (5K12HS026393 to GMS). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the funders, institutions, the Department of Veterans Affairs, or the United States Government. All authors contributed to the conceptual ideas, interpretation of findings, and manuscript writing that warrant authorship.
Abbreviations:
- EFA
exploratory factor analysis
- CI
confidence interval
- OR
odds ratio
- HCP
healthcare provider
- LGBTQ
lesbian, gay, bisexual, transgender, and queer
- US
United States
Footnotes
Conflict of Interest Disclosures: The authors have no conflicts of interest relevant to this article to disclose.
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