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Introduction to Access to Gender-affirming Care

Access to care refers to how well a healthcare system meets the needs of the community it serves.1 To be accessible, healthcare services should be available, geographically accessible, affordable, acceptable, and accommodating of individuals.1 Having access to healthcare that is supportive and affirming of gender is important for TTNB youth wellbeing.2,3 Gender-affirming care is the process through which a health care system cares for and supports an individual while recognizing and acknowledging their gender identity and expression.4 Gender-affirming care can include primary care, mental healthcare, and gender-affirming medical interventions, such as puberty blockers and hormone therapy.

Research about Access to Gender-affirming Care

The following sections summarize research findings showing that access to healthcare is important for TTNB youths’ well-being and documenting barriers youth experience in accessing that care. Following this summary, ideas to support TTNB in accessing gender-affirming healthcare are presented.

Access to healthcare is important for TTNB youth wellbeing  

Access to primary care that is gender-affirming is linked to better health outcomes. TTNB youth who feel comfortable with their primary care providers, and whose providers are aware of their genders, tend to report better general and mental health, compared with TTNB youth who are not comfortable with or out to their providers.2 Non-binary youth are less likely to report feeling comfortable talking with primary care providers about their gender and gender health needs, compared to binary trans youth.3

Gender-affirming mental health care is also important for supporting TTNB youth wellbeing. Approaches to mental healthcare that are affirming of youth living in the gender that feels most real or comfortable to them are important for youth well-being, while approaches that are not affirming or seek to change a person’s gender can be harmful.5,6 Recent research confirms the importance that TTNB youth and their parents place on affirming mental healthcare for youth wellbeing.7

Access to gender-affirming medical interventions significantly improves TTNB youth health. TTNB youth who have required and accessed puberty blockers, hormone therapy, and gender-affirming surgery have better mental health outcomes, such as lower rates of depression and anxiety.8–10Access to puberty blockers and hormone therapy can also reduce suicidality.8,10,11 TTNB youth with access to gender-affirming medical interventions report life satisfaction and happiness similar to cisgender youth.9 Older TTNB youth who have required and accessed gender-affirming surgeries report better mental health than those who are not able to access this care.12

TTNB youth face barriers to accessing healthcare  

It can be hard to find a healthcare provider who provides gender-affirming care. TTNB youth may not be able to access needed care because it is not available in their area.2,7,13,14 It may be particularly difficult to find a healthcare provider who will assess for and prescribe gender-affirming hormone therapy.3 Parents have also identified lack of providers as a barrier to accessing care for their children.13 Healthcare providers’ lack of understanding about gender-affirming care can be a barrier for TTNB youth.15 Overall, healthcare provider education on youth gender-affirming care is lacking.13,16,17

Some youth are denied gender-affirming care or referrals to specialists. Whether due to discrimination or lack of knowledge, many TTNB youths are denied care by healthcare providers they try to go to.18–20 For example, youth may be denied hormone therapy, including prescription refills when seeking care.2,20 Primary care providers may also be uncomfortable making referrals for gender-affirming care.7

Some youth do not seek care because they are afraid of discrimination. Some TTNB youth may not access healthcare when they need it because they fear discrimination.3,19 For example, youth may worry about how both staff and healthcare providers will treat them.19 Those who anticipate facing stigma in healthcare are more likely to delay accessing care.21

Youth who have negative healthcare experiences may not go back. Feeling uncomfortable with a primary care provider is connected to TTNB youth not seeking out needed mental health care.2 Negative experiences include being treated disrespectfully by staff and other patients and confidentiality not being maintained.22,23 Lack of knowledge about and comfort with gender-affirming care contributes to negative healthcare experiences for TTNB youth.2,22

Other barriers include lack of transportation, costs, and long wait times. TTNB youth may not have transportation to get to appointments due to travel distance or lack of family support. 2,7,19,22 In addition, the cost of gender-affirming care, particularly medications, can be a barrier to care.2,3,7,22,23 Lastly, wait times to see doctors, including any specialist care that is needed, are long and can be frustrating.3,14,22

Helping TTNB youth access healthcare  

Ask youth what kind of help they need. You can offer to help by:

  • Finding a gender-affirming healthcare provider
  • Calling to make appointments
  • Preparing questions for appointments
  • Going with youth to appointments  
  • Advocating at appointments for people to use correct names, pronouns, and gender(s)

References

  1. Penchansky R, Thomas JW. The Concept of Access: Definition and Relationship to Consumer Satisfaction. Med Care.1981;19(2):127.
  2. Clark BA, Veale JF, Greyson D, Saewyc E. Primary care access and foregone care: a survey of transgender adolescents and young adults. Fam Pract. 2018;35(3):302-306.doi:10.1093/fampra/cmx112
  3. Clark BA, Veale JF, Townsend M, Frohard-Dourlent H, Saewyc EM. Non-binary youth: Access to gender-affirming primary health care. Int J Transgenderism. 2018;19(2):158-169.doi:10.1080/15532739.2017.1394954
  4. Trans Care BC. Glossary. Accessed April 12, 2024.http://www.phsa.ca/transcarebc/gender-basics-education/terms-concepts/glossary#undefined
  5. Hidalgo MA, Ehrensaft D, Tishelman AC, et al. The gender affirmative model: What we know and what we aim to learn. Hum Dev. 2013;56(5):285-290. doi:10.1159/000355235
  6. Turban JL, Ehrensaft D. Research Review: Gender identity in youth: treatment paradigms and controversies. J Child Psychol Psychiatry. 2018;59(12):1228-1243. doi:10.1111/jcpp.12833
  7. Paceley MS, Ananda J, Thomas MMC, Sanders I, Hiegert D, Monley TD. “I Have Nowhere to Go”: A Multiple-Case Study of Transgender and Gender Diverse Youth, Their Families, and Healthcare Experiences. Int J Environ Res Public Health. 2021;18(17):9219.doi:10.3390/ijerph18179219
  8. Chen D, Berona J, Chan YM, et al. Psychosocial Functioning in Transgender Youth after 2 Years of Hormones. NEngl J Med. 2023;388(3):240-250. doi:10.1056/NEJMoa2206297
  9. de Vries ALC, McGuire JK, Steensma TD, Wagenaar ECF, Doreleijers TAH, Cohen-Kettenis PT. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics. 2014;134(4):696-704. doi:10.1542/peds.2013-2958
  10. Tordoff DM, Wanta JW, Collin A, StepneyC, Inwards-Breland DJ, Ahrens K. Mental Health Outcomes in Transgender and Non binary Youths Receiving Gender-Affirming Care. JAMA Netw Open.2022;5(2):e220978. doi:10.1001/jamanetworkopen.2022.0978
  11. Turban JL, King D, Kobe J, Reisner SL, Keuroghlian AS. Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. PLoS ONE. 2022;17(1).doi:10.1371/journal.pone.0261039
  12. Tan KKH, Byrne JL, Treharne GJ, Veale JF. Unmet need for gender-affirming care as a social determinant of mental health inequities for transgender youth in Aotearoa/New Zealand. J Public Health Oxf Engl. 2023;45(2):e225-e233. doi:10.1093/pubmed/fdac131
  13. Gridley SJ, Crouch JM, Evans Y, et al.Youth and caregiver perspectives on barriers to gender-affirming health carfor transgender youth. J Adolesc Health. 2016;59(3):254-261.doi:10.1016/j.jadohealth.2016.03.017
  14. Kearns S, Kroll T, O‘Shea D, Neff K. Experiences of transgender and non-binary youth accessing gender-affirming care: A systematic review and meta-ethnography. PLOS ONE.2021;16(9):e0257194. doi:10.1371/journal.pone.0257194
  15. Johns MM, Gordon AR, Andrzejewski J, etal. Differences in Health Care Experiences among Transgender and Gender Diverse Youth by Gender Identity and Race/Ethnicity. Prev Sci.2023;24(6):1128-1141. doi:10.1007/s11121-023-01521-5
  16. van Heesewijk J, Kent A, van de Grift TC, Harleman A, Muntinga M. Transgender health content in medical education: a theory-guided systematic review of current training practices and implementation barriers & facilitators. Adv Health Sci Educ. 2022;27(3):817-846. doi:10.1007/s10459-022-10112-y
  17. Eisenberg ME, McMorris BJ, Rider GN, Gower AL, Coleman E. “It’s kind of hard to go to the doctor’s office if you’re hated there.” A call for gender-affirming care from transgender and gender diverse adolescents in the United States. Health Soc Care Community.2020;28(3):1082-1089. doi:10.1111/hsc.12941
  18. Wall CSJ, Patev AJ, Benotsch EG. Trans broken arm syndrome: A mixed-methods exploration of gender-related medical misattribution and invasive questioning. Soc Sci Med. 2023;320:115748.doi:10.1016/j.socscimed.2023.115748
  19. Ferrara A. “You just end up feeling quite rejected by the entire healthcare system” A mixed methods study of perceived barriers to healthcare access in New Zealand LGBTQ+ teens, and their impact on sexual risk behaviour. Published online 2022. Accessed April 11, 2024.https://hdl.handle.net/10092/105377
  20. McGeough BL, Paceley MS, Greenwood E (M),et al. Transgender and Gender Diverse Youth’s Perspectives of Affirming Healthcare: Findings From a Community-Based Study in Kansas. SAGE Open.2023;13. doi:10.1177/21582440231184843
  21. Goldenberg T, Jadwin-Cakmak L, Popoff E, Reisner SL, Campbell BA, Harper GW. Stigma, Gender Affirmation, and Primary Healthcare Use Among Black Transgender Youth. J Adolesc Health.2019;65(4):483-490. doi:10.1016/j.jadohealth.2019.04.029
  22. Chong LSH, Kerklaan J, Clarke S, et al. Experiences and Perspectives of Transgender Youths in Accessing Health Care: A Systematic Review. JAMA Pediatr. 2021;175(11):1159-1173.doi:10.1001/jamapediatrics.2021.2061
  23. Pampati S, Andrzejewski J, Steiner RJ, et al. “We Deserve Care and we Deserve Competent Care”: Qualitative Perspectives on Health Care from Transgender Youth in the Southeast United States. J Pediatr Nurs. 2021;56:54-59. doi:10.1016/j.pedn.2020.09.021

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