- How do people living with gender dysphoria experience the initiation of gender affirming therapy and what are their expectations of this process?
- Given that the initiation of gender affirming therapy has traditionally been within the domain of specialist practitioners, how do primary care providers caring for people living with gender dysphoria understand their role in, and comfort level with, initiating this process?
- How are primary care providers involved in decision-making regarding gender affirming therapy? How is this experienced by patients? By primary care providers?
Transgender youth and adults faced numerous obstacles when seeking gender affirming care. Their journey required self-advocacy, and they often encountered stigma and discrimination. There was no evidence that the decision to undergo hormone replacement therapy was a shared decision between patients and providers. Transgender youth developed an understanding of the transgender experience through their own research. Primary care physicians often lacked knowledge about hormone replacement therapy and would sometimes refer patients elsewhere. This treatment delay could result in increased levels of anxiety and suicidality. Participants described educating their primary care physicians by providing them with resources or information about continuing education. Participants noted that it can be difficult to access gender affirming care because the assessment criteria for gender dysphoria are highly subjective. Some individuals described efforts to present in a way that is consistent with the assessment criteria. Individuals with complex mental health problems, or those with financial insecurity, faced particular barriers to care, as clinicians could make the decision that they were not ready to transition. Non-binary individuals also face unique challenges because their needs regarding hormone therapy and surgeries are not consistent with a binary narrative. In general, participants expressed a preference for having primary care physicians rather than specialists provide hormone replacement therapy and surgery referrals. Primary care physicians were viewed as preferable because of their greater accessibility and because they were viewed as more able to provide holistic care that included medical, psychological and social needs.Social and environmental factors are also relevant. Participants sought supportive primary care physicians who could provide positive spaces. However, participants frequently reported experiencing discriminatory encounters in the health care setting, such as misgendering, deadnaming or being outed in the health care space, which often led to the avoidance of health care, including gender affirming care. Both clinicians and transgender patients thought that primary care physicians lack foundational knowledge regarding transgender health needs. Clinicians reported that they had received virtually no formal education regarding transgender health. Many clinicians were aware of the discrimination and stigma faced by their transgender patients. However, clinicians did not seem aware of other aspects of the health care environment that are important to transgender individuals, such as the need for privacy and sensitivities regarding the physical exam.