Sexuality Research and Social Policy

, Volume 15, Issue 1, pp 48–59 | Cite as

Barriers to Gender-Affirming Care for Transgender and Gender Nonconforming Individuals

  • Jae A. PuckettEmail author
  • Peter Cleary
  • Kinton Rossman
  • Brian Mustanski
  • Michael E. Newcomb


Gender-affirming care, including hormone therapy, “top” (e.g., chest reconstruction surgery) and “bottom” (e.g., vaginoplasty, phalloplasty, metoidioplasty, etc.) surgeries, and puberty blockers, is an efficacious treatment of gender dysphoria for transgender and gender nonconforming (TGNC) individuals. However, many TGNC people encounter significant barriers in accessing gender-affirming care, which we detail via results from on online study. Participants included 256 TGNC individuals (78.9% White, ages 16–73, M age = 28.4). Among participants, 61.3% were receiving hormone therapy, 22.7% had undergone top surgery, and 5.5% had undergone bottom surgery. Open-ended responses (n = 201) were thematically analyzed and common barriers included finances and insurance issues, a lack of service availability, and fears or worries. Participants reported various systemic issues and incidents of bias within medical and mental health fields, as well as a lack of medical provider awareness and education. Other themes were interpersonal barriers (e.g., fears of rejection); age and need of parental consent for minors; other medical issues; and a lack of information about how to acquire care. These findings can be utilized to educate professionals in medical and mental health fields about barriers their TGNC patients may encounter in receiving affirming care and suggest a number of ways to improve access to these services.


Transgender Gender nonconforming Genderqueer Gender-affirming care Barriers to transition Healthcare stigma 



The authors would like to thank the members of the Trans Health Community Advisory Board who assisted with this project for their time, feedback, and dedicated involvement in this work.


The project described herein was supported by a grant from the National Institute on Drug Abuse (1F32DA038557).

Conflict of Interest

The authors declare that they have no conflict of interest.

Compliance with Ethical Standards

All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.


  1. Alegria, C. (2011). Transgender identity and health care: Implications for psychosocial and physical evaluation. Journal of the American Academy of Nurse Practitioners, 23(4), 175–182.CrossRefPubMedGoogle Scholar
  2. American Psychological Association. (2015). Guidelines for psychological practice with transgender and gender nonconforning people. The American Psychologist, 70, 832–864.CrossRefGoogle Scholar
  3. Ansara, Y. (2015). Challenging cisgenderism in the ageing and aged care sector: Meeting the needs of older people of trans and/or non-binary experience. Australasian Journal on Ageing, 34, 14–18.CrossRefPubMedGoogle Scholar
  4. Anton, B. S. (2009). Proceedings of the American Psychological Association for the legislative year 2008: Minutes of the annual meeting of the Council of Representatives, February 22-24, 2008, Washington, DC, and August 13 and 17, 2008, Boston, MA, and minutes of the February, June, August, and December 2008 meetings of the Board of Directors. The American Psychologist, 64, 372–453.CrossRefGoogle Scholar
  5. Bailey, L., Ellis, S., & McNeil, J. (2014). Suicide risk in the UK trans population and the role of gender transition in decreasing suicidal ideation and suicide attempt. Mental Health Review Journal, 19(4), 209–220.CrossRefGoogle Scholar
  6. Bauer, G., Hammond, R., Travers, R., Kaay, M., Hohenadel, K., & Boyce, M. (2009). “I don’t think this is theoretical; this is our lives”: How erasure impacts health care for transgender people. The Journal of the Association of Nurses in AIDS Care, 20(5), 348–361.CrossRefPubMedGoogle Scholar
  7. Bradford, J., Reisner, S., Honnold, J., & Xavier, J. (2013). Experiences of transgender-related discrimination and implications for health: Results from the Virginia transgender health initiative study. American Journal of Public Health, 103(10), 1820–1829.CrossRefPubMedPubMedCentralGoogle Scholar
  8. Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., et al. (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism, 13(4), 165–232.CrossRefGoogle Scholar
  9. Conron, K., Scott, G., Stowell, G., & Landers, S. (2012). Transgender health in Massachusetts: Results from a household probability sample of adults. American Journal of Public Health, 102(1), 118–122.CrossRefPubMedPubMedCentralGoogle Scholar
  10. Davis, S. A., & Meier, S. C. (2014). Effects of testosterone treatment and chest reconstruction surgery on mental health and sexuality in female-to-male transgeder people. International Journal of Sexual Heath, 26, 113–128.CrossRefGoogle Scholar
  11. Dickey, L. M., Budge, S. L., Katz-Wise, S. L., & Garza, M. V. (2016). Health disparities in the transgender community: Exploring differences in insurance coverage. Psychology of Sexual Orientation and Gender Diversity, 3, 275–282.CrossRefGoogle Scholar
  12. Gehi, P., & Arkles, G. (2007). Unraveling injustice: Race and class impact of Medicaid exclusions of transition-related health care for transgender people. Sexuality Research & Social Policy, 4(4), 7–35.CrossRefGoogle Scholar
  13. Grant, J., Mottet, L., Tanis, J., Harrison, J., Herman, J., & Keisling, M. (2011). Injustice at every turn: A report of the National Transgender Discrimination Survey. Washington, DC: Washington National Center for Transgender Equality and National Gay and Lesbian Task Force.Google Scholar
  14. Grossman, A., & D’Augelli, A. (2006). Transgender youth: Invisible and vulnerable. Journal of Homosexuality, 51(1), 111–128.CrossRefPubMedGoogle Scholar
  15. James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The report of the 2015 U.S. transgender survey. Washington, DC: National Center for Transgender Equality.Google Scholar
  16. Kenagy, G. (2005). Transgender health: Findings from two needs assessment studies in Philadelphia. Health & Social Work, 30(1), 19–26.CrossRefGoogle Scholar
  17. Klein, A., & Golub, S. A. (2016). Family rejection as a predictor of suicide attempts and substance misuse among transgender and gender nonconforming adults. LGBT Health, 3, 193–199.CrossRefPubMedGoogle Scholar
  18. Lombardi, E. (2010). Transgender health: A review and guidance for future research—Proceedings from the Summer Institute at the Center for Research on Health and Sexual Orientation, University of Pittsburgh. International Journal of Transgenderism, 12(4), 211–229.CrossRefGoogle Scholar
  19. Meier, S. C., Fitzgerald, K., Pardo, S., & Babcock, J. (2011). The effects of hormonal gender affirmation treatment on mental health in female-to-male transsexuals. Journal of Gay & Lesbian Mental Health, 15(3), 281–299.CrossRefGoogle Scholar
  20. Miles, M., & Huberman, M. (1994). Qualitative data analysis: An expanded sourcebook. London: Sage.Google Scholar
  21. Olson, K. R., Durwood, L., DeMeules, M., & McLaughlin, K. A. (2016). Mental health of transgender children who are supported in their identities. Pediatrics, 137, 31–38.CrossRefGoogle Scholar
  22. Pflum, S. R., Testa, R. J., Bongar, B., Balsam, K. F., & Goldblum, P. B. (2015). Social support, trans community connectedness, and mental health symptoms among transgender and gender nonconforming adults. Psychology of Sexual Orientation and Gender Diversity, 2, 281–286.CrossRefGoogle Scholar
  23. Poteat, T., German, D., & Kerrigan, D. (2013). Managing uncertainty: A grounded theory of stigma in transgender health care encounters. Social science and medicine, 84, 22–29.CrossRefPubMedGoogle Scholar
  24. Sanchez, N., Sanchez, J., & Danoff, A. (2009). Health care utilization, barriers to care, and hormone usage among male-to-female transgender persons in New York City. American Journal of Public Health, 99, 713–719.CrossRefPubMedPubMedCentralGoogle Scholar
  25. Sevelius, J. (2013). Gender affirmation: A framework for conceptualizing risk behavior among transgender women of color. Sex Roles, 68, 675–689.CrossRefPubMedGoogle Scholar
  26. Shipherd, J., Green, K., & Abramovitz, S. (2010). Transgender clients: Identifying and minimizing barriers to mental health treatment. Journal of Gay & Lesbian Mental Health, 14, 94–108.CrossRefGoogle Scholar
  27. Simons, L., Schrager, S. M., Clark, L. F., Belzer, M., & Olson, J. (2013). Parental support and mental health among transgender adolescents. The Journal of Adolescent Health, 53, 791–793.CrossRefPubMedGoogle Scholar
  28. Snelgrove, J., Jasudavisius, A., Rowe, B., Head, E., & Bauer, G. (2012). “Completely out-at-sea” with “two-gender medicine”: A qualitative analysis of physician-side barriers to providing healthcare for transgender patients. BMC Health Services Research, 12, 110–123.CrossRefPubMedPubMedCentralGoogle Scholar
  29. Sperber, J., Landers, S., & Lawrence, S. (2008). The health and social services needs of transgender people in Philadelphia. International Journal of Transgenderism, 8(2–3), 31–47.Google Scholar
  30. Viera, A. J., & Garrett, J. M. (2005). Understanding interbserver agreement: The Kappa statistic. Family Medicine, 37, 360–363.Google Scholar
  31. Wilson, E. C., Chen, Y., Arayasirikul, S., Raymnd, H. F., & McFarland, W. (2016). The impact of discrimination on the mental health of trans* female youth and the protective effect of parental support. AIDS and Behavior, 20, 2203–2211.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  • Jae A. Puckett
    • 1
    Email author
  • Peter Cleary
    • 3
  • Kinton Rossman
    • 2
  • Brian Mustanski
    • 3
  • Michael E. Newcomb
    • 3
  1. 1.Department of PsychologyUniversity of South DakotaVermillionUSA
  2. 2.Trans and Sexuality Teaching, Advocacy, and Research (TSTAR)LouisvilleUSA
  3. 3.Department of Medical Social Sciences, Institute for Sexual and Gender Minority Health and WellbeingNorthwestern UniversityChicagoUSA

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