Introduction

Transgender, gender diverse, and non-binary (TGDNB) people face heightened rates of mental ill-health, psychological distress, and psychiatric diagnoses (Hill et al., 2021). The mental health of TGDNB people can be undermined by negative experiences associated with being a gender minority in society, with heightened rates of discrimination, rejection, and internalised stigma each being shown to predict mental health concerns among TGDNB individuals (Valentine & Shipherd, 2018). Many TGDNB people who show evidence of psychological distress do not access services (Shipherd et al., 2010), and a range of barriers to service access have been identified in the literature (McCormick, 2020). To address these potential barriers, the present study aimed to examine mental health service use, satisfaction with services, barriers to accessing services, and desires for tailored interventions in a sample of TGDNB people. It also sought to evaluate whether these service use-related patterns are associated with help-seeking intentions.

The TGDNB population consists of people whose sex assigned at birth does not align with their gender identity and/or expression, whereas those whose gender aligns with their sex assigned at birth are referred to as cisgender (Matsuno & Budge, 2017). For some transgender or gender diverse people, their gender may be transmasculine (e.g. man, trans man) or transfeminine (e.g. woman, trans woman), while others may not identify with the binary categories of ‘man’ or ‘woman’ but instead (or additionally) be non-binary (e.g. non-binary, agender, genderqueer). While these communities can be referred to collectively using umbrella terms such as TGDNB or trans, there are unique experiences for members of these communities, including whether and how they socially or medically affirm their gender, and how they are viewed and treated in society (Winter et al., 2016).

The stigma and marginalisation that TGDNB people experience has been theorised in Minority Stress Theory (Hendricks & Testa, 2012; Meyer, 1995) to explain the high rates of poor mental health among TGDNB people. Minority stressors may vary as a function of gender due to the unique experiences of those with transfeminine, transmasculine, and non-binary genders (Lefevor et al., 2019). For instance, a recent Australian study found that in the previous 12 months, young trans women reported more verbal and sexual harassment, and equivalent rates of physical harassment, compared with trans men and non-binary people (Hill et al., 2021). Those who do not adhere to gender stereotypes, such as some non-binary people, can be more likely to avoid accessing required services (Smith et al., 2014). Despite access to healthcare being a fundamental human right (Europe, 2019), evidence from the USA suggests that, relative to transfeminine individuals, transmasculine people report more challenges in gaining access to health services because of their gender identity or expression (Bockting et al., 2013). Clearly, members of the TGDNB population have different experiences in society relating to their gender and may therefore have different needs regarding mental health service use and might also experience different barriers to accessing care.

Mental Health Outcomes

Those in TGDNB communities experience higher rates of psychiatric diagnoses, psychological distress, and suicidality than their cisgender counterparts. Evidence from the UK demonstrates a high prevalence of psychopathology among TGDNB people, with higher rates of ‘probable or possible’ depression (23.9%) and anxiety (68.8%) found in transgender adults compared to a matched cisgender control group (4.5% and 34.5%, respectively; Bouman et al., 2017; Witcomb et al., 2018). An Australian study found that 46% of TGDNB respondents reported high or very high levels of psychological distress compared to 13% of people in the general population (ABS, 2018; Bariola et al., 2015). Furthermore, TGDNB people have consistently been identified as having higher rates of suicidality than cisgender people (e.g. Adams & Vincent, 2019; Nock et al., 2008). When taking into account the large body of national and international evidence suggesting that TGDNB people have poorer well-being across multiple domains compared to their cisgender counterparts, it is apparent that TGDNB mental health is a significant public health concern.

Unmet Mental Health Needs

The experience of mental illness is not directly related to uptake of mental health services; cultural attitudes, personal values and resources, and other barriers may explain the presence of unmet mental health needs. For instance, self-stigma and public stigma against mental illness may inhibit service access (Ran et al., 2021). While Australia appears to display less stigma relating to mental illness, and either equivalent or greater help-seeking behaviour than other countries in the Asia–Pacific region (e.g. Japan, Ran et al., 2021), cultural attitudes of stoicism (Kaukiainen & Kolves, 2020) may undermine mental health help-seeking. Nonetheless, when considering the level of psychological distress among TGDNB individuals, it is unsurprising that rates of mental health service use are higher than in cisgender populations. For instance, 55.3% of transgender men and 57.4% of transgender women accessed mental health services in Australia in the past 12 months (Leonard et al., 2015), compared to only 8.5% and 12.6% for cisgender men and women, respectively (AIHW, 2020).

The higher rates of service use among TGDNB people may reflect that many TGDNB people seeking gender-affirming medical care (e.g. hormones, surgeries) are first required to undergo a mental health assessment (Coleman et al., 2022). However, this likely only accounts for some of the heightened proportion of TGDNB people accessing services. It is important to consider the rates of unmet mental health needs, referring to the experience of clinically significant psychological distress in the absence of recent service access (Shipherd et al., 2010) or in the presence of ongoing mental health support that is not adequately meeting a person’s mental health needs. Research conducted in the USA suggests that 52% of TGDNB people were experiencing psychological distress but not receiving mental health support (Shipherd et al., 2010), while in Canada, 43.9% of TGDNB people reported needing general healthcare in the past year but not receiving it, compared to 10.7% of cisgender people (Giblon & Bauer, 2017). It is thus critically important to examine how TGDNB people engage with services, including satisfaction with services, and barriers experienced when accessing services. This would enhance our understanding of areas to be addressed to improve experiences of service use and help-seeking.

Despite the high rate of service access within the TGDNB population, service satisfaction and timely access to effective services is likely to vary (Ho & Mussap, 2017). TGDNB people working with a transgender-inclusive healthcare provider report significantly lower rates of depression and suicidality compared to those seeking help from a provider who is not specifically transgender-inclusive (Kattari et al., 2016). Due to the paucity of practitioners who specialise in or are trained and competent to provide care to TGDNB people, it seems likely that TGDNB people seeking help from less experienced practitioners may not consistently have their service needs met (Heng et al., 2018). While there are clinical guidelines available to inform the provision of safe and appropriate gender-affirming mental health care in Australia (e.g. ACT Government, 2022; Orygen, 2021) and internationally (e.g. Transgender Europe, 2019), it is not known the extent to which practitioners incorporate these guidelines. These factors may contribute to the high rates of unmet mental health needs in TGDNB individuals.

Barriers to Accessing Mental Health Services

Individual, external, and systemic barriers can prevent access to services for TGDNB people (Hughto et al., 2015). While we were unable to identify research comparing barriers to service access between TGDNB and cisgender populations, several studies have identified a range of barriers experienced by TGDNB individuals that are likely to limit their capacity to access and continue with mental health support. These barriers include the cost of services, time constraints, and distance to services (McCann & Sharek, 2016; Shipherd et al., 2010).

In addition to the general barriers described above, there are also several minority stress-related barriers that may impact service access (Hatzenbuehler et al., 2013). These may include a perception that providers are untrained or lack experience working with TGDNB people, fears of being treated unkindly or unfairly, health practitioners declining care to TGDNB people, limited availability of TGDNB-specific services, and community stigma against TGDNB people (Cronin et al., 2021). A significant proportion of mental health providers hold discriminatory attitudes towards TGDNB people in Australia (Riggs & Sion, 2017), and these attitudes are likely to serve as barriers for TGDNB to access services. Given the unique experiences for those of different genders, there may be distinctions in both general and minority stress-related barriers between genders that are important to investigate. No studies to our knowledge have examined differences in service access barriers between genders within the TGDNB population.

Help-Seeking Intentions

Elevated levels of service access are evident in TGDNB people when compared to the general population. However, it is unclear the extent to which TGDNB people access different services for their mental health. There are a number of avenues for mental health support that people may access, including general practitioners and psychologists, and other specialist support services such as social workers, psychiatrists, and phone help lines. Intentions to seek help from these forms of support may be informed by past positive and negative experiences with mental health services and a person’s barriers to accessing services (Bohon et al., 2016). Specifically, those who have more barriers to accessing services may have lower help-seeking intentions. This may vary as a function of experiences of past service use, whereby barriers to accessing services may be more or less impactful on help-seeking intentions when satisfaction with services is lower or higher, respectively. It is currently unknown the degree to which TGDNB people intend to access mental health services in the future or predictors of help-seeking intentions. It is plausible based on the existing research that low satisfaction with services and more barriers to accessing services would be associated with reduced help-seeking intentions.

Aims

The present research aimed to explore mental health service use in a sample of TGDNB adults living in Australia. Specifically, the present study assessed mental health service use, barriers to accessing services, and help-seeking intentions among TGDNB adults and tested for differences in these factors between transmasculine, transfeminine, and non-binary people. Due to the paucity of quantitative research comparing people of different genders on their experiences of accessing mental health services, the study was primarily exploratory, and no specific hypotheses were made about gender differences. The following aims and hypotheses were made:

  1. 1.

    To examine mental health help-seeking experiences in TGDNB adults, including the extent to which the sample accessed mental health services, their satisfaction with services, barriers to accessing services, desire for tailored services, and help-seeking intentions. We also explored potential gender differences in these factors; and

  2. 2.

    To examine associations between barriers to accessing services, service satisfaction, and help-seeking intentions.

It was hypothesised that greater general and minority stress-related barriers to accessing services would be associated with lower intentions to seek help from a psychologist and general practitioner and higher intentions not to seek help from anyone (as represented by the likelihood a person would seek help from no one). It was further hypothesised that these relationships would be moderated by satisfaction with past service use, wherein the relationship between barriers and help-seeking intentions would vary depending on levels of service satisfaction.

Methods

Participants

Participants were 178 TGDNB people living in Australia who responded to an online advertisement. Of this group, 28 participants were excluded from analysis; five did not meet the age criterion of being 18 years of age or over, and 23 did not complete the survey after commencing. This left a final total of 150 participants for analysis. This group ranged in age from 18 to 81 (M = 37.19; SD = 15.73). Gender identity distribution included those who were transfeminine (n = 77, 51.3%), transmasculine (n = 37, 24.7%), or non-binary (n = 36, 24%). Birth assigned sex was primarily male (n = 82, 54.7%), with the remainder having a female birth assigned sex (n = 68, 45.3%). Most participants were born in Australia (n = 120, 80%), with Anglo-Celtic being the primary ethnicity reported (n = 117, 78%), followed by non-Angle-Celtic European (n = 13, 8.7%), Indigenous Australian (n = 2, 1.3%), or another ethnicity (n = 18, 12%). All states and territories of Australia were represented, with regional distributions indicating most respondents lived in urban areas (n = 117, 78%), followed by inner regional (n = 23, 15.3%), outer regional (n = 8, 5.3%), and remote areas (n = 1, 0.7%; one participant provided a response that was invalid for classification). The majority of participants were educated at a university level, either undergraduate (n = 42, 28%) or postgraduate (n = 36, 24%), with the remainder having completed non-university tertiary education (n = 41, 27.3%) and secondary or lower (n = 31, 20.7%).

Measures

Service Use

Participants responded to three items assessing their mental health service use. Mental health service utilisation was assessed with one item asking respondents, ‘If ever, when did you last receive counselling for any problems with your emotions, nerves, or mental health?’ (Stanley & Duong, 2015). Responses were rated as Never, because it was not needed; Never, but it would have been helpful; In the past month; In the past 6 months; and Longer than 12 months ago. Participant responses were dichotomised, with 1 (recent service use), capturing those who had accessed services in the past one month or six months, and 0 (no recent service use), capturing those who had accessed services in the last year, over a year ago, or never accessed services despite it potentially being helpful. Responses of never, because it was not needed were excluded from the analysis. To assess satisfaction with services, participants were asked ‘How satisfied were you with the quality of psychological assistance or therapy you received?’, with response options ranging from 1 (very dissatisfied) to 5 (very satisfied), with an option for N/A for those who had never accessed psychological assistance or therapy. Participants were asked how important it would be for therapists or services to tailor their approach to meet the needs of TGDNB people, with response options ranging from 1 (not at all important) to 4 (extremely important).

Barriers to Help-Seeking

Barriers to help-seeking were assessed using an adapted version of existing scales measuring barriers to help-seeking (Heckman et al., 1998; Shipherd et al., 2010), adapted to use language inclusive of TGDNB individuals. Participants responded to the question ‘Please indicate to what extent each of the following circumstances makes it difficult for you to receive the care, services, or opportunities you wish to obtain’, for 14 potential barriers to accessing services on a 4-point Likert-type scale ranging from 0 (no problem at all) to 3 (major problem). Examples of barriers include, ‘Long distances to facilities and personnel’, and ‘Lack of professionals who are adequately trained and competent to work with TGDNB individuals’. The measure has demonstrated acceptable reliability in previous research with sexual minorities (Cronin et al., 2021). A total score for the measure was computed (α = 0.87) in addition to two subscale scores measuring general barriers to accessing services (10 items, potential range = 0–30) applicable to the general population (e.g. time, cost, distance to services, α = 0.79) as well as minority stress-related barriers (4 items, potential range = 0–12) that are applicable specifically to gender minorities (e.g. lack of professionals trained to work with TGDNB people, community residents’ stigma against TGDNB people, α = 0.84).

Help-Seeking Intentions

To assess intentions to seek help in the future, the General Help-Seeking Questionnaire (Wilson et al., 2005) was used. The 11-item questionnaire is a psychometrically reliable and valid measure of prospective help-seeking intentions with demonstrated associations with actual help-seeking behaviours. Participants responded to a prompt about how likely it is that they would seek help if they were experiencing a personal or emotional problem from the following response options: general practitioner, psychologist, social worker, phone help line, intimate partner, friend, parent, non-parent family, no one, work colleagues, or religious leader. Responses ranged from 1 (extremely unlikely) to 7 (extremely likely), with reverse scoring of the response option ‘no one’ for computing a total score (α = 0.71). A total score and item level descriptive statistics for each source of support were generated. Participant intentions to seek help from a psychologist or general practitioner, and the likelihood of not seeking help from anyone, were used in analyses of help-seeking intentions given the aims of the paper were to assess mental health care access.

Procedure

Participants were recruited using paid online advertising on the social media website Facebook.com, with adverts targeted to those living in Australia, aged 18–65 + years old, with interest in topics relating to TGDNB people. Advertisements specifically requested participation from those who identified as TGDNB to engage in a study examining well-being and service access in TGDNB Australians. Participants read an information statement before providing informed consent and then completed a series of questionnaires online using Qualtrics survey software. Participant responses were de-identified and anonymised, stored separately from any identifying information used as part of a larger longitudinal study examining mental health in the TGDNB Australian population. Participants were not compensated for their participation in this wave of data collection. Ethical clearance was provided for the study by the University Human Ethics Committee.

Data Analysis

A priori power analyses were conducted, with power set at 0.8, α = 0.05, and a medium effect size of 0.30, 0.30, and 0.15 for chi-square, ANOVA, and regression analyses, respectively. Power analyses were conducted for the total sample size, based on a small-to-medium effect size found in previous research relating to gender differences in help-seeking attitudes (Nam et al., 2010). Gender differences in service use were examined using chi-square analysis, with a service use variable generated by splitting responses into recent service use (in the last 6 months) or no recent service use (more than 6 months prior or never), with the minimum sample size of 108 exceeded. Multiple ANOVAs were used to compare transmasculine, transfeminine, and non-binary genders on their satisfaction with services, desire for tailored interventions, general and minority stress-related barriers to accessing services, and help-seeking intentions, with an estimated sample size needed of 111 being met. Univariate regression analyses were conducted to identify significant sociodemographic predictors of help-seeking intentions (including age, education, ethnicity, gender affirmation), none of which were significantly predictive of outcomes and were therefore not included in multivariate analysis. Multivariate linear regression was conducted to assess the relationship between barriers to accessing services (with separate analyses for general and minority stress-related barriers) and intentions to seek help from a psychologist, general practitioner, and no one. Gender was included as a covariate, with satisfaction with services used as a moderator variable for this analysis using the SPSS Process Macro (Hayes, 2013), with an estimated sample size needed of 85 met with the present sample of 150.

Results

Service Use

The majority of participants had accessed psychological services in their lifetime (n = 137, 91.3%), with the remainder never having accessed these services even though it would have been beneficial (n = 8, 5.3%), or not accessing services because they were not needed (n = 5, 3.3%).1 More specifically, 59 (39.3%) respondents had accessed services in the last month, 24 (16%) in the last 6 months, 19 (12.7%) in the last year, and 35 (23.3%) more than a year ago. Although non-binary participants appeared somewhat more likely to have used mental health services in the last 6 months (72.2%) compared to transmasculine (52.8%) and transfeminine (52.1%) participants, these differences were not significant (χ2(2) = 4.40, p = 0.111).

Satisfaction with Services

The majority of participants were generally satisfied with the psychological assistance or therapy they had received. Specifically, 42 (28%) were very satisfied, 49 (32.7%) were somewhat satisfied, 12 (8%) were neither satisfied nor dissatisfied, 21 (14%) were somewhat dissatisfied, and 15 (10%) were very dissatisfied, while 11 (7.3%) reported that they had never accessed psychological assistance or therapy.Footnote 1 When comparing the three gender groups on their satisfaction with services, no significant differences were found (see Table 1).

Table 1 Barriers to accessing services in those who report need or past access to services
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Barriers to Accessing Services

To assess barriers to accessing services and help-seeking intentions, participants who had not previously accessed services because it was not needed were excluded, leaving n = 145 for these analyses. Barriers to accessing services are reported in Fig. 1. Barriers that were frequently endorsed as a major problem for accessing services included the following: Lack of professionals who are adequately trained and competent to work with TGDNB individuals (42.8%); personal financial resources (41.4%); services cost too much (39.3%); concern with being treated unfairly or unkindly (27.6%); shortage of psychologists, social workers, and mental health counsellors who can help address mental health issues (24.1%); and community residents’ stigma against TGDNB individuals (22.1%).

Fig. 1
figure 1

Barriers to accessing psychological services, represented as percentage of barriers

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Significant differences emerged when comparing the three gender groups on their barriers to accessing services (see Table 1). Specifically, there was a significant difference between genders in both general (p = 0.018, η2 = 0.06) and minority stress-related barriers (p = 0.001, η2 = 0.09). Post hoc Tukey tests showed that transfeminine people had fewer general barriers to accessing services than transmasculine people (p = 0.032, d = 0.49), with no significant difference when comparing transfeminine and non-binary people (p = 0.096, d = 0.46) or when comparing transmasculine and non-binary people (p = 0.917, d = 0.09). Similarly, transfeminine participants had fewer minority stress-related barriers to accessing services than transmasculine people (p = 0.004, d = 0.66) and non-binary people (p = 0.011, d = 0.60), with no significant differences observed between transmasculine and non-binary participants (p = 0.965, d = 0.06). Minority stress-related barriers were consistently rated higher than general barriers to accessing services across genders.

Desire for Tailored Interventions

Most participants believed that it would be extremely important (n = 88, 58.7%) or very important (n = 45, 30%) for services to be tailored to meet the needs of TGDNB people, while only 14 (9.3%) and 3 (2%) reported this as slightly important or not at all important, respectively. No significant differences emerged between genders regarding desire for tailored interventions (see Table 1).

Help-Seeking Intentions

Prospective help-seeking intentions are reported in Table 2. People were likely (as represented by being somewhat likely, very likely, or extremely likely, combined into a single category) to seek help from the following if they were to have a personal or emotional problem: friend (84.8%), intimate partner (65.6%), psychologist (61.4%), general practitioner (44.2%), no one (42.1%), a parent (33.7%), non-parent family member (32.4%), or a phone help line (26.2%). No significant differences were found between genders (see Table 1).

Table 2 Percentages and mean scores of help-seeking intentions for formal and informal supports
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Predictors of Help-Seeking Intentions

To identify predictors of help-seeking intentions, regression analyses were conducted examining: (1) general barriers to accessing services and (2) minority stress-related barriers to accessing services. Each predictor was analysed with the outcome variable of intentions to seek help from a psychologist, general practitioner, and no one, with an interaction term included for satisfaction with services (see Table 3).

Table 3 Associations between barriers to accessing mental health, service satisfaction, and intentions to seek help from a psychologist, general practitioner, or no one
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General Barriers to Accessing Services

As displayed in Table 3, all three models (models 1, 3, and 5) that focused on general barriers to accessing services accounted for variance in help-seeking intentions. These explained 23% (model 1), 9% (model 3), and 10% (model 5) of the variance for intentions to seek help from a psychologist, general practitioner, and no one, respectively. Within each of these models, general barriers, service satisfaction, and the interaction term did not show significant independent associations with help-seeking intentions. No significant interaction effects were identified.

Minority Stress-Related Barriers to Accessing Services

As displayed in Table 3, all three models (models 2, 4, and 6) that focused on minority stress-related barriers significantly accounted for variance in help-seeking intentions. These explained 25% (model 2), 8% (model 4), and 12% (model 6) of the variance for intentions to seek help from a psychologist, general practitioner, and no one, respectively. However, there were some variations in specific predictors. Greater minority stress-related barriers were significantly associated with lower intentions to seek help from a psychologist. Satisfaction with service use moderated the association between minority stress-related barriers and help-seeking intentions. Specifically, minority stress-related barriers were associated with lower intentions to seek help from a psychologist, but only among those with lower levels of satisfaction with prior service use. A visual representation of this result is presented in Fig. 2. In regard to intentions to seek help from a general practitioner, no significant associations were identified between predictor variables and help-seeking intentions, nor were any significant interactions identified. Finally, greater satisfaction with prior service use was associated with a lower likelihood of participants indicating they would not seek help from anyone. No significant interaction effect was identified.

Fig. 2
figure 2

Minority stress-related barriers to accessing services predicting mean intentions to seeking help from a psychologist, as moderated by satisfaction with past service use

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Discussion

The present study examined the rates and experiences of mental health service use in a sample of TGDNB adults in Australia. Most participants had accessed mental health services in the past one (39.3%) or six (55.3%) months, with few participants (5.3%) never having accessed care despite reporting that this may have been beneficial. A large proportion of participants were dissatisfied with mental health services; under two thirds of participants were very satisfied (28%) or somewhat satisfied (32.7%) with their past service use. Help-seeking intentions varied depending on the source of support, with participants being at least somewhat likely to seek help from a general practitioner (44.2%), psychologist (61.4%), a friend (84.8%), or an intimate partner (65.6%). Furthermore, 42.1% of participants indicated that they were at least somewhat likely to not seek help from anyone. Most participants thought it would be extremely important (58.7%) or very important (30%) for services to be tailored to meet the needs of TGDNB people. There were no significant gender differences identified for these service use variables. A range of general and minority stress-related service-access barriers were identified, with transfeminine people reporting fewer minority stress-related barriers to accessing services compared to transmasculine and non-binary individuals. Models containing general and minority stress-related barriers to accessing services, service satisfaction, and an interaction term were negatively associated with help-seeking intentions. Furthermore, the hypothesis that service satisfaction would moderate the relationship between barriers and help-seeking intentions was partly supported, whereby the association between minority stress-related barriers and intentions to seek help from a psychologist were stronger among those who were satisfied with prior service use. However, no other significant interaction effects were identified to support this hypothesis.

Mental Health Service Use

Findings from the present study are consistent with previous research that TGDNB people access mental health services at high rates (Hill et al., 2021; Shipherd et al., 2010). A majority of participants had recently accessed services (55.3%), and 68% had accessed services in the past 12 months. This is higher than the general Australian population, with an estimated 10.6% of people accessing services in the past 12 months (AIHW, 2020). While most participants were satisfied with past service use (60.7%), about one third of the sample expressed dissatisfaction with past service use. Again, this appears to be higher than estimates in the general Australian population, with research suggesting rates of satisfaction with mental health services accessed in the past 3 months being rated by the majority as excellent (39%), very good (28%), or good (21%), with few people reporting mental health services as fair (8%) or poor (4%; NSW Ministry of Health, 2017).

The results of the present study suggest that TGDNB people access mental health services at high rates, but a significant proportion report being unsatisfied with these services, indicating a high degree of unmet mental health needs in this population. The present study did not elicit the reasons why participants were satisfied or dissatisfied with services. Previous research suggests that TGDNB people may be dissatisfied with services because the service or service provider did not adequately meet their needs (Bockting et al., 2004; Ho & Mussap, 2017). Specific needs of TGDNB people accessing services include being treated with understanding, sensitivity, and respect and for interventions to attend to minority stressors specific to the individual (e.g. discrimination, internalised stigma; Austin & Craig, 2015; McCann & Sharek, 2016). It is likely that these needs are not being consistently addressed by mental health professionals when providing services to TGDNB people, and this might explain the high rates of dissatisfaction with services in the present study. There are several guidelines and resources available to support mental health practitioners in providing safe and appropriate gender-affirming care within the Australian (ACT Government, 2022; Orygen, 2021) and international contexts (e.g. the USA: APA, 2015; Europe: Transgender Europe, 2019). Integrating these guidelines into standard clinical practice for healthcare providers could be achieved by health practitioner regulation agencies (e.g. AHPRA in Australia) or professional bodies mandating a minimum level of acceptable training for healthcare practitioners to work with TGDNB people and other marginalised communities. While these guidelines do not seek to change potentially discriminatory attitudes of healthcare practitioners, which likely requires increased education and ongoing shifts in societal attitudes towards TGDNB people, affirmative training programs have demonstrated effectiveness in reducing mental health practitioner negative attitudes towards TGDNB people (Pepping et al., 2018). Increasing training for healthcare providers and ensuring adherence to minimum acceptable standards of care would aid in reducing two key minority stress-related barriers identified in the present study: A lack of practitioners who are trained and competent in working with TGDNB people and concern with being treated unfairly or unkindly.

No significant gender differences were observed in rates of service use, satisfaction, or desire for tailored interventions in the present study, though further research is needed to examine these research questions with larger samples. For instance, non-binary people trended towards having higher rates of recent service use (72.2%) when compared to transmasculine (52.8%) and transfeminine (52.1%) participants, though these differences were not significant. These rates of service use are comparable to rates of service use identified in previous research, with 55.3% of transgender men and 57.4% of transgender women accessing services in the past 12 months (Leonard et al., 2015). A higher rate of service use was identified in the present study when compared to rates of men (8.5%) and women (12.6%) accessing services in the general population of Australia (AIHW, 2020). Further research would be important to identify any unique experiences of services between genders that would benefit from specific public health interventions or policy, such as education about mental health care programs targeted to specific subsets of the TGDNB communities and funding for additional targeted services.

Barriers to Accessing Mental Health Services

A number of barriers to accessing services were identified in the present research. There were several general barriers that were highly endorsed in the present sample, including personal financial resources; services costing too much; and a shortage of psychologists, social workers, or mental health counsellors in one’s local area. These findings are consistent with previous international research with TGDNB people (Shipherd et al., 2010), with financial concerns identified as a key barrier in the present and previous studies. Minority stress-related barriers were rated as more problematic for participants than general barriers, with shortages of practitioners trained or competent to work with TGDNB people the most endorsed minority stress-related barrier to accessing treatment, followed by concerns about being treated unkindly or unfairly, community stigma against TGDNB people, and personnel declining to provide care to TGDNB people. The high levels of endorsement of these barriers to accessing services converge with research pertaining to other marginalised communities in Australia and Ireland, such as sexual minority individuals (Cronin et al., 2021; McCann & Sharek, 2014). Results of the present research suggest that transfeminine people have fewer general barriers to accessing services than transmasculine people, and fewer minority stress-related barriers to accessing services than both transmasculine and non-binary people. Distinctions in barriers may relate to the visibility and acceptance of transfeminine people in healthcare services. Gender-affirming services historically targeted transfeminine people, with less provision of services to transmasculine and non-binary people (Riseman, 2022). While challenges to accessing services remain regardless of gender, this may explain why transfeminine people in the present study had lower barriers to accessing mental health services than transmasculine and non-binary people. Prior research was not identified regarding distinctions in barriers to accessing care between transfeminine, transmasculine, and non-binary people. However, cisgender women typically have higher rates of help-seeking than cisgender men (AIHW, 2020), and previous research has shown a higher rate of general barriers to accessing services in cisgender sexual minority women, and equivalent minority stress-related barriers between sexual minority women and men (Cronin et al., 2021). Distinctions in barriers between genders may relate to differences in sociodemographic characteristics, such as employment and income, distinctions in mental health, or potential distinctions in minority stress. Future research would benefit from further exploring these differences in barriers to accessing services between genders.

There are several potential strategies that may reduce barriers to accessing care and subsequently reduce the unmet mental health needs for TGDNB people. In regard to cost of services, reduced service fees for marginalised communities such as TGDNB people would potentially alleviate this barrier. In Australia, the government provides a rebate of a fixed amount per consultation when seeking help from mental health practitioners, though clients are often left with sizeable out of pocket costs. Furthermore, the number of consultations is capped to 10 per year (with a recent increase to 20 during the COVID-19 pandemic ending in 2022), which is inadequate to meet the needs of those with complex mental health concerns (Australian Psychological Society, 2022), such as TGDNB people experiencing significant minority stress and associated psychological distress. To reduce the financial burden associated with accessing services, higher rebates for services provided to TGDNB people may aid in reducing the gap between government or insurance rebates and actual appointment fees, increasing the accessibility of services for marginalised communities. Additionally, an increase in the number of free or low-cost services targeted to TGDNB individuals, such as increasing the number of government-rebated mental health consultations available per year, may increase accessibility for a population with high rates of under-employment and unemployment (Leppel, 2016). Alternatively, an allocation of services directly targeted to the TGDNB communities that are implemented nationally, with remote accessibility via telehealth technology, may aid in increasing access to those in underserved regional and remote communities. Services targeted to meet the needs of sexual and gender minorities have been shown to have better acceptability than services for the general population (Hill et al., 2021). Accordingly, access to services specifically targeted towards TGDNB individuals may aid in reducing barriers to accessing services, increase service use, as well as potentially improving clinical outcomes associated with service access.

Help-Seeking Intentions

There were a range of services and informal sources of support that participants reported they would access if they needed support for an emotional or personal problem. Encouragingly, most participants indicated that they would seek help from a psychologist or general practitioner if needed, and there were relatively high intentions to seek help from a friend or an intimate partner. Despite phone help lines aiming to support those in crisis, just over a quarter of participants reported being likely to access support from a phone help line, replicating Australian research which suggests few TGDNB people access phone help lines to cope with a personal crisis (Lim et al., 2021). Of particular importance, about 42% of participants indicated that they would be somewhat, very, or extremely likely to not seek help from anyone. Additionally, service satisfaction was associated with reduced intentions to seek help from no one (see model 6; Table 3). These results suggest that while people are clearly knowledgeable of both personal and professional supports, a large portion of respondents were likely to access support from no one; this was even more likely among those who were dissatisfied with past service use. This result may partly explain previous findings that TGDNB people have high rates of unmet health needs (i.e. health or mental health need in the absence of current service use; Giblon & Bauer, 2017; Shipherd et al., 2010), with TGDNB people finding the services they have accessed previously unsatisfactory and intending to not seek help from anyone as a consequence. It is important to note that a limitation of breaking down the data in this manner is that participants were asked to select how likely they were to access each area of support, with potential for people to strongly endorse competing response options of ‘no one’ and ‘friend’ or ‘psychologist’, and that the cross-sectional nature of the research precludes an examination of causation.

Analyses suggest that general and minority stress-related barriers were significantly associated with help-seeking intentions. This association was negative, meaning that more barriers were associated with less intentions to seek help. Minority stress-related barriers were specifically found to be negatively associated with help-seeking intentions to see a psychologist. Additionally, an interaction term demonstrated that the association between minority stress-related barriers and help-seeking intentions is stronger among those who were satisfied with services. That is, even when faced with significant barriers to accessing services, having a positive experience with services in the past may help to overcome these barriers and foster intentions to seek help again.

One potential strategy to address barriers could be to improve satisfaction with services for those currently accessing services. Past research has demonstrated that TGDNB people are more satisfied with services when practitioners are respectful, caring, knowledgeable of TGDNB issues, and able to provide timely access to services (Heng et al., 2018). Furthermore, emerging evidence demonstrates high levels of service satisfaction from those participating in interventions targeted to sexual and gender minorities (Craig et al., 2021). More services are clearly needed that are designed specifically to work with TGDNB people, as well as an increase in training for practitioners who do not currently work with TGDNB people. This may increase the number of practitioners who are competent to provide care to this population, which may then improve satisfaction with services. Specific training programs designed to increase practitioner readiness to work with the LGBTIQA + communities have demonstrated effectiveness in Australia (Pepping et al., 2018). Accordingly, rolling out established programs for training health and mental health practitioners to work with TGDNB people and increasing practitioner use of established clinical guidelines may aid in reducing the systemic barrier of too few providers perceived as competent to work with TGDNB people. More instances of respectful, caring, and attuned mental health care access may increase TGDNB individuals’ satisfaction with services, which may aid in reducing the impact of barriers to accessing mental health service on help-seeking intentions.

Generalisability, Limitations, and Future Directions

The results of the present research are likely to be generalisable to the TGDNB population when considering demographic representation. Sociodemographic information, such as age and education level, was similar to recent Australian research in this area (Hill et al., 2020); however, the present research appears to be less culturally diverse with a majority Anglo-Celtic sample and to have a greater representation of transfeminine people. Thus, we cannot assume that the results generalise to cultural minority groups. Despite this, results were similar to those found in previous national and international research in this area, including service use and barriers to accessing services (Leonard et al., 2015; McCann & Sharek, 2016; Shipherd et al., 2010). It is important to note that we used medium effect sizes for sample size calculations in order to identify meaningful effects when accounting for a relatively small sample size. Thus, it is possible that very small effects may not have been detected in the present study.

For the purposes of examining group differences between gender identities, we asked participants to select the gender category that best matched their gender identity. This may mean that the gender categories did not entirely capture the identities for at least some participants. Future research with larger samples will be needed to examine the help-seeking experiences of TGDNB individuals using more refined gender categories. This study focused on barriers to accessing services but did not evaluate factors that may facilitate service access or help-seeking intentions, such as psychological, social, or practical facilitators. Future research should assess both barriers and facilitators to service access in TGDNB people, using both qualitative and quantitative methods. The present research was cross-sectional, precluding examination of causation. Additionally, the measure of help-seeking intentions does not assess actual help-seeking behaviours. While past and current service use were assessed, future research would benefit from examining barriers to accessing services, satisfaction with services, help-seeking intentions, and service use in longitudinal research designs to enable examination of temporal precedence. The present research focused on the experiences of TGDNB adults in the Australian context. While these findings may be generalisable to other English-speaking countries, there are likely to be differences between countries on the experiences of healthcare access for TGDNB people due to unique cultural attitudes and healthcare policies. Finally, only those with internet and Facebook access could participate in the present study, meaning that those with limited financial resources to afford internet access, those in remote areas with minimal internet connectivity, and those without Facebook accounts or who were not open about their interest in TGDNB topics on Facebook were unlikely to be sampled in the present study.

Conclusions

Results of the present research suggest that Australian TGDNB people have significant barriers to accessing care and have high levels of unmet mental health needs despite their high rates of recent service access. Transfeminine people reported fewer barriers to accessing mental health care, but there were otherwise no significant gender differences in relation to service use, satisfaction with services, or intentions to seek help. Barriers to accessing services and satisfaction with past services were significantly associated with help-seeking intentions. Furthermore, the association between minority stress-related barriers and lower help-seeking intent was significantly weaker among those who were more satisfied with prior service use. These findings address a gap in knowledge relating to how TGDNB Australians face ongoing systemic discrimination that impedes their uptake of needed mental health services. These findings should inform public health and social policies, such as mandating training in gender-affirming care for health practitioners and increasing the rebate and number of consultations available per year in government-funded mental health programs, which may aid in reducing the unmet mental health needs of TGDNB people. Future research is needed to qualitatively examine the ways in which TGDNB people experience barriers and potential facilitators to accessing mental health services. Furthermore, research is needed to examine strategies to enhance service access, including methods by which barriers and facilitators of service use can be targeted.