title: Youth and Caregiver Perspectives on Barriers to Gender-Affirming Health Care for Transgender Youth.
abstract: Few transgender youth eligible for gender-affirming treatments actually receive them. Multidisciplinary gender clinics improve access and care coordination but are rare. Although experts support use of pubertal blockers and cross-sex hormones for youth who meet criteria, these are uncommonly offered. This study's aim was to understand barriers that transgender youth and their caregivers face in accessing gender-affirming health care.
  
  
  
  Transgender youth (age 14-22 years) and caregivers of transgender youth were recruited from Seattle-based clinics, and readerships from a blog and support group listserv. Through individual interviews, focus groups, or an online survey, participants described their experiences accessing gender-affirming health care. We then used theoretical thematic analysis to analyze data.
  
  
  
  Sixty-five participants (15 youth, 50 caregivers) described barriers spanning six themes: (1) few accessible pediatric providers are trained in gender-affirming health care; (2) lack of consistently applied protocols; (3) inconsistent use of chosen name/pronoun; (4) uncoordinated care and gatekeeping; (5) limited/delayed access to pubertal blockers and cross-sex hormones; and (6) insurance exclusions.
  
  
  
  This is the first study aimed at understanding perceived barriers to care among transgender youth and their caregivers. Themed barriers to care led to the following recommendations: (1) mandatory training on gender-affirming health care and cultural humility for providers/staff; (2) development of protocols for the care of young transgender patients, as well as roadmaps for families; (3) asking and recording of chosen name/pronoun; (4) increased number of multidisciplinary gender clinics; (5) providing cross-sex hormones at an age that permits peer-congruent development; and (6) designating a navigator for transgender patients in clinics.
authors.affiliation: Vanderbilt University School of Medicine, Nashville, Tennessee; Seattle Children's Research Institute, Seattle, Washington.
authors.forename: Samantha J
authors.initials: SJ
authors.lastname: Gridley
authors.affiliation: Seattle Children's Research Institute, Seattle, Washington.
authors.forename: Julia M
authors.initials: JM
authors.lastname: Crouch
authors.affiliation: Seattle Children's Research Institute, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington.
authors.forename: Yolanda
authors.initials: Y
authors.lastname: Evans
authors.affiliation: Department of Pediatrics, University of Washington, Seattle, Washington.
authors.forename: Whitney
authors.initials: W
authors.lastname: Eng
authors.affiliation: Department of Pediatrics, University of Washington, Seattle, Washington.
authors.forename: Emily
authors.initials: E
authors.lastname: Antoon
authors.affiliation: Department of Psychosocial and Community Health, University of Washington School of Nursing, Seattle, Washington.
authors.forename: Melissa
authors.initials: M
authors.lastname: Lyapustina
authors.affiliation: Seattle Children's Research Institute, Seattle, Washington; Loyola University Maryland, Baltimore, Maryland.
authors.forename: Allison
authors.initials: A
authors.lastname: Schimmel-Bristow
authors.affiliation: Seattle Children's Research Institute, Seattle, Washington; Carleton College, Northfield, Minnesota.
authors.forename: Jake
authors.initials: J
authors.lastname: Woodward
authors.affiliation: Department of Pediatrics, University of Washington, Seattle, Washington.
authors.forename: Kelly
authors.initials: K
authors.lastname: Dundon
authors.affiliation: Division of Adolescent Medicine, Seattle Children's Hospital, Seattle, Washington.
authors.forename: RaNette
authors.initials: R
authors.lastname: Schaff
authors.affiliation: Seattle Children's Research Institute, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington.
authors.forename: Carolyn
authors.initials: C
authors.lastname: McCarty
authors.affiliation: Seattle Children's Research Institute, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington.
authors.forename: Kym
authors.initials: K
authors.lastname: Ahrens
authors.affiliation: Seattle Children's Research Institute, Seattle, Washington. Electronic address: david.breland@seatttlechildrens.org.
authors.forename: David J
authors.initials: DJ
authors.lastname: Breland
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D017028:Caregivers / Q000523:psychology*; D005260:Female; D006297:Health Services Accessibility; D062985:Health Services for Transgender Persons / Q000600:supply & distribution*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010290:Parents / Q000523:psychology*; D036301:Qualitative Research; D011787:Quality of Health Care; D063106:Transgender Persons / Q000523:psychology*; D055815:Young Adult
keywords: Adolescents; Barriers; Cross-sex hormones; Gender dysphoria; Gender incongruence; Multidisciplinary gender clinic; Preferred name; Puberty suppression; Qualitative study; Transgender