Factors associated with facilitators and barriers to gender-affirming care among transgender and nonbinary youth and young adults in Washington: A mixed-methods approach

Background: Access to gender-affirming care is associated with improved mental health among transgender and nonbinary (TNB) individuals, particularly among TNB youth. We conducted a mixed-methods study to examine the association of age with prevalence of facilitators and barriers to gender-affirming care among youth and adults who identify as TNB residing in Washington. In addition, we qualitatively assessed system and interpersonal level factors that potentially facilitate and/or create barriers to access among trans youth in Seattle. Methods: In the quantitative study, sociodemographic characteristics and responses related to healthcare discrimination and access to gender-affirming medical care were collected via the 2022 Pride Survey by Public Health – Seattle & King County. Age was the exposure variable and various forms of facilitators and barriers to care were the outcome variables. Multivariate Poisson regression with robust standard estimates were used to estimate the association between age and facilitators and barriers to care. In the qualitative study, one-on-one interviews and a focus group were conducted with trans youth in the Seattle area. Participants were asked questions related to navigating healthcare, disclosing gender identity in health-related situations, and experiences of receiving gender-related care. Integration of qualitative and quantitative data during analysis and interpretation occurred via a contiguous approach. Results: Our quantitative findings (N=496) indicate that the prevalence of facilitators and barriers to care did not differ between TNB youth (13 to 24, n=189) and young adults (25 to 34, n=307). About a quarter (25%) of participants reported that they had access to all the gender-affirming treatments that they want or need. Youth were 45% less likely to experience provider refusal of care than young adults (PR=0.55, 95% CI: (0.38, 0.80), p<0.008). Interviews with youth participants (N=19) highlighted various facilitators and barriers to care, including ways in which providers interacted with the participant and their families, family support for or resistance to their transition, knowledge of gender-affirming care at the community-level and within healthcare settings, healthcare structure, and dominant narratives about transness. Conclusion: Many TNB youth lack access to gender-affirming care. Our findings affirm the importance of creating a safe space for youth to explore their gender identity and have access to medical professionals and communities that validate their varied experiences. These findings indicate important policy implications on creating more equitable access to gender-affirming services.