https://orcid.org/0000-0002-4982-1323
Figures
Abstract
Purpose
The purpose of this study is to identify and explore the educational needs of and broader barriers experienced by clinicians who provide care to transgender, nonbinary, and gender diverse (TGD) young adults (aged 18–24), with a focus on unique healthcare needs and challenges.
Methods
Between April 2022 – July 2022, we conducted qualitative interviews with 13 clinicians (n = 9 medical and n = 4 mental health) about perceived needs and barriers relating to the care of TGD young adults. Clinicians were recruited throughout the Southeastern and Mid-Atlantic United States and were a mix of general practitioners and specialists. Using a hybrid deductive and inductive thematic analysis approach, the interview transcripts were analyzed and key themes identified.
Results
Thematic analyses of these interviews identified three main themes: the need for knowledgeable clinicians, the need and desire for reliable training resources and mentorship, and concerns surrounding the impact of the sociopolitical environment. Many participants noted a lack of access to local educational opportunities and mentorship but expressed willingness to seek these out if centralized resources, such as national platforms or accessible training modules, were available.
Conclusion
This study identifies both gaps in clinician education and broader barriers – such as local politics and access to mentorship – that hinder the ability to provide effective care to TGD young adults. These findings will help to inform the development of clinician education and support programs.
Citation: Kremen J, Quint M, Tham R, Kane K, Boskey ER, Morrow C, et al. (2025) Barriers experienced by and educational needs of clinicians who provide care for transgender, nonbinary, and gender-diverse young adults in the Mid-Atlantic and Southern United States. PLoS One 20(6): e0326420. https://doi.org/10.1371/journal.pone.0326420
Editor: Adedotun Ogunbajo, RAND Corporation, UNITED STATES OF AMERICA
Received: November 26, 2024; Accepted: May 27, 2025; Published: June 23, 2025
Copyright: © 2025 Kremen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant de-identified data are reported in the paper. No other datasets were generated as part of this study.
Funding: This work was supported by the National Institutes of Health (NIH) through U01 grant number 5U01MH136558, awarded to authors SLR and RX. The NIH sponsor had no role in the study design, data collection and analysis, or decision to publish. No commercial companies funded the study or provided salary or other financial support to any of the authors.
Competing interests: The authors have declared that no competing interests exist.
Introduction
In the United States (U.S.), an estimated 1.3% of individuals ages 18–24 years identify as transgender, and an additional percentage of U.S. young adults identify as nonbinary [1,2]. Transgender, nonbinary, and other gender diverse (TGD) young adults and their families view clinicians as a trusted source of support and information when questions arise regarding gender identity, general health, and mental health concerns [3,4]. Additionally, TGD individuals require routine preventative medical and dental services but may avoid wellness visits and other routine health maintenance if clinic practices are perceived to be unwelcoming [5].
This study focuses on TGD young adults (aged 18–24), who are in a critical developmental period characterized by social, emotional, and psychological change. This age group faces distinct challenges that differ from those experienced by adolescents or older adults – both social and legal. By concentrating on young adults, this research aims to explore the unique needs and barriers to care they encounter, which may not be fully captured in studies of broader age groups.
Access to competent medical and behavioral health care has been shown to improve mental health outcomes and psychosocial functioning for TGD young adults [6,7]. It is therefore important that clinicians understand how to have supportive interactions with TGD young adults and their families. Despite this need, many clinicians do not feel equipped to care for TGD individuals in their practices and lack the necessary educational resources and training.
While previous work has characterized some of the barriers to providing care, including a lack of formal training and limited support systems [8–9], a need persists for greater understanding of clinicians’ training gaps, goals, and desired resources to inform interventions and programming. These insights are crucial for developing targeted interventions and resources that can better equip clinicians to offer competent care. Recent studies have indicated that clinicians often feel unprepared due to limited training on care of TGD patients during their formal education [10]. These barriers are particularly evident in primary care and mental health settings. Further, clinicians’ perceived barriers to providing care may be influenced by the contemporary U.S. political climate and evolving policy environment, including the increasing number of anti-trans bills introduced that target TGD healthcare (185 bills in 2023, as compared to 40 bills in 2021 and only 4 bills in 2019) [11].
In this qualitative study, we sought to explore the past and current training experiences and needs of medical and mental health clinicians providing care to TGD young adults. This research inquiry, conducted as part of TransHealthGUIDE, a National Institutes of Health (NIH)-funded project (U01MH136558) to improve mental health outcomes for TGD young adults via innovative interventions, aimed to delineate specific gaps in the training, resources, and support systems available for clinicians caring for TGD young adults. While much of the foundational knowledge on clinicians’ needs and barriers related to providing care of TGD patients has been established [12,13], this study seeks to provide a more detailed understanding of how these challenges manifest in clinical practice, particularly for the young adult patient population. By focusing on these dynamics, the study aims to inform future interventions and program development that can more effectively equip clinicians to provide competent and compassionate care for TGD young adults.
Methods
Recruitment and eligibility
TransHealthGUIDE is a multi-component study that aims to improve the mental health of TGD young adults through educational interventions for health care clinicians, TGD young adults, and their family members. To identify the training experiences and needs of health care clinicians, one-on-one in-depth interviews were conducted with a total of 13 health care clinicians between April 2022 and July 2022. Eligible participants were healthcare clinicians aged 18 or older who provided care to TGD young adults, defined as individuals aged 18–24 years. Participants self-identified as providing care to this population based on their own assessment of their patient demographic, rather than a predefined threshold for practice composition. Recruitment materials specified this age range to ensure alignment with study objectives.
Purposive sampling was implemented to ensure diversity of participants by geography, specialty, and clinician type [14]. Geographic recruitment was first limited to the Southeastern U.S. because the TransHealthGUIDE study initially focused on this region. As the U.S. legislative landscape changed during the study, the geographic focus of the overall study was adjusted, and clinicians in the Mid-Atlantic were included.
Recruitment was conducted through electronic flyers, emails to organizations serving the TGD community, clinician listservs, and referrals from the research team’s national network. All study activities received approval from the Institutional Review Board at Boston Children’s Hospital (IRB-P00040048), and ethical standards were rigorously followed. Given the study’s minimal risk and the remote, geographically dispersed nature of participants, written consent was not obtained to prevent potential identification as members of a stigmatized group. Instead, the IRB approved the use of verbal informed consent, which was documented by audio-recording each participant’s verbal agreement at the beginning of the interview.
Participants received a $50 Amazon gift card as compensation for their time. Compensation was approved by the Institutional Review Board (IRB) and was not contingent on specific responses.
Data collection
An hour-long, semi-structured, audio-recorded Zoom interview was conducted with each consenting participant. Verbal consent was obtained from all participants at the beginning of the interview. Two to four members of the study team participated as interviewers or notetakers. Participants were instructed to comment on their experiences and the care they provided to TGD young adults, defined as individuals aged 18–24. Participants were asked about their experiences caring for TGD young adults, facilitators and barriers to providing care, and resources they used to learn and teach others about caring for TGD individuals. Although some participants may have also referenced adolescents and adults due to the nature of their practices, the focus of the broader study was on young adults. Participants were also asked to self-report demographic details, including race, ethnicity, and professional background.
Audio recordings were transcribed verbatim by the study team.
Data analysis
After transcription, data were analyzed using a hybrid deductive and inductive thematic analysis approach [15]. Initial codes were developed inductively through open coding of the first set of transcripts by two independent coders (authors MQ and EB). A preliminary codebook was iteratively refined through team discussions, incorporating deductive elements informed by prior research on TGD healthcare education. Codes were applied line-by-line, and themes were reassessed throughout the analysis.
To assess inter-rater reliability, a subset of transcripts (20%) was independently coded by MQ and EB. Coding discrepancies were reviewed in consensus meetings, and modifications to the codebook were made iteratively to improve alignment. Rather than using a statistical inter-rater reliability measure, agreement was ensured through discussion and reconciliation of coding differences, with input from additional team members (JK, RT, KK, SR, and RX) as needed. Once consistency was established, the remaining transcripts were coded by a single coder with periodic team reviews.
Themes were refined using a constant comparison approach, ensuring that newly identified patterns were consistently evaluated against prior codes across transcripts. Regular team discussions were held to compare emerging themes, refine code definitions, and resolve discrepancies. Investigator triangulation was employed, with multiple team members (MQ, EB, JK, RT, KK, SR, and RX) independently reviewing and validating key themes to ensure analytical rigor. Refinements were made iteratively based on consensus, and thematic saturation was assessed to confirm that no new patterns emerged.
The codebook included predefined themes informed by prior research, operational definitions, and example quotes. New codes emerging from the data were discussed in weekly team meetings and integrated through iterative revisions. Reliability was maintained by double-coding a subset of transcripts, with inter-coder agreement established via consensus discussions rather than statistical measures.
Qualitative coding was implemented using Dedoose software
Results
Sample characteristics
A total of 13 clinicians across seven states in the Mid-Atlantic and Southern U.S. were interviewed. Nine were medical clinicians, and four were mental health clinicians. Of the medical clinicians, five had MD/DO degrees (55.5%), three were nurse practitioners (33.3%), and one was a medical student (11.1%).
Six (66.7%) were general practitioners in primary care or family medicine practices, and three (33.3%) were specialists. Of the mental health clinicians, two were psychologists (50%), and two were master’s level therapists (50%). Of the 13 participants, 7 identified as White, 2 as Asian, 2 as Black, 1 as Hispanic, and 1 as multiracial.
Themes
Themes coalesced into three broad categories: (1) the need for clinicians knowledgeable about the care of TGD young adults, (2) the need and desire for reliable learning resources to train clinicians in caring for TGD young adults and their families, and (3) concerns about the impacts of the sociopolitical environment on care delivery.
Theme 1: The need for knowledgeable clinicians.
This theme highlights how clinicians take initiative to educate themselves due to the absence of formal training opportunities. It encompasses two interrelated sub-themes: the need for more clinicians competent and comfortable in care for transgender people (subtheme 1.1) and the need for trusted colleagues and care networks (subtheme 1.2). In subtheme 1.1, clinicians expressed that the demand for care for transgender people exceeds the number of trained clinicians, forcing many to learn independently. In subtheme 1.2, many clinicians described seeking informal peer networks due to the absence of structured mentorship. A mental health clinician noted, “I belong to a couple of LGBTQ therapist groups on Facebook to find out who’s doing workshops, how do I sit in on this -- but it’s a lot of legwork, I would say, to collect information and collaborate (Table 1).”
Subtheme 1.1: The need for more clinicians competent in caring for TGD young adults: Clinician narratives identified a significant need for more clinicians interested and competent in providing care to TGD young adults. Many clinicians discussed their own reasons for initially becoming engaged in care for transgender people. Most medical and mental health clinicians said they did not enter medical/mental health fields with plans to focus on providing care to TGD patients but were motivated to do so by a perceived unmet need for available clinicians to address the concerns of TGD young adults and their family members
Clinicians felt that this unmet need grew out of discomfort among other clinicians and because of frequent negative healthcare experiences among TGD young adults and family members seeking care in other clinical contexts. As Medical Clinician B reflected, “And, to be honest I literally thought that all you did was walk into your primary care and say, hey I’m trans… It was completely not the case at all….” This highlights the gap in understanding and the discomfort some clinicians feel when working with TGD individuals, which further contributes to the challenges in accessing competent care. Upon offering care, clinicians saw a rapid influx of TGD patients; in some cases, these patients filled their patient panels, and clinicians took on additional clinic days to meet demand for care. Clinicians explicitly noted how they created a welcoming clinic environment to indicate that the clinic was a safe place for LGBTQ+ patients. Visual safety signaling and positive interactions resulted in positive word of mouth in the community.
Subtheme 1.2: The need for trusted colleagues and care networks: Clinicians described relationships with colleagues knowledgeable about the needs of TGD young adults as essential for their own clinical practice and learning. In the absence of structured networks or formal support, many clinicians felt that it would be difficult for them to continue providing care for TGD individuals. Mental Health Clinician B described their experience: “But mostly my training has been a lot of piecemeal and fortuitously crossing paths with providers. It’s a lot of knowledge sharing that goes on, but I seek out a lot of continuing education workshops.” This highlights the challenges faced by clinicians who, without a solid network or mentorship, are left to rely on fragmented sources of knowledge and self-directed learning. These gaps in training and resources can hinder the ability to offer consistent, high-quality care to TGD individuals, underscoring the need for more coordinated support and educational frameworks.
Referral networks of trusted colleagues were important to clinicians for several reasons. First, clinicians described the value of having colleagues with whom they could discuss clinical questions related to care of TGD patients; this theme is explored further in the next section.
Second, clinicians emphasized the importance of knowing they could refer TGD patients to clinicians/practices where patients would not be stigmatized or mistreated. Some primary care clinicians further reported that insurance coverage of certain types of care would only be possible if ordered by certain subspecialists, necessitating access to subspecialists who were also competent in providing care to TGD patients.
Theme 2: The need and desire for reliable training resources for clinicians caring for TGD young adults and families.
This theme captures the structural challenges that prevent clinicians from accessing adequate education. It encompasses two interrelated sub-themes: challenges associated with lack of formal training programs (subtheme 2.1) and the desire for mentorship and collaboration (subtheme 2.2). Subtheme 2.1 details how medical education lacks standardized curricula for TGD healthcare, leaving gaps in clinician competency. Subtheme 2.2 details how despite the need for mentorship, many clinicians struggle to find experienced mentors. One medical clinician shared, “I wanted to be mentored. I…wanted to be mentored really bad and I couldn’t find somebody to mentor me, and so I asked her if she would, and she agreed, and then she never followed through with allowing me to go and just see her clinic a little bit. There’s a lot to be said for just plain old mentorship (Table 1).”
Subtheme 2.1: Clinician responses to the lack of formal training programs and resources: Clinicians discussed learning best practices for the care of TGD young adults by taking World Professional Association for Transgender Health (WPATH) courses; reviewing professional society guidelines, including Endocrine Society clinical practice guidelines [16], WPATH Standards of Care [17], and University of California San Francisco primary care guidelines [18]; and accessing educational resources published by the National LGBTQIA+ Health Education Center [19] (Table 2). However, many participants identified the absence of a centralized, easily accessible training platform as a barrier to developing expertise in caring for TGD young adults.
Several described developing or feeling motivated to create self-guided training programs and/or their own educational resources, drawing from existing guidelines and multiple professional societies. Clinicians also emphasized the importance of clinical experiences, both formal and informal, with colleagues and training programs. Further, some noted that the lack of professional continuing education credits was a deterrent to accessing certain educational resources.
Subtheme 2.2: The desire for mentorship/collaboration: While clinicians expressed strong interest in mentorship and learning from colleagues, some were unable to establish these relationships. Those who were able to do so reported positive experiences related to receiving clinical instruction from more knowledgeable peers and mentors and in turn mentoring others. Those who went on to teach peers and trainees were particularly emphatic about the importance of developing a strong understanding of the material.
Professional training courses were identified as useful opportunities to learn from colleagues with experience providing care to TGD young adults, but cost and required time commitment were noted as barriers to access. Several clinicians participated in the care of TGD young adults during their training, but others reported that colleagues interested in providing care to TGD individuals have been hindered by a paucity of training opportunities.
Subtheme 2.3 The need for multidisciplinary teams: Medical and mental health clinicians were enthusiastic about cross-disciplinary educational opportunities encompassing medical specialists, mental health clinicians, and administrative staff. Clinicians wanted to ensure that patients had access to specialty and mental health care beyond their own practices. They also emphasized supporting families to access resources and care.
Clinicians expressed desire for more opportunities to educate clinic staff, including nurses, clinical assistants, and front desk staff. Some clinicians also noted that encounters with TGD young adults and families in their practice helped them to identify educational resources and highlighted gaps in existing knowledge.
Theme 3: Sociopolitical environment.
Clinicians identified the U.S. legislative environment as a barrier to providing care for TGD individuals, citing uncertainty about legal implications. Proposal or passage of legislation relating to care for transgender people was a concern for multiple clinicians, who reported needing to understand frequent changes in the status of legislation (Table 3). Clinicians in states without legislation relating to care for transgender people also expressed concerns about managing patient demand. Mental Health Clinician B explained, “We’re already so busy with people in our own state, how are we going to handle it if we’re getting an influx from other states? How do we keep up with the demand? I’m hearing nervousness and concern kind of on both sides.” This sentiment underscores the strain on healthcare systems and the growing anxiety among clinicians who may face an increase in patient volumes from states with less supportive environments or fewer legal protections for TGD individuals.
While the study focuses on the needs of young adults (aged 18–24), some clinicians referenced concerns about their broader clinical practices, spanning a wider age range.
Multiple clinicians discussed the fear that threats related to providing care to TGD individuals represented a significant barrier for other clinicians who might otherwise wish to develop further expertise. Clinicians also expressed concern about the potential strain on resources resulting from an influx of patients and the lack of clarity about whether providing care to out-of-state patients would be legal. Despite the uncertainty of the legislative environment, some clinicians expressed an interest in continuing to provide care for TGD patients.
Several clinicians discussed their involvement in state-based advocacy and national professional organizations. Additionally, clinicians expressed interest in receiving training regarding advocacy and understanding the potential impacts of legislation on their practice.
Discussion
This qualitative study employed a semi-structured interview design to explore the educational landscape for medical and mental health clinicians caring for TGD young adults. A purposive sampling strategy was used to recruit participants with varying levels of experience in care for transgender people, ensuring a diverse range of insights. Thematic analysis of clinician interviews identified key barriers to education for clinicians interested in caring for TGD individuals, including lack of formal training in traditional educational settings, limited access to mentorship, and inconsistent institutional support. This study advances understanding of many of the barriers to care for TGD young adults and their families.
A major challenge facing clinicians who care for TGD individuals is the lack of formal training in medical and mental health education programs. Research indicates that most medical schools allocate fewer than five hours to LGBTQ+ health content, often without specific coverage of transgender care [20,21]. While previous research has identified similar barriers [8,9,22], this study is unique in demonstrating that clinicians are willing to seek out and undergo systematic training outside of their local practice environment to address gaps in their formal medical education regarding care for transgender people. Many clinicians interested in developing expertise in the care for TGD populations have committed considerable time to developing self-directed learning plans, synthesizing guidelines across multiple professional societies, and identifying their own professional networks for training and patient referral. This initiative is often motivated by patient needs, personal commitment to inclusivity, and frustration with inadequate institutional training. However, self-directed learning presents challenges, including limited access to high-quality resources, time constraints, and a lack of structured mentorship.
Beyond initial training, professional development opportunities remain limited. Many CME-programs focusing on transgender healthcare are either cost-prohibitive or inaccessible, particularly in states with restrictive policies. Even when training opportunities exist, clinicians report a lack of accreditation or formal institutional support, making it difficult to justify the time investment. Additionally, cultural competence training is often insufficient, with many clinicians lacking exposure to TGD patients during their clinical education. Without structured learning opportunities, clinicians may struggle with inclusive communication, appropriate medical decision-making, and understanding the broader psychosocial needs of TGD individuals.
The study findings underscore the importance of including information on caring for TGD people in undergraduate and graduate medical and health professions education [23] and highlight an opportunity to develop accessible, high-quality, and centralized training programs, resources, and mentorship opportunities. Building on our findings, we recommend that TGD healthcare training programs incorporate standardized, competency-based curricula into medical and mental health education. Structured training should include case-based learning, simulated patient interactions, and interdisciplinary collaboration. Additionally, expanding accessible CME opportunities and fostering the development of clinician mentorship networks will improve clinician competency.
Importantly, participants in this study expressed a strong desire for cross-disciplinary educational opportunities and for fostering multidisciplinary networks. Connecting education across fields – such as nursing, social work, psychology, and medicine – may enhance continuity and coordination of care, ultimately improving healthcare experiences for TGD individuals. Interdisciplinary collaboration not only strengthens clinician competency but also fosters comprehensive care models that integrate medical, mental health, and social support services, ensuring a more holistic approach to care that is consistent with TGD patients’ self-articulated healthcare needs [24]. By reducing the burden on individual clinicians, these strategies may enhance clinician confidence, improve patient care, and ensure equitable access for TGD populations.
Moreover, an intersectional lens is useful for analyzing the ways race, ethnicity, class, religion, and immigration status inform TGD healthcare experiences. Structural inequities in healthcare may be reinforced through curriculum bias and inadequate cultural competency training, which fail to address the barriers faced by TGD individuals from marginalized communities. These systemic shortcomings could exacerbate healthcare disparities if clinicians are unprepared to deliver culturally responsive and equitable care. Addressing these issues requires updating curricula to include intersectional perspectives and implementing practices that promote equitable care for all TGD individuals.
The present study also provides valuable insight into the specific impacts of U.S. legislation on clinician education. Concerns about the impact of legislation on availability of compassionate and competent care for TGD populations are consistent with previous published findings [25]. Findings from this study suggest that the legislative landscape significantly impacts the ability of clinicians to provide care for TGD individuals. Recent laws in several Southern and Mid-Atlantic states have restricted access to certain forms of care for these populations. Even in states where care remains legal, clinicians still face challenges, including insurance denials and administrative burdens that limit service availability.
Beyond direct care restrictions, legal uncertainties have created a chilling effect among healthcare professionals. The risk of criminal or licensure consequences, lack of clarity or understanding about the nuances of the legal landscape in each state, and the possibility of new legislation being proposed or passed have led many clinicians to withdraw from care of TGD populations, exacerbating workforce shortages. Despite increasing demand for clinicians knowledgeable about the general health and mental health needs of TGD young adults, clinicians who would otherwise be interested in learning about care for TGD individuals may be deterred by active or pending legislation. Institutions may also hesitate to offer TGD healthcare training due to political pressures, further restricting clinician competency development. Addressing these barriers will be critical to ensuring equitable access to care and supporting clinicians committed to serving TGD populations.
A growing need exists for clinicians who can care for TGD young adults and their families. Training clinicians to engage effectively with and identify the needs of TGD individuals is essential to address the increased risk of mental health problems in this population. Bridging this gap will require efforts on multiple fronts. First, additional rigorous research is needed to define best practices for the care of TGD young adults. Second, relevant clinical care competencies must be delineated for clinicians who see TGD young adults in their practice. For example, managing patients with questions and concerns about gender identity may require skills for engaging in conversations about gender, creating a welcoming clinic environment, establishing a relationship of trust so that patients are more likely to comply with routine health maintenance, and facilitating referrals to other trusted clinicians when appropriate. Third, evidence-based and accessible training resources need to be developed to support clinicians in achieving these clinical competencies. Fourth, facilitating mentorship relationships among interested clinicians can further support professional development.
This study uniquely highlights the perspectives of a small but diverse group of medical and mental health clinicians with variable levels of training. The study contributes to the existing literature by emphasizing the willingness of clinicians to engage in self-directed learning and the challenges they face in doing so. Unlike previous research that primarily documents systemic barriers [26,27], this study offers insights into the personal motivations, resourcefulness, and adaptability of clinicians who seek to bridge their own educational gaps. These findings underscore the need for scalable, accessible, and competency-based training solutions tailored to the realities of clinicians working in diverse clinical settings.
Addressing these barriers requires systemic efforts to educate and support clinicians to provide compassionate and competent care to TGD populations. Expanding structured, accredited medical education on TGD healthcare may help counteract gaps in clinician preparedness. As policy landscapes continue to evolve, strategies are also needed to ensure that healthcare professionals are supported to understand the implications of legislation and tailor their care appropriately.
Limitations
This study has several limitations. The sample size is small but appropriate for the goals of this qualitative inquiry [28]. While financial incentives may influence participation, the compensation for this study was modest, and efforts were made to recruit a diverse sample of clinicians with varying levels of experience in care for transgender people. Given the purposive sampling approach, this is a non-representative sample by design. Clinicians who participated in the study likely have more interest in, exposure to, and experience with managing TGD patients in their practice as compared to many general practitioners. As such, their perspectives may not be generalizable.
This study included a variety of clinician types across different stages of training and experience (e.g., fellowship-trained clinicians, primary care clinicians, mental health professionals, and one medical student) to gauge a variety of perspectives on educational challenges. The experiences and educational needs of these diverse clinician groups nevertheless may not be representative of the overall healthcare clinician population, as their training, responsibilities, and exposure to care for transgender people vary widely. For example, fellowship-trained clinicians have extensive experience but typically focus on a single specialty, while general practitioners may address a more diverse array of medical and mental health concerns. The medical student was in the early stages of training, lending a different perspective on care needs and barriers.
Additionally, the relatively small number of participants may have affected thematic and theoretical saturation. While some degree of saturation was reached, the diversity in clinician types makes it difficult to fully determine whether all relevant themes were explored. Larger studies with more homogenous groups of clinicians, or stratified analyses based on clinician experience and training, could help to validate and expand the understanding of educational needs and barriers.
Gender identity data were not systematically collected from participants. Future studies should consider including gender identity data to better understand how clinician gender identity influences experiences in TGD healthcare.
Nevertheless, the findings of this study highlight many of the concerns and barriers to training that other clinicians are likely to experience. General practitioners who encounter TGD young adults in their practices must be equipped with the knowledge and skills to conduct informed conversations, assess and triage health needs, and direct patients and families to appropriate resources. This study underscores the importance of understanding clinicians’ unmet educational needs and developing effective and accessible clinician training tools to address them.
Conclusion
There is a growing need for clinicians knowledgeable about the mental health needs of TGD young adults, yet gaps exist in clinician education and training. Barriers to addressing these gaps include lack of reliable and accessible training sources, lack of mentorship, and a changing sociopolitical environment. Many clinicians are interested in and willing to seek out training and mentorship opportunities. These findings will help to inform the development of clinician training curricula at a national level.
References
- 1.
Herman JL, Flores AR, O’Neill KK. How many adults and youth identify as transgender in the United States? The Williams Institute, UCLA School of Law. 2022. Available from: https://williamsinstitute.law.ucla.edu/wp-content/uploads/Trans-Pop-Update-Jun-2022.pdf.
- 2.
Blazina C. About 5% of young adults in the U.S. say their gender is different from their sex assigned at birth. Pew Research Center. Available from: https://www.pewresearch.org/short-reads/2022/06/07/about-5-of-young-adults-in-the-u-s-say-their-gender-is-different-from-their-sex-assigned-at-birth/.
- 3. Boskey ER, Quint M, Xu R, Kremen J, Estrada C, Tham R, et al. Gender affirmation-related information-seeking behaviors in a diverse sample of transgender and gender-diverse young adults: survey study. JMIR Form Res. 2023;7:e45952. pmid:37581925
- 4. Tarantino MR, Tham RL, Quint MR, Kremen J, Kane K, Rangel-Gomez M, et al. “We followed their lead”: exploring relational change and support among caregivers of transgender and gender diverse youth. SSM Qual Res Health. 2024;5:100429. pmid:38778873
- 5. Kcomt L, Gorey KM, Barrett BJ, McCabe SE. Healthcare avoidance due to anticipated discrimination among transgender people: A call to create trans-affirmative environments. SSM Popul Health. 2020;11:100608. pmid:32529022
- 6. Turban JL, King D, Kobe J, Reisner SL, Keuroghlian AS. Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. PLoS One. 2022;17(1):e0261039. pmid:35020719
- 7. Tordoff DM, Wanta JW, Collin A, Stepney C, Inwards-Breland DJ, Ahrens K. Mental health outcomes in transgender and nonbinary youths receiving gender-affirming care. JAMA Netw Open. 2022;5(2):e220978. pmid:35212746
- 8. Vance SR Jr, Halpern-Felsher BL, Rosenthal SM. Health care providers’ comfort with and barriers to care of transgender youth. J Adolesc Health. 2015;56(2):251–3. pmid:25620310
- 9. Korpaisarn S, Safer JD. Gaps in transgender medical education among healthcare providers: A major barrier to care for transgender persons. Rev Endocr Metab Disord. 2018;19(3):271–5. pmid:29922962
- 10. Domalaon KO, Parsons AM, Thornton JA, Do KH, Roberts CM, Schvey NA, et al. Military family physicians’ readiness to provide gender-affirming care: a serial cross-sectional study. J Prim Care Community Health. 2024;15:21501319241264193. pmid:39129425
- 11. Trans Legislation Tracker. Available from: https://translegislation.com/learn. [Last accessed: March 17, 2025].
- 12. Marshall SA, Stewart MK, Barham C, Ounpraseuth S, Curran G. Facilitators and barriers to providing affirming care for transgender patients in primary care practices in Arkansas. J Rural Health. 2023;39(1):251–61. pmid:35644535
- 13. Ebert MR, Guo MS, Klein SJ, Doren EL, Klement KA. Barriers of access to gender-affirming health care and surgery: a systematic review. Transgender Health. 2024.
- 14. Palinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K. Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Adm Policy Ment Health. 2015;42(5):533–44. pmid:24193818
- 15. Fereday J, Muir-Cochrane E. Demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development. Int J Qualitative Methods. 2006;5(1):80–92.
- 16. Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2017;102(11):3869–903. pmid:28945902
- 17. Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, et al. Standards of care for the health of transgender and gender diverse people, version 8. Int J Transgend Health. 2022;23(Suppl 1):S1–259. pmid:36238954
- 18.
UCSF Gender Affirming Health Program. Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people. Department of Family and Community Medicine, University of California San Francisco. 2016. Available from: https://transcare.ucsf.edu/guidelines
- 19. LGBTQIA+ Health Education Center. LGBTQIA+ health education center. Available from: https://www.lgbtqiahealtheducation.org/resources/.
- 20. Obedin-Maliver J, Goldsmith ES, Stewart L. Lesbian, gay, bisexual, and transgender–related content in undergraduate medical education. N Engl J Med. 2011;364(10):895–903.
- 21. Dubin SN, Nolan IT, Streed CG Jr, Greene RE, Radix AE, Morrison SD. Transgender health care: improving medical students’ and residents’ training and awareness. Adv Med Educ Pract. 2018;9:377–91. pmid:29849472
- 22. Gridley SJ, Crouch JM, Evans Y, et al. Youth and caregiver perspectives on barriers to gender-affirming health care for transgender youth. J Adolesc Health. 2016;59(3):254–261.
- 23. Keuroghlian AS, Charlton BM, Katz-Wise SL, Williams K, Jarvie EJ, Phillips R, et al. Harvard medical school’s sexual and gender minority health equity initiative: curricular and climate innovations in undergraduate medical education. Acad Med. 2022;97(12):1786–93. pmid:35947484
- 24. Quint M, Bailar S, Miranda A, Bhasin S, O’Brien-Coon D, Reisner SL. The AFFIRM Framework for gender-affirming care: qualitative findings from the Transgender and Gender Diverse Health Equity Study. BMC Public Health. 2025;25(1):491. pmid:39915834
- 25. Gupta P, Barrera E, Boskey ER, Kremen J, Roberts SA. Exploring the impact of legislation aiming to ban gender-affirming care on pediatric endocrine providers: a mixed-methods analysis. J Endocr Soc. 2023;7(10):bvad111. pmid:37732157
- 26. Hughto JMW, Gunn HA, Rood BA, Pantalone DW. Social and medical gender affirmation experiences are inversely associated with mental health problems in a U.S. non-probability sample of transgender adults. Arch Sex Behav. 2020;49(7):2635–47. pmid:32215775
- 27. Stroumsa D, Wu JP. Welcoming transgender and nonbinary patients: expanding the language of “women’s health”. Am J Obstet Gynecol. 2018;219(6):585.e1–585.e5. pmid:30267652.
- 28. Hennink M, Kaiser BN. Sample sizes for saturation in qualitative research: A systematic review of empirical tests. Soc Sci Med. 2022;292:114523. pmid:34785096