Your privacy, your choice

We use essential cookies to make sure the site can function. We also use optional cookies for advertising, personalisation of content, usage analysis, and social media.

By accepting optional cookies, you consent to the processing of your personal data - including transfers to third parties. Some third parties are outside of the European Economic Area, with varying standards of data protection.

See our privacy policy for more information on the use of your personal data.

for further information and to change your choices.
Skip to main content
Download PDF

The AFFIRM Framework for gender-affirming care: qualitative findings from the Transgender and Gender Diverse Health Equity Study

BMC Public Health volume 25, Article number: 491 (2025) Cite this article

Abstract

Background

Transgender, nonbinary, and gender diverse (TGD) people experience stigma in healthcare settings impacting healthcare utilization, including avoidance of care due to anticipated discrimination. Gender-affirming care refers to care for medical gender affirmation, such as gender-affirming hormones and surgery, as well as general care that affirms and respects TGD patients. This study sought to explore the experiences of TGD adults to inform gender-affirming care delivery and develop an actionable framework for practice.

Methods

Between May–October 2021, one-time individual in-depth interviews were conducted with 27 TGD adults receiving any healthcare in the greater Boston Massachusetts area to gather data about gender-affirming care. Interviews were semi-structured, explored prior and current experiences in healthcare and ideal gender-affirming care models, and conducted virtually via a secure Zoom platform. Analyses were conducted using immersion crystallization and reflexive thematic analysis; interview transcripts were double coded by two coders.

Results

Participants had a mean age of 28.5, ranging 18–45 years, and were: 7 transgender men, 6 transgender women, 8 nonbinary, 3 genderqueer, 1 agender, and 2 gender not specified. Themes about gender-affirming care coalesced into the acronym AFFIRM: (1) Affirms in individual interactions: Participants called for affirmation of TGD identity, lived expertise, and competent TGD providers and staff. (2) Flexible and accessible: Participants expressed the need for gender-affirming care to be available beyond urban population-specific clinics, in a timely fashion without long wait lists, and in a community-centered manner such as offering non-traditional times and settings. (3) Fights systemic oppression: Participants emphasized the need for providers and health systems to eliminate gatekeeping practices for gender-affirming care and create care models that resist intersecting oppressive systems such as racism and cisgenderism. (4) Interacts with community: Patients desired intentional interaction with TGD community to holistically address health and unmet gender affirmation needs. (5) Retains patients in care: Patients shared the need to collaboratively identify and problem-solve obstacles to gender-affirming care with providers and healthcare systems to optimize TGD-specific retention strategies. (6) Multidisciplinary: Patients called for interdisciplinary teams with co-located services such as primary care and mental healthcare with letter-writing for surgical care, and incorporation of peer navigators to meet the broader social, health, and well-being needs of TGD people.

Conclusions

Findings from this study and the AFFIRM Framework which emerged from TGD patient narratives can be applied to improve current care and set benchmarks for high-quality gender-affirming care delivery and practice.

Peer Review reports

Background

Transgender, nonbinary, and gender diverse (TGD) adults, an estimated 0.5% of the United States (U.S.) population [1], exhibit worse physical and mental health outcomes than the general population [2, 3], including in comorbid chronic health conditions [4], cardiovascular disease risk [5], HIV infection [6], suicidality [7], psychological distress [8, 9], preventive screening behaviors [10, 11], and mortality [12]. Clinical care is central to improving TGD population health. Medicine has begun to make progress in de-pathologizing TGD people, pushing for greater access to and competency in gender-affirming care [13, 14]. Yet, TGD individuals continue to experience discrimination and stigmatization in healthcare [15, 16], including care refusal and verbal abuse, and the consequences of mistreatment, such as healthcare avoidance mental health distress, and low care quality [17,18,19,20,21,22].

TGD individuals face unique care access barriers [22], including being less likely to be insured than cisgender adults [23]. Among the insured, TGD people are regularly denied coverage for gender-affirming surgery and routine preventive care [15]. TGD people avoid seeking necessary healthcare due to fear of experiencing transphobia [15]. Low quality care adversely affects engagement and retention in care. TGD patients who must teach providers about transgender people are four times more likely to delay needed care than those who have not had to educate providers [19]. TGD individuals report verbal harassment through misgendering, deadnaming (using name assigned at birth instead of chosen name), being asked invasive questions, and even experiencing physical assault [15, 16]. Structural oppression in healthcare systems, including erasure due to cisnormativity [24] and exclusionary institutional practices (e.g., absence of routine gender identity data collection), often shape TGD people’s individual clinical experiences and place the onus on individual TGD patients to remedy systemic challenges [25].

Gender-affirming care for TGD people refers to care specifically for medical gender affirmation, such as gender-affirming hormones and surgery, as well as to care generally that affirms and respects TGD patients [26, 27]. Clinical guidelines exist for gender-affirming care delivery, including those from the World Professional Association for Transgender Health Standards of Care Version 8 [14] and Endocrine Society Clinical Practice Guideline [28]. Prior work has articulated gender-affirming care models for TGD youth [29, 30]. The notion of community-driven gender-affirming care has been advanced in the Canadian context, describing the importance of intentional integration of community stakeholders to shape care and service provision for TGD adults [31]. Yet to our knowledge, no brief, accessible, and integrated framework exists for TGD adult care that has been derived from the experiences of TGD patients in the U.S. Improving care for the TGD population—both access to and quality of care—requires increasing the competency and ability of staff, providers, and medical systems. Integrated care frameworks have been previously articulated across a range of health issues, conditions, and populations to guide patient care provision [32,33,34,35], underscoring the utility and effectiveness of integrated frameworks to enhance care provision. Tangible and actionable TGD-specific frameworks are needed to guide medical professionals and healthcare systems in gender-affirming care.

This qualitative study sought to explore the healthcare experiences of TGD adults who received care in the Greater Boston Massachusetts Area and develop an actionable framework to guide gender-affirming care provision, centered in TGD patient experiences, for health systems and providers to evaluate and improve care delivery.

Methods

Participants and procedures

Between May 1, 2021 and October 1, 2021, qualitative data were collected as part of the Transgender and Gender Diverse Health Equity Study, a study conducted to explore the healthcare experiences of TGD individuals to inform enhancements in patient care. Individual, semi-structured, in-depth interviews were conducted virtually with 27 eligible TGD participants. Participants also completed a 10–15 min sociodemographic survey. Participants received a $50 gift card upon completion of study activities. Individuals were eligible for the study if they identified as TGD, were age 18 years or older, reported having a safe place to participate in a virtual interview, and reported receiving any healthcare in the Boston, Massachusetts area. Informed consent was obtained verbally (for interviews) and electronically (for the survey). All study activities were approved by the Mass General Brigham Institutional Review Board.

Community-based methods were utilized to recruit participants, including posting study flyers in online TGD groups, tabling at TGD events, sending email blasts to LGBTQ + organizations and providers with requests to place flyers in waiting rooms, and obtaining peer referrals. Participants were purposively sampled [36] to ensure a wide range of experiences across gender identity and race/ethnicity.

Interviews were designed to be 60 min and conducted via Zoom by a TGD-identified team member (MQ). Interviewer-interviewee concordance was designed to center the shared experiences of TGD people and promote empathy and rapport-building in the interviewing process [37]. Participants were asked to be in a private and safe space where they could speak freely about their experiences. Participants were asked to provide a pseudonym to be used in any publication; if a pseudonym was not selected by the participant, one was selected by the study team (3 participants requested the study team select a pseudonym on their behalf). The interviewer took detailed notes during the interview process to aid in codebook development. Zoom’s automatic transcription and recording features were used and files were stored securely for analysis.

Data collection instruments

Data were collected using a semi-structured interview guide developed for this study, informed by a review of existing research and input from TGD-identified staff and gender-affirming care stakeholders with expertise in clinical care (see Supplemental Material Table 1). Participants were asked to describe prior healthcare experiences since first realizing they were TGD to the present day. Probing questions were used to understand how experiences might have been improved. Participants also provided feedback on current care models, additional ways healthcare providers and systems could support their needs, and ideal gender-affirming healthcare delivery. Participants completed a brief sociodemographic survey designed for this study including age, race/ethnicity, gender identity, recent gender-affirming care history, education, and insurance status (see Supplementary MaterialTable 2). Survey data were used to descriptively characterize the sample and contextualize interview data.

Table 1 Demographics of transgender, nonbinary, and gender diverse participants (N = 27)
Full size table
Table 2 Quotes from transgender, nonbinary, and gender diverse participants
Full size table

Data analysis

Upon interview completion, Zoom’s automatic transcripts were compared to audio files and edited by SB and AM to be verbatim. Any potentially identifying information was redacted, Interviews were double-coded using an immersion-crystallization [38] and a reflexive thematic analysis [39, 40] approach. Dedoose software [41] was utilized for analysis. Throughout the interview, transcription, and review process, the team immersed themselves in each of the interviews. MQ, SB, and AM developed, iteratively refined, and applied an initial codebook that emerged through the immersion process to all interviews. The analysis team met weekly to obtain consensus between coders, iteratively refine themes and subthemes, and collaboratively consolidate and organize codes with a focus on reflective and reflexive engagement [39, 40]. Meetings were also held with members of the investigative team to discuss and refine codes. Representative quotes were selected for reporting. For readability purposes, filler and repeated words were removed from quotations.

Positionality statement

Interviews were conducted by a TGD team-member, which allowed for rapport building with participants. The analysis and reporting process were completed by a primarily TGD-identified team with support from cisgender researchers and gender-affirming clinical providers. The team was comprised of Asian American, Latine, Indian, and White American individuals. Multiple team members have navigated medical systems both as TGD-identifying people and chronically ill individuals. The analysis and interpretations of this study are informed by our positionalities, identities, and experiences.

Results

AFFIRM Framework overview

Participants (demographics in Table 1) shared stories of both affirming and disaffirming healthcare experiences. These experiences occurred in seeking gender-affirming medical care (i.e., medical care explicitly related to transition/gender-affirmation, such as hormones or surgery) and other medical care not explicitly related to gender-affirmation (i.e., healthcare that is gender-affirming). Needs coalesced into six main actionable components for gender-affirming care as described by the acronym AFFIRM (Fig. 1): (1) Affirms in individual interactions: Participants called for affirmation of TGD identity, lived expertise, and experience from TGD providers and staff. (2) Flexible and accessible: Participants expressed the need for gender-affirming care to be available beyond urban, population-specific clinics and in a timely (e.g., no year-long wait list) and community-centered manner (e.g., non-traditional healthcare times and settings). (3) Fights systemic oppression: Participants emphasized the need for providers and health systems to eliminate gatekeeping practices for gender-affirming care and create models of care that resist oppressive systems, including intersectional oppression (e.g., racism, cisgenderism). (4) Interacts with community: Patients desired intentional interaction with TGD communities to holistically address health and unmet gender affirmation needs. (5) Retains patients in care: Patients shared the need to collaboratively identify and problem-solve obstacles to gender-affirming care with providers and healthcare systems to optimize TGD-specific retention strategies. (6) Multidisciplinary: Patients called for teams that are interdisciplinary (e.g., integrate primary care, mental healthcare, letter-writing for surgical care) and that incorporate non-healthcare professionals (e.g., peer navigators) to meet the broader health and wellbeing needs of TGD people (e.g., social service needs).

Fig. 1
figure 1

Overview of the AFFIRM Framework: Affirms in individual interactions, is Flexible and accessible, Fights systemic oppression, Interacts with community, Retains patients in care, and is Multidisciplinary. TGD = transgender, nonbinary, gender diverse

Full size image

Table 2 contains sub-themes that comprise AFFIRM and all participant quotes. Participant quotes are identified by numbers in brackets throughout the Results. Pseudonyms are used throughout the manuscript for readability.

(1) Affirms in individual interactions

Uses chosen name, pronouns, and other gender-affirming language

Participants discussed affirming language as a priority and highlighted the importance of asking names and pronouns on paperwork and using these in interactions with front desk staff “to judge how the interaction will probably go after that” (1). Some participants shared that while this information was initially collected, providers and their teams often failed to “actually make use” (2) of the information. One participant, Hayden, noted that providers and staff must be trained to use this information (3). Vee suggested that deadnames, or names people no longer use, be treated as “confidential information” (4). Participants noted that having their legal names easily accessible in electronic health records (EHR) for insurance and billing purposes resulted in it being misused by providers and support staff.

Has other TGD people present and active allies

Participants described being the only TGD person in waiting rooms can “get scary,” and that having other TGD people around increased their comfort (5). Lyle said that not seeing other queer people was a “red flag” for them (6), potentially indicating that an office might not be affirming of TGD people. Participants were interested in having a TGD-identified provider, but Lucrezia recognized that there are few in medicine (7). Lucrezia also stressed the importance of having TGD staff present in care settings.

Eliminates transphobia and inappropriate verbal and non-verbal interactions with providers

Most participants reported hearing transphobic sentiments from their providers including intentional misgendering of public figures (8), inappropriate inquiries regarding surgical regret (9), and sexually charged statements (10). Some participants felt these were intentional, while others did not. Hayden felt that statements by their provider came from a place of ignorance, but the painful moment “stuck with them” regardless of intent (9). Body language and other nonverbal cues were also discussed. Sarah stated, “I can tell when a medical provider thinks that I’m disgusting” (11). Rather than being covert, body language and other non-verbal cues from providers were described as overtly communicating transphobia.

Recognizes TGD patients as experts and centers goal-oriented gender-affirming care

Many participants expressed wanting providers to trust that they had “thought about things” and were experts in their own gender experience. As Vee noted, “You don’t accidentally stumble into a consultation” (12). Vee also remarked that you can’t “scan [someone’s] brain and know their gender….and the only way that other people can gain information about that is by [talking to] the original person” (13). Sarah appreciated that their provider allowed them to be the “driver” in their affirmation journey, and felt the provider just helped them to drive the car “safely” (14). In contrast, Vee described a provider who perceived the patient as “going back and forth” about seeking gender-affirming care, which resulted in denial of care (15).

Many participants wanted providers to ask them about their gender-affirming care goals. Several participants spent time researching risks and benefits of gender-affirming care and determined that their transition needs greatly outweighed potential risks (16). Nick expressed challenges with the speed and manner at which his provider wanted to go about transition, which did not align with update-to-date medical guidelines or with his peers (17). Treating patients as experts in their own experience and asking about goals were highlighted as essential for gender-affirming care.

(2) Flexible and accessible

Makes gender-affirming care available beyond urban population-specific clinics, offers care at non-traditional times and settings, and addresses challenges with proximity to care

Finding affirming providers who were in geographic proximity and having clinical care outside of traditional work hours were described as unmet needs by multiple participants. Participants seeking non-surgical care often had to travel into Boston for care. Lyle described needing to travel far distances to get care saying, “I don’t have the luxury of being able to have a choice” (18). Link made up excuses to sneak out of work early to be able to travel for care (19). Participants seeking surgical care had even greater challenges finding competent surgeons nearby resulting in interstate and international travel (20). Many participants expressed frustration about trying to find affirming providers within reasonable geographic proximity.

Reduces wait times through facilitated linkages to gender-affirming providers

Wait times and finding affirming providers with availability resulted in significantly delays in care. One participant was on a three-year waitlist at a local provider for vaginoplasty and ultimately sought care out of state (21). Sylvi described difficulty figuring out who would be affirming, given many providers who list themselves as “LGBTQ friendly” may not have the actual skills to support TGD care (22). Other participants discussed affirming care experiences, particularly in LGBTQ + clinical settings, but noted high provider turnover as a challenge in maintaining care continuity (23, 24).

Improves disability-related accessibility for TGD patients with disabilities

Some participants discussed the overlap between queer identity and disability, noting the requirement that healthcare spaces be accessible for physical, developmental, and sensory-related disabilities (25). Lyle expressed challenges accessing healthcare when using a wheelchair (26). Jeff described challenges finding gender-affirming surgeons capable of managing complex medical conditions during surgery, like a bleeding disorder (27).

Increases financial accessibility of gender-affirming services

Participants expressed challenges in affording and getting gender-affirming care covered by insurance. Several participants relied on financial support from family or partners. For example, one participant discussed challenges paying back an ex-partner for top surgery (28). Link, a participant with access to insurance, had to become their “own advocate, and… an expert to navigate the world of healthcare” to get facial feminization surgery (29). Participants recognized that this healthcare access advocacy would benefit them and others but noted that it required time and was draining. One participant stocked up on medications in case the copay was raised, or they lost their job, and shopped for cheapest price medications (30), something other patients might not have the time or knowledge to do.

(3) Fights systemic oppression

Dismantles gatekeeping practices related to gender-affirming care

Many participants described gatekeeping experiences wherein providers and systems prevented or made it difficult to access treatment. Participants stressed how “incredibly hard” it was to “fight for access to being who you are in your basic identity” amidst gatekeeping systems inhibiting access (31). One of Link’s providers denied their hormone therapy despite persistent gender dysphoria because of his own assumptions and biases about what a TGD person should look like (32). Another participant discussed the stark differences between pursuing knee surgery versus gender-affirming care (33), highlighting high costs of therapy needed to obtain letters supporting gender-affirming care. The same participant appreciated that their therapist and endocrinologist directly named their “gatekeeping position” and enhanced their “agency” in decision-making (34). Gatekeeping was also discussed in relation to information-seeking. Vee could not find any accessible lay-language information to make decisions about surgeries, other than metoidioplasty, phalloplasty, and vaginoplasty surgeries (35). Another participant expressed frustration because some community websites, where surgical results were shared within community, had been shut down, limiting the available information about surgeon’s results (36).

Understands intersectional experiences of TGD patients (e.g., racism, cisgenderism)

Many participants had intersecting marginalized identities and described multiple forms of oppression in relation to healthcare experiences, such as racism, ableism (discrimination and social prejudice against people with disabilities), and transphobia. These participants expressed frustrations in seeking care as a person of color or disabled person on top of seeking care as a TGD person. Ace shared that they moved states because they needed access to a more diverse community and medical support (37). Black, Indigenous, and other People of Color (BIPOC) participants commonly discussed provider stereotypes about patients of their racialized identity group, including racist stereotypes in relation to patients with Black and Asian identities (38, 39). For several participants, having a BIPOC provider for gender-affirming care was a priority. Buttercup summarized: “I at least want someone who is BIPOC who looks like me, honestly identifies as me, I feel like that would help so much” (40).

Navigates complex power dynamics and medical culture to ensure TGD patient-centeredness

Multiple participants expressed concerns about power dynamics in medical spaces. For Hellen and Sylvie, this meant staying closeted in a “bro-y” environment (an environment dominated by cisgender men where non-cisgender men may feel like they do not have space) (41), and fearing being open with doctors because “they have a lot of power” (42). One participant was taken to an emergency room after, what they described as, an intentional hit and run by a cop, and relayed the traumatizing nature of the incident and re-traumatization at the hospital when male doctors asked her to take off her clothing in an uncompassionate and uncomfortable manner. She alluded to her discomfort and power dynamics, which ultimately caused her to leave despite still needing medical attention (43).

(4) Interacts with community

Creates TGD community advisory boards

All participants saw potential benefits associated with Community Advisory Boards (CAB) for TGD health programs to share feedback with health providers to iteratively improve health systems (44–46). Despite ultimately supporting the idea of a TGD CAB, one participant was concerned about the marginal difference between what a CAB offers and what is currently implemented at already gender-affirming health centers. Aaron stressed, “The people who really need to be informed by [a CAB] are the ones who aren’t even listening in the first place” (47).

Shows up to be present for and sponsors TGD community events

Multiple participants expressed their desire to see healthcare teams attend and sponsor community events. Sylvie heard about the current study through a local TGD rights march, where they had also found a new healthcare provider (48). Aaron saw TGD health programs at other pride events, stating that it was an effective way to “get the word out” (49). Participants suggested hosting clothing swaps (50), holding peer support groups (51), putting up targeted ads on social media (52), connecting with local college health centers (52), sponsoring TGD health history discussions at local libraries (53), and having story hours (54). Lucrezia stated that these events would make people “feel like more safe in the hospital” (54).

Addresses holistic gender-affirming care needs to ensure positive “word of mouth” communication in TGD communities

Participants described “word of mouth” in TGD communities. As Evan noted, even with advertising people might be “hesitant to go” to a clinic if they don’t know whether other TGD people have had a positive or negative experience (55). They also stressed the need to prioritize individual patient experiences to keep them coming back. This sentiment was held by multiple participants, including Vee, who wanted healthcare organizations to attend events to get their name into the community, but also highlighted the need to maintain TGD community trust through ongoing, positive individual healthcare interactions (56).

(5) Retains patients in care

Recognizes the need for trauma-informed gender-affirming care

Participants discussed past traumatic experiences outside and inside of medical settings which they carried with them, emphasizing the need for trauma-informed care. One participant described a doxing experience where they were “put on blast” by an anti-transgender online account that “spread [their personal] information”, resulting in receiving thousands of threatening messages, and consequently having a steep and rapid decline in her mental health and considering suicide (57). This participant expressed how they carry this and other traumatic experiences into the healthcare setting, meaning providers must navigate patient’s traumas even when they are not directly related to, but can indirectly impact, their physical health. Evan could not even bring themselves to talk about abuse they experienced at the hands of past providers (58). Another participant described being sexually assaulted by a provider (59).

Builds and re-builds trust with TGD communities

Participants described distrust or difficulty establishing trust with providers (60). As a result, Buttercup did not want to transition to adult care and stayed with their supportive pediatrician (61). Sylvi said they “graduated” from pediatric care but “put off finding a new doctor because it seems [like] a lot of work to find a doctor that [they] actually trust” (62). For some participants, TGD-experienced providers experienced garnered their trust, while for others, that professional expertise did not extend to “the comfort part” (63). One participant stated a surgeon’s problematic attitude was a primary reason for not selecting him: “[it] didn’t feel like an actual genuine understanding of what he’s trying to do as a surgeon and the relationship to the trans community… [he] felt like a used car salesman” (64). Vee noted that hearing inaccurate and uncomfortable language eroded trust in providers but discounted it saying, “it wasn’t verbal abuse” (65). Lack of trust resulted in healthcare avoidance or delay for many participants.

Provides TGD patients with gender-affirming care referrals for unmet needs

Participants generally indicated difficulties with referrals, including referrals to gender-affirming providers and the structure of referrals themselves. Participants explained how a provider being affirming does not always translate to safe referrals (66), as providers don’t necessarily know which other providers are “trans competent” (67). Some participants discussed issues with referral logistics, such as disliking being referred externally (68), or frustration with the long process and time it can take to be referred to another provider (69).

(6) Multidisciplinary

Builds integrated and connected health care teams (e.g., primary care, mental healthcare), incorporates non-medical professionals (e.g., peer navigators), and addresses broader TGD-related health needs (e.g., social services)

Participants desired care across multiple areas of their health and well-being, including physical health, mental health, and socio-material needs. Participants described the need for “networks” of integrated health services at large hospitals. Aaron desired trans competent patient advocates to support them across healthcare spaces (70). Peer navigation and social work services were highlighted as unmet needs. Participants also saw healthcare teams as a natural place to integrate support for well-being needs beyond physical health, such as “intimidating” name change processes (71). Hellen expressed how their primary care provider did not have the necessary knowledge to write a surgical support letter, so they asked a social worker friend for peer support, who helped guide the physician in letter-writing (72). One participant shared about local support services for housing, name change, and other financial support that few TGD people know about (73), seeing healthcare spaces as prime locations to share resources and provide social support.

Discussion

This study of TGD adult patients identified multiple unmet needs in the provision of gender-affirming care, extending prior research on this topic to the U.S. context [22, 42, 43]. Our findings also expand upon the notion of community-driven gender-affirming care described in Canada, which emphasizes the need for intentional integration of community stakeholders to shape care and service provision [31]. Consistent with existing clinical guidelines [14], gender-affirming care was not only described as care specific to medical gender affirmation, such as hormones or surgery, but also to general care that affirms and respects TGD patients. Gender-affirming care included supporting TGD patients in who they are in terms of affirming their gender identities and expressions, identifying and flexibly responding to TGD patient needs, creating an affirming environment and interactions, offering safe and welcoming spaces, and delivering care using principles that address systemic inequities TGD patients often experience in healthcare settings.

While not explicitly stated by our participants, concerns spanned across the four levels comprising the healthcare system [44, 45]: (1) Patient, (2) Care team, (3) Organization/institution (e.g., hospitals/clinics), and (4) Socio-political and economic environment [45, 46]. Given the interplay between levels, our findings suggest that healthcare providers have multiple opportunities to expand how they conceptualize and deliver gender-affirming healthcare, develop care networks, and advocate for systemic change. Our results also highlight the need to engage multiple key stakeholders to intervene structurally, including healthcare agencies, administrators and executives, health insurers, and policy makers to change policies and practices. This is especially true in the current socio-political environment, with increasing anti-trans legislation and laws limiting or banning gender-affirming care for minors and some young adults [47], which has created a climate of fear and avoidance of healthcare for TGD people.

Based on participant experiences, we developed the AFFIRM Framework, a practical and actionable tool for clinical settings and systems to guide delivery of responsive gender-affirming care for TGD adults. In Table 3 we offer actionable items and evaluation measures for each aspect of AFFIRM that providers and healthcare systems can use to optimize care for TGD patients. In the context of myriad physical and mental health inequities burdening TGD populations [2, 48], and the legacy of experiences of stigma and discrimination in healthcare settings [15], access to trauma-informed [49] gender-affirming care represents a vital intervention point to address interpersonal and structural barriers TGD people face when engaging in care systems. The authors acknowledge the difficulty of implementing many of these action items in the face of multiple points of resistance to change throughout healthcare system [46]. Yet, continued efforts are needed to advocate for healthcare system change, including addressing bureaucratic and systemic barriers that make navigating current health systems challenging for TGD patients and communities.

Table 3 AFFIRM Framework: Actionable steps for gender-affirming care systems and providers
Full size table

Limitations

This sample was geographically restricted to the Boston, Massachusetts area and was largely White and young (average age 28.5). This study may not be representative of those in gender-affirming care deserts, older populations, or a more racially diverse sample. Interviews were conducted in summer 2021, after the onset of the COVID-19 pandemic but prior to the fall 2022 influx of anti-transgender legislation across the U.S. [47]. Though Massachusetts has not proposed anti-transgender legislation, participants’ healthcare experiences and well-being may have been impacted by the geopolitical environment during which interviews were conducted. A strength of this study was having a primarily TGD analytic team as well as a TGD study PI, supported by cisgender clinical experts, offering a unique blend of lived and professional experiences throughout analysis and interpretation of findings.

Conclusions

There is an urgent need for competent gender-affirming care for TGD people. Study findings and the novel AFFIRM Framework which emerged from patient narratives can be applied to optimize current gender-affirming care, inform future delivery of care, and set benchmarks for healthcare systems to provide high-quality care for this health disparities population. Further, the current study offers rare qualitative data to support what policy-making bodies such as Association of American Medical Colleges (AAMC), Lambda Legal, National Center for Transgender Equality (NCTE), Advocates for Trans Equality (A4TE), and other leading organizations have put out as recommendations for healthcare systems to make TGD care more accessible. Findings can be used to advance these recommendations and enhance provision and access to gender-affirming care for TGD people in the U.S.

Data availability

Data cannot be shared publicly because interview transcripts have sensitive data (e.g., extensive health histories) that could be used to harm or identify participants by their health providers. Researchers may contact the corresponding author to determine whether they meet the criteria to access confidential data and discuss potential project ideas.

Abbreviations

TGD:

Transgender, Nonbinary, and Gender Diverse

References

  1. Herman J, Flores A, K ON. How Many Adults and Youth Identify as Transgender in the United States? . Los Angeles, CA: The Williams Institute, UCLA School of Law; 2022.

  2. Scheim AI, Rich AJ, Zubizarreta D, Malik M, Baker KE, Restar AJ, et al. Health status of transgender people globally: A systematic review of research on disease burden and correlates. PLoS ONE. 2024;19(3): e0299373.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  3. Cicero EC, Reisner SL, Merwin EI, Humphreys JC, Silva SG. The health status of transgender and gender nonbinary adults in the United States. PLoS ONE. 2020;15(2): e0228765.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  4. Hughes L, Shireman TI, Hughto J. Privately Insured Transgender People Are At Elevated Risk For Chronic Conditions Compared With Cisgender Counterparts. Health Aff (Millwood). 2021;40(9):1440–8.

    Article  PubMed  Google Scholar 

  5. van Zijverden LM, Wiepjes CM, van Diemen JJK, Thijs A, den Heijer M. Cardiovascular disease in transgender people: a systematic review and meta-analysis. Eur J Endocrinol. 2024;190(2):S13–24.

    Article  PubMed  Google Scholar 

  6. Stutterheim SE, van Dijk M, Wang H, Jonas KJ. The worldwide burden of HIV in transgender individuals: An updated systematic review and meta-analysis. PLoS ONE. 2021;16(12): e0260063.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  7. Tebbe EA, Moradi B. Suicide risk in trans populations: An application of minority stress theory. J Couns Psychol. 2016;63(5):520–33.

    Article  PubMed  Google Scholar 

  8. Tebbe EA, Budge SL. Factors that drive mental health disparities and promote well-being in transgender and nonbinary people. Nat Rev Psychol. 2022;1(12):694–707.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Pinna F, Paribello P, Somaini G, Corona A, Ventriglio A, Corrias C, et al. Mental health in transgender individuals: a systematic review. Int Rev Psychiatry. 2022;34(3–4):292–359.

    Article  PubMed  Google Scholar 

  10. Peitzmeier SM, Khullar K, Reisner SL, Potter J. Pap test use is lower among female-to-male patients than non-transgender women. Am J Prev Med. 2014;47(6):808–12.

    Article  PubMed  Google Scholar 

  11. Fleming J, Grasso C, Mayer KH, Reisner SL, Potter J, Streed CG, Jr. Gender-Affirming Hormone Therapy and Cervical Cancer Screening Rates in Transgender Men and Nonbinary People: A Cross-Sectional Study from a Boston Community Health Center. LGBT Health. 2024.

  12. de Blok CJ, Wiepjes CM, van Velzen DM, Staphorsius AS, Nota NM, Gooren LJ, et al. Mortality trends over five decades in adult transgender people receiving hormone treatment: a report from the Amsterdam cohort of gender dysphoria. Lancet Diabetes Endocrinol. 2021;9(10):663–70.

    Article  PubMed  Google Scholar 

  13. World Health Organization (WHO). Gender incongruence and transgender health in the ICD. Geneva, Switzerland: WHO; 2024.

  14. 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.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  15. James SE, Herman JL, Rankin S, Keisling M, Mottet L, M A. The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality; 2016.

  16. James SE, Herman JL, Durso LE, Heng-Lehtinen R. Early Insights: A Report of the 2022 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality; 2024.

  17. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Hughto JMW, Pachankis JE, Reisner SL. Healthcare Mistreatment and Avoidance in Trans Masculine Adults: The Mediating Role of Rejection Sensitivity. Psychol Sex Orientat Gend Divers. 2018;5(4):471–81.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Jaffee KD, Shires DA, Stroumsa D. Discrimination and Delayed Health Care Among Transgender Women and Men: Implications for Improving Medical Education and Health Care Delivery. Med Care. 2016;54(11):1010–6.

    Article  PubMed  Google Scholar 

  20. Levine S, Heiden-Rootes K, Salas J. Associations Between Healthcare Experiences, Mental Health Outcomes, and Substance Use Among Transgender Adults. J Am Board Fam Med. 2022;35(6):1092–102.

    Article  PubMed  Google Scholar 

  21. Trinh MH, Quint M, Coon D, Bhasin S, Tocci B, Reisner SL. Transgender Patients Report Lower Satisfaction with Care Received than Cisgender Patients Receiving Care in an Academic Medical Care System. LGBT Health. 2024;11(3):202–9.

    Article  PubMed  Google Scholar 

  22. Berrian K, Exsted MD, Lampe NM, Pease SL, Akre EL. Barriers to quality healthcare among transgender and gender nonconforming adults. Health Serv Res. 2024.

  23. Downing J, Lawley KA, McDowell A. Prevalence of Private and Public Health Insurance Among Transgender and Gender Diverse Adults. Med Care. 2022;60(4):311–5.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Bauer GR, Hammond R, Travers R, Kaay M, Hohenadel KM, Boyce M. “I don’t think this is theoretical; this is our lives”: how erasure impacts health care for transgender people. J Assoc Nurses AIDS Care. 2009;20(5):348–61.

    Article  PubMed  Google Scholar 

  25. Wesp LM, Malcoe LH, Elliott A, Poteat T. Intersectionality Research for Transgender Health Justice: A Theory-Driven Conceptual Framework for Structural Analysis of Transgender Health Inequities. Transgend Health. 2019;4(1):287–96.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Reisner SL, Radix A, Deutsch MB. Integrated and Gender-Affirming Transgender Clinical Care and Research. J Acquir Immune Defic Syndr. 2016;72 Suppl 3(Suppl 3):S235–42.

  27. Restar AJ. Gender-affirming care is preventative care. Lancet Reg Health Am. 2023;24: 100544.

    PubMed  PubMed Central  Google Scholar 

  28. 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.

    Article  PubMed  Google Scholar 

  29. Hidalgo MA, Ehrensaft D, Tishelman AC, Clark FC, Garofalo R, Rosenthal SM, et al. The Gender Affirmative Model: What We Know and What We Aim to Learn. Hum Dev. 2013;56(5):285–90.

    Article  Google Scholar 

  30. Chen D, Hidalgo MA, Leibowitz S, Leininger J, Simons L, Finlayson C, et al. Multidisciplinary Care for Gender-Diverse Youth: A Narrative Review and Unique Model of Gender-Affirming Care. Transgend Health. 2016;1(1):117–23.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Kia H, Kenney KA, Abramovich A, Ferlatte O, MacKinnon KR, Knight R. “Nowhere else to be found”: Drawing on peer support experiences among transgender and gender-diverse people to substantiate community-driven gender-affirming care. Soc Sci Med. 2023;339: 116406.

    Article  PubMed  Google Scholar 

  32. Ehrenberg N, Vandenbroeck P, Sørensen M, Vandensande T. Integrated Community Care—A Community-Driven, Integrated Approach to Care. In: Amelung V, Stein, V., Suter, E., Goodwin, N., Nolte, E., Balicer, R., editor. Handbook Integrated Care (2nd Ed). Switzerland AG: Springer Nature 2021. p. pp 105–18.

  33. Cohn J, Corrigan J, Lynn J, Meier D, Miller J, Shega J, et al. Community-Based Models of Care Delivery for People with Serious Illness: NAM Perspectives Discussion Paper. Washington, DC: National Academy of Medicine; 2017.

    Book  Google Scholar 

  34. Aveling EL, Martin G, Herbert G, Armstrong N. Optimising the community-based approach to healthcare improvement: Comparative case studies of the clinical community model in practice. Soc Sci Med. 2017;173:96–103.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Hamilton-Burgess C, Berkley-Patton J, Allsworth J, Bowe Thompson C, Thompson FE, Burgin T, et al. The Importance of Community-Based and Community-Partnered COVID-19 Testing for Reducing Disparities Among African American Populations. Health Equity. 2024;8(1):147–56.

    Article  PubMed  PubMed Central  Google Scholar 

  36. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Ross LE. An account from the inside: Examining the emotional impact of qualitative research through the lens of “insider” research. Qual Psychol. 2017;4(3):326–37.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Borkan JM. Immersion-Crystallization: a valuable analytic tool for healthcare research. Fam Pract. 2022;39(4):785–9.

    Article  PubMed  Google Scholar 

  39. Braun V, V C. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3(2):77–101.

  40. Braun V, Clarke V. Reflecting on reflexive thematic analysis. Qual Res Sport Exerc Health. 2019;11(4):589–97.

    Article  Google Scholar 

  41. Dedoose. Dedoose Version 9.0.17, cloud application for managing, analyzing, and presenting qualitative and mixed method research data Los Angeles, CA: SocioCultural Research Consultants, LLC; 2021 [Available from: www.dedoose.com.

  42. Teti M, Kerr S, Bauerband LA, Koegler E, Graves R. A Qualitative Scoping Review of Transgender and Gender Non-conforming People’s Physical Healthcare Experiences and Needs. Front Public Health. 2021;9: 598455.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Hines DD, Laury ER, Habermann B. They Just Don’t Get Me: A Qualitative Analysis of Transgender Women’s Health Care Experiences and Clinician Interactions. J Assoc Nurses AIDS Care. 2019;30(5):e82–95.

    Article  PubMed  Google Scholar 

  44. National Academy of Engineering (US) and Institute of Medicine (US) Committee on Engineering and the Health Care System. Building a Better Delivery System: A New Engineering/Health Care Partnership. In: Reid PP, Compton WD, Grossman JH, Fanjiang G, editors. The National Academies Collection: Reports funded by National Institutes of Health. Washington, DC2005.

  45. Ferlie EB, Shortell SM. Improving the quality of health care in the United Kingdom and the United States: a framework for change. Milbank Q. 2001;79(2):281–315.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  46. Braithwaite J. Changing how we think about healthcare improvement. BMJ. 2018;361: k2014.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Trans Legislation Tracker. 2021 Anti-Trans Bills Tracker. Trans Legislation Tracker; 2024.

  48. Rich AJ, Scheim AI, Koehoorn M, Poteat T. Non-HIV chronic disease burden among transgender populations globally: A systematic review and narrative synthesis. Prev Med Rep. 2020;20: 101259.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Reeves E. A synthesis of the literature on trauma-informed care. Issues Ment Health Nurs. 2015;36(9):698–709.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors would like to thank all the participants who contributed their voices to this study and for trusting us to do right by their experiences.

Funding

This study was partly funded by the Department of Medicine Health Equity Innovation Pilot Grant from Brigham and Women’s Hospital (PI: Reisner); the Department of Men’s Health, Metabolism, and Aging at Brigham and Women’s Hospital (PI: Bhasin); the National Institutes of Health under award number P30 AG031679 (PI: Bhasin); and the Patient-Centered Outcomes Research Institute (PCORI) under award number AD-2017C1-6569 (PI: Reisner).

Author information

Authors and Affiliations

  1. Stanford School of Medicine, Stanford, CA, 94305, USA

    Meg Quint

  2. Department of Epidemiology, University of Michigan, Ann Arbor, MI, 48109, USA

    Meg Quint & Sari L. Reisner

  3. Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, MA, 02115, USA

    Meg Quint, Schuyler Bailar, Alexis Miranda, Shalender Bhasin & Sari L. Reisner

  4. Department of Epidemiology, Harvard School of Public Health, Boston, MA, 02115, USA

    Alexis Miranda & Sari L. Reisner

  5. Research Program in Men’s Health: Aging and Metabolism, Claude D. Pepper Older Americans Independence Center, Brigham and Women’s Hospital, Boston, MA, 02115, USA

    Shalender Bhasin

  6. Division of Plastic Surgery, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA, 02115, USA

    Devin O’Brien-Coon

  7. Departments of Plastic Surgery and Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA

    Devin O’Brien-Coon

  8. The Fenway Institute, Fenway Health, Boston, MA, 02215, USA

    Sari L. Reisner

  9. Department of Epidemiology, University of Michigan School of Public Health, 1415 Washington Heights, SPH 1-2649A, Ann Arbor, MI, 48109, USA

    Sari L. Reisner

Authors
  1. Meg Quint
    View author publications

    You can also search for this author inPubMed Google Scholar

  2. Schuyler Bailar
    View author publications

    You can also search for this author inPubMed Google Scholar

  3. Alexis Miranda
    View author publications

    You can also search for this author inPubMed Google Scholar

  4. Shalender Bhasin
    View author publications

    You can also search for this author inPubMed Google Scholar

  5. Devin O’Brien-Coon
    View author publications

    You can also search for this author inPubMed Google Scholar

  6. Sari L. Reisner
    View author publications

    You can also search for this author inPubMed Google Scholar

Contributions

Quint: Conceptualization, software, validation, formal analysis, investigation, data curation, writing-original draft, visualization, writing-review & editing. Bailar: Formal analysis, data curation, writing-original draft, visualization, writing-review & editing. Miranda: Formal analysis, data curation, writing-original draft, writing-review & editing. Bhasin: Writing-review & editing, funding acquisition. Coon: Writing-review & editing. Reisner: Conceptualization, methodology, validation, resources, writing-original draft, supervision, project administration, funding acquisition, writing-review & editing. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Sari L. Reisner.

Ethics declarations

Ethics approval and consent to participate

This study was approved by the Mass General Brigham Institutional Review Board. All participants provided informed consent to participate. This research was conducted in accordance with the principles of the Belmont Report and the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

Reisner receives royalties from McGraw Hill for co-editing the textbook, “Transgender and Gender Diverse Health Care: The Fenway Guide.”

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Quint, M., Bailar, S., Miranda, A. et al. The AFFIRM Framework for gender-affirming care: qualitative findings from the Transgender and Gender Diverse Health Equity Study. BMC Public Health 25, 491 (2025). https://doi.org/10.1186/s12889-024-21261-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12889-024-21261-7

Keywords

BMC Public Health

ISSN: 1471-2458

Contact us