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“I’m not challenging you, I just need help”

A Qualitative Study into how Transgender People Navigate the Barriers to Accessing Gender-Affirming Health Care.


Introduction

For many transgender individuals, their physical, mental, and social wellbeing hinges entirely upon their ability to access gender-affirming health care (GAHC). While a person’s transition is underpinned by a complex network of interpersonal processes through which an individual’s identity is recognised across social, legal, and medical environments, GAHC is often perceived by transgender people as the final step in fortifying their gender expression (Kearns et al. 2021). GAHC assists a transgender person in affirming their identity within their own body, and within social and legal spheres through facilitating services including hormone replacement therapy, gender-affirming surgery, and gender dysphoria diagnoses (Reisner et al. 2016). However, transgender people’s right to ensure their own health through receiving GAHC has been historically limited and is now becoming increasingly compromised. GAHC has become the target of conservative political agendas, allowing for transphobic rhetoric to increasingly spread misinformation, prejudice, and life-threatening injunctions upon the medical autonomy of transgender individuals (Park, Das & Drolet 2021). While the impact of these barriers has been explored within existing literature, the aim of this report is to extend scholarly understanding beyond that initial social criticism. Through providing a personal insight into how transgender people have been impacted by these barriers surrounding GAHC, this qualitative research investigates how transgender people not only experience, but also navigate, the challenges they face throughout the access, delivery, and maintenance of GAHC. Therefore, this article will be answering the following research questions:


How are the barriers to gender affirming health care experienced by transgender people?

And how do transgender people navigate these barriers when accessing and receiving gender-affirming health care?


Background and Literature

The development, access, and delivery of GAHC has been established as a systematically insufficient medical service throughout the existing literature. Through utilising a qualitative approach, snowball sampling and semi-structured individual interviews with a variety of medical professionals, Snelgrove et al. (2012) concluded that, “The concept of “two-gender medicine” … (fails) in recognising and accommodating the healthcare needs of trans patients” (pg.7). Experiences of physician discomfort, confusion and misunderstanding were extracted from the qualitative data, highlighting the deficits within the medical education system and the subsequent ‘physician-side barriers’ to the access and delivery of GAHC (Snelgrove et al. 2012).


The qualitative study conducted by Gridley et al. (2016) focused upon how barriers to GAHC impacted transgender youth and their carers. They utilised a convenience sampling method to recruit for a series of individual interviews, focus groups and an online survey. Gridley et al. (2016) extracted six thematic barriers experienced by transgender youth and their carers including minimal GAHC providers, delayed access to treatment and inconsistent use of the patients’ chosen name and pronouns.


Furthermore, Kearns et al. (2021) conducted a systematic review and meta-ethnography which synthesised qualitative data from ten separate studies. Through comparing the barriers reported by transgender people across the ten studies, Kearns et al. (2021) highlighted how the prejudice experienced within medical environments also extends to personal, social, economic, and psychosocial spheres. The authors also commented upon the lack of existing literature surrounding transgender people’s experiences with GAHC, with a disproportionate scholarly gap in data detailing the barriers most impacting GAHC.

Overall, there is a limited body of literature surrounding GAHC, with the little existing research holding a narrow focus towards physician-side barriers and transgender youth. This study extends the existing literature through focusing on transgender people who are aged 18 and over, thereby exploring experiences which encompass the wider transgender community. Furthermore, through conducting this project as a transgender researcher, this investigation has allowed for a more personal, detailed, and authentic approach to sampling, data collection and analysis, which previous cisgender researchers could not achieve.


Research Methodology and Method:

The method of semi-structured interviews was selected to obtain the qualitative data for this research report. This method allowed for a deeper exploration of the participants’ personal stories, opinions, and backgrounds, which may have become clouded within a focus group setting (O’Leary 2014, 218). The research questions also carried an inherent sensitivity which was better suited to the private setting of an interview, where participant anonymity could be further ensured, and a stronger sense of rapport and trust could be built to encourage open and authentic dialogue (O’Leary 2014, 217).


The method of semi-structured interviews also aligned with my research framework being grounded within the criticalist paradigm (Waller, Farquharson & Dempsey 2016, 76). This research was conducted within the criticalist paradigm due to the topic of transgender health rights and GAHC being inextricably tied to political discourse (Park, Das & Drolet 2021). Through embracing the flexibility of semi-structured interviews within the criticalist paradigm, my research empowers the minority voice of the transgender community by illuminating their personal stories as a direct representation of the disproportionate health barriers they face.


I was able to purposively sample 4 participants from my social network who satisfied the key informant eligibility criteria, which included identifying as transgender and having experience with GAHC (O’Leary 2014, 190). The sample population was balanced between two trans-masculine identifying people and two trans-feminine identifying people, with three participants conducting their interviews over Zoom, and one in-person. For all participants, both a laptop and phone were used to create two audio recordings of each interview, thereby minimising the risk of technological issues (Waller, Farquharson & Dempsey 2016). There was no significant difference between the engagement, rapport, and trust built across the virtual and face-to-face interviews, with all participants providing openly authentic responses.


The data was collected, coded, and analysed using an Interpretative Phenomenological Analysis (IPA) method (Smith, Flowers & Larkin 2022, pp. 1-4). This method of qualitative data analysis was selected as it illuminated how transgender people made sense of the barriers to accessing GAHC as a major steppingstone in their lives. Furthermore, IPA allowed for me, as the researcher, to participate in understanding the reflective process which participants undertook when exploring their GAHC journey, thereby allowing for me to engage in far more personal data collection and analysis (Smith, Flowers & Larkin 2022, pp. 1-4). My data collection and analysis was also influenced by my identity as a transgender researcher, through incorporating elements of autoethnographic reflection alongside IPA. I ensured that my own biases surrounding the research questions did not influence the participants in anyway, and instead utilised the criticalist paradigm to break down the traditional barriers between the researcher and the participants, thereby allowing for emotionality, subjectivity, and empathetic dialogue to inform my qualitative data analysis.


Ethics

To ensure ethical practice, this research was guided by the core principles of consent, care, and confidentiality, as provided by O’Leary (2014, 64). Prior to being recruited for the study, participants were provided with an information statement which detailed the aim, benefits, risks, and demands of the research. After fully reading and understanding the information statement, the participants returned their written consent to me, thereby ensuring they did not experience any pressure or coercion to participate. I ensured participant consent was continually affirmed beyond the initial consent forms through participants being asked to give verbal consent to be recorded during the interview and receiving numerous reminders of their autonomous capacity to withdraw from the research at any time.


While no participants experienced any emotional distress throughout the interviews, I had several support numbers and websites such as ‘QLife’ prepared to ensure participants felt supported and safe throughout all stages of participation. My interview schedule was also flexible to move around any uncomfortable topics for the participants, thus actively balancing focus on both positive and negative experiences to minimise repeatedly depressing reflections.


Confidentiality was especially important since transgender people are at a high risk of being persecuted for their identity and any criticisms they may express towards individuals or organisations. In accordance with the practices outlined by Waller, Farquharson & Dempsey (2016), I promptly anonymised transcripts through utilising pseudonyms to de-identify any names, locations, occupations, organisations, or relationships expressed by participants. All data has been secured within a password protected OneDrive folder and consent forms have been kept separately from their corresponding data.


Overall, the sampling, data collection and analysis process were all successful. However, while there was a good balance of trans-masculine and trans-feminine participants, it should be noted that due to the limitations of my immediate social network, all the participants were white and in their late teens or early-mid 20s. Therefore, future research should aim to increase the generalisability of the data through recruiting participants who exhibit a wider age range and racial diversity.


Findings

Table 1 - Participant Characteristics:

Name:

Pronouns:

Age:

Experience with GAHC:

Celeste

She/Her

24

- Gender Dysphoria Diagnosis

- Facial Feminisation Surgery

- Hormone-Replacement Therapy (Hormone Blockers and Estrogen)

- Vaginoplasty

River

They/He

20

- Gender Dysphoria Diagnosis

- Hormone Replacement Therapy (Testosterone)

- Top Surgery

Ivy

She/Her

22

- Gender Dysphoria Diagnosis

- Hormone Replacement Therapy (Hormone Blockers and Estrogen)


Miles

He/They

19

- Gender Dysphoria Diagnosis

- Hormone Replacement Therapy (Hormone Blockers and Testosterone)


Barriers

Each of the participants repeatedly noted that the central barrier towards accessing GAHC was the lack of accessibility within the medical system. This criticism is evident throughout existing literature, with many studies acknowledging how the current medical system is insufficient in meeting the demands of transgender patients (Gridley et al. 2016; Kearns et al. 2021; Snelgrove et al. 2012). Notably, Celeste contextualised this barrier within a NSW setting.


‘I will say that…specialists in Sydney are booked up like crazy, impossible to get into and difficult to access, which is the same in Newcastle. That’s a huge issue across the board and I mean I know it definitely is in NSW.’ (Celeste)


Alongside Celeste, all participants commented upon how they had struggled to access GAHC due to the lack of available resources. However, for both trans-feminine participants, the barrier of accessibility was a repeated issue for gender-reassignment surgery, also known as vaginoplasty. Ivy is yet to receive gender-affirming surgery due to the lack of surgeons available in Australia, and described how she perceives the ethical dilemma this presents for other transgender women.


“You’re looking at these people who have to wait at least a year for the surgery or they tell you the only other option is flying over to a third world country and getting it done in a really dangerous way” (Ivy)


Interestingly, Celeste detailed how she was faced with this exact same dilemma, where she made the decision to seek GAHC overseas due to a lack of resources in Australia.


“At the beginning of 2018. I tried to get bottom surgery in Thailand…and it cost like $15,000 and I sort of got there and realised that the conditions of the surgery were not what I expected them to be, so I just bailed on that and was like that’s not okay, and I am not going to do that” (Celeste)


Furthermore, both transmasculine participants placed a heavier focus upon the economic restraints associated with GAHC, as opposed to the availability of surgeons. However, like Ivy, Miles illustrated a similar ethical dilemma transgender people are faced with, where the lack of available resources forces them to consider how willing they are to wait for the care they need due to limited financial support.


“It’s just so hard with how expensive everything is and I’m still living at home, but I just can’t see getting surgery…I’m going to say it’s probably 5 years away…It’s so hard, I just wish I could get it now” (Miles)


This ethical dilemma was once again realised within the reflection made by River, which revealed how he navigated these economic restraints to afford his top surgery.


“I did it by essentially living in poverty for about a year, willingly, I saved the vast majority of my income for a year and was essentially living below the poverty line just to be able to keep on living because the option was either live in poverty for a year, get the surgery, and then live as opposed to not get the surgery and not live” (River)


River’s reflection notably emphasises how paradoxical the inaccessibility of GAHC is, as it is viewed as lifesaving for many transgender people (Kearns et al. 2021). This feeling of dismissal was also reflected within the participant’s commentary surrounding the structure of the medical system, which is inherently orientated within a cis-heteronormative lens (Snelgrove et al. 2012). When asked to reflect upon how GAHC is perceived by the wider medical community, Miles stated that GAHC is seen, “…as optional, like a cosmetic surgery”, despite it being, “…literally a lifesaving…service”. This additional barrier was affirmed in the findings of Snelgrove et al. (2012), who described the modern medical system as being rooted within “…two gender medicine”, which is inflexible and unempathetic to the diverse spectrum of identity experienced within the transgender community. Surprisingly, Celeste noted this barrier had quite a minimal impact upon her transition.


“…Part of the reason that was smooth for me is because my transition is very typical and very much what people expect from a trans person. I know people who have less typical journeys or are more gender non-conforming have a variety of more issues. “ (Celeste)


However, her smooth experience only exemplifies the continual binary barriers implemented within GAHC, as ‘two gender medicine’ has extended to only encompass transgender people who exist within the cis-heteronormative understanding of gender, as opposed to the holistic spectrum of queer identity (Snelgrove et al. 2012). The implications of this cis-heteronormative rhetoric underpinning transgender health services was described by River as an experience of denial.


“I had a friend in Ireland who…was denied a diagnosis for gender dysphoria at the time…it was entirely because they weren’t confident in 1 or 2 of their answers and they were completely denied” (River)


The experience of River’s friend illuminates how all transgender people are subjected to intense medical scrutiny through a cisgendered lens of understanding, therefore resulting in misinformed denial and dismissal on the basis of a binary checklist which is unsuitable for most transgender individuals. This theme was also reflected within the barriers surrounding the delivery of GAHC as well, with all participants detailing experiences of suffering insufficient care due to the actions of a misinformed medical professional practicing within a cisgender paradigm. It became clear that it was extremely rare to find educated medical professionals, as participants often described how they needed to fill gaps in knowledge, as opposed to their needs being a part of the assumed medical knowledge for health professionals.


“…past GP’s have been like ‘oh we’ll leave it to your psychiatrist’, rather than being actually informed and try to understand what’s happening to me and what healthcare I’m actually accessing and what’s it doing” (Miles)


“…she was like I don’t know what to do, this isn’t right, this is all broken you should probably just see someone who like specialises in trans stuff…, it’s just very frustrating and it’s like I’m challenging them, they always feel challenged and it’s like I’m not challenging you, I just need help.” (Celeste)


“And I think the only reasons why my psychologist and GP didn’t go through any sexual health aspects was because they just weren’t informed on it...I think it’s just not as well-researched to the point where just a psychologist or a GP would have that detailed information” (River)


These experiences were repeatedly affirmed across the existing literature, with physician-side barriers significantly shifting the burden onto transgender people to explain and educate physicians of their needs when seeking support (Kearns et al. 2021, Snelgrove et al. 2012). Despite all receiving different GAHC treatments and procedures, all participants highlighted how their individual journeys are underpinned by a shared experience of these systematic barriers, therefore revealing the universal impact of inaccessibility enforced by cisgendered medical paradigms and unknowledgeable professionals.


Self-Reliance

While the previously established barriers to GAHC were effectively affirmed by the experiences of the participants, the steps they took to navigate these challenges have not been explored within the existing literature. Through interviewing adult participants who were GAHC patients for at least a year, all participants were able to provide retrospective data which encompassed their journey from the early steps to accessing GAHC, to their current treatment maintenance. A central point of navigation explored by all four participants was their initial exposure to the concept of GAHC itself, which was entirely self-led through independent research.


“I had to do all of the research myself, I didn’t receive any support from any medical professionals prior to the age of 18. So, from 13 to 18 it was just word of mouth and hearing other people’s stories online, that was it” (River)


As described by River, medical professionals and previous education provided little to no guidance in learning about GAHC and how to access it, therefore leading many participants to rely upon social media as a key method of research. Miles discussed how social media provided him with, “…a lot of resources” and that, “…without seeing transness on the media I probably would have transitioned a lot later”. However, both River and Celeste commented on the consequences of isolating yourself within purely self-lead research which is dependent on the subjective experiences of online strangers.


“…look I did not know any other trans women, like I was very much on my own in that regard…went through a lot of reddit pages, sometimes to my detriment…I formed some very unhealthy beliefs of what it means to be a trans woman and what you need to do as a trans woman to be accepted in society” (Celeste)


“I ran into some people who had some very harmful views of the trans community and had a lot of internalised transphobia that started to lead me down an unfortunately very hateful path… If you’re only in contact with other 16- to 17-year-olds on the internet who have never had any real-world experience with the trans community then it’s easier to fall down that very bigoted pipeline, which is very concerning.” (River)


Celeste, River, and Miles’ responses show that self-reliance as a navigation technique is a double-edged sword, as independent research provided a wider opportunity for learning and identity exploration, but also increased the chances of being exposed to harmful misinformation. The participants implicitly described this compromising situation through noting how independent research is often not enough to supplement the medical knowledge needed to efficiently navigate the GAHC system.


“…there is actually not a lot of information, of the information there is, it is very vague and conflicting but there is actually a very small amount of information. And there’s no identifiable path to go down, you sort of have to make it up as you go, and you have to hope that your GP is well-versed in those sort of issues” (River)


“You have to go through point a, point b, point c, point d and then back to the start, and if you get that you move onto the next stage and do it again, again, and again every step of the way…it feels like you’re going on a random scavenger hunt where you have to go to this place and the next place without really knowing what to do.” (Ivy)


While this theme of self-reliance was not explicitly explored within the existing literature, it does emphasise the consequences of the physician-side barriers outlined by Snelgrove et al. (2012), where a lack of existing medical knowledge from professionals forces transgender patients to seek guidance from alternative sources. Therefore, through considering not only how, but also why transgender patients are so independent when accessing GAHC, a shift in the burden of medical responsibility to the patient themselves can be understood as a consequential experience of these barriers.


Community

While self-reliance was thoroughly discussed by all participants all four participants established that community was the core navigation technique underpinning their independent research. Scholarly acknowledgement of the necessity of community is extremely limited, with the main mentions of community support only encompassing the support of a transgender person’s wider social networks, as opposed to analysing the direct impact of their surrounding queer community (Kearns et al. 2021). To fully comprehend the significance of community within navigating GAHC, all participants were posed the question of how they would advise a young transgender person just beginning their GAHC journey. Notably, each participant threaded the same advice; community matters more than anything.


“I honestly don’t know how one would start their journey if they didn’t have some sort of community to lean on, like if they had no trans friends or had no queer friends even or if they were in a rural area and they didn’t have any queer organisations they could lean on. I genuinely don’t know how you could even begin to try because it’s so community focused or community led.” (River)


“There’s always new groups to join everyday who are a supportive safe space for everyone who is going through the same journey in their own way. If you think there’s no one around that will support you, try and keep going and looking for these groups that will support you because they will support you and they will accept you.” (Ivy)


“And so I think generally it’s just setting people up with community and stressing the importance of talking to other trans people and finding people who have an experience like your own” (Celeste)


This collective opinion illuminates a significant gap within the existing literature surrounding GAHC, as all participants described communal reliance as not only a shared experience, but a necessary one. The participants all provided a personal story surrounding either their own experience of being guided by their community or how they acted in a supportive capacity for another transgender person within their community. It became evident that while self-reliance could be an isolating and sometimes misleading route to follow, the support of community ultimately underpinned the very existence and possibility of self-led research. River described how the systematic gaps in knowledge identified within the existing literature (Gridley et al. 2016; Kearns et al. 2021; Snelgrove et al. 2012), have only been filled through community efforts.


“I found a GP through an online forum where it was a sub-reddit about gender affirming doctors in Australia…we’ve made resources for ourselves and for other people once we figure(ed) out how to do what we need to do”. (River)


This reveals that GAHC navigation is not only a personal journey, but ultimately a communal effort, as the transgender community have attempted to rectify the lack of resources due to medical misinformation and negligence through creating their own banks of knowledge for individuals to rely upon throughout their independent research.



Sacrifice

A theme which was almost entirely omitted from the existing literature was the experiences of self-sacrifice made by transgender people throughout their GAHC journeys. The experience of sacrifice has been previously investigated within a youth context, which Miles affirmed through describing how transgender youth have, “…little to no control” over their medical autonomy and choices (Gridley et al. 2016). However, there is little exploration into how transgender adults continue to face similar threats to their medical autonomy as a result of their transition. To have your sex legally changed in Australia, you must undergo a gender-reassignment surgical procedure. While this is not only socioeconomically discriminatory as surgeons remain inaccessible and increasingly expensive, Celeste described how seeking legal recognition of your identity invites the government to evaluate the validity of your identity and invade your personal privacy.


“…you need several letters from health professionals…and these doctors are literally meant to inspect your genitals to make sure you’ve had surgery…the emotional labour of that is too much” (Celeste)


Celeste’s experience explores how GAHC is inherently positioned to challenge transgender people to meet exceedingly impossible standards of cisgender expression. It became clear that once an individual began GAHC, the medical system was bound to view their gender as an ‘abnormality’, as opposed to an assumed aspect of their existence. Ivy explored how this perception caused her identity to influence her external medical care which was completely unrelated to her transgender identity.


“I remember when I was trying to get NDIS payments…you had to give them a list of medical conditions you have and I remember that on that list there was gender dysphoria even though it had absolutely nothing to do with my other disabilities…so it would still be a part of me no matter what” (Ivy)


Similar experiences were mirrored across all participants, where external medical treatment was always undermined by concerns about their gender identity for no identifiable reason other than medical ignorance. There was consistent mention of having to ‘prove yourself’ to whomever you encountered, which often involved being forced to out yourself as transgender to navigate any medical service. River criticised this expectation of transgender people to always be open to proving their gender identity within a medical context and how this causes transgender people to sacrifice their personal privacy and integrity.

“People [should] not have to forcibly out themselves to government institutions and [should] maintain at least some semblance of privacy in their lives and not be constantly questioned about the way they present and their gender” (River)

This enlightens a completely unexplored aspect of GAHC, as sacrifice has been previously understood as a consequence of barriers, not a navigational strategy. The barriers to GAHC extend far beyond the immediate economic, social, and legal spheres of a transgender person’s life (Kearns et al. 2021), and instead manifest into a lifelong process which can only be navigated through constantly sacrificing privacy and integrity in alignment with cis-heteronormative expectations of gender identity.


Conclusion

While the sample population for this research was small and each participant held a distinct individual journey, they all directly affirmed the findings of existing literature through detailing universal experiences with the barriers to GAHC (Gridley et al. 2016; Kearns et al. 2021; Snelgrove et al. 2012). Subsequently, this research reflects that the existing sociological criticism of the inaccessible and cis-heteronormative structures underpinning GAHC are experienced by transgender people on a universal basis. Through incorporating the criticalist paradigm, IPA, and autoethnographic reflection into data sampling and analysis, this research extends beyond the external social barriers surrounding GAHC and instead illuminates the subjective, interpersonal, and communal navigational strategies undertaken by transgender people as a result of the barriers they face. Previous cisgender researchers have failed to access an esoteric understanding of GAHC and allow empathetic subjectivity to inform their research beyond the identification of the barriers themselves. Through illuminating how these barriers were learnt, understood, and navigated by transgender people, this research emphasises the equal importance of the navigational strategies of self-reliance, community, and self-sacrifice in informing the sociological perception of GAHC as a whole. Therefore, future research should extend this line of qualitative investigation so that transgender people’s voices can continue to be empowered to motivate societal change towards a GAHC system which prioritises the comfortability of its patients, and not it’s physicians (Kearns et al. 2021).









Reference list

Gridley, SJ, Crouch, JM, Evans, Y, Eng, W, Antoon, E, Lyapustina, M, Schimmel-Bristow, A, Woodward, J, Dundon, K, Schaff, R, McCarty, C, Ahrens, K & Breland, DJ 2016, ‘Youth and Caregiver Perspectives on Barriers to Gender-Affirming Health Care for Transgender Youth’, Journal of Adolescent Health, vol. 59, no. 3, pp. 254–261.

Kearns, S, Kroll, T, O‘Shea, D & Neff, K 2021, ‘Experiences of transgender and non-binary youth accessing gender-affirming care: A systematic review and meta-ethnography’, in M Torok (ed.), PLOS ONE, vol. 16, no. 9.

O’Leary, Z 2014, Essential guide to doing your research project., 2nd edn, Sage Publications, London.

Park, BC, Das, RK & Drolet, BC 2021, ‘Increasing Criminalization of Gender-Affirming Care for Transgender Youths—A Politically Motivated Crisis’, JAMA Pediatrics, vol. 175, no. 4.

Reisner, SL, White Hughto, JM, Pardee, D & Sevelius, J 2016, ‘Syndemics and gender affirmation: HIV sexual risk in female-to-male trans masculine adults reporting sexual contact with cisgender males’, International Journal of STD & AIDS, vol. 27, no. 11, pp. 955–966.

Smith, JA, Flowers, P & Larkin, M 2022, Interpretative phenomenological analysis: Theory, method and research, 2nd edn, SAGE, London, pp. 1–4.

Snelgrove, JW, Jasudavisius, AM, Rowe, BW, Head, EM & Bauer, GR 2012, ‘“Completely out-at-sea” with “two-gender medicine”: A qualitative analysis of physician-side barriers to providing healthcare for transgender patients’, BMC Health Services Research, vol. 12, no. 1.

Waller, V, Farquharson, K & Dempsey, D 2016, Qualitative social research : contemporary methods for the digital age, Sage, Los Angeles.



Appendix 1 – Interview Schedule:

Transgender People and Their Health Beliefs and Practices

Interview Schedule

Prefacing informed consent questions: · Have you had time to read through the information sheet and consent form? · Do you have any questions about either of these? · Do you consent to take part in this interview, and to have it recorded and transcribed? · Do you understand that you can end the interview at any point in time? Framing Statements: Thank you for agreeing to this interview. This interview is a part of a series of interviews with transgender individuals in the Newcastle area. The purpose of the interview is to gain some understanding into how transgender people navigate the medical system when accessing gender affirming health care. As you know, you will remain anonymous after the completion of this interview, so you are encouraged to speak openly on all aspects of your experience that you feel comfortable discussing, but please do not hesitate to pause or end the interview at any time if needed.

Please note that as a semi-structured interview, the schedule will be used flexibly and additional questions may be asked. The following are indicative questions:

Background:

Can you please tell me about what led you to begin your transition?

How did you express your identity before accessing gender affirming health care?

Individual Context:

When did you first consider engaging with gender affirming health care?

Why did you choose to engage with gender affirming health care as part of your transition journey?

What gender affirming health care/procedures have you received and/or are currently receiving?

In what ways has your gender affirming health care impacted your health as a whole?

The Journey to GAHC:

How did you first learn about gender affirming health care?

(Prompt: discuss and compare influences of medical professionals, personal research, word of mouth etc.)

Could you talk me through what steps you had to take to access and receive gender affirming health care?

(Prompt: if they accessed GAHC while under 18, ask how their experience may have differed due to being a minor at the time)

Can you provide me a specific example of a challenge you faced in accessing gender affirming health care?

Can you describe any reasons as to why you experienced these challenges?

How did you navigate these challenges?

Can you recall any positive experiences with medical professionals who were associated with your gender affirming care?

(Prompt: Why were they positive, what made them different from other experiences?)

External Health Care Experiences:

Can you recall of any times where your identity has influenced any medical care unrelated to your transition?

Do you believe that experience was fair within the circumstances, or unnecessary?

Advice:

With recent events in America, how are those bills impacting you here in Australia?

(Prompt: Do you fear that similar legislation will happen in Australia?)

If you had to identify three main issues with the GAHC system, what would they be?

(Prompt: can you suggest any solutions to those problems?)

If you were to provide advice based upon your experience to a transgender person looking to access gender-affirming health care, what would you say?

Do you have anything further you would like to add to this discussion?


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