The experiences of transgender and nonbinary adults in primary care: A systematic review

Figures & data

Table 1. Inclusion and exclusion criteria.

Inclusion Criteria	Studies focusing on TNB^a people
	Studies focusing on experiences or interactions with general practice, primary care, family physicians, general practitioners or family medicine
	Primary research studies including quantitative, qualitative and mixed methods methodologies
	Any country for study location
Exclusion Criteria	Editorials, opinion pieces and non-primary data
	Studies published not in English
	Publication date prior to 2005
	Duplicate study
	No mention of TNB people as a population or participant focus
	Studies with a specific healthcare focus other than primary care (e.g. secondary or tertiary care services, social services)
	Studies focusing on TNB youth below age 18 years

^a TNB: transgender and nonbinary.

Table 2. Quality assessment of sixteen included studies using MMAT [23].

Study Design	Author, year of study	Methodological study criteria
		Is the qualitative approach appropriate to answer the research question?	Are the qualitative data collection methods adequate to address the research question?	Are the findings adequately derived from the data?	Is the Interpretation of results sufficiently substantiated by data?	Is there coherence between qualitative data sources, collection, analysis and interpretation?
Qualitative	Wright et al. 2021 [24]	Yes	Yes	Yes	Yes	Yes
	Haire et al. 2021 [25]	Yes	Yes	Yes	Yes	Yes
	Ker et al. 2020 [26]	Yes	Yes	Can’t tell	Yes	Can’t tell
	Willis et al. 2020 [27]	Yes	Yes	Yes	Yes	Yes
	Allory et al. 2020 [28]	Yes	Yes	Yes	Yes	Yes
	Bell and Purkey 2019 [29]	Yes	Yes	Yes	Yes	Yes
	Zwickl et al. 2019 [30]	Yes	Can’t tell	Yes	Can’t tell	Yes
	Vermeir et al. 2017 [31]	Yes	Can’t tell	Yes	Yes	Yes
	Westerbotn et al. 2017 [32]	Yes	Yes	Yes	Yes	Yes
	Melendez et al. 2009 [33]	Yes	Yes	Yes	Yes	Yes
Quantitative descriptive		Is the sampling strategy relevant to address the research question?	Is the sample representative of the target population?	Are the measurements appropriate?	Is the risk of nonresponses bias low?	Is the statistical analysis appropriate to answer the research questions?
	Treharne et al. 2022 [34]	Yes	Can’t tell	Yes	Yes	Yes
	Kattari et al. 2021 [35]	Yes	Can’t tell	Can’t tell	Yes	Yes
	Bauer et al. 2015 [7]	Yes	Can’t tell	Yes	Can’t tell	Yes
Mixed methods		Is there an adequate rationale for using a mixed methods design to address the research question?	Are the different components of the study effectively integrated to answer the research question?	Are the outputs of the integration of qualitative and quantitative components adequately addressed?	Are divergences and inconsistencies between quantitative and qualitative results adequately addressed?	Do the different components of the study adhere to the quality criteria of each tradition of the methods involved?
	Tan et al. 2022 [36]	Yes	Yes	Yes	Yes	Yes
	Goldenberg et al. 2021 [37]	Yes	Yes	Yes	Can’t tell	Yes
	Hinrichs et al. 2018 [38]	Yes	Can’t tell	Yes	Can’t tell	Yes

Both screening questions were positive for all included studies: 1) Are there clear research questions? (2) Do the collected data allow to address the research questions?

Figure 1. PRISMA diagram showing study selection process.

Table 3. Summary of the 16 included studies.

Author, year, country	Study type	Participant characteristics	Experiences and perceptions of primary care	Expectations from a primary care service/healthcare providers	Key findings
Wright et al. 2021, UK, [24]	Qualitative study, interview	Transgender people who had also taken part in the HIV Self-Testing Public Health Intervention (SELPHI) randomised control trial Total participants − 20 Gender − 7 trans women, 12 trans men, 1 nonbinary trans masculine person Ages − 21–57	Examination of the pathway from primary care to specialist gender identity services in the UK	NR	GPs are poorly informed about TNB identities and care pathways Cisnormative views enforcing the gender binary may alter how patients present to primary care in order to access care Positive interactions with GPs are when they prioritise treating the patient holistically as a whole person and have a willingness to learn and take responsibility
Haire BG et al. 2021, Australia, [25]	Qualitative study, interview	TNB people living in Australia, recruitment facilitated by the Gender Centre Total participants − 12 Gender − 9 trans women, 1 trans man, 2 nonbinary people Ages − 19 to 59 Race/Ethnicity − 5 participants were Indigenous	Experiences of healthcare access in trans and gender diverse people with complex health needs	NR	TNB people have to navigate multiple HCPs and HCS and HCPs act as gatekeepers Perceived erasure of nonbinary identities and a need to conform to gender stereotypes to access care Perceived ignorance and stigma from HCPs common A welcome physical environment and supportive peer community seen as vital
Ker et al. 2020, New Zealand, [26]	Qualitative, interview	TNB people accessing a primary care pilot clinic providing HRT Total participants − 4 TNB people and 4 HCPs Gender – of the service users: 3 female, 1 nonbinary and neutrois Ages − 18-26	Exploring the experiences of a primary care-based pilot clinic providing gender-affirming hormone therapy in New Zealand	NR	Primary care led clinics were perceived as more accessible, with less waiting times and less gatekeeping HCPs emphasised partnership with service users and that the service provided was adaptable Perception it depathologised gender diversity Efforts to centralise care seen as minimising the power dynamic
Willis et al. 2020, Wales, [27]	Qualitative, interview	Older TNB people who were trying to medically transition later in life Total participants − 19 Gender − 15 trans women, 4 trans men Ages − 50 to 74	Examining supportive and obstructive points of interaction with health-care professionals	NR	GPs were inconsistent allies Participants often forced into the role of patient educators as GPs lacked knowledge of trans needs, available treatments and care pathways Perception HRT could be GP managed but seen as too specialist Some GPs would act as individual gatekeepers
Allory et al. 2020, France, [28]	Qualitative interview	TNB adults in France recruited through local trans or LGBTI (lesbian, gay, bisexual, trans, and/or intersex) associations, primary care providers, and social networks Total participants − 27 Gender − 14 trans men, 12 trans women, 1 nonbinary person Ages − 18 to 60	Exploring the difficulties experienced by transgender people in accessing primary health-care services	Exploring expectations towards primary care providers to improve their health-care access.	Nano, micro, meso and macro levels of difficult accessing primary care services Anxiety in anticipating GP responses and being “outed” in waiting rooms TNB people form peer community networks and refer on trusted HCPs Healthcare systems not adapted to TNB people Expectations of gender normativity common and pressure to conform to gender stereotypes to access care Expectations included self-determination and reducing the need for psychiatric assessment TNB people want primary care led services for initiating and following up treatments, perceived to be more holistic and accessible
Bell et al. 2019, Canada, (29)	Qualitative, interview	TNB people in Ontario recruited through family medicine clinics and community agencies Total participants − 11 Gender − 4 trans men, 6 trans women, 1 GNC	Exploring past experiences of TNB people in primary care	Describing expectations of members of the trans community regarding the delivery of primary care by their family physicians	Perceived HCP knowledge of TNB identities found lacking overall and limited knowledge about hormones Patient self-advocacy beyond what would be expected, e.g. bringing in guidelines or referring GPs to local events Discrimination by HCPs common Primary care led treatment preferred as perceived to be more holistic though more education is needed More research into the systemic oppression of trans people which has led to an intersectionality with poverty, mental illness and substance abuse
Zwickl et al. 2019, Australia, [30]	Qualitative, survey	TNB adults in Australia recruited through the trans medical research Facebook group Total participants − 928 Gender − 37% trans women or trans femme, 36% trans men or trans masc, 27% nonbinary identities	Exploring health needs of trans and gender diverse people in Australia	NR	80% have a regular HCP Mainstreaming services to primary care will likely improve accessibility TNB people should guide research priorities and health service delivery 44.8% said HCP knowledge lacking Positive interactions including respecting names, pronouns, not asking invasive questions and knowing about care pathways Need for more research about HRT risks long term and about improving care
Vermeir et al. 2017, Canada, [31]	Qualitative, interview	TNB adults living in Nova Scotia who wanted to experience, or had tried to experience, primary and/or emergency care within the last two years Total participants − 8 people Gender − 3 trans women, 1 trans man, 1 trans masc guy, 1 transsexual man, 1 genderqueer and nonbinary person, 1 dude/guy/demi-guy/person Ages − 18 to 44	Exploring the barriers trans adults encounter when pursuing primary and emergency care in Nova Scotia, Canada		Interpersonal barriers to care included HCP knowledge and patients having to educate HCPs Reasons as to why patients seeking care taking a backseat Perceived uncomfortable attitudes by HCPs, including deadnaming, being “outed”, “gendering” care, invasive questioning Lack of welcome physical spaces e.g. gender neutral bathrooms, exclusion of TNB inclusive information on posters and forms Extensive wait times for specialist care
Westerbotn et al. 2017, Sweden, [32]	Qualitative interview	TNB people living in Stockholm with experience of the Swedish healthcare system Total participants − 14 Ages − 20 to 50	Experiences of TNB people meeting with healthcare professionals	Exploring expectations TNB have before and upon meeting HCPs	Clear knowledge gap among HCPs TNB people wanted to be treated like anyone else TNB people often expected ignorance or discrimination Many participants felt anxious before meeting with HCPs which led to avoidance of services of fear of being exposed / questioned by HCP and reception staff
Melendez et al. 2009, USA, [33]	Qualitative, interview	Trans women who took part in a study around their ideas of best practice for HIV prevention and primary care in a specific community-based clinic in New York City. Total participants − 20 Gender - all trans women Ages − 18 to 53 Race/ethnicity − 16 were Latina (14 Puerto Ricans, 1 Central American, one South American), 4 were African American	Exploring the experience of trans women at this particular primary care and HIV prevention clinic, which was not an LGBT-specific clinic.	Exploring what trans women think best practice looks like for providing primary care and HIV prevention support to trans women in a community clinic.	Some participants preferred using a general health clinic to an LGBT specific clinic because they saw themselves as women, rather than transgender women, and because of tensions within the LGBT community. The participants reported feeling safe at the clinic and many had been recommended the clinic by friends as it had been reported to be safe. Factors influencing their feelings of safety included being called by their preferred names, feeling cared for, and understood their community, including the intersection of their (primarily Latinx) racial/ethnic identity and their identity as trans women. They also reported feeling like the clinic could provide a ‘one stop shop’ for medical care, sexual healthcare and gender affirming care.
Treharne et al. 2022, New Zealand, [34]	Quantitative, survey	TNB people living in New Zealand with a primary care doctor or GP Recruited through social networks and within local trans and queer communities Total participants − 948 Gender − 29% trans women, 29% trans men, 42% nonbinary identities Ages − 14 to 83	Experiences of the most common positive and negative experiences with primary care doctors for TNB people	NR	Supportive experiences include equitable treatment from doctors and cultural competence Negative healthcare experiences associated with distress and non-suicidal self-injury and suicidality 47% had to educate healthcare providers, 28% were told gender-affirming care could not be provided on account of lack of knowledge 48% had primary care doctors supportive of their healthcare needs Nonbinary people more likely to have negative healthcare experiences in accessing gender affirming care
Kattari et al. 2021, USA, [35]	Quantitative, cross-sectional survey	Transgender Adults (18+) in the US, recruited online. Total participants − 27,715 Gender − 28.6% man/ trans man, 33.85% woman / trans woman, 34.15% nonbinary/genderqueer, 2.62% cross-dresser = 2.62% Age: M = 31.23 Ethnicity − 80.76% white/European American, 5.24% Latinx/Hispanic, 4.65% Biracial/Multiracial, 2.79% Black/African American, 2.52% Asian/Asian American, 1.07% American Indian, 2.96% Other	To assess how many TNB individuals see a physician on a yearly basis; how many TNB individuals have a regular primary care provider (PCP); and how many of these individuals have a PCP who they would consider to be knowledgeable about transgender health	NR	17.8% reported that their PCP knew almost nothing about TNB health, 17.7% that their PCP knew some things, 12.6% that their PCP knew most things, and 15.2% that their PCP knew almost everything. The remaining 36.7% did not know how much their PCP knew about TNB health. Being nonbinary/genderqueer or a crossdresser was associated with lower levels of PCP knowledge, being a trans woman was associated with higher levels of PCP knowledge.
Bauer et al. 2015, Canada, (7)	Quantitative, cross-sectional survey	Transgender people in Canada, recruited online using respondant-driven sampling. Total participants − 433 Gender − 184 (52%) were assigned female at birth (AFAB), 172 (48%) were assigned male at birth (AMAB) Ages − 16 to 25 = 41% TM 20.9% TF; 25-45 = 48.8% TM, 47.6% TF; 45 + 10.2% TM, 31.5% TF. Race/ethnicity − 68.1% were white, 31.9% were racialised or Aboriginal.	To assess how comfortable participants are to discuss trans healthcare with their PCP (Discomfort/Comfort). Checklist of 9 trans-specific negative experiences with GPs. Provider knowledge of trans issues, 4-point Likert scale.	NR	47.7% AFAB trans people and 54.5% AMAB trans people were not comfortable discussing trans issues with their doctor. This discomfort was present despite accounting for factors such as access to a regular family physician and having universal healthcare insurance. Having a provider perceived as knowledgeable was associated with more comfort, and previous negative experiences were associated with more discomfort. Higher levels of transphobia were independently and negatively associated with discomfort among transfeminine participants.
Tan et al. 2022, New Zealand, [36]	Mixed methods, cross-sectional survey with quantitative and qualitative outcome variables	Trans people (aged 14+) living in New Zealand who are accessing primary care. Total participants – Quantitative n = 871, qualitative n = 153 Gender – Quantitative: 29.1% trans women, 29% trans men, 41.9% nonbinary Qualitative: 12.3% trans women, 20.1% trans men, 33.3% nonbinary Ages – Quantitative: 15.3% aged 14–18, 28.1% aged 19–24, 34.6% aged 25–39, 13.4% aged 40–54, 8.3% aged 55+. Qualitative: 7.5% aged 14–18, 10.1% aged 19–24, 21.3% aged 25–39, 19.8% aged 40–54, 27.3% aged 55+. Race/ethnicity – Quantitative: 84.3% New Zealand/European, 12.9% Maori, 1.5% Samoan, 1.4% Chinese. Qualitative: 18.3% Maori, 16.6% NZ European, 10.3% other.	To assess participants confidence in their GP in explaining information, involving them in decision-making and consideration of financial factors To explore broader experiences in primary care	NR	Transgender participants had greater risk of feeling no confidence in their GPs (Cohen’s d = 0.39), reporting barriers accessing primary care due to cost (38.4% vs 17.4%; RR = 2.21), and transport issues (13.5% vs 3.0%; RR = 4.58) compared to the general population Enabling resources relating to affordability of care and transport were key factors in accessing primary care, with regional variability comparing suburban to rural areas.
Goldenberg et al. 2021, USA, [37]	Mixed methods, cross-sectional survey and individual in-depth interviews	Trans youth of colour living in 14 US cities who had experienced using healthcare. Survey, total N = 79 Interviews, total N = 33 Gender – Trans femme = 20, Trans masc = 13. Ages − 16 to 24 Race – Non-Hispanic Black = 14, Asian/Pacific Islander = 4, Latinx/Hispanic = 11, Multiracial = 4.	To explore quantitatively the need for, and access to, gender affirmation within healthcare To qualitatively explore healthcare experiences, and barriers and facilitators to accessing care.	NR	Finding a provider was described as challenging, although some had positive experiences due to being referred to specific affirmative providers via other services or through recommendations from within the trans community. They described barriers in making an appointment and being in the waiting room. Participants reported positive and negative healthcare experiences, according to provider knowledge, whether they were treated with respect, and how much support they were given to navigate the healthcare system. They reported more negative experiences as being linked to healthcare avoidance Healthcare avoidance was associated with providers using inappropriate words for body parts, not having gender neutral bathrooms, and not being able to access referrals
Hinrichs, 2018, USA, [38]	Mixed methods	TNB participants who have accessed TNB-related and/or primary care at Smiley’s family medicine clinic in Minnesota Total participants − 22 Gender − 4 transgender man, 4 transgender man/male, 3 transgender women/female, 3 female, 1 transgender woman, 1 transgender male, 1 transgender man/other, 1 trans man/genderqueer/GNC, 1 trans woman/other, 1 GNC transmasc bigender, 1 GNC/other Ages − 18 to 65	To explore how primary care clinics can improve care for TNB patients	NR	Negative experiences of misgendering, stereotypes, stigma and/or rejection of services from HCPs TNB people need time to build trust and HCPs need to be willing to learn Need for sensitive and inclusive HCPs where patients can seek care for non-transition related care as well where their identity isn’t the focus Patients would prefer HRT to be primary care led and wanted more research into the long-term impact of HRT Challenges of mainstreaming TNB competent primary care services included inconsistency of HCP education, reluctance to adapt and struggles to ensure clinic wide consistency

NR: not relevant; TNB: transgender and nonbinary; GP: General practitioner; HCP: healthcare provider; HCS: healthcare system(s); GNC: gender non-conforming; LGBTQ+: lesbian, gay, bisexual, transgender, queer and plus; HRT: hormone replacement therapy; PCP: primary care provider; AFAB: assigned female at birth; AMAB: assigned male at birth.

Table 4. Descriptive quality appraisal of included studies.

Study design	Author	Description
Qualitative	Wright et al. 2021 [24]	Clear qualitative aims and the qualitative approach and method were appropriate (semi-structured interviews). Data collection was adequate to address the research question. Qualitative data collection and analysis were described (thematic analysis). Quotes used to justify themes were adequate.
	Haire et al. 2021 [25]	Clear qualitative aims and the qualitative approach and method were appropriate (semi-structured interviews). The recruitment strategy could have been expanded to include more networks. There was limited discussion of the potential bias of recruiting participants who may have had a prior relationship with an interviewer. Qualitative analysis described (reflexive thematic analysis). Quotes used to justify themes were adequate. Interpretation is substantiated by the data.
	Ker et al. 2020 [26]	Clear qualitative aims and the qualitative approach and method were appropriate (in-depth interviews). Participant recruitment was poorly described. Qualitative data collection and analysis were described in-depth (thematic analysis). Interpretation is substantiated by the data. There is coherency between data sources, collection, analysis and interpretation.
	Willis et al. 2020 [27]	Clear qualitative aims and the qualitative approach and method were appropriate (life-history and semi-structured interviews). Participant recruitment was well-described. Data collection and analysis were described in-depth (thematic analysis using the framework method). There is coherency between data sources, collection, analysis and interpretation.
	Allory et al. 2020 [28]	Clear qualitative aims and the qualitative approach and method were appropriate (semi-structured interviews). Participant recruitment, data collection and analysis were thoroughly described (reflexive thematic analysis in an inductive approach).
	Bell et al. 2019 [29]	Clear qualitative aims and appropriate qualitative design and methodology (qualitative phenomenological approach using semi-structured interviews). Data collection and analysis were clearly outlined (thematic analysis). The quotes used to justify the themes were adequate. However, the researchers discarded phrases interpreted as ‘important’ yet not representing a common experience. This could have been discussed further.
	Zwickl et al. 2019 [30]	Research aims are clear with an appropriate methodology and design. Participants’ demographics are described clearly by gender. There is no data on demographics such as age, ethnicity or socio-economic status. It is difficult to ascertain as to whether this sample is representative of the target population. Not stated as to whether the survey was pre-tested prior to data collection. Qualitative interviews may have been a more appropriate method of data collection. There are variations in the number of answers to the questions of focus for analysis. Reasons behind the non-response rate to specific questions were not given. Statistical analysis well-described.
	Vermeir et al. 2017 [31]	Clear qualitative aims and the qualitative design was appropriate (methods influenced by social constructivism, queer theory and Rhodes risk environment framework). Data collection and analysis thoroughly described (one-on-one interviews; analysis through the constant comparative method and framework analysis). There were clear links between data sources, collection, analysis and interpretation. However, the sample size was small so the research question may not have been best addressed.
	Westerbotn et al. 2017 [32]	Clear qualitative aims and a descriptive qualitative design was used. Data collection and analysis were detailed (qualitative inductive content analysis following in-depth interviews). Interpretation of results were supported by the data collected.
	Melendez et al. 2009 [33]	Clear qualitative aims and methodology (semi-structured interviews). Participant recruitment and data collection were well-described. There was a small sample size and potential selection bias though interpretation of results were supported by the data collected.
Quantitative	Treharne et al. 2022 [34]	Research aims are clearly established with an appropriate methodology and design. Context is clearly described. However it is unclear how representative the sample population is of the target population. The measurements are appropriate for answering the research questions. Reasons for non-response and exclusion of participants from the study were not made fully clear. It was difficult to ascertain risk of non-response bias.
	Kattari et al. 2021 [35]	The research aims are clear and associated variables are clearly described. Participant demographics are described clearly by gender, sexuality, race and socioeconomic status. Though the sample was large it was unclear if it was representative of the population. The measurements are appropriate for answering the research question.
	Bauer et al. 2015 [7]	The research aims are clear with an appropriate methodology and design. However, it is unclear how representative the sample population is of the target population and there is mixed data including results from under-18s within the cohort. There was limited discussion of bias and there was no information on the number of exclusions or non-response from participants.
Mixed methods	Tan et al. 2022 [36]	The rationale for a mixed-methods approach was clear with appropriate methodology. There were in-depth discussion of both quantitative and qualitative results and how they interlinked. The data was integrated and cohesive.
	Goldenberg et al. 2021 [37]	There were clear and appropriate mixed-methods design and methodology, integrating multiple frameworks. Both quantitative and qualitative results were discussed and integrated with each study component adhering to their respective quality criteria.
	Hinrichs et al. 2018 [38]	The rationale for a mixed-methods appraoch was somewhat unclear but the methodology seems appropriate. There was limited discussion around the quantitative results and how this may have impacted participants overall healthcare experiences and their answers in the qualitative section. More could have been done to integrate findings. The different study components adhere to the respective quality criteria.

Table 5. Quotations from included studies.

Theme	Sub-theme	Quotation number	Quotation
1.0 PCP attitudes	Upholding cisnormative views and stereotypes	1 2 3	“[His PCP said they] ‘saw a trans man, he was really a man, he wasn’t like you, he really looked like a man (laughs) he had a beard and everything’ during an appointment.” (27) “There is a widespread perception that primary care does not have good skills for dealing with transgender people. I would rather wait a while and see if my health issues subside by themselves before I seek healthcare.” (28) “[I] feel very, like, trapped by my doctor into presenting a certain way and if I even deviate from that a little bit then I won’t have my options.” (24)
	1.2 PCP knowledge	4	‘She [GP] said to me, “Well, I don’t agree with the NHS paying for medication of this sort for people like you”. I was really taken aback by that…. With a very meek voice, I said, “I’m willing to pay for them”. “Right,” she says, “If you’re willing to pay for them.”’ (29)
2.0 The patient-provider relationship	2.1 Perceived Affirmation or Rejection of Participants’ Gender Identity	5	“It is gold that when I come in, we’re having a conversation as two people who have information about the issue in question. One from a medical perspective and one from actually living it, and they are equally valid. You have resources I don’t, I have resources you don’t, and we’re a team. I really value that we are totally equal partners in what we’re doing.” (37)
	2.2 Ongoing support and gaps in medical research	6	“Research is totally lacking. I think we’re ignored as a population. The healthcare offered doesn’t seem to be based on good evidence and it’s like we’re medical research subjects undergoing experimental treatment. Nobody knows what they’re doing.” (30)
3.0 Healthcare settings	3.1 The physical environment	7 8	Like some sort of sign that has a statement that wouldn’t mean anything to anyone except transgender people. So, like ‘people of all genders.’ … A trans person sees that and is like … ‘all genders? … are they on board?’ It’s nice and stealthy and it opens the door. … It’s just enough to start putting the barriers down, breaking down the walls, and be like ‘I feel safer already.’ (31) “If I don’t see like a sign or an Aboriginal flag, or something referring to Aboriginal health services, I kind of get worried ‘cause I just think about the demographic of the area.” (25)
	3.2 The desire for more primary care-led services	9 10	“That was useful, you know, having a place I was familiar with and someone I was familiar with there, and also just being able to come up to campus and do it. It was much easier I think than - hospitals are scary.” (26) “In an ideal world it would be really nice if your family doctor could do it directly because you know, like, it’s really hard getting [hormones]. So it’s nice to have it with somebody you have an actual relationship with all the time.” (29)
	3.3 Expectations of primary care services	11 12	“So finally, between a GP that I can see quite easily and an endocrinologist who will potentially be more expensive and less accessible.” (28) “I would love it if everyone would have the expertise to deal with it. I would love it. The realist in me says ‘Let’s start small.’ Starting with just the desire and the understanding to want to learn and to know where to go to get the answers. And be willing to take that journey. That would be the willingness. Let’s start with the willingness to not be afraid of taking a new patient when they say ‘Oh, by the way, I’m transgendered.’ You don’t want to hear click, zzzzzz. It’s not a big deal—say ‘Yeah, oh, sure’—whatever. Right. That’s—we need health care. We need basic-human-right health care. That’s all we’re asking. That’s it.” (29)

Hong QP, Fabregues S, Bartlett G, et al. Mixed methods appraisal tool (MMAT) 2018. 2022 [cited 2022 Aug 1]. http://mixedmethodsappraisaltoolpublic.pbworks.com/w/file/127916259/MMAT_2018_criteria-manual_2018-08-01_ENG.pdf.

 Google Scholar

Wright T, Nicholls EJ, Rodger AJ, et al. Accessing and utilising gender-affirming healthcare in England and Wales: trans and non-binary people’s accounts of navigating gender identity clinics. BMC Health Services Res. 2021;21(1):609.

 PubMed Web of Science ®Google Scholar

Haire BG, Brook E, Stoddart R, et al. Trans and gender diverse people’s experiences of healthcare access in Australia: a qualitative study in people with complex needs. PLOS One. 2021;16(1):e0245889. doi: 10.1371/journal.pone.0245889.

 PubMed Web of Science ®Google Scholar

Ker A, Fraser G, Lyons A, et al. Providing gender-affirming hormone therapy through primary care: service users. J Prim Health Care. 2020;12(1):72–78. doi: 10.1071/HC19040.

 PubMed Web of Science ®Google Scholar

Willis P, Dobbs C, Evans E, et al. Reluctant educators and self-advocates: older trans adults’ experiences of health-care services and practitioners in seeking gender-affirming services. Health Expect. 2020;23(5):1231–1240. doi: 10.1111/hex.13104.

 PubMed Web of Science ®Google Scholar

Allory E, Duval E, Caroff M, et al. The expectations of transgender people in the face of their health-care access difficulties and how they can be overcome a qualitative study in France. Prim Health Care Res Dev. 2020;21:e62. doi: 10.1017/S1463423620000638.

 PubMed Web of Science ®Google Scholar

Bell J, Purkey E. Trans individuals’ experiences in primary care. Can Fam Physician. 2019;65(4):E147–E154.

 PubMed Web of Science ®Google Scholar

Zwickl S, Wong A, Bretherton I, et al. Health needs of trans and gender diverse adults in Australia: a qualitative analysis of a national community survey. Int J Environ Res Public Health. 2019;16(24):5088. doi: 10.3390/ijerph16245088.

 PubMed Web of Science ®Google Scholar

Vermeir E, Jackson LA, Marshall EG. Barriers to primary and emergency healthcare for trans adults. Cult Health Sex. 2018;20(2):232–246. doi: 10.1080/13691058.2017.1338757.

 PubMed Web of Science ®Google Scholar

Westerbotn M, Blomberg T, Renström E, et al. Transgender people in Swedish healthcare: the experience of being met with ignorance. Nord J Nurs Res. 2017;37(4):194–200. doi: 10.1177/2057158517695712.

 Google Scholar

Melendez RM, Pinto RM. HIV prevention and primary care for transgender women in a community-based clinic. JANAC. 2009;20(5):387–397.

 Google Scholar

Treharne GJ, Carroll R, Tan KKH, et al. Supportive interactions with primary care doctors are associated with better mental health among transgender people: results of a nationwide survey in Aotearoa/New Zealand. Fam Pract. 2022;39(5):834–842. doi: 10.1093/fampra/cmac005.

 PubMed Web of Science ®Google Scholar

Kattari SK, Call J, Holloway BT, et al. Exploring the experiences of transgender and gender diverse adults in accessing a trans knowledgeable primary care physician. Int J Environ Res Public Health. 2021;18(24):13057. doi: 10.3390/ijerph182413057.

 PubMed Web of Science ®Google Scholar

Bauer GR, Zong X, Scheim AI, et al. Factors impacting transgender patients’ discomfort with their family physicians: a respondent-driven sampling survey. PLOS One. 2015;10(12):e0145046. doi: 10.1371/journal.pone.0145046.

 PubMed Web of Science ®Google Scholar

Tan KKH, Carroll R, Treharne GJ, et al. “I teach them. I have no choice": experiences of primary care among transgender people in Aotearoa New Zealand. N Z Med J. 2022;135(1559):59–72.

 PubMed Web of Science ®Google Scholar

Goldenberg T, Gamarel KE, Reisner SL, et al. Gender affirmation as a source of resilience for addressing stigmatizing healthcare experiences of transgender youth of color. Ann Behav Med. 2021;55(12):1168–1183. doi: 10.1093/abm/kaab011.

 PubMed Web of Science ®Google Scholar

Hinrichs A, Link C, Seaquist L, et al. Transgender and gender nonconforming patient experiences at a family medicine clinic. Acad Med. 2018;93(1):76–81. doi: 10.1097/ACM.0000000000001837.

 PubMed Web of Science ®Google Scholar

Data availability statement

The data underlying this article are available from the corresponding author on reasonable request.