Barriers and facilitating strategies for healthcare access and reception for transgender children and adolescents

Silveira, Juliana Cristina Pereira; Souza, Danton Matheus de; Cardoso, Clarissa de Souza; Oliveira, Márcia Aparecida Ferreira de

doi:10.1590/0034-7167-2024-0266

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REVIEW • Rev. Bras. Enferm. 78 (Suppl 2) • 2025 • https://doi.org/10.1590/0034-7167-2024-0266 linkcopy

Barriers and facilitating strategies for healthcare access and reception for transgender children and adolescents

Barreras y estrategias facilitadoras en el acceso y atención a la salud de niños y adolescentes transgénero

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objectives: to identify barriers and strategies that facilitate access and welcoming transgender children and adolescents in the Healthcare Network.

Methods: an integrative literature review, with articles, available in full, with children and adolescents between 6 and 19 years of age, published between January 2013 and April 2023, in Portuguese, English or Spanish. The level of evidence was assessed using the JBI classification.

Results: the main barriers were low professional knowledge, hostile professional interactions, and sexual presumption. Facilitating strategies included continuing education, questioning about gender and pronouns, and encouraging a respectful and welcoming environment.

Conclusions: this study indicates numerous barriers to access and support for transgender children and adolescents and strategies that can transform this context, aiming to move towards comprehensive care that recognizes, validates and supports gender identity with appropriate, safe and inclusive care.

Descriptors:
Transgender Persons; Sexual and Gender Minorities; Child; Adolescent; Barriers to Access of Health Services

Author, year and country	Objective	Design and level of evidence	Results/conclusion
American Academy of Pediatrics, 2013, United States(²⁰)	Discuss strategies for welcoming transgender children and adolescents in medical offices.	Expert report; Level VII	Experts point to sexual presumption, lack of gender identification, and an unwelcoming environment with structural homophobia as barriers. The manuscript discusses mainly two strategies: approaching transsexuality in a welcoming manner and continuing education for healthcare professionals.
Vance SRJ et al.; 2015; United States(²¹)	Explore clinical experiences, comfort, professional confidence, and barriers to providing care to transgender youth.	Qualitative study; Level VI	Professionals reported as barriers low knowledge on the subject, interactions marked by judgments and prejudices linked mainly to the low frequency of care for transgender youth, and lack of interconnection in the RAS. The strategies were training, since graduation, which continues in professionals’ work.
Gridley SJ et al.; 2016; United States(²²)	Understand the barriers that transgender youth and their caregivers face in accessing transgender healthcare.	Qualitative study; Level VI	Young people and their caregivers reported barriers such as the use of registered names, outdated and offensive language used by professionals, hostile interactions, reduced clinical complaints and overvaluation of gender, low professional knowledge, lack of protocols, interconnection between the RAS and low health insurance coverage. The strategies used were questioning gender and pronouns, continuing education, formulation of clinical protocols and respectful and inclusive environments.
Clark BA et al.; 2017; Canada(²³)	Analyze the issues of access to primary care among transgender adolescents and youth.	Qualitative study; Level VI	Young people indicated that the lack of a welcoming space was a barrier to accessing healthcare services, mainly associated with previous negative experiences, limited healthcare service coverage and the fear that communications would not be confidential. The strategies indicate the future possibility of teleconsultations.
Rider GN et al.; 2019; United States(²⁴)	Analyze the experiences and attitudes of healthcare professionals about working with transgender youth.	Qualitative study; Level VI	Professionals indicated as barriers fear, mainly, in questioning the social name and pronouns, their low knowledge, hostile interactions, which visualize the performance by colleagues, and lack of interconnection between the RAS. The strategies refer to the desire for professional training, with continuing education offered by healthcare services.
Eisenberg ME et al.; 2019; United States(⁸)	Describe transgender adolescents’ experiences, concerns, and needs in healthcare settings.	Qualitative study; Level VI	Low professional knowledge was identified as a barrier. As strategies, two main topics were identified in the reports, such as questioning about gender and pronouns, and healthcare professionals’ continuing education. Furthermore, the manuscript indicates the need to focus on health complaints and promote a respectful and inclusive environment.
Acosta W et al.; 2019; United States(²⁵)	Understand transgender adolescents’ experience in healthcare services.	Qualitative study; Level VI	Adolescents identified as barriers presumption of sexuality, lack of gender identification, repeated use of registered name, low professional knowledge that leads to hostile interactions. Strategies included questioning gender and pronouns in case of unconscious use, apologizing, making an effort to respect, offering space to speak, in a respectful and inclusive environment, and continuing education.
Pontes JC et al.; 2020; Brazil(²⁶)	Describe and discuss the meanings and concepts attributed by a group of healthcare professionals to the categories of trans “children” and “adolescents” and their relationship with the care practices carried out.	Qualitative study; Level VI	A reduction in transsexuality to transitory stages was observed, with hostile interactions. There is a reduced number of professionals in the multidisciplinary team, and those present tend to downplay complaints and overvalue gender, indicating an unwelcoming environment, with structural homophobia. Strategies were questioning gender identity and the use of pronouns, promoting a space for speech, with a focus on complaints.

BARRIERS

STRATEGIES

• Professional presumption of transgender children’s and adolescents’ sexuality, with reductionist treatments(²⁰,²⁴,²⁵);

• Absence of identification of gender identity with social name and/or pronouns, such as in medical records, identification bracelets and medication administration documentation(²⁰,²⁵);

• Unconscious or conscious use of children’s and adolescents’ registered name, often repetitively, even after corrections by patients and/or their family (²²,²⁵);

• Professionals are afraid of asking patients about their social name and/or pronouns and making a mistake that could cause offense(²⁴);

• Professionals use outdated and offensive language(¹⁸);

• Lack of a sense of a welcoming space for gender-related health demands, with fear that therapeutic communications would not be confidential(²³);

• Low professional knowledge, which results in unresponsive care, marked by stigmas and prejudices, with beliefs, personal values and common sense perceptions in the care of both children and adolescents and their families(⁸,²³,²⁴,²⁵);

• Hostile interactions between professionals, with minimization of gender identity and association of transsexuality with a transitory stage of human development and/or a pathological view of childhood(²²,²⁴,²⁵,²⁶);

• Absence of professionals in the multidisciplinary team who could provide welcoming care, such as mental healthcare professionals and social workers(²⁶);

• Absence of institutional protocols for welcoming and care of transsexual children and adolescents, with dependence on professional knowledge and judgment for quality care(²²);

• Reduction in health complaints among children and adolescents, which led them to seek healthcare services for transsexuality, with a lack of interest in the demand for care and gender overvaluation(²²,²⁶);

• Difficulty in accessing the RAS, due to the lack of specialized services in the region of residence or due to distance, or the perception that the RAS is not available to meet their demands(²³);

• Lack of interconnection between the RAS, especially specialized and non-specialized centers for the care of transgender children and adolescents, with pilgrimages in search of shelter, especially in cases where care is related to transsexuality(²¹,²²);

• Limited health insurance coverage for healthcare related to transsexuality, with the absence of a service that provides care free of charge(²²,²³);

• Unwelcoming healthcare service environment, with structural homophobia(²⁰,²⁶).

• Ask children and adolescents, from the moment they are admitted to the healthcare service, about their gender and the pronouns to be used, in a simple and respectful manner, such as: what are your pronouns? How would you like to be called? The answer should be identified in the medical record, provided that patients and family allow it so that it can be disseminated in the approaches by all professionals in care(⁸,²⁰,²¹,²²);

• In the event of unconscious use of the incorrect name and/or pronoun, it is recommended that professionals not be shy about apologizing to children and adolescents, and call them as they request(²⁵);

• Offer a space to speak to transgender children and adolescents, in a respectful manner, with active listening, without judgments and reprisals, acting with empathy, by all professionals who provide assistance, throughout the RAS(²⁵,²⁶);

• Training on transsexuality and care for the LGBTQIA+ population from professional graduation onwards(²¹,²⁴);

• Continuing education, with constant training and updates, for all those who communicate with transgender children and adolescents in the RAS. If possible, it is recommended that training be carried out by a transgender person(⁸,²⁰,²¹,²⁴,²⁵);

• Efforts by healthcare professionals to respect children, adolescents and their families, regardless of gender identity(²⁵);

• Development of clear, evidence-based protocols, with an age-appropriate care plan, focusing on children, adolescents and their families(²²);

• Focus on health complaints brought by children, adolescents and families instead of gender issues, which should be addressed as a way of providing responsive and respectful care, and focused on when the complaint brought is relevant(⁸,²⁶);

• Telecare as a strategy for welcoming transgender children and adolescents with health demands, regardless of where they live, without the need for transportation(²³);

• Encouraging a respectful and inclusive environment. Environmental adaptations, with posters indicating that children and adolescents are welcome in healthcare services (“This is a neutral place” or “This is a safe place”; use of LGBTQIA+ flag), using pendants on professionals’ clothing that refer to the population. In the long term, construction of neutral bathrooms and beds(⁸,²²,²⁵).

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