Barriers to sexual and reproductive health care faced by transgender and gender diverse people: a systematic review.

A total of 53 studies examining barriers to SRH services for transgender and gender diverse people were identified and included in the systematic review.

• Studies were sourced from MEDLINE, CINAHL, Embase, PsycInfo, and Global Index Medicus, with a search cutoff of August 17, 2023.
• The review included qualitative, quantitative, and mixed-methods studies.
• Eight studies were deemed moderate quality; the remaining 45 were high quality as assessed using CASP checklists.
• Participant ages across included studies ranged from 18 to 78 years.

The vast majority of included studies were conducted in high-income countries, with very limited evidence from low- and middle-income settings.

• 49 of the 53 included studies were conducted exclusively in high-income countries.
• Only 4 studies were not exclusively from high-income countries.
• This geographic skew limits the generalizability of findings to global transgender and gender diverse populations.

Fertility care was the most studied SRH domain, represented by 20 of the 53 included studies.

• 20 studies related to fertility care.
• 15 studies related to reproductive cancer screening.
• 9 studies addressed antenatal, intrapartum, and postnatal care.
• 4 studies covered contraception, 2 covered abortion care, and 3 spanned multiple SRH domains.

Most included studies were conducted from the perspective of transgender and gender diverse people themselves, with fewer studies capturing health provider perspectives.

• 40 studies were conducted from the perspectives of trans and gender diverse people.
• 10 studies were conducted from the perspective of health providers.
• 3 studies incorporated both perspectives.
• This imbalance may limit understanding of systemic and provider-level barriers from a clinical standpoint.

Financial accessibility was identified as a cross-cutting barrier to SRH services across multiple service domains.

• Financial barriers were identified as both domain-specific and cross-cutting across the SRH service domains examined.
• Financial accessibility issues affected access to fertility care, reproductive cancer screening, and other SRH services.
• This barrier was identified using an inductive thematic approach from which organic themes emerged across domains.

Lack of provider knowledge and education was identified as a significant cross-cutting barrier to SRH care for transgender and gender diverse people.

• Insufficient provider knowledge was noted across multiple SRH domains including fertility care, antenatal care, and reproductive cancer screening.
• This barrier was identified from both the perspectives of trans and gender diverse people and health providers.
• Limited provider education was described as contributing to inadequate or inappropriate care.

Cis-normative and gender-biased health system practices were identified as a systemic barrier unique to transgender and gender diverse patients.

• Cis-normative practices were found across SRH service domains including reproductive cancer screening and antenatal care.
• These practices reflect health systems designed around cisgender assumptions, creating structural exclusion for trans and gender diverse people.
• The review distinguishes this barrier as one not shared with cisgender women, representing a unique obstacle for trans and gender diverse people.

Gender dysphoria associated with SRH treatments and procedures was identified as a barrier specific to transgender and gender diverse people.

• Dysphoria was identified as a barrier across multiple SRH domains, including reproductive cancer screening (e.g., cervical and breast screening) and fertility-related procedures.
• Procedures that involve gendered body parts were particularly associated with dysphoria-related avoidance.
• This barrier was categorized as one of the unique barriers not shared with cisgender women.

Systemic and interpersonal discrimination were identified as cross-cutting barriers to SRH services for transgender and gender diverse people.

• Discrimination was documented at both systemic (institutional) and interpersonal (provider-patient) levels.
• Discrimination was identified across service domains including fertility care, antenatal care, and reproductive cancer screening.
• This barrier was identified through inductive thematic analysis across the 53 included studies.

Limited availability of information relevant to transgender and gender diverse people's SRH needs was identified as a cross-cutting barrier.

• Limited information availability was noted across multiple SRH domains.
• Trans and gender diverse people reported difficulty finding relevant, inclusive, and accurate SRH information.
• This barrier compounds other barriers such as lack of provider knowledge and cis-normative health system practices.

Transgender and gender diverse people share some SRH barriers with cisgender women but also face unique barriers not experienced by cisgender populations.

• Shared barriers with cisgender women include financial accessibility and general systemic discrimination.
• Unique barriers include gender dysphoria associated with SRH procedures and cis-normative health system practices.
• The review concludes that 'both systems- and individual-level reform is necessary to improve not only gender responsiveness but also gender-inclusivity.'