Qualitative insights into the experiences and consequences of inconsistent access to gender-affirming care among transgender and gender expansive people

Background Structural stigma remains a robust barrier to critical, life-saving healthcare access, especially regarding gender-affirming hormone therapy (GAHT), among transgender and/or gender expansive communities in the United States. Structural stigma is evident in the prevalence of provider cultural incompetence, the lack of access to insurance, and discrimination, leading many to access and consume unprescribed hormones, which increases health risks. Methods We conducted qualitative interviews (June–October 2023) with a diverse sample across gender, race/ethnicity, and residential neighborhood of 29 TGE adults in the Philadelphia Metro Area. Thematic analysis was performed on their narratives concerning consistent access to general health services and gender-affirming care. Results Three major themes emerged: (1) Loss of access to essential healthcare services, including GAHT, experienced by over two thirds of the sample and driven by cost, insurance, and discriminatory barriers; (2) using and/or sharing unprescribed hormones, which resulted in significant stress and shame, but fostered community solidarity; and (3) recommendations for improving healthcare access, including expanded insurance coverage, mandatory TGE health training for providers, and specialized community health resources. Conclusions Multilevel interventions are needed to address inconsistent healthcare access and its associated risks, particularly using unprescribed hormones.