Mapping barriers and enablers to gender-affirming surgery access for transgender and gender-diverse people: a systematic review using Levesque et al.’s Healthcare Access Framework

Background Gender-Affirming Surgery (GAS) is an important component of gender-affirming care associated with improved wellbeing among Transgender and Gender-Diverse (TGD) populations. Yet, access to GAS remains variable and under-explored.Objectives To identify and map published studies reporting barriers and enablers to accessing GAS across the surgical pathway for TGD people, and to identify patterns and gaps within the literature.Methods A systematic review was conducted using PubMed, CINAHL, PsycINFO, and Scopus from 2015 to 2025. Peer-reviewed qualitative, quantitative, and mixed-methods empirical studies addressing GAS access among TGD adults were included. Systemic and individual barriers and enablers were mapped to Levesque et al.’s Healthcare Access Framework and analyzed descriptively.Results Of 5,516 records identified, 38 studies met the inclusion criteria. Approachability was the least represented domain, while Ability to Perceive was the only domain in which enablers were reported more frequently than barriers. Barriers predominated across Availability/Accommodation, Ability to Reach, Affordability, and Ability to Pay, whereas both barriers and enablers were commonly reported across Acceptability, Ability to Seek, Appropriateness, and Ability to Engage. TGD subgroup (i.e. transmasculine, transfeminine, and non-binary) reporting was inconsistent, particularly for non-binary participants, limiting interpretation of subgroup-specific access.Conclusion GAS access barriers were concentrated in reaching and paying for care, while barriers and enablers were both commonly reported across interactions with healthcare services. These findings identify important evidence gaps and demonstrate the value of examining healthcare access across the full pathway. Future research could examine how barriers and enablers are described and experienced within the literature to inform future research, policy, and service planning.Review Registration Open Science Framework (https://osf.io/dvmp2/overview)