{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,13]],"date-time":"2026-10-13T21:22:48Z","timestamp":1791926568026,"version":"4.3.4"},"reference-count":108,"publisher":"MDPI AG","issue":"14","license":[{"start":{"date-parts":[[2023,7,15]],"date-time":"2023-07-15T00:00:00Z","timestamp":1689379200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100001826","name":"Personalized care for individuals experiencing gender dysphoria","doi-asserted-by":"publisher","award":["606360098510"],"award-info":[{"award-number":["606360098510"]}],"id":[{"id":"10.13039\/501100001826","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>When seeking gender-affirming care, trans* and gender-diverse individuals often describe experiencing barriers. However, a deeper understanding of what constitutes such barriers is generally lacking. The present research sought to better understand the barriers trans* and gender-diverse individuals experienced, and their effects, when seeking gender-affirming care in the Netherlands. Qualitative interviews were conducted with trans* and gender-diverse individuals who sought care at a Dutch multidisciplinary medical center. Twenty-one participants were included, of which 12 identified as (trans) male, six identified as (trans) female, one as trans*, and one as gender-nonconforming (GNC)\/non-binary. The interviews were mostly conducted at the homes of the participants and lasted between 55 min and 156 min (mean = 85 min). Following data collection and transcription, the interviews were analyzed using axial coding and thematic analysis. A total of 1361 codes were extracted, which could be classified into four themes describing barriers: lack of continuity: organizational and institutional factors (ncodes = 546), patient\u2013staff dynamics (ncodes = 480), inadequate information and support (ncodes = 210), and lack of autonomy in decision making (ncodes = 125). Within our study, trans* and gender-diverse individuals described encountering multiple and diverse barriers when seeking gender-affirming care in the Netherlands. Future studies are needed to evaluate whether individualized care, the decentralization of care, and the use of decision aids can improve the experienced barriers of trans* and gender-diverse individuals seeking gender-affirming care within the Dutch healthcare system.<\/jats:p>","DOI":"10.3390\/ijerph20146367","type":"journal-article","created":{"date-parts":[[2023,7,17]],"date-time":"2023-07-17T00:56:47Z","timestamp":1689555407000},"page":"6367","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":33,"title":["Voices from a Multidisciplinary Healthcare Center: Understanding Barriers in Gender-Affirming Care\u2014A Qualitative Exploration"],"prefix":"10.3390","volume":"20","author":[{"given":"Maeghan B.","family":"Ross","sequence":"first","affiliation":[{"name":"Department of Plastic Reconstructive and Hand Surgery, Amsterdam University Medical Centers, Location VUmc, 1081 HV Amsterdam, The Netherlands"},{"name":"Amsterdam Public Health Institute, 1081 BT Amsterdam, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hiba","family":"Jahouh","sequence":"additional","affiliation":[{"name":"Department of Plastic Reconstructive and Hand Surgery, Amsterdam University Medical Centers, Location VUmc, 1081 HV Amsterdam, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6407-5405","authenticated-orcid":false,"given":"Margriet G.","family":"Mullender","sequence":"additional","affiliation":[{"name":"Department of Plastic Reconstructive and Hand Surgery, Amsterdam University Medical Centers, Location VUmc, 1081 HV Amsterdam, The Netherlands"},{"name":"Amsterdam Public Health Institute, 1081 BT Amsterdam, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Baudewijntje P. C.","family":"Kreukels","sequence":"additional","affiliation":[{"name":"Amsterdam Public Health Institute, 1081 BT Amsterdam, The Netherlands"},{"name":"Department of Medical Psychology, Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Location VUmc, 1081 HV Amsterdam, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4382-7000","authenticated-orcid":false,"given":"Tim C.","family":"van de Grift","sequence":"additional","affiliation":[{"name":"Department of Plastic Reconstructive and Hand Surgery, Amsterdam University Medical Centers, Location VUmc, 1081 HV Amsterdam, The Netherlands"},{"name":"Amsterdam Public Health Institute, 1081 BT Amsterdam, The Netherlands"},{"name":"Department of Medical Psychology and Psychiatry, Zaans Medisch Centrum, 1502 DV Zaandam, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,7,15]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"357","DOI":"10.1080\/15532739.2018.1543066","article-title":"Transgender and gender diverse people\u2019s involvement in transgender health research","volume":"19","author":"Bouman","year":"2018","journal-title":"Int. J. Transgenderism"},{"key":"ref_2","first-page":"253","article-title":"Quality of Life Following Male-To-Female Sex Reassignment Surgery","volume":"116","author":"Weinforth","year":"2019","journal-title":"Dtsch Arztebl Int."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"21","DOI":"10.1089\/trgh.2015.0008","article-title":"A Systematic Review of the Effects of Hormone Therapy on Psychological Functioning and Quality of Life in Transgender Individuals","volume":"1","author":"Hughto","year":"2016","journal-title":"Transgender Health"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"281","DOI":"10.1080\/19359705.2011.581195","article-title":"The Effects of Hormonal Gender Affirmation Treatment on Mental Health in Female-to-Male Transsexuals","volume":"15","author":"Amand","year":"2011","journal-title":"J. Gay Lesbian Ment. Health"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"675","DOI":"10.1007\/s11199-012-0216-5","article-title":"Gender Affirmation: A Framework for Conceptualizing Risk Behavior Among Transgender Women of Color","volume":"68","author":"Sevelius","year":"2013","journal-title":"Sex Roles"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"113","DOI":"10.1080\/19317611.2013.833152","article-title":"Effects of Testosterone Treatment and Chest Reconstruction Surgery on Mental Health and Sexuality in Female-To-Male Transgender People","volume":"26","author":"Davis","year":"2014","journal-title":"Int. J. Sex. Health"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"813","DOI":"10.1016\/j.jsxm.2018.03.088","article-title":"Shared Decision Making in Gender-Affirming Surgery. Implications for Research and Standards of Care","volume":"15","author":"Mullender","year":"2018","journal-title":"J. Sex. Med."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"727","DOI":"10.1176\/appi.ajp.2019.19010080","article-title":"Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study","volume":"177","author":"Pachankis","year":"2020","journal-title":"Am. J. Psychiatry"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"611","DOI":"10.1001\/jamasurg.2021.0952","article-title":"Association Between Gender-Affirming Surgeries and Mental Health Outcomes","volume":"156","author":"Almazan","year":"2021","journal-title":"JAMA Surg."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"303","DOI":"10.1016\/j.disamonth.2019.07.004","article-title":"Caring for the transgender adolescent and young adult: Current concepts of an evolving process in the 21st century","volume":"65","author":"Agana","year":"2019","journal-title":"Disease-a-Month"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"123","DOI":"10.1097\/ANS.0000000000000256","article-title":"Healthcare experiences of transgender adults: An integrated mixed research literature review","volume":"42","author":"Cicero","year":"2019","journal-title":"ANS Adv. Nurs. Sci."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"582","DOI":"10.1016\/j.jsxm.2018.01.016","article-title":"The Amsterdam Cohort of Gender Dysphoria Study (1972\u20132015): Trends in Prevalence, Treatment, and Regrets","volume":"15","author":"Wiepjes","year":"2018","journal-title":"J. Sex. Med."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"48","DOI":"10.1177\/1363460717740257","article-title":"Rethinking queer failure: Trans youth embodiments of distress","volume":"22","author":"Roen","year":"2019","journal-title":"Sexualities"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"26","DOI":"10.1080\/26895269.2021.1964409","article-title":"Experienced barriers of care within European treatment seeking transgender individuals: A multicenter ENIGI follow-up study","volume":"24","author":"Ross","year":"2023","journal-title":"Int. J. Transgender Health"},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders: DSM-5, The American Psychiatric Association.","DOI":"10.1176\/appi.books.9780890425596"},{"key":"ref_16","unstructured":"World Health Organization (2019). International Statistical Classification of Diseases and Related Health Problems, WHO. [11th ed.]."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Loo, S., Almazan, A.N., Vedilago, V., Stott, B., Reisner, S.L., and Keuroghlian, A.S. (2021). Understanding community member and health care professional perspectives on gender-affirming care\u2014A qualitative study. PLoS ONE, 16.","DOI":"10.1371\/journal.pone.0255568"},{"key":"ref_18","first-page":"23","article-title":"Gender-affirming Care for Transgender Patients","volume":"19","author":"Bhatt","year":"2022","journal-title":"Innov. Clin. Neurosci."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"111","DOI":"10.1089\/trgh.2021.0206","article-title":"Telehealth for Gender-Affirming Care: Challenges and Opportunities","volume":"7","author":"Dowshen","year":"2022","journal-title":"Transgender Health"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"e2011161","DOI":"10.1001\/jamanetworkopen.2020.11161","article-title":"Association of Media Coverage of Transgender and Gender Diverse Issues With Rates of Referral of Transgender Children and Adolescents to Specialist Gender Clinics in the UK and Australia","volume":"3","author":"Pang","year":"2020","journal-title":"JAMA Netw. Open"},{"key":"ref_21","unstructured":"Mann, S., Campbell, T., and Hien, N.D. (2022, August 07). Access to Gender-Affirming Care and Transgender Mental Health: Evidence from Medicaid Coverage. Available at SSRN 4164673. Available online: https:\/\/papers.ssrn.com\/sol3\/papers.cfm?abstract_id=4164673."},{"key":"ref_22","unstructured":"Spade, D. (2022, January 01). Mutilating Gender. Makezine2000. Available online: http:\/\/www.makezine.org\/mutilate.html."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Martos, A.J., Wilson, P.A., and Meyer, I.H. (2017). Lesbian, gay, bisexual, and transgender (LGBT) health services in the United States: Origins, evolution, and contemporary landscape. PLoS ONE, 12.","DOI":"10.1371\/journal.pone.0180544"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"168","DOI":"10.1097\/MED.0000000000000227","article-title":"Barriers to healthcare for transgender individuals","volume":"23","author":"Safer","year":"2016","journal-title":"Curr. Opin. Endocrinol. Diabetes Obes."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"201","DOI":"10.1080\/00981389.2018.1532941","article-title":"Profound health-care discrimination experienced by transgender people: Rapid systematic review","volume":"58","author":"Kcomt","year":"2019","journal-title":"Soc. Work Health Care"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"86","DOI":"10.1089\/lgbt.2021.0391","article-title":"Gender-Affirming Primary Care Access Among Rural Transgender and Gender Diverse Adults in Five Northeastern U.S. States","volume":"10","author":"Almazan","year":"2023","journal-title":"LGBT Health"},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Kearns, S., Kroll, T., O\u2018shea, D., and Neff, K. (2021). Experiences of transgender and non-binary youth accessing gender-affirming care: A systematic review and meta-ethnography. PLoS ONE, 16.","DOI":"10.1371\/journal.pone.0257194"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"3559","DOI":"10.1007\/s11606-021-07001-2","article-title":"Identifying and Addressing Barriers to Transgender Healthcare: Where We Are and What We Need to Do About It","volume":"36","author":"Warner","year":"2021","journal-title":"J. Gen. Intern. Med."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"100517","DOI":"10.1016\/j.xcrm.2022.100517","article-title":"Medicine as constraint: Assessing the barriers to gender-affirming care","volume":"3","author":"Kumar","year":"2022","journal-title":"Cell Rep. Med."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1082","DOI":"10.1111\/hsc.12941","article-title":"\u201cIt\u2019s kind of hard to go to the doctor\u2019s office if you\u2019re hated there.\u201d A call for gender-affirming care from transgender and gender diverse adolescents in the United States","volume":"28","author":"Eisenberg","year":"2020","journal-title":"Health Soc. Care Community"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"18","DOI":"10.1186\/1475-9276-12-18","article-title":"Patient-centred access to health care: Conceptualising access at the interface of health systems and populations","volume":"12","author":"Levesque","year":"2013","journal-title":"Int. J. Equity Health"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"726","DOI":"10.1111\/1468-0009.12297","article-title":"Barriers to care among transgender and gender nonconforming adults","volume":"95","author":"Gonzales","year":"2017","journal-title":"Milbank Q."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1089\/trgh.2016.0024","article-title":"Transgender Noninclusive Healthcare and Delaying Care Because of Fear: Connections to General Health and Mental Health Among Transgender Adults","volume":"2","author":"Seelman","year":"2017","journal-title":"Transgender Health"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"983","DOI":"10.1016\/j.clinbiochem.2014.02.009","article-title":"Barriers to quality health care for the transgender population","volume":"47","author":"Roberts","year":"2014","journal-title":"Clin. Biochem."},{"key":"ref_35","unstructured":"James, S., Herman, J., Rankin, S., Keisling, M., Mottet, L., and Anafi, M.A. (2016). The Report of the 2015 US Transgender Survey, The National Center for Transgender Equality."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1302","DOI":"10.1197\/j.aem.2004.08.032","article-title":"Nonurgent Emergency Department Patient Characteristics and Barriers to Primary Care","volume":"11","author":"Afilalo","year":"2004","journal-title":"Acad. Emerg. Med."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"357","DOI":"10.1176\/ps.2007.58.3.357","article-title":"Perceived Barriers to Mental Health Service Utilization in the United States, Ontario, and the Netherlands","volume":"58","author":"Sareen","year":"2007","journal-title":"Psychiatr. Serv."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"e3008","DOI":"10.1097\/GOX.0000000000003008","article-title":"Barriers to Gender-affirming Surgery Consultations in a Sample of Transmasculine Patients in Boston, Mass","volume":"8","author":"Tabaac","year":"2020","journal-title":"Plast. Reconstr. Surg. Glob. Open"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"409","DOI":"10.17763\/haer.79.3.n0016675661t3n15","article-title":"Suspending Damage: A Letter to Communities","volume":"79","author":"Tuck","year":"2009","journal-title":"Harv. Educ. Rev."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"48","DOI":"10.1007\/s13178-017-0295-8","article-title":"Barriers to Gender-Affirming Care for Transgender and Gender Nonconforming Individuals","volume":"15","author":"Puckett","year":"2018","journal-title":"Sex. Res. Soc. Policy"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"216","DOI":"10.1089\/trgh.2016.0019","article-title":"Opportunities and Gaps in Primary Care Preventative Health Services for Transgender Patients: A Systematic Review","volume":"1","author":"Edmiston","year":"2016","journal-title":"Transgender Health"},{"key":"ref_42","unstructured":"Grant, J.M., Motter, L.A., and Tanis, J. (2011). Injustice at Every Turn: A Report of the National Transgender Discrimination Survey, National Center for Transgender Equality and National Gay and Lesbian Task Force."},{"key":"ref_43","unstructured":"Riggs, D.W., and Kentlyn, S. (2014). Queering Motherhood: Narrative and Theoretical Perspectives, Demeter Press."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"135","DOI":"10.1089\/trgh.2020.0155","article-title":"Gender-Affirming Care Without Walls: Utilization of Telehealth Services by Transgender and Gender Diverse People at a Federally Qualified Health Center","volume":"7","author":"Grasso","year":"2022","journal-title":"Transgender Health"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1089\/jchc.21.09.0094","article-title":"Implementing Gender-Affirming Care in Correctional Settings: A Review of Key Barriers and Action Steps for Change","volume":"29","author":"Murphy","year":"2023","journal-title":"J. Correct. Health Care"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"287","DOI":"10.1037\/pst0000034","article-title":"Psychotherapists as gatekeepers: An evidence-based case study highlighting the role and process of letter writing for transgender clients","volume":"52","author":"Budge","year":"2015","journal-title":"Psychotherapy"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"22","DOI":"10.1016\/j.socscimed.2013.02.019","article-title":"Managing uncertainty: A grounded theory of stigma in transgender health care encounters","volume":"84","author":"Poteat","year":"2013","journal-title":"Soc. Sci. Med."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"1820","DOI":"10.2105\/AJPH.2012.300796","article-title":"Experiences of Transgender-Related Discrimination and Implications for Health: Results From the Virginia Transgender Health Initiative Study","volume":"103","author":"Bradford","year":"2013","journal-title":"Am. J. Public Health"},{"key":"ref_49","doi-asserted-by":"crossref","unstructured":"Snelgrove, J.W., Jasudavisius, A.M., Rowe, B.W., Head, E.M., and Bauer, G.R. (2012). \u201cCompletely out-at-sea\u201d with \u201ctwo-gender medicine\u201d: A qualitative analysis of physician-side barriers to providing healthcare for transgender patients. BMC Health Serv. Res., 12.","DOI":"10.1186\/1472-6963-12-110"},{"key":"ref_50","first-page":"323","article-title":"Monopoly and Power Implications for Trans Health Care Specialists Working in a Centralised Setting: A Qualitative Study","volume":"1","author":"Geurts","year":"2020","journal-title":"Int. J. Gend. Sex. Law"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"254","DOI":"10.1016\/j.jadohealth.2016.03.017","article-title":"Youth and Caregiver Perspectives on Barriers to Gender-Affirming Health Care for Transgender Youth","volume":"59","author":"Gridley","year":"2016","journal-title":"J. Adolesc. Health"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"e2018005","DOI":"10.4178\/epih.e2018005","article-title":"Experiences of and barriers to transition-related healthcare among Korean transgender adults: Focus on gender identity disorder diagnosis, hormone therapy, and sex reassignment surgery","volume":"40","author":"Lee","year":"2018","journal-title":"Epidemiol. Health"},{"key":"ref_53","unstructured":"Keuzenkamp, S. (2012). Worden Wie Je Bent. Het Leven van Transgenders in Nederland. [Be Who You Are. The Lives of Transgender Individuals in the Netherlands], Sociaal en Cultureel Planbureau."},{"key":"ref_54","unstructured":"Karsay, D. (2018). Protecting LGBTQI Rights in Europe. Submission to the Second Review of the Council of Europe Recommendation on Measures to Combat Discrimination on Grounds of Sexual Orientation or Gender Identity (CM\/Rec(2010)5), ILGA-Europe, Transgender Europe, and OII Europe."},{"key":"ref_55","unstructured":"(2019). Ervaringen en Behoeften van Transgenders in de Zorg [Care Experiences and Needs of Transgender Individuals], Zorgvuldig Advies."},{"key":"ref_56","unstructured":"AMC (2023, April 05). Actuele wachttijden bij het Kennis- en Zorgcentrum Genderdysforie (KZcG). Available online: https:\/\/www.amc.nl\/web\/specialismen\/genderdysforie\/trans-gender\/wachttijden-5.htm."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"679","DOI":"10.1038\/s41443-021-00432-9","article-title":"Trans and gender diverse people\u2019s experiences and evaluations with general and trans-specific healthcare services: A cross-sectional survey","volume":"33","author":"Burgwal","year":"2021","journal-title":"Int. J. Impot. Res."},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"348","DOI":"10.1016\/j.jana.2009.07.004","article-title":"\u201cI Don\u2019t Think This Is Theoretical; This Is Our Lives\u201d: How Erasure Impacts Health Care for Transgender People","volume":"20","author":"Bauer","year":"2009","journal-title":"J. Assoc. Nurses AIDS Care"},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"341","DOI":"10.1016\/j.jana.2009.06.004","article-title":"Moving Forward: Transgender Persons as Change Agents in Health Care Access and Human Rights","volume":"20","author":"Cobos","year":"2009","journal-title":"J. Assoc. Nurses AIDS Care"},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"218","DOI":"10.1080\/15532739.2019.1629370","article-title":"Health disparities between binary and non binary trans people: A community-driven survey","volume":"20","author":"Burgwal","year":"2019","journal-title":"Int. J. Transgenderism"},{"key":"ref_61","doi-asserted-by":"crossref","unstructured":"Eyssel, J., Koehler, A., Dekker, A., Sehner, S., and Nieder, T.O. (2017). Needs and concerns of transgender individuals regarding interdisciplinary transgender healthcare: A non-clinical online survey. PLoS ONE, 12.","DOI":"10.1371\/journal.pone.0183014"},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"e025435","DOI":"10.1136\/bmjopen-2018-025435","article-title":"International phase I study protocol to develop a patient-reported outcome measure for adolescents and adults receiving gender-affirming treatments (the GENDER-Q)","volume":"8","author":"Klassen","year":"2018","journal-title":"BMJ Open"},{"key":"ref_63","doi-asserted-by":"crossref","unstructured":"Oorthuys, A.O.J., Ross, M., Kreukels, B.P.C., Mullender, M.G., and van de Grift, T.C. (2022). Identifying Coping Strategies Used by Transgender Individuals in Response to Stressors during and after Gender-Affirming Treatments\u2014An Explorative Study. Healthcare, 11.","DOI":"10.3390\/healthcare11010089"},{"key":"ref_64","doi-asserted-by":"crossref","unstructured":"Ross, M.B., Wesseling, S., Mullender, M., Kreukels, B.P., and van de Grift, T. (2023). Expectations and Experienced Outcomes Regarding Gender-Affirming Surgeries: A Pilot Study. Transgender Health.","DOI":"10.1089\/trgh.2022.0118"},{"key":"ref_65","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1191\/1478088706qp063oa","article-title":"Using thematic analysis in psychology","volume":"3","author":"Braun","year":"2006","journal-title":"Qual. Res. Psychol."},{"key":"ref_66","doi-asserted-by":"crossref","first-page":"171","DOI":"10.1370\/afm.2654","article-title":"Standardization vs Customization: Finding the Right Balance","volume":"19","author":"Sinsky","year":"2021","journal-title":"Ann. Fam. Med."},{"key":"ref_67","doi-asserted-by":"crossref","unstructured":"de Vries, E., Kathard, H., and M\u00fcller, A. (2020). Debate: Why should gender-affirming health care be included in health science curricula?. BMC Med. Educ., 20.","DOI":"10.1186\/s12909-020-1963-6"},{"key":"ref_68","doi-asserted-by":"crossref","first-page":"2534","DOI":"10.1002\/hpm.3531","article-title":"Centralization and innovation: Competing priorities for health systems?","volume":"37","author":"Scarffe","year":"2022","journal-title":"Int. J. Health Plan. Manag."},{"key":"ref_69","doi-asserted-by":"crossref","first-page":"3907","DOI":"10.1080\/00036841003742579","article-title":"The impact of decentralization of health services on health outcomes: Evidence from Canada","volume":"43","author":"Rubio","year":"2011","journal-title":"Appl. Econ."},{"key":"ref_70","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1016\/S0840-4704(10)60279-7","article-title":"Regionalization of Health Care from a Political and Structural Perspective","volume":"22","author":"Elson","year":"2009","journal-title":"Healthc. Manag. Forum"},{"key":"ref_71","doi-asserted-by":"crossref","first-page":"1395","DOI":"10.1007\/s10508-020-01754-3","article-title":"\u201cYou Have to Wait a Little Longer\u201d: Transgender (Mental) Health at Risk as a Consequence of Deferring Gender-Affirming Treatments During COVID-19","volume":"49","author":"Raaijmakers","year":"2020","journal-title":"Arch. Sex. Behav."},{"key":"ref_72","doi-asserted-by":"crossref","first-page":"e2020042762","DOI":"10.1542\/peds.2020-042762","article-title":"A Waitlist Intervention for Transgender Young People and Psychosocial Outcomes","volume":"148","author":"Allen","year":"2021","journal-title":"Pediatrics"},{"key":"ref_73","doi-asserted-by":"crossref","first-page":"o1949","DOI":"10.1136\/bmj.o1949","article-title":"Integrating transgender care into mainstream medicine\u2014An essay by Guy T\u2019Sjoen and Joz Motmans","volume":"379","author":"Sjoen","year":"2022","journal-title":"BMJ"},{"key":"ref_74","doi-asserted-by":"crossref","first-page":"277","DOI":"10.1080\/00926230490422467","article-title":"Patient Satisfaction with Transgender Health Services","volume":"30","author":"Bockting","year":"2004","journal-title":"J. Sex Marital. Ther."},{"key":"ref_75","doi-asserted-by":"crossref","first-page":"491","DOI":"10.1353\/pbm.2007.0047","article-title":"Ethical Problems with the Mental Health Evaluation Standards of Care for Adult Gender Variant Prospective Patients","volume":"50","author":"Hale","year":"2007","journal-title":"Perspect. Biol. Med."},{"key":"ref_76","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1080\/15532730903008032","article-title":"The Ten Tasks of the Mental Health Provider: Recommendations for Revision of the World Professional Association for Transgender Health\u2019s Standards of Care","volume":"11","author":"Lev","year":"2009","journal-title":"Int. J. Transgenderism"},{"key":"ref_77","doi-asserted-by":"crossref","first-page":"409","DOI":"10.1177\/1049732319860265","article-title":"Unmet Expectations in Health Care Settings: Experiences of Transgender and Gender Diverse Adults in the Central Great Plains","volume":"30","author":"Meyer","year":"2020","journal-title":"Qual. Health Res."},{"key":"ref_78","doi-asserted-by":"crossref","first-page":"147","DOI":"10.1080\/26895269.2020.1742842","article-title":"Experiences of surgery readiness assessments in British Columbia","volume":"21","author":"MacAulay","year":"2020","journal-title":"Int. J. Transgender Health"},{"key":"ref_79","doi-asserted-by":"crossref","first-page":"72","DOI":"10.1177\/0022167817745217","article-title":"The Informed Consent Model of Transgender Care: An Alternative to the Diagnosis of Gender Dysphoria","volume":"58","author":"Schulz","year":"2018","journal-title":"J. Humanist. Psychol."},{"key":"ref_80","doi-asserted-by":"crossref","first-page":"3577","DOI":"10.1111\/jocn.13271","article-title":"\u2018Wouldn\u2019t it be easier if you continued to be a guy?\u2019\u2014A qualitative interview study of transsexual persons\u2019 experiences of encounters with healthcare professionals","volume":"25","author":"Milton","year":"2016","journal-title":"J. Clin. Nurs."},{"key":"ref_81","unstructured":"Stokoe, E., and Speer, S.A. (2011). Conversation and Gender, Cambridge University Press."},{"key":"ref_82","doi-asserted-by":"crossref","first-page":"591","DOI":"10.1016\/j.jsxm.2018.01.017","article-title":"Association Between Gender Confirmation Treatments and Perceived Gender Congruence, Body Image Satisfaction, and Mental Health in a Cohort of Transgender Individuals","volume":"15","author":"Gerth","year":"2018","journal-title":"J. Sex. Med."},{"key":"ref_83","doi-asserted-by":"crossref","unstructured":"U.S. Department of Health and Human Services FDA Center for Drug Evaluation and Research, and U.S. Department of Health and Human Services FDA Center for Devices and Radiological Health (2006). Guidance for industry: Patient-reported outcome measures: Use in medical product development to support labeling claims: Draft guidance. Health Qual. Life Outcomes, 4, 79.","DOI":"10.1186\/1477-7525-4-79"},{"key":"ref_84","doi-asserted-by":"crossref","first-page":"1231","DOI":"10.1111\/hex.13104","article-title":"Reluctant educators and self-advocates: Older trans adults\u2019 experiences of health-care services and practitioners in seeking gender-affirming services","volume":"23","author":"Willis","year":"2020","journal-title":"Health Expect."},{"key":"ref_85","doi-asserted-by":"crossref","first-page":"241","DOI":"10.1007\/s10730-019-09376-6","article-title":"Integrative Clinical Ethics Support in Gender Affirmative Care: Lessons Learned","volume":"31","author":"Hartman","year":"2019","journal-title":"HEC Forum"},{"key":"ref_86","doi-asserted-by":"crossref","first-page":"687","DOI":"10.1007\/s11019-021-10023-6","article-title":"Decision-making approaches in transgender healthcare: Conceptual analysis and ethical implications","volume":"24","author":"Gerritse","year":"2021","journal-title":"Med. Health Care Philos."},{"key":"ref_87","first-page":"224","article-title":"Tertium non datur\u2014Either\/or reactions to transsexualism amongst health care professionals: The situation past and present, and its relevance to the future","volume":"2","author":"Nieder","year":"2011","journal-title":"Psychol. Sex."},{"key":"ref_88","first-page":"e147","article-title":"Trans individuals\u2019 experiences in primary care","volume":"65","author":"Bell","year":"2019","journal-title":"Can. Fam. Physician"},{"key":"ref_89","doi-asserted-by":"crossref","first-page":"E423","DOI":"10.1001\/amajethics.2020.423","article-title":"What Does the Evolution From Informed Consent to Shared Decision Making Teach Us About Authority in Health Care?","volume":"22","author":"Childress","year":"2020","journal-title":"AMA J. Ethics"},{"key":"ref_90","doi-asserted-by":"crossref","first-page":"1361","DOI":"10.1007\/s11606-012-2077-6","article-title":"Shared Decision Making: A Model for Clinical Practice","volume":"27","author":"Elwyn","year":"2012","journal-title":"J. Gen. Intern. Med."},{"key":"ref_91","doi-asserted-by":"crossref","unstructured":"Jarrett, B.A., Peitzmeier, S.M., Restar, A., Adamson, T., Howell, S., Baral, S., and Beckham, S.W. (2021). Gender-affirming care, mental health, and economic stability in the time of COVID-19: A multi-national, cross-sectional study of transgender and nonbinary people. PLoS ONE, 16.","DOI":"10.1371\/journal.pone.0254215"},{"key":"ref_92","doi-asserted-by":"crossref","first-page":"1147","DOI":"10.1001\/journalofethics.2016.18.11.sect1-1611","article-title":"Informed Consent in the Medical Care of Transgender and Gender-Nonconforming Patients","volume":"18","author":"Cavanaugh","year":"2016","journal-title":"AMA J. Ethics"},{"key":"ref_93","doi-asserted-by":"crossref","first-page":"22","DOI":"10.1089\/trgh.2021.0033","article-title":"Factors Associated with Experiences of Gender-Affirming Health Care: A Systematic Review","volume":"8","author":"Howell","year":"2021","journal-title":"Transgender Health"},{"key":"ref_94","doi-asserted-by":"crossref","first-page":"S1","DOI":"10.1080\/26895269.2022.2100644","article-title":"Standards of Care for the Health of Transgender and Gender Diverse People, Version 8","volume":"23","author":"Coleman","year":"2022","journal-title":"Int. J. Transgender Health"},{"key":"ref_95","doi-asserted-by":"crossref","unstructured":"Gerritse, K., Martens, C., Bremmer, M.A., Kreukels, B.P.C., de Boer, F., and Molewijk, B.C. (2022). Sharing decisions amid uncertainties: A qualitative interview study of healthcare professionals\u2019 ethical challenges and norms regarding decision-making in gender-affirming medical care. BMC Med. Ethics, 23.","DOI":"10.1186\/s12910-022-00880-y"},{"key":"ref_96","first-page":"CD001431","article-title":"Decision aids for people facing health treatment or screening decisions","volume":"4","author":"Stacey","year":"2014","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_97","doi-asserted-by":"crossref","first-page":"149","DOI":"10.1093\/hsw\/hlz016","article-title":"Barriers to Mental Health Care for Transgender and Gender-Nonconforming Adults: A Systematic Literature Review","volume":"44","author":"Snow","year":"2019","journal-title":"Health Soc. Work"},{"key":"ref_98","doi-asserted-by":"crossref","first-page":"251","DOI":"10.1016\/j.jadohealth.2014.11.002","article-title":"Health Care Providers\u2019 Comfort With and Barriers to Care of Transgender Youth","volume":"56","author":"Vance","year":"2015","journal-title":"J. Adolesc. Health"},{"key":"ref_99","doi-asserted-by":"crossref","first-page":"2067","DOI":"10.1016\/j.jsxm.2020.06.017","article-title":"Evaluation of the Decision Aid for Genital Surgery in Transmen","volume":"17","author":"Mokken","year":"2020","journal-title":"J. Sex. Med."},{"key":"ref_100","unstructured":"Gerritse, K. (2023). Shared Decision-Making in Transgender Healthcare: Ethical and Conceptual Challenges and the Co-Creation of an Ethics Support Tool. [Ph.D. Thesis, Vrije Universiteit Amsterdam]."},{"key":"ref_101","doi-asserted-by":"crossref","first-page":"107854","DOI":"10.1016\/j.pec.2023.107854","article-title":"GenderJourney: Participatory development of an ethics support tool to foster dialogue and reflection on shared decision-making in gender-affirming medical care","volume":"114","author":"Gerritse","year":"2023","journal-title":"Patient Educ. Couns."},{"key":"ref_102","doi-asserted-by":"crossref","first-page":"2201","DOI":"10.1111\/jsm.13033","article-title":"Partial Treatment Requests and Underlying Motives of Applicants for Gender Affirming Interventions","volume":"12","author":"Beek","year":"2015","journal-title":"J. Sex. Med."},{"key":"ref_103","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1007\/s10508-013-0140-y","article-title":"Gender Identities and Gender Dysphoria in the Netherlands","volume":"43","author":"Kuyper","year":"2014","journal-title":"Arch. Sex. Behav."},{"key":"ref_104","doi-asserted-by":"crossref","first-page":"234","DOI":"10.1080\/26895269.2022.2131675","article-title":"Body image and treatment desires at clinical entry in non-binary and genderqueer adults","volume":"24","author":"Huisman","year":"2022","journal-title":"Int. J. Transgender Health"},{"key":"ref_105","doi-asserted-by":"crossref","first-page":"287","DOI":"10.1089\/trgh.2019.0039","article-title":"Intersectionality Research for Transgender Health Justice: A Theory-Driven Conceptual Framework for Structural Analysis of Transgender Health Inequities","volume":"4","author":"Wesp","year":"2019","journal-title":"Transgender Health"},{"key":"ref_106","doi-asserted-by":"crossref","first-page":"341","DOI":"10.1037\/sgd0000235","article-title":"Suicide in trans populations: A systematic review of prevalence and correlates","volume":"4","author":"McNeil","year":"2017","journal-title":"Psychol. Sex. Orientat. Gend. Divers."},{"key":"ref_107","doi-asserted-by":"crossref","first-page":"56","DOI":"10.1353\/wp.1996.0023","article-title":"Insights and Pitfalls: Selection Bias in Qualitative Research","volume":"49","author":"Collier","year":"1996","journal-title":"World Politics"},{"key":"ref_108","doi-asserted-by":"crossref","first-page":"615","DOI":"10.1097\/01.ede.0000135174.63482.43","article-title":"A Structural Approach to Selection Bias","volume":"15","author":"Robins","year":"2004","journal-title":"Epidemiology"}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/20\/14\/6367\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T20:12:41Z","timestamp":1760127161000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/20\/14\/6367"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,7,15]]},"references-count":108,"journal-issue":{"issue":"14","published-online":{"date-parts":[[2023,7]]}},"alternative-id":["ijerph20146367"],"URL":"https:\/\/doi.org\/10.3390\/ijerph20146367","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,7,15]]}}}