Transgender and Gender Diverse Youth’s Perspectives of Affirming Healthcare: Findings From a Community-Based Study in Kansas

Transgender and gender diverse (TGD) youth experience disproportionate rates of stigma and discrimination, contributing to health concerns. TGD people also report limited access to affirming healthcare, yet little is known about TGD youth and affirming healthcare in the Midwestern U.S. We utilized a community-based, mixed methods survey to explore the health and healthcare experiences of TGD youth in Kansas. Participants (n = 89) were predominantly non-binary (49.4%) and transgender boys/transmasculine (28.1%). Approximately 20% reported discrimination by a healthcare provider and half reported at least one affirming experience (58.5%). Affirming practices included providers using correct names and pronouns (43.1%), asking about gender (38.4%), facilitating access to gender-affirmative healthcare services (20.0%), and connecting to TGD resources (18.5%). Thematic analysis of open-ended responses revealed contextual details about TGD youth’s experiences. These findings are relevant to medical and mental health providers, as well as advocates training providers to offer more accessible and affirming care for TGD youth.

access to medical interventions, such as hormone blockers and gender affirming hormones, is associated with decreased depression, self-harm, and suicidal thoughts among TGD youth (Tordoff et al., 2022).Alternatively, in a study of TGD adults, Kattari et al. (2020) found that lower levels of respect from providers was associated with higher rates of depression and suicidality.Research in this area is limited in scope; while this research indicates gender affirming care is associated with positive outcomes among TGD people, few studies specifically include TGD youth or focus on target areas of the United States in which TGD youth experience high rates of victimization, such as the Midwest and South (Kosciw et al., 2020).It is possible that TGD youth's experiences with and barriers to care may be different in these regions relative to regions with lower rates of victimization.Therefore, this study aimed to redress this gap in the literature by partnering with community organizations and advocates to better understand the healthcare experiences of TGD youth in Kansas, a Midwestern U.S. state, and identify key recommendations and strategies to promote affirming care for TGD youth.

Gender-Affirming Care
Affirming healthcare for TGD people can be defined in both broad and specific terms.Broadly, gender-affirming care includes medical or mental health practices that support and validate a TGD person, such as acceptance of their chosen name and pronoun and using inclusive forms (e.g., providing gender options other than ''male'' or ''female'').Specifically, gender-affirming care includes gender-specific health or mental health care and treatments aimed at affirming one's gender.For youth, these practices may include hormone blockers, genderaffirming hormones, and/or gender-affirming therapy, but rarely include surgical procedures.In this study, we use gender-affirming care to describe the broad practices that all providers can use to support and validate TGD youth.Alternatively, we use the phrase gender-affirmative treatment to describe the latter practices related to medically affirming a TGD person's gender (see Rafferty et al., 2018).

TGD Youth Experiences With Healthcare
TGD youth face significant discrimination and stigma in their experiences with healthcare providers (McCann et al., 2019).This stigma can be seen with providers in an array of healthcare settings and geographic locations (Goldenberg et al., 2021).Studies across both the United States (Goldenberg et al., 2021) and Canada (Heard et al., 2018) demonstrate that even youth who report positive healthcare experiences remain likely to have had negative provider experiences, highlighting the need to advance affirming care practices for TGD youth.Furthermore, less than half (47.1%) of medical providers are confident in their ability to provide genderaffirmative treatment to TGD youth (Vance et al., 2015).Another study of an integrated Midwestern health system found that less than 60% of providers said they were comfortable providing even routine care for youth who identify as TGD (Shires et al., 2017).Perhaps unsurprisingly, this may result in youth needing to travel long distances to find providers who can best help them, as was found by Pampati et al. (2019) in their sample of TGD youth in Atlanta, GA.
It is important to attend to the intersections of marginalization among TGD youth and healthcare.For example, for TGD youth who are low-income (Shook, 2020), people of color (Goldenberg et al., 2019;Shook, 2020), or non-binary (Clark et al., 2018), there may be even less equitable experiences accessing and benefitting from providers (Kattari et al., 2020) than for white, middle-upper class, and gender binary youth.While research exploring these intersections among youth is limited, one study with a sample of TGD adults in the United States found that TGD adults of color were significantly more likely to experience discrimination in numerous healthcare settings and interactions, including emergency departments, with physicians, and in hospital settings (Kattari et al., 2015).In a study of Black TGD youth, Goldenberg et al. (2019) found that when Black TGD youth are affirmed in their gender, this increases their access to healthcare, illustrating the importance of an intersectional approach to understanding TGD healthcare.
Only two studies were located that examined the healthcare experiences of TGD youth in Midwestern U.S. states.In one study, TGD youth identified aspects of their communities that contributed to their experiences with stigma or support, as well as key areas in which their communities needed improvement (Author et al., 2020).TGD youth identified a need for medical and mental healthcare that was affirming of their gender identities.In a multiple case study of TGD youth and their families in a Midwestern state, Author et al. (2021) found that families struggled to locate providers who would affirm their child's gender and who were knowledgeable about gender-affirmative treatments.

Characteristics of Affirming and Non-Affirming Care
Literature on TGD youth experiences with healthcare providers has uncovered qualities that TGD youth associate with affirming care, as well as qualities they associate with non-affirming care.In a study using a sample of youth from Los Angeles, California, Corliss et al. (2007) found that affirming providers are described as ''supportive, caring, nonjudgmental, open-minded, sincere, trustworthy, professional, knowledgeable, and accessible'' and are able to support youth ''to achieve a desired goal'' while providing ''support and validation'' (p. 55).Recent studies (e.g., Clark et al., 2021) in Canada echo these findings, describing affirming care for TGD youth as ''safe, trusting, helpful, and accepting'' (p. 573).These providers are often useful in offering recommendations and referrals to other affirming providers when necessary, serving as a critical link for youth navigating a complex continuum of care (Garcia et al., 2021).
In contrast, non-affirming and unhelpful providers may be cisnormative, as found in an integrative review of literature by Laiti et al. (2019).As demonstrated by Corliss et al.'s (2007) California-based study, these providers do not validate TGD youth, may come off as judgmental, or may make the youth's goals-like hormone replacement therapy-seem unattainable.These providers may come off as adhering to a ''paternalistic, gatekeeping role,'' as they hold the power to ultimately decide who receives hormone therapy (Clark et al., 2018, p. 575).They may neglect to ask for or use chosen names and personal pronouns or may have generally poor ''bedside manner'' (Pampati et al., 2019), and they may be dismissive of youth's ability to self-define their identity due to their young age (Laiti et al., 2019).These negative experiences may occur with both providers and office staff, leading to holistically poor experiences for youth (Pampati et al., 2019).Consequently, TGD youth may be accessing care at lower rates than their cisgender counterparts and may be unlikely to self-disclose to their providers (Laiti et al., 2019;Pampati et al., 2019).

Promoting Affirming Care
Past research has identified strategies for improving affirming care for TGD youth by employing strategies such as implementing standardized protocols for using chosen names and pronouns, offering cultural sensitivity training for providers, and expanding insurance coverage for TGD youth (e.g., Gridley et al., 2016;Heard et al., 2018;Torres et al., 2015;Vance et al., 2015).These studies illustrate the importance of healthcare that affirms TGD youth's genders, particularly given the vast health disparities between TGD and cisgender youth.However, these studies are limited in context, failing to provide an understanding of TGD youth healthcare experiences in the Midwest, particularly within a state that has aimed to restrict access to gender affirming care and enact other anti-trans policies (Author et al., 2020;Author et al., 2021).Additionally, there are a lack of studies that attend to the experiences of non-binary youth, which may be different from binary transgender youth (Kearns et al., 2021).For example, Kattari et al. (2020) found that non-binary adults reported lower levels of respect from medical providers compared with transgender men and women, and yet also reported a lower burden of educating their providers about TGD identities.

The Current Study
Given the limitations in the existing literature and the importance of gender-affirming care for TGD youth, this study aimed to redress these gaps in the literature using a community-based study to explore TGD youth's experiences with medical and mental health providers in Kansas, including both affirming and discriminatory experiences.

Methods
This study employed a community-based, mixed methods design utilizing online survey methods.The study was approved by the University of Kansas Institutional Review Board (Study #146818) and the GLSEN Research Ethics Review Committee and consent was obtained from all participants.

Community-Based Research
The study was initiated by community partners at the Wichita LGBT Health Coalition and the Kansas Chapter of GLSEN, a national organization promoting safe and affirming schools for LGBTQ + youth.Community partners met with university researchers to explore the possibility of conducting a statewide survey of LGBTQ + youth focused on health and healthcare experiences.Key volunteers from these community organizations participated as members of the research team, engaging in study conceptualization and design, data collection and recruitment, manuscript authorship, and advising on data analysis and dissemination of findings.Additionally, students in an undergraduate research course assisted with development and planning for the study, with two students continuing their work on the project after the course concluded by assisting with data analysis and dissemination.

Mixed Methods Design
We utilized a concurrent mixed methods design (Greene, 2006) in which quantitative and qualitative data were collected from the same participants during the same time period.This design allows for the development of contextual and in-depth understanding alongside the enumeration of experiences across a sample (Greene, 2006).An online survey was utilized to collect numerical and open-ended data on health, mental health, healthcare, victimization, and related topics from LGBTQ + youth living in the United States state of Kansas during the fall of 2021.

Sampling and Recruitment
Participants were recruited via email, social media, and personal connections among the community partners, and via the researchers' professional networks.To participate in the study, youth were required to: (1) identify as LGBTQ + or as not heterosexual or not cisgender; (2) be between the ages of 13 and 18 years, inclusive; and (3) live in Kansas at the time of data collection.

Data Collection
The survey was distributed online via Qualtrics.Potential participants clicked the link and answered eligibility questions about their age, LGBTQ + identity, and state of residence.If they were eligible, they were taken to an informed consent/assent page that provided details about the study.Youth indicated whether they wanted to participate or not and, if they indicated a desire to participate, were taken to the survey.Parental consent was waived by the IRB due to the risk of requiring LGBTQ + youth to disclose their LGBTQ + identity to parents in order to participate in research (Taylor, 2008).At the close of the survey, youth were provided an option to enter a drawing to receive 1 of 25 gift cards (five $50, ten $25, and ten $10).Completion of the survey was not required to enter the drawing.
Measures.The online 100-item survey included questions about demographic and social identity characteristics, physical and mental health, healthcare experiences and access, experiences with victimization and bullying, family climate, and community climate.Only questions and measures pertaining to these analyses are discussed here: demographics, physical and mental health, and discriminatory and affirming healthcare experiences.Additionally, specific questions were added to assess for bots or fraudulent responders (Chandler & Paolacci, 2017).
Demographics.Participants answered questions regarding age, gender, sexual orientation, and race/ethnicity.Participants were asked to indicate their age from a list of ages ranging from 13 to 18 years.Gender, sexual orientation, and race/ethnicity included multiple questions including open-and closed-ended response options in order to provide participants the ability to self-identify and promote inclusion.Gender was assessed with one open-ended and two closed-ended questions.First, participants were asked ''What is your gender?''and provided a fill-in-the-blank text option.Next, they were asked to identify ''Which of the following most closely represent your gender?''from a list of options that included (1) cisgender man, transgender man, transmasculine; (2) cisgender woman, transgender woman, transfeminine; (3) nonbinary, agender, genderqueer; (4) two-spirit; (5) other; (6) not sure; or (7) prefer not to say.Finally, participants indicated whether they were TGD with the following question: ''Are you trans, transgender, non-binary, agender, two-spirit, genderqueer, or non-cisgender?''Response options included yes, no, not sure, and prefer not to say.Sexual orientation was assessed in the same manner with an open-ended question followed by a closed-ended question with response options of ( 1 8) Prefer not to say.Participants could select more than one identity category; due to the small number of participants selecting more than one racial identity category, all participants selecting more than one racial category were classified as multi-racial.See Table 1 for a full list of participant demographics.
Physical and Mental Health.Questions related to physical and mental health symptoms and diagnoses included open-ended questions and screening measures related to depression, anxiety, disordered eating, suicidality and self-harm, and binge drinking.Participants were asked, ''Has a doctor told you that you have any physical health conditions (e.g., a heart condition, migraines, etc.)?''and, ''Has a doctor told you that you have any mental health conditions (e.g., depression, anxiety, etc.)?'' with response options of yes (specify), no, and not sure.The Patient Health Questionnaire for Anxiety and Depression (PHQ-4) was used to screen for depression and anxiety (Kroenke et al., 2009).Participants indicated over the past 2 weeks if they had been bothered by problems, such as ''feeling nervous, anxious or on edge,'' ''not being able to stop or control worrying,'' ''feeling down, depressed or hopeless,'' and ''little interest or pleasure in doing things.''Response options included ''not at all = 0, several days = 1, more than half the days = 2, and nearly every day = 3.''Scores were totaled to assess for anxiety (3 or more) and depression (3 or more).
The SCOFF questionnaire is a screening tool for eating disorders that includes five questions used to identify whether an individual may have an eating disorder (Morgan et al., 2000).Questions include: ''S-Do you make yourself Sick because you feel uncomfortably full?C-Do you worry you have lost Control over how much you eat? O-Have you recently lost more than One stone [14 pounds] in a three-month period?F-Do you believe yourself to be Fat when others say you are too thin?F-Would you say Food dominates your life?''Participants indicated yes = 1 or no = 0.Although scores of two or greater are considered cutoff for warranting further assessment for an eating disorder, three or more is considered a more accurate score that is both sensitive and specific (Morgan et al., 2000).Therefore, we utilized a cutoff of three or more in this study.
To assess for self-harm, we adapted several questions from the Self-Injurious Thoughts and Behaviors Interview (SITBI; Nock et al., 2007), including, ''In the past year, did you ever engage in self-harm (i.e., hurt yourself on purpose without attempting to die?)'' and, ''In the past year, did you attempt suicide?''(yes, no, not sure).Lastly, to assess for binge drinking we employed a single item from the Alcohol Use Disorders Identification Test-Concise (AUDIT-C; Bush, 1998), ''How often did you have six or more drinks on one occasion in the past year?''(never, less than monthly, monthly, weekly, daily, or almost daily).Participants were categorized as having engaged in binge drinking if they responded ''less than monthly'' or more frequently (Bush, 1998) Discriminatory and Affirming Healthcare.Participants answered questions about affirming and discriminatory care they received from medical and mental health providers.The same questions were employed to assess for discriminatory experiences in physical and mental health settings but these settings were assessed separately using three questions each: Two closed-ended questions asked ''Have you ever experienced discrimination in a (physical/mental) healthcare setting?''(yes, no, I don't know) and ''Was any of this discrimination due to your..'' with a checklist of social identities including gender iden- tity.An open-ended question asked participants to ''Describe a time you felt discriminated against or unsupported in your identities by your (physical/mental) health provider(s).''Affirming care was assessed using both closed-and open-ended questions.First, participants answered: ''Have you had physical or mental healthcare experiences that were affirming/supportive of your gender identity?''(yes, no, I don't know).Next, they were asked to mark all that applied from a list of affirming experiences ''what was affirming about that experience?''(See Table 3 for  response options).An open-ended question requested participants ''Describe a time when you felt affirmed in your gender identity by a provider.''Assessing Fraudulent Responses.With online surveys, particularly with an incentive attached, it is essential to assess data for responses that may not be people (e.g., bots) or are people taking the survey quickly, without regard to accuracy, to receive an incentive (i.e., fraudulent responders; Chandler & Paolacci, 2017).In the survey, we built in several questions to allow us to assess for eligibility in multiple ways and for inconsistent or nonsensical responses.This involved two strategies: (1) asking similar questions in separate parts of the survey and ( 2) including open-ended questions.Similar questions used throughout to assess for consistency included (1) age and year of birth and (2) zip code and town name.Examples of open-ended responses in which participants were prompted, yet not required, to answer included ''Tell us about your physical health'' and ''What else do you want to share?''Strategies for assessing these responses are included in the next section.

Data Cleaning
Prior to data analysis, data cleaning involved assessing for incomplete data, ineligible participants, and fraudulent responses.A total of 371 surveys were started in Qualtrics.We first assessed for ineligible, incomplete, or

Participants
The final sample included 129 participants, of which 89 (69.0%) were TGD and included in these analyses.
Participants were a mean of 15.3 years old (SD = 1.4).
Participants held a variety of gender identities, with the most common gender identity in the sample being nonbinary (e.g., non-binary, agender, or genderqueer; n = 44; 49.4%).Participants held a broad range of sexual identities, with the plurality of respondents endorsing multiple sexual identities (n = 27; 30.3%); 59.3% (n = 16) of the respondents endorsing multiple sexual identities held an asexual identity in addition to other identities.The sample was predominantly white, with 75.3% (n = 67) participants exclusively identifying as white.See Table 1 for a full description of participants' gender, sexual, and racial/ethnic identities.

Data Analysis
Descriptive statistics were generated to report the demographic characteristics of the sample (sexual orientation, gender, and race) using the items described above.Descriptive statistics were also generated to report rates of mental and physical health problems.This included determining depression and anxiety symptoms employing the PHQ-4 (Kroenke et al., 2009), eating disorder symptoms employing the SCOFF (Morgan, 2000), suicidal behavior employing the SITBI (Nock et al., 2007), and binge drinking employing an item from the AUDIT-C (Bush, 1998).Measures were scored using the cut-offs enumerated above.Lastly, descriptive statistics were generated for rates of discriminatory and affirmative experiences in mental and physical healthcare settings employing the items described above.All quantitative analyses were conducted in StataSE 15 (Longest, 2020).
Open-ended survey responses were coded using thematic analysis (Braun & Clarke, 2006).Open-ended responses related to the research questions were downloaded and reviewed by a subset of three researchers.After establishing familiarity with the qualitative content, the analytic team used the survey questions to deductively establish a tentative codebook (e.g., with broad codes for ''affirming behaviors'' or ''discriminatory behaviors'').Initial rounds of coding sorted youth's openended responses into these codes.Later rounds of coding organized them into themes and sub-themes related to the various ways in which TGD youth were affirmed by or discriminated against by their providers.The analytic team discussed the codes, themes, and sub-themes until consensus was reached.The final set of themes and subthemes were compared with the quantitative analyses to identify where the data converged or diverged.

Discriminatory Care
The majority of the 89 TGD participants (n = 61; 68.5%) answered questions about experiences of discrimination in physical and mental healthcare settings.Of these 61 participants, 19.7% (n = 12) reported having had an experience of discrimination in a physical healthcare setting and 27.9% (n = 17) reported an experience of discrimination in a mental healthcare setting.Though participants reported experiencing discrimination in physical and mental healthcare settings that targeted a range of identities, the most commonly reported identity targeted was gender identity, with 19.7% (n = 12) of TGD respondents reporting experiences of discrimination targeting their gender identity in a physical healthcare setting and 26.2% (n = 16) of TGD respondents reporting discrimination targeting their gender identity in a mental healthcare setting.See Table 2 for a full description of experiences of discrimination in physical and mental healthcare settings.
Open-ended responses revealed numerous incidents of discrimination in physical and mental healthcare settings based on gender identity.Two themes arose in the analysis: (1) Deadnaming and Misgendering and (2) Providing Paternalistic, Harmful Care.All quotes shared to illustrate the findings are kept as youth provided them and not edited, including spelling or grammatical inconsistencies.
Deadnaming and Misgendering.Numerous participants shared that they were misgendered or that their provider used their name given at birth instead of their chosen name (a process known as ''deadnaming'').One youth (#124) expressed frustration that ''my doctor's office doesn't ask my gender identity or pronouns,'' while others shared how their providers or staff used the wrong name or pronoun even when the providers and staff knew their chosen name or pronoun.One participant (#205) said: ''After I changed my name legally, many offices would not change it in their system or they would change it incorrectly even when I/my mother filled out a form and showed proof.Many places wouldn't call me by my name even before it was legally changed because it 'wasn't legally changed yet.'''Several youth talked about therapists engaging in this discriminatory behavior, as well.One participant (#189) said: ''I had a therapist who believes me to be confused and would not take me seriously, and another who claimed to accept me but actively misgendered/dead-named me to my face.''Another participant (#157) shared: ''My therapist said I was changing my name for attention.''This pattern of misgendering and deadnaming sent a message to participants that they were not safe or respected in those healthcare settings.
Providing Paternalistic, Harmful Care.Participants described experiences where they were provided with inadequate care based on their transgender identity.Sometimes providers refused to offer medical or mental healthcare that was gender-specific, such as access to hormone treatment therapy, whereas other times, care was provided, yet providers were not knowledgeable or skilled in issues related to gender identity.For example, one participant (#60) said: Even though I had all the letters from therapists required, [the doctor] did not want to give me hormones again due to weight.Also, [they tried] to prescribe an incredibly low dosage and dismissed my concerns and thoughts .[they] told me the low dosage on pills only was enough, dismissing all the other trans people I had met for which injections had worked much better compared to pills.soI was either being misinformed by someone who didn't know what they were talking about or just lied to.
Another participant (#165) shared: ''The first few doctors I visited [when] trying to get testosterone treated me very badly.They didn't think I was trans and tried to tell me I needed several therapist notes to even talk about getting started on testosterone.''One participant (#279) said they were told their ''period pain shouldnt be taken seriously when it actually hurts more than normal.''Youth who saw mental health providers also shared being denied affirming mental healthcare because therapists did not believe they were trans or felt like being trans was wrong.One youth (#177) said: ''i was told 'it's just a phase' and that 'I'll grow out of it' and that I'm depressed because I'm lgbtq.''Another (#165) shared: ''In therapy, i had a few therapists tell me i was sick and needed to be given shock therapy to fix me.The first few times i tried to talk about being asexual, which i have stopped telling people, i was told it wasn't real by doctors and therapists and that I couldn't be asexual.'' Finally,one youth (#196) said: ''I went to the mental hospital at age 13 and got told I'm too young to understand sexuality and that being gay was a sin.''

Affirming Care
Next, 65 of the 89 TGD participants (73.0%) answered questions about experiences that they had in physical and mental healthcare settings that were affirming of their gender identities.Overall, 58.5% (n = 38) reported having experienced a physical or mental healthcare setting that was affirming of their gender identity.Though a range of affirming behaviors was reported, the most common was using the correct name and pronouns (n = 25; 28.1%).See Table 3 for a full description of experiences of gender-affirming behaviors.
Participants also shared varying ways that providers were affirming of their gender identity.Two themes emerged in the thematic analysis and were generally the opposite of what youth experienced as discriminatory: (1) Using Correct Names, Pronouns, and Identities and (2) Elevating TGD Youth Perspectives and Concerns.
Using Correct Names, Pronouns, and Identities.Youth who indicated experiencing affirming healthcare almost always mentioned that their ''correct pronouns were used'' (#288) or that their provider ''completely respects my gender identity and used all of the correct names and pronouns'' (#176).Being asked this information by providers was meaningful to participants, as indicated by participant #205: ''Some of my specialists have asked if I had a preferred name, what my pronouns were, and actually made an effort to use the correct pronouns.Some have also asked me about my gender identity.''One participant (#157) shared how when their provider corrected others, this was also affirming: ''She corrected my mom when the wrong pronouns were used.''Elevating TGD Youth Perspectives and Concerns.Participants also shared the ways in which providers engaged in affirming care by elevating the TGD youth's perspectives and concerns.One youth (#264) shared that after disclosing their gender identity to their doctor, ''She was conscious of how certain things might make me dysphoric and was able to make me feel safe.''This demonstrated that the doctor had some understanding of gender dysphoria.Another participant (#124) shared that their doctor ''validated my gender identity and offered to address any related concerns and treatment options.''Participants also shared specific affirming practices that their providers engaged in.One participant (#165) said: ''My therapist and doctors have both helped me get my name changed, letter for top surgery, and pointed me to (local LGBTQ center).''Another (#200) said: ''When I was trying to get a therapist .she supported me through trying to get me a chest binder.''Finally, one youth indicated that their provider helped them receive hormone treatments and that their therapist was an LGBTQ + specialist.

Discussion
The findings of this study reveal that TGD youth in Kansas report high levels of mental health symptoms, diagnoses, and challenges (e.g., depression, anxiety, disordered eating, self-harm, and suicidality) and regularly experience both discrimination and affirmation in the context of physical and mental healthcare.Though this study cannot establish causal relationships between mental health and experiences of healthcare, past research leveraging the Gender Minority Stress Model suggests that discriminatory experiences in healthcare likely exacerbate mental health problems for TGD youth (Tan et al., 2019).Given the high rates of both mental health concerns alongside the significant and pervasive barriers to effective care, this is a critical area for research and practice.Spaces that exist for the purpose of promoting health should not have the opposite effect.
While a little over half of TGD youth described affirming experiences by healthcare providers, TGD youth also shared experiences of being deadnamed and misgendered and receiving harmful care that often invalidated their lived experience and failed to meet their medical needs.Though minimal research has examined the effects of co-occurring experiences of discrimination and affirmation in healthcare, past research has considered the effects of co-occurring experiences of microaffirmations, microaggressions, and victimization for TGD youth in family contexts, comparing the mental health outcomes of youth experiencing various levels and combinations of microaffirmations, microaggressions, and victimization (Sterzing et al., 2019).This research found that although affirmation is critical for the mental health of TGD youth, microaffirmations are insufficient to protect from the effects of microaggressions and victimization.Though it is critical to replicate these findings in the context of healthcare, this research suggests the importance of both enhancing affirming experiences and reducing discriminatory experiences in order to promote mental health among TGD youth.
The discrimination TGD youth reported occurred across multiple axes of identities (e.g., sexual orientation, race, and age; Table 2).Though this analysis only examined frequencies of discrimination, rather than the nuances of how discrimination occurred, it may be that younger TGD participants experience greater dismissal when disclosing their gender identities to providers and TGD participants of color experience racist microaggressions when engaging with providers who offer gender affirming care, as been documented in past research (Alvarez et al., 2022;Laiti al., 2019).This is an important consideration as past research has documented the compounding effects of discrimination across numerous social identities (Butz & Gaynor, 2022;Cavalhieri & Wilcox, 2022).The identification of populations with intersecting marginalized identities and their experiences within healthcare settings highlight the need for tailored research and practice approaches, discussed below, to meet the needs of TGD youth experiencing multiple axes of marginalization.
Findings from this study are situated within an understudied Midwestern state, contributing to our understanding of the importance of geographic context.These findings are consistent with prior research that indicates TGD youth need, and often lack, access to genderaffirming care and provide a unique examination of the experiences of Kansas TGD youth.Related studies suggest that TGD youth in Kansas have challenges accessing and utilizing gender-affirming healthcare, despite its benefits (Author et al., 2020;Author et al., 2021).Additional research in the Midwest finds numerous barriers to affirming supportive resources for TGD and LGBTQ + youth more broadly (Author et al., 2019).
Finally, this study contributes to our understanding of the Gender Minority Stress Model through a more indepth exploration of geographic context and enhances our knowledge about the role of healthcare as a context that both contributes to and can ameliorate harm.While the cross-sectional nature of the study and the geographically bound sample do not allow us to identify associations between geographic region and healthcare experiences, the findings do enhance our understanding in this area and warrant further examination.Given the rise of anti-transgender policies across the U.S. in 2020 to 2023, and the bulk of these proposed bills and policies centered in Midwestern and Southern states in the U.S. (Freedom for All Americans, 2023), it is essential to attend to the places in which TGD youth live.

Limitations
While these findings make important contributions to the literature and our understanding of TGD youth healthcare experiences, there are several important limitations to note.First, the sample was limited to one state in the U.S., which resulted in a small sample compared to larger quantitative surveys.Additionally, while generally consistent with Kansas racial demographics (U.S. Census Bureau, 2021), the sample is predominantly white with limited heterogeneity in other areas.The small and homogenous sample prevents us from exploring sub-group analyses.Additionally, the data is crosssectional and we are not able to establish causality between important factors, such as discriminatory health practices and TGD youth mental health symptoms.Importantly, while the study design allows us to explore the healthcare experiences of TGD broadly, there are limitations in the questions asked.For example, we did not assess whether TGD youth were out to their provider(s).Youth may not have reported discrimination because they had not disclosed their identity to providers as of yet; however, we are unable to assess for this.Despite these limitations, this study has numerous strengths that support the contributions to the literature.The study utilized a community-based research team, including service providers and community members in the design, development, analysis, and dissemination, to ensure that the study meets the needs of local advocates and providers.Additionally, we sampled youth directly rather than the typical young adults or college-aged samples, providing access to current experiences of TGD youth rather than retrospective accounts.Finally, this study centered rural communities in an understudied Midwestern state.

Implications for Practice
The findings from this study have important implications for practice that can offer nuance to existing practice recommendations.Concerns such as providers not asking for or using chosen names and pronouns might be addressed through standardized protocols (Gridley et al., 2016).Critics of this approach point out that affirming models of care ''[do] not automatically mean that all TGD youth and their parents experience the care they receive as affirming,'' and additional factors-including the individual characteristics of providers-may influence how affirming a youth's care is (Bartholomaeus et al., 2021, p. 58).Thus, in addition to instating standard protocols, it is also necessary to monitor adherence to these protocols, gathering data about provider use of chosen names and pronouns and rates and satisfaction of provision of gender affirming care.
To address the impact of an individual provider's characteristics, such as knowledge and attitudes, on affirming care and to enhance the abilities of providers to meet the mandates of gender affirming standardized protocols, numerous scholars have called for increasing training for providers on how to be affirming and the positive impacts of affirming care for TGD youth (Gridley et al., 2016;Heard et al., 2018;Torres et al., 2015;Vance et al., 2015).Torres et al. (2015) found that providers desire training on how to best serve TGD youth.Furthermore, Shires et al. (2017) found that about a third of providers in their study reported that they would be willing to provide care to TGD patients with proper training.Expanding training to medical and mental health providers during early educational experiences, as well as through advanced specialization, licensing, and continuing education may improve care toward TGD across specializations.
While many argue for more training to providers to improve providers' approaches with TGD youth, there are multiple facets of training to be considered.Though establishing a baseline knowledge of the needs of TGD youth patients is necessary for the provision of affirmative care, knowledge alone cannot erase the impact that individual provider characteristics may have on care.Hoffman et al. (2009) found that interpersonal skills were more important than knowledge in predicting affirming care outcomes for LGBTQ + youth broadly.Furthermore, ''knowledge'' on affirming care for TGD individuals is predicted less by hours of training and more so by levels of transphobia exhibited by providers; as such, knowledge-focused training does not necessarily lead to competence (Stroumsa et al., 2019).It is also critical for providers to develop skills for engaging with TGD youth clients about their needs and preferences.Some well-meaning providers may not want to offend youth and lose trust by talking openly about gender and identity, and thus may benefit from sensitivity training that helps them to cultivate the skills to have these conversations in affirming ways (Rider et al., 2018).As noted previously, many TGD youth experience multiple axes of marginalization, so it is critical that both knowledge and sensitivity trainings include content that is tailored for working with youth who carry multiple marginalized identities.Such trainings should include strategies for minimizing discriminatory behaviors and maximizing affirming behaviors, as both are likely essential for providing care that meets the mental health needs of TGD clients.Importantly, protocols and trainings often focus on medical staff, yet many of the problems described by participants in this study, such as misgendering, commonly occurred with administrative staff, as well.Thus, it is critical to include administrative staff and other personnel in these trainings and tailor content to the unique roles of these employees.

Implications for Research
Future research can build on this study by further examining the co-occurring experiences of discrimination and affirmation.Additional studies may also employ longitudinal data and methods that allow for the identification of causal relationships between mental health and experiences with healthcare.This study identified that TGD participants experience discrimination targeting multiple identities (e.g., sexual orientation, race, and age) but did not examine the qualitative aspects or the impacts of these experiences, or experiences and impacts of potential affirmations occurring at these intersections.Future research should identify subpopulations of TGD, examine how experiences of discrimination and affirmation and the impacts of these experiences vary for participants holding different intersections of identities, and employ measures that can capture the intersectional facets of discrimination and affirmation experienced by multiply marginalized TGD youth (e.g., The LGBT People of Color Microaggressions Scale; Balsam et al., 2011).
Moreover, this study highlights areas in which additional training for health practitioners and administrative staff may be beneficial to advancing affirming care for TGD youth.While this finding is consistent across multiple studies (Gridley et al., 2016;Heard et al., 2018;Torres et al., 2015;Vance et al., 2015), further research is needed regarding how best to implement this training.Research can illuminate the precise content that may be most impactful for healthcare providers to develop their affirming care, the optimal length and frequency of training, and the most effective training modalities for eliciting change to promote affirming care with TGD youth generally, as well as for intersectionality-informed subpopulations of TGD youth.Lastly, as previous research suggests, training alone may not be enough to overcome individual-level characteristics of providers that can affect whether TGD youth experience the care they receive as affirming (Bartholomaeus et al., 2021).While standardized protocols can be a logical next step to address this possibility, further empirical research into how to mitigate the adverse effects of individual-level characteristics on affirming care is warranted.

Conclusion
This study explored the health and healthcare experiences of TGD youth in Kansas, a state and region of the U.S. with high rates of anti-TGD victimization and stigma and minimal access to affirming resources (Kosciw et al., 2020).Findings illustrate the widespread nature of discrimination for TGD youth in Kansas and highlight the negative and harmful experiences in medical and mental healthcare settings.Importantly, the findings also reveal strategies for affirming TGD youth as authentic and whole people who deserve knowledgeable and supportive providers who can meet their diverse healthcare needs.Medical and mental healthcare professionals should utilize these findings to examine their own practices and behaviors, and the broader practices in their agencies, to ensure TGD youth receive affirming and competent care of the highest quality.

Table 1 .
Demographic Characteristics.duplicatesurveys.Of these, 65 completed eligibility criteria only but none of the survey, 20 completed eligibility and demographics but none of the other survey items, and 72 were identified by Qualtrics as duplicate surveys.We assessed the remaining 214 for fraudulent responses.Of these, an additional 15 were deemed ineligible based on answers to the sexual orientation, gender identity, and/or zip code/town name questions (e.g., a participant indicating they lived outside of Kansas).Of the remaining 199, 80 were identified as likely fraudulent based on multiple inconsistencies between similar questions (e.g., zip code and town name didn't match), inconsistencies between open-ended and closed-ended responses (e.g., writing in gay as sexual orientation, but marking heterosexual only), and/or open-ended responses that did not make sense based on the question (e.g., providing only a year in response to ''Tell me about a time you felt affirmed by a medical provider.'').This left a total sample size of 129.

Table 2 .
Frequency and Types of Discrimination Experienced by TGD Participants in Healthcare Settings.

Table 3 .
Frequency and Types of Affirmative Behavior Experienced by TGD Participants in Any Healthcare Settings.