Systemic transphobia and ongoing barriers to healthcare for transgender and nonbinary people: A historical analysis of #TransHealthFail

Transgender (T+) people report negative healthcare experiences such as being misgendered, pathologizing gender, and gatekeeping care, as well as treatment refusal. Less is known about T+ patients’ perceptions of interrelated factors associated with, and consequences of, negative experiences. The purpose of this analysis was to explore T+ patients’ negative healthcare experiences through Twitter posts using the hashtag #transhealthfail. Publicly available Tweets published between July 2015 and November 2021 from US-based Twitter accounts were collected via Mozdeh. Tweets were deductively analyzed for content using a list of a-priori codes developed from existing literature. Additional codes were developed as new ideas emerged from the data. When possible, type of care location, providers interacted with, and initial reason for seeking care were extracted. Each Tweet was coded by at least two team members using NVivo12. A total of 1,340 tweets from 652 unique Twitter users were analyzed. Negative experiences were reported across healthcare settings and professional types, with physicians, nurses, and counselors/therapists being named most frequently. Primary antecedents of negative healthcare experiences and barriers to accessing care were related to health insurance issues and providers’ lack of knowledge, discomfort, and binary gender beliefs. Negative healthcare interactions led T+ patients to perceive receiving a different standard of care and having unmet needs, which could lead to delaying/avoiding care in the future. As such, these results highlight the potential for direct and indirect harm related to providers’ specific actions. Patient strategies to prevent and/or manage negative encounters and care facilitators were also identified. A multi-pronged approach addressing healthcare policy, improving knowledge and attitudes of healthcare providers and ancillary staff, and creating clinical settings that are physically and psychologically safe for T+ patients is critical to improving the healthcare experiences, and ultimately health, of T+ people.Author summary: Transgender people, who have a gender identity that is different than societal expectations based on their assigned sex at birth, have worse physical and mental health compared to their non-transgender counterparts, which could be due to unequal healthcare treatment. We conducted a historical analysis of Twitter data to healthcare experiences reported by transgender people using #TransHealthFail, which was introduced on Twitter in 2015 to bring attention to the frequently poor treatment experienced by transgender people seeking healthcare. Transgender people reported a range of barriers to healthcare at the level of healthcare systems, including insurance issues and organizational policies. Negative interactions were identified across healthcare setting and provider types, often demonstrating providers’ lack of knowledge about, discomfort with, and negative attitudes toward transgender people. Our findings reinforce that negative healthcare experiences have the potential to impact transgender individuals’ health both directly and indirectly. Despite general improvements in social attitudes about transgender people since #TransHealthFail was introduced, many of the problems and negative experiences that were identified in the historical tweets are still common themes in more current literature. Our results highlight the critical need to address healthcare issues at all levels of influence to improve the health of transgender people.