109. “It will just grow this large target on my back” Barriers Pediatric Primary Care Providers Experience to Providing Pediatric Gender-Affirming Care in Primary Care

Both affirming environments and access to gender-affirming medical care positively impact transgender and gender diverse (TGD) youth’s mental health, however many TGD youth experience barriers to accessing this care. Pediatric primary care providers (PCPs) have the opportunity to play an important role in expanding access to gender-affirming care for TGD youth by providing this care in the primary care setting, however this infrequently occurs. The purpose of this study was to explore pediatric PCPs’ perspectives regarding the barriers they experience to providing gender-affirming care in the primary care setting. Pediatric PCPs who had sought support from the Seattle Children’s Gender Clinic were recruited via email to participate in semi-structured, hour-long, individual, interviews that were conducted virtually over Zoom. All interviews were transcribed and then analyzed in Dedoose qualitative analysis software using an inductive thematic analysis framework. Almost half of the 15 PCPs interviewed (47%) practiced in an urban area, with the remaining divided evenly amongst rural and suburban practices. PCPs identified both health-system and community-level barriers to providing gender-affirming care to youth. Health-system-level barriers included: (1) lack of provider foundational knowledge and skills, (2) limited clinical decision-making support related to things like “understanding and negotiating the issues of consent and confidentiality” and (3) health system design limitations like having electronic health records and clinic forms that were not inclusive or staff members who were uncomfortable providing this care “When I first started this work, my nurse went on a tirade [saying], she's not doing this, she's not calling someone by a different pronoun”. Additionally, PCPs noted challenges related to not having enough time during visits, insurance related challenges and not having access to clearly defined protocols, making it easier to just submit a referral. Community-level barriers included (1) community and institutional biases including fear of political, personal, or professional backlash, “I don't feel like I can be a good advocate or an outspoken advocate in my state, because it will just grow this large target on my back and potentially put me in physical harm but also professional harm” (2) provider attitudes regarding gender-affirming care provision and (3) challenges identifying community resources to support TGD youth, particularly around finding affirming behavioral health providers and navigating support for youth in schools. Our findings highlight the need to both improve education about gender-affirming care and develop clinical decision-making support tools for providers currently in practice. PCPs noted fears about being targeted or criminalized for providing this care, highlighting the need to advocate against legislation threatening to ban access to this care and create more welcoming environments for TGD youth in their communities. Because of the clear association between access to gender-affirming care and improved mental health, overcoming these community and health-system-level barriers will make gender-affirming care more accessible for TGD youth and their families.