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.