Equitable Access to Gender-Affirming Care for Transgender and Gender Diverse People with Severe Mental Illness: A Reverse Integration Approach

Transgender and gender diverse (TGD) people with severe mental illness (SMI) face significant barriers to health care access, leading to unmet needs and inequitable health outcomes. Reverse integration models embed primary care services within mental health centers (MHCs) that serve as primary contact points to broader health care systems for people with SMI. Such models have been shown to improve health outcomes in this population by promoting access to screening, preventative care, and chronic metabolic condition management. This article highlights the benefits of gender-affirming medical care (GAMC)-including reductions in depression, at-risk substance use, and suicidality-and explores reverse integration models for promoting equitable access to GAMC for TGD people with SMI. We propose two strategies: (1) colocation of GAMC services within MHCs and (2) coordinated referrals to external GAMC practices. Additionally, we address clinical considerations for supporting GAMC access for people with SMI, emphasizing the importance of individualized, person-centered care, clinician education, care coordination, and ongoing collaboration between MHCs and gender-affirming medical practitioners to equitably serve this population. Recognizing the ethical principles of justice and autonomy, we advocate for integrating supportive GAMC pathways within MHCs to ensure access to comprehensive, affirming care in settings that foster trust and continuity.