Instruments used to assess gender-affirming healthcare access: a scoping review protocol

Background: Internationally, the demand for gender-affirming care has increased exponentially in recent years. The clinical presentation of those seeking care has changed with an increase in transmasculine and non-binary identities and a decrease in the average age of those seeking care. Healthcare navigation remains complicated for this population and warrants further investigation in light of ongoing changes in the field. This paper presents a protocol for a scoping review to map and synthesise the academic and grey literature on instruments used to assess healthcare navigation and access for transgender and non-binary individuals seeking gender-affirming care. Methods: This review will search databases (PsychINFO, CINAHL, Medline, and Embase.) and grey literature sources. In line with the methodological framework for scoping reviews, the following six stages will be undertaken: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, (5) collating, summarising and reporting results and (6) consultation. The PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and explanation will be utilised and reported. The research team will undertake the study as outlined in this protocol and an expert panel of young transgender and non-binary youth will oversee the project through patient and public involvement. Conclusions: This scoping review has the potential to inform policy, practice, and future research through enhanced understanding of the complex interplay of factors that impact healthcare navigation for transgender and non-binary people seeking gender-affirming care. The results from this study will inform further research into healthcare navigation considerations generally and will inform a research project entitled “Navigating access to gender care in Ireland—a mixed-method study on the experiences of transgender and non-binary youth”.


Introduction
The World Professional Association of Transgender Health (WPATH) describes the goal of gender-affirming care as partnering with transgender and gender-diverse individuals and working in a holistic manner to address social, mental, and medical health needs (Coleman et al., 2022). This supportive work is often across the lifespan of an individual from youth to older age and includes fostering a space to explore and question gender openly without influence towards a particular intervention (Spencer et al., 2021). Due to the complexity of this work, it is best delivered by staff experienced in gender work, and care should be individually tailored to the individual and their specific needs. Medical interventions may include hormone blockers, cross-sex hormones, and surgical procedures (Coleman et al., 2022).
As our understanding of gender grows, there is a recognition that gender-diverse presentations may be binary or non-binary and either may seek gender-affirming care inclusive of medical and/or surgical interventions. (Monro, 2019; Scandurra et al., 2019). In recent years there has been an unprecedented increase in demand for gender-related healthcare and clinical presentations have changed with an increase in natal females and a decrease in the age of presentation to services (Thompson et al., 2022). Due to the evolving nature of this field of work, continued research is needed to seek to understand the dynamic landscape of gender healthcare.
Currently, gender-related healthcare is typically delivered through either centralised or decentralised models of care (Koehler et al., 2021). Centralised models of care are described as institutions that provide all or most gender-related services at one location or as one team. In contrast, decentralised care is described as care delivered by multiple different autonomous services. In Europe, the term "gender clinics" or "gender identity clinics " are commonly used to describe centralised services. There is little evidence of preferred models of care and Koehler et al. ( This study is particularly interested in exploring access to gender-related healthcare. The study will seek to explore and understand how healthcare is accessed in this population. Various theories have been proposed to explain health-seeking behaviours in this population. Minority Stress has been frequently referenced as a source of social stress, due to stigma and discrimination, that can impair healthcare access and mental health (Hunter et al., 2021). The Gender Affirmation Model has been referenced as a potential protective factor, describing how access can improve when healthcare professionals are known to be affirming and supportive of a person's gender identity (Hidalgo et al., 2013). The Anderson healthcare utilisation model has been used to describe barriers related to healthcare access in gender-diverse youth that encompass multiple factors, including social stressors (Kearns et al., 2021).
Regarding further protective factors, Resilience and hardiness emerge as critical constructs in understanding the experiences of transgender youth in their healthcare-seeking journey. Despite encountering numerous obstacles and facing high levels of discrimination, transgender youth exhibit remarkable resilience in navigating healthcare systems and accessing gender-affirming care. This resilience is characterised by their ability to adapt, cope, and maintain positive mental health outcomes in the face of adversity. Research by Goldenberg et al.
(2020) emphasizes the resilience of transgender youth in their pursuit of healthcare services. The study suggests that stigma and resilience experienced both inside and outside of health care settings can play a role on access to care. In addition, the study found having a positive sense of identity resulted in less difficulties accessing health care.
Furthermore, the concept of hardiness, as proposed by Kobasa (1979), provides further insight into the experiences of transgender youth in healthcare seeking. Hardiness refers to a set of personal qualities including commitment, control, and challenge, which enable individuals to effectively cope with stressful situations. For transgender youth, the commitment to their authentic gender identity, the sense of control over their healthcare decisions, and the willingness to face and overcome challenges are key components of their hardiness.

Amendments from Version 2
The revised edition of the paper incorporates several modifications in response to the suggestions provided by the reviewer. These revisions encompass alterations in sentence structure, elaboration on our approach to grey literature, and a more comprehensive introduction highlighting protective factors among youth. Additionally, we have included commentary on known barriers derived from existing literature. In light of an overarching mixed methods study, our conclusion has been aligned, and the authors have supplied a justification for the significance of this review.

REVISED
Transgender youth face unique challenges when it comes to accessing healthcare, which are influenced by several key features. First, stigma and discrimination from healthcare providers can act as significant barriers, resulting in reluctance to seek care, increases in internalised transphobia and compromised healthcare experiences (White Hughto et al., 2015). Second, limited provider knowledge and understanding of transgender health needs can impede access to appropriate and gender-affirming care (Mikulak et al., 2021). Additionally, systemic factors such as lack of insurance coverage, financial constraints, and limited availability of transgender-inclusive healthcare services further exacerbate healthcare access disparities (Puckett et al., 2018). While existing literature has shed light on these features, further exploration is needed to understand the intersectional experiences of transgender youth, including factors such as race, ethnicity, neurodiversity status, socioeconomic status, and geographic location, which may contribute to additional barriers or disparities in accessing healthcare services. Moreover, the impact of a well-supported social transition on healthcare access is underexplored in the literature.
To the best of the authors' knowledge, no quantitative review of the literature regarding healthcare access has been completed to date. Therefore, the authors propose a scoping review to: i) ascertain a broad overview of the established quantitative literature, ii) examine how the research has been conducted, iii) map the results thematically, iv) identify gaps in the evidence base that can inform future studies.
Due to the nature of this research topic, natal sex and gender will be different from one another. For the purposes of reporting, the authors will disaggregate by gender identity and this will be clearly described, where possible. The framework consists of six iterative stages including 1.) identification of the scoping review question, 2.) identifying relevant studies, 3.) selection of eligible studies, 4.) charting the data, and 5.) collating, summarising and reporting of the results, and 6.) consulting with key stakeholders. The research team feels consultation is crucial with populations that are often omitted from research that studies them. The research team will therefore utilise an already-established expert panel to consult with key stakeholders. The expert panel consists of ten young adults who have lived experience of being transgender or non-binary and interfacing with health systems. They have reviewed the research question and will be consulted with throughout the stages below. Lastly, they will help to disseminate the results to community members and key stakeholders.

This scoping review is informed by methods outlined by Arksey and O'Malley (2005) and includes enhancements by
Stage one: Identification of the scoping review research question Initially, the literature was read broadly to ascertain the current research priorities and gaps. The Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) Checklist framework guidelines will guide the systematic scoping review (Tricco et al., 2018). The research teams' own background and work in the clinical area aided the questioning. In developing the research question, the mnemonic population, concept, and context framework guided the formulation of the study components (Peters et al., 2020). In this study, transgender and non-binary individuals seeking gender-affirming care are the identified population, the concept is a healthcare accessibility instrument, and the context is gender-related healthcare access.
The overall aim of the scoping review is to identify, explore and map the existing literature pertaining to healthcare access for transgender and non-binary individuals. The clinical team wishes to compare the literature base between adults and youth. Specifically, the research team is interested in identifying the quantitative instruments used to measure barriers to care.
Thus, the main research question guiding this review is: What factors help and hinder access to gender-related healthcare and how are these factors identified by quantitative instruments?
Inclusion and Exclusion criteria: This scoping review will consider quantitative studies that assess healthcare access. The studies must include an instrument (i.e. a questionnaire) and access must be related specifically to gender-affirming healthcare. There is no limit on the years published but the included studies must be in English. For full inclusion and exclusion criteria see Table 1.

Study objectives:
The objectives of this scoping review are to: 1. Identify the instruments/tools used in assessing healthcare for transgender and non-binary individuals seeking gender-affirming care.

Compare instruments geographically.
3. Determine the theories underpinning the research.
4. Ascertain the most commonly reported barriers to healthcare navigation.
5. Describe typical methodological aspects, such as study design and outcomes.
6. Identify potential gaps in the research.
The research will examine the above aims in both adult and youth cohorts. Ultimately, the findings will be used to inform the development of a comprehensive healthcare navigation instrument for transgender and non-binary healthcare seekers.

Stage two: Identifying relevant studies
Identification of studies relevant to this review will be achieved by searching electronic databases of published literature. For this review, we will search: 1.) PsychINFO, 2.) CINAHL, 3.) Medline, and 4.) Embase. These databases were chosen due to their relevance to the chosen topic. A University librarian was employed to assist with the formation of the search strategy as recommended by McGowan et al. (2020). Each strategy was amended to the database-specified requirements in relation to MeSH headings, Boolean operators, and truncation markers. A sample search strategy can be found in Table 2.
The study team further agreed to hand-search the reference list of included studies to increase rigour of the search. A grey literature search will be completed to identify potentially missed studies that meet the inclusion criteria via "Google Scholar" and "web searches". This is common practice in scoping review methods and the authors will search the first hundred results from identified key words and assess eligibility. As noted by Godin et al. (2015), the authors should set a number of grey studies in advance that they will review and account for the relevancy ranking features of the sites.
However, if the authors find a high yield of results, they can re-evaluate the limit they set.
To the best of the authors' knowledge, no scoping review has been completed on this topic and the findings will seek to add novel data to the current evidence base.

Stage three: Selection of eligible studies
The review process will consist of two stages. Stage one will be a review of titles and abstracts against an agreed inclusion and exclusion criteria by two researchers (SK and PH). Both reviewers will screen independently using Rayyan software and their results will then be compared and discussed. Rayyan will remove duplicate articles and assist with the screening process. A third reviewer will be available if an agreement cannot be reached (KN). Prior to this, a pilot test will be completed with a sample of studies (n=50) so that the inclusion and exclusion criteria are clear, and decision-making is consistent. As part of the pilot, kappa inter-rater reliability will be used to assess the agreement between reviewers when screening and selecting studies for inclusion, ensuring a consistent and reliable method is used to identify relevant literature.
Stage two will involve a full-text review against the same inclusion and exclusion criteria by (SK and KN). Kappa inter-rater reliability will be used to ensure consistency here too. DOS will be available as a third reviewer as needed. A PRISMA flow diagram will be created to visually represent the process and ensure transparency.
The process of study selection will be reported using the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) (Tricco et al., 2018).
Stage four: Charting the data SK created a data extraction form that will be used to extract data from the chosen studies as per JBI guidelines (2015) and Peters et al. (2020). Data will be charted in Microsoft Excel. Updates and modifications to the data extraction may be added as needed allowing for necessary evolution as data emerges. Modifications may emerge during full text review (by SK and KN) and if a new category is to be added, we will report this in the methods section of review paper and consult with the study team prior (DOS, PH) with rationale.
Initially, the following categories will be charted:

Overall findings
Stage five: Collating, summarising and reporting of the results Extracted data will be collated using Excel and will be shared among the research team for review and final sign-off. Results will be summarised in a narrative manner in keeping with scoping review guidelines. These results will be presented to the PPI group and their insights elicited. The aim of a scoping review is to provide a broad overview of the findings and therefore a quality assessment will be outside the scope of this project. The results will be reported as a report where thematic analysis will summarise the extracted data in response to the scoping reviews aims, for example, the inclusion of patient and public involvement in instrument design may be discussed as a finding. Importantly, gaps in literature will be reported and direction for future research identified.

Stage six: Consultation and dissemination
The lead researcher will discuss the findings with an expert panel of transgender and non-binary youth (n=10). They will be consulted regarding dissemination and included where appropriate. In addition, the findings will be discussed with clinicians who work in the provision of gender care. Regarding dissemination, the authors will aim to publish the protocol and findings in peer-reviewed academic journals. In addition, the results will be presented at LGBT conferences (nationally and internationally) and shared with relevant stakeholders and policymakers in the area.

Conclusion
The results of the scoping review on quantitative instruments used to assess healthcare access will serve as a valuable foundation for a subsequent mixed-method study. The mixed methods study protocol is outlined in more detail in a published paper (Kearns et al., 2022).
By thoroughly examining and synthesising existing quantitative measures, the scoping review will identify gaps, limitations, and areas for improvement in current assessment tools. This comprehensive understanding, alongside a qualitative investigation findings will inform the design of a new quantitative questionnaire that aims to be more comprehensive in capturing the nuances of healthcare access for young transgender and non-binary people in the Irish context.
The mixed-method study, utilising the newly developed questionnaire, holds several benefits for young people and their parents. Firstly, it will provide a more accurate and comprehensive assessment of healthcare access experiences, allowing for a deeper understanding of the challenges and barriers faced by this population. The questionnaire's improved design will enable a more nuanced exploration of factors such as affordability, availability, provider attitudes, and cultural competence, thus capturing the multifaceted nature of healthcare access.
Overall, the mixed-method study, informed by the results of the scoping review, aims to develop a more comprehensive and context-specific quantitative questionnaire. By combining quantitative data with qualitative insights, this research endeavor will contribute to a deeper understanding of healthcare access challenges, promote tailored interventions, and ultimately improve the healthcare experiences and outcomes for young people and their parents in Ireland.

Study status
This study is at Stage 2 -a preliminary search of the literature has been conducted and the software packages Mendeley and Rayyan have been trialled.

Data availability
No data are associated with this article.
be changed to Approved.
is the worth of carrying out the scoping review. It would also be beneficial to outline how young people and other stakeholders (most importantly parents and healthcare providers) will benefit from the study.

Maxence Ouafik
Research Unit of Primary Care and Health, Department of General Medicine, Faculty of Medicine, University of Liège, Liège, Belgium Thank you for the opportunity to review this scoping review protocol. The protocol describes how the authors intend to conduct their scoping review on the topic of access to gender-affirming healthcare. The study aims to identify, explore and map the existing literature concerning healthcare access for transgender and non-binary individuals. The authors have elaborated the following research question: "What factors help and hinder access to gender-related healthcare and how are these factors identified by quantitative instruments?".
The protocol is well-constructed, the rationale is clear and the objectives well described. The authors have taken into account the different guidelines for scoping reviews. Additionally there is a strong focus on patient and public involvement. Nevertheless we have a few points of concern that we have elaborated on below: In the introduction, the authors state that this care is best delivered in a multidisciplinary manner. Could they elaborate on this, particularly on the setting in which they envisage such care? The rationale seems to be that this supportive work is delivered across the lifespan, which is a characteristic of primary care and not necessarily a characteristic of multidisciplinary work per se. We are concerned that the search strategy may need refining to make it more specific. We tried it in Pubmed and returned more than 65,000 hits. It might be necessary to review and refine it with a librarian. One additional element of concern is that 'intersex*' is part of the search strategy, while constituting a different population than the studied population.
The inclusion criteria indicates that qualitative data will be excluded. The first part of the research question is relatively qualitative in nature, given that it asks about promoting and hindering factors we wonder if the authors may regret this exclusion since so much nuance is found in qualitative analyses. This may be something that could be assessed during stage 2 of the review. On the other hand, it seems that the authors have already completed a systematic qualitative review so perhaps these results will be pooled. We hope there is enough quantitative data available to feed into this review.
During stage 3 the authors do not mention how they will evaluate the results from the different reviewers. They could consider the option to calculate a Kappa inter-rater reliability score to check that they are reviewing in a similar way, this would allow them to adjust the process if necessary.
In stage 4 we would suggest splitting point 2 study title and aim since these are often somewhat different.
In stage 5 it would be nice if the PPI panel could participate as well. Their appraisal of the information could be valuable at this point.
A minor point, at the end of paragraph 5 do the authors mean assessed or accessed? "The study will seek to explore and understand how healthcare is assessed in this population." In general we feel this is an interesting scoping review and will provide helpful insights.