Improving the healthcare experiences of transgender and gender-diverse youths: a mixed-methods systematic review of interventions

Figures & data

Table 1. PICO eligibility criteria and search strategy.

PICO framework	Inclusion criteria	Exclusion criteria	Associated search terms
Population	Studies which focus on transgender and gender-diverse youths, under 18-years-old, across healthcare settings. Studies which include healthcare staff and transgender and gender-diverse youths.	Studies which utilize cisgender or non-gender-diverse youths. Studies which utilize an adult transgender and gender-diverse population.	Transgender* OR trans OR transsexual* OR “Female To Male” OR “Male To Female” OR FTM OR MTF OR “trans man” OR “trans woman” OR “Gender Non-conforming” OR “Gender Non-Conforming” OR GNC OR TGNC OR Non-binary OR “Non Binary” OR “Demi Gender” OR “Demi Girl” OR “Demi Boy” Or Demi-Gender OR Demi-boy OR Demi-girl OR BiGender OR “Bi Gender” OR Genderless OR “Non Gender*” OR Non-gender* OR Genderqueer OR “Gender Queer” OR “Gender Fluid” OR Genderfluid OR “Multi Gender” OR Multigender OR Multi-gender OR Intersex OR Neutrois OR “Gender Variant” OR “Third Gender” Or “Two Spirit*” OR “2 Spirit*” OR LGBT* OR Transsexual OR agender OR gender identit* AND Youth* OR kid OR kids OR child* OR teen* OR “young person*” OR “young people” OR adolesce*
Intervention	Studies which utilize an intervention to improve the experience of transgender and gender-diverse individuals across healthcare. Studies which utilize all forms of intervention-based research, i.e. RCT, quasi-experimental, pre and posttest designs. Studies which include a qualitative element which identifies staff or transgender and gender-diverse youths’ experience of the intervention or experience post the intervention. Studies which implement the intervention with either healthcare professionals and/or transgender and gender-diverse youths whereby the aim of the intervention is to improve the experiences of the youths and not staff.	Studies which do not use an intervention to improve the experiences of transgender and gender-diverse youths. Studies which identify the experiences of transgender and gender-diverse and/or healthcare staff across healthcare where the experience is not based around the implementation of an intervention	Intervention* OR strateg* OR program* OR educat* OR campaign* OR experiment* OR initiative* OR approach*
Comparison	Studies comparing outcomes pre- and post-intervention or post-intervention only. Studies comparing outcomes among two different groups	Studies without a comparator will be excluded	N/A
Outcome	Studies which identify and discuss the impact/effect of the intervention on the experiences of transgender and gender-diverse youths. Studies which identify the experience of transgender and gender-diverse youths post the implementation of the initiative	Studies which do not discuss the impact/effect of the intervention on transgender or gender-diverse youths.	Healthcare OR “healthcare system” OR “healthcare setting*” OR “healthcare access*” OR “healthcare service*” OR “healthcare facilit*” OR “health system*” OR “health setting*” OR “health service*” OR “health access*” OR “health facilit*” OR “health care system*” OR “health care setting*” OR “health care service*” OR “health care access*” OR “health care facilit*”
MESH headings
PubMed		“Transgender Persons”[Mesh] OR “Transsexualism”[Mesh] OR “Gender Identity”[Mesh] OR “Intersex Persons”[Mesh] AND “Health Services”[Mesh] OR “Health Facilities”[Mesh] AND “Adolescent”[Mesh] OR “Child”[Mesh] OR “Minors”[Mesh] AND “Education”[Mesh]
CINAHL		MH “Gender Identity” OR MH “Nonbinary Persons” OR MH “Gender-Non-conforming Persons” OR MH “Intersex Persons” OR MH “Hijras” OR MH “Transgender Persons” OR MH “Trans Women” OR MH “Trans Men” OR MH “Transsexuals” AND MH “Health Facilities” OR MH “Health Services” OR MH “Child Health Services” OR MH “Community Health Services” OR MH “Adolescent Health Services” OR MH “Assistive Technology Services” OR MH “Dental Health Services” OR MH “Emergency Medical Services” OR MH “Mental Health Services” OR MH “Military Health Services” OR MH “Nursing Care” OR MH “Nutrition Services” OR MH “Rehabilitation” OR MH “Rural Health Services” OR MH “Social Work” OR MH “Substance Use Rehabilitation Programs” OR MH “Urban Health Services” OR MH “Veterans Health Services” OR MH “Women’s Health Services” OR MH “Peer Assistance Programs” OR MH “Health Services for Persons with Disabilities” OR MH “Health Services for the Indigent” OR MH “Health Services, Indigenous” OR MH “Academic Medical Centers” OR MH “Alternative Health Facilities” OR MH “Ambulatory Care Facilities” OR MH “Ancillary Services, Hospital” OR MH “Community Health Centers” OR MH “Dental Facilities” OR MH “Fertility Clinics” OR MH “Health Facility Departments” OR MH “Anesthesiology Service” OR MH “Waiting Rooms” OR MH “Social Work Service” OR MH “Respiratory Therapy Service” OR MH “Radiology Service” OR MH “Psychiatric Service” OR MH “Physical Therapy Service” OR MH “Pharmacy Service+” OR MH “Pain Clinics” OR MH “Outpatient Service” OR MH “Occupational Therapy Service” OR MH “Obstetric Service” OR MH “Nursing Service” OR MH “Midwifery Service+” OR MH “Intravenous Therapy Department” OR MH “Information Systems Department” OR MH “Health Information Management Service” OR MH “Housekeeping Department” OR MH “GI Laboratories” OR MH “Food Service Department” OR MH “Emergency Service+” OR MH “Electrophysiology Laboratories” OR MH “Clinical Laboratories” OR MH “Chaplaincy Service, Hospital” OR MH “Dental Offices” OR MH “Dental Clinics” OR MH “Core Laboratories” OR MH “Clinical Laboratories, Hospital” OR MH “Hospital Units+” OR MH “Delivery Rooms+” OR MH “Intensive Care Units+” OR MH “Intensive Care Units, Pediatric+” OR MH “Pediatric Units+” OR MH “Rehabilitation Centers+” OR MH “Hospitals+” OR MH “Residential Facilities+” AND MH “Adolescence” OR MH “Child” OR MH “Minors Legal” AND MH “Education”
ERIC		DE “Sexual Identity” AND DE “Health Facilities” OR DE “Clinics” OR DE “Health Services” OR DE “Hospitals” OR DE “Medical Services” AND DE “Early Adolescents” OR DE “Late Adolescents” OR DE “Preadolescents” OR DE “Adolescents” OR DE “Youth” OR DE “Young Children” OR DE “Children” AND DE “Intervention” OR DE “Education”
Academic Search Complete		DE “TRANSGENDER people” OR DE “TRANS men” OR DE “TRANS women” OR DE “TRANSGENDER children” OR DE “TRANSGENDER youth” OR DE “TRANSSEXUALS” OR DE “TWO-spirit people” OR DE “GENDER-nonconforming people” OR DE “INTERSEX people” OR DE “GENDER identity” OR DE “GENDER nonconformity” OR DE “GENDER transition” OR DE “THIRD gender” OR DE “TRANSGENDER identity” OR DE “NONBINARY people” AND DE “HEALTH service areas” OR DE “HEALTH facilities” AND DE “CHILDREN” OR DE “MINORS” OR DE “YOUTH” OR DE “ADOLESCENCE” OR DE “TEENAGERS” AND DE “EDUCATION”
PsycArticles		DE “Transgender” OR DE “Transsexualism” OR DE “Gender Identity” OR DE “Gender Nonbinary” OR DE “Gender Nonconforming” OR DE “Two-Spirit” OR DE “Intersex” AND DE “Health Care Services” AND DE “Late Adolescence” OR DE “Early Adolescence” AND DE “Intervention” OR DE “Education” OR DE “Initiative”
PsycInfo		DE “Transgender” OR DE “Gender Nonbinary” OR DE “Gender Non-conforming” OR DE “Two-Spirit” OR DE “Gender Identity” OR DE “Intersex” AND DE “Health Care Services” AND DE “Late Adolescence” OR DE “Early Adolescence” AND DE “Intervention” OR DE “Education” OR DE “Initiative”
SOCIndex		DE “TRANSGENDER people” OR DE “TRANS men” OR DE “TRANS women” OR DE “GENDER-nonconforming people” OR DE “TRANSSEXUALISM” OR DE “GENDER identity” OR DE “NONBINARY people” OR DE “INTERSEX people” OR DE “INTERSEXUAL identity” OR DE “BIGENDER people” OR DE “MULTIGENDER people” AND DE “HEALTH facilities” OR DE “MEDICAL care” OR DE “PUBLIC health” OR DE “CHILD health services” OR DE “COMMUNITY health services” OR DE “CURATIVE medicine” OR DE “DENTAL care” OR DE “EMERGENCY medical services” OR DE “HOSPITAL care” OR DE “HUMANISTIC medicine” OR DE “MEDICAL screening” OR DE “MENTAL health services” OR DE “OCCUPATIONAL health services” OR DE “OUTPATIENT medical care” OR DE “PATIENT care” OR DE “PREVENTIVE health services” OR DE “PREVENTIVE medicine” OR DE “PRIMARY health care” OR DE “RURAL health services” OR DE “SCHOOL health services” OR DE “WOMEN’S health services” AND DE “YOUTH” OR DE “TEENAGERS” OR DE “ADOLESCENCE” OR DE “CHILDREN” OR DE “MINORS” AND DE “EDUCATION”
Trial registry
ClinicalTrials.gov		Transgender OR gender-diverse OR gender non-conforming OR non binary OR gender identity AND healthcare Limit: Child OR Adolescent
WHO International Trial Registry		Transgender OR gender-diverse OR gender non-conforming OR non binary OR gender identity AND healthcare Limit: Child OR Adolescent
Clinical Registry EU		Transgender OR gender-diverse OR gender non-conforming OR non binary OR gender identity AND healthcare Limit: Child OR Adolescent

Table 2. Grey literature search strategy.

Grey literature database Country and website	Keywords
BASE	Transgender youth intervention healthcare
WorldCat	Transgender youth intervention healthcare
Google Scholar	Transgender youth intervention healthcare
USA	Transgender youth intervention healthcare
UK	Transgender youth intervention healthcare
Canada	Transgender youth intervention healthcare
Germany	Transgender youth intervention healthcare
Netherlands	Transgender youth intervention healthcare
Australia	Transgender youth intervention healthcare
France	Transgender youth intervention healthcare
Belgium	Transgender youth intervention healthcare
Brazil	Transgender youth intervention healthcare
Spain	Transgender youth intervention healthcare
India	Transgender youth intervention healthcare
Italy	Transgender youth intervention healthcare
Peru	Transgender youth intervention healthcare

Table 3. Condensed data extraction table (n = 9).

Author, year, aim	Study population	Design	Description of the intervention	Impact of intervention on TGD youths	Impact of intervention on healthcare providers
Dahlgren Allen et al. (2021) To determine the impact of the FASST intervention on the mental health and wellbeing of TGD youths	Quantitative arm: TGD youths pre-post test (n = 142) TGD youths historical control (n = 120) Qualitative arm: TGD youths (n = 14)	Convergent parallel mixed-methods	First Assessment Single-Session Triage (FASST) clinic that provided information and support to young people and their families and triages them onto a secondary waitlist for subsequent multidisciplinary care.	Quantitative arm: Higher rates of social transition Pre: Socially transitioned: n = 45 (33.3%) Concerns about support: n = 83 (60.6%) Post: Socially transitioned: n = 69 (51.9%) Concerns about support: n = 54 (40%) p < 0.001
				Greater use of menstrual suppression among AFAB No change to antidepressant use Minimal difference in health professional use Increase in GP visits.
				Improved mental health Parent rated Child Behavior Checklist (CBCL) Depression p = <0.001 Anxiety p = 0.025 Youth Self Report (YSR) Depression p = 0.002 Anxiety p = 0.029 Child Health Utility 9D (CHU9D) Quality of life p < 0.001 Unhealthy Family Functioning range reduced by 11%
				Historical control group CBCL Depression p = 0.065 Anxiety p = 0.21 YSR Comparison not possible
				Qualitative arm: Changes related to topics directly addressed in FASST: Organizational supports Learning about RCHGS Receiving appointments and referrals Links to support groups
				Social transition Undergoing further social transition after FASST. Significant positive step. Increased agency: More influence, control, and ownership over their lives.
				Agency resulted from changes to outlook, validation, sense of self and confidence.
Jadwin-Cakmak et al. (2020) Evaluate the impact of the Health Access Initiative (HAI) program delivered to healthcare providers.	Healthcare professionals (n = 153) across 10 sites	Quasi-experimental Mixed-methods	Stage 1: Online training—1-h webinar Stage 2: In-person training—2-h training Stage 3: Technical assistance (TA)—3 months post in-person training HAI program staff work with clinic liaisons to identify any TA needs		Affirming TGD practices: Use of preferred name: M: Pre: 4.72/5, Post: 4.76/5, p = 0.657 Use of preferred pronouns: M: Pre: 4.51/5, Post: 4.55/5, p = 0.661 Knowledge: M: baseline: 7.22/12, post: 7.82/12, p = 0.009 Attitude: M: baseline = 3.40/4 6-month follow up = 3.61/4, p = 0.002 Assume they identify with sex assigned at birth until they tell me otherwise: M: Pre: 3.26/5, Post: 2.27/5, p = 0.001 Overall, I think our clinic is a safe space for TGD youth: M: Pre: .87/1, Post: .99/1, p = 0.0007 I am willing to work with colleagues to create an affirming clinic for TGD youth: M: Pre: .98/1, Post: 1.00/1, p = 0.082 (Significant at .10)
					TA interviews: 80% of sites are updating their medical record system to allow for capture of patient’s gender identity, pronouns, preferred name
Martin et al. (2022) To evaluate educational resource material on the healthcare needs of TGD youths for healthcare trainees and professionals Designed in collaboration with TGD youths	Healthcare trainees and professionals (n = 467)	Randomized control trial (RCT)	Four parallel groups: Group 1: Transgender female presenting the teaching material with videos. Group 2: Cisgender woman presenting teaching material with videos. Group 3: Cisgender woman presenting teaching materials with no videos. Group 4: No intervention control. Video clips of two TGD adolescents sharing aspects of their lived experience		Mean scores increased for 6 domains in the video group compared with the no video group with a reduced effect after 30 days. The only outcome not changed at the 30-day mark was warmth for a TGD family member. Every outcome measure improved between pre and post when all active interventions were combined, p ≤ 0.02. When individually considered each of the groups had different levels of change after the intervention. TgV—6 domains CgV—3 domains CgN—2 domains
					Knowledge: Combined active arms Statistical difference in knowledge, McNemar; Cochran-Mantel-Haenszel (CMH) across groups >0.05 4/5 questions p < 0.001 1/5 questions p < 0.01
					Beliefs: Temperature rating scale: 3 Combined active arms Friend or social acquaintance (p < 0.001) Teacher or fellow student (p < 0.01) Family member (p < 0.001)
					TgV group: Only group to individually identify a significant change in belief. Friend or social acquaintance (p < 0.05) Teacher or fellow student (p < 0.01) Family member (p < 0.05).
					Social tolerance subscale: 3 Combined active arms, p < 0.05 Those who were fully accepting had higher outcome values at baseline. Those who were not accepting had larger differences in mean scores after the intervention.
Riggs (2021) “…examine outcomes from a four-part webinar series on affirming approaches to working with trans and non-binary young people in terms of Australian psychologists’ confidence in working with this population” p. 181	Psychologists who had been practicing for 15 years in a private clinic (n = 55)	Quasi-experimental pre-post test (mixed-methods)	Four 90-min synchronous webinars over a two-month period facilitated by a psychotherapist with specialism in TGD youths.		Previous TGD training: Yes: n = 34(62%) No: n = 21(38%) Greater confidence in those who previously undertook training when working with TGD youths: p = 0.001
					Number of TGD youths previously worked with: M = 3.85, SD = 4.19, Range 1–20 Greater confidence in those who previously worked with TGD youths: p = 0.05 Number of TGD youths worked with and amount of confidence: r = .48, p = 0.001
					Aware of DSM5 diagnosis of gender dysphoria: Pre-webinars: Yes: n = 46(84%) No: n = 9(16%) Post-webinars: Yes: n = 55(100%) No: n = 0(0%) Greater confidence working with TGD youths post webinar: p = 0.02 Understanding the information sheet and confidence working with TGD youths post webinar: r = .46, p = 0.05 Understanding of gender identity and confidence working with TGD youths post webinar. r = .85, p = 0.03 GENDER mnemonic would be helpful n = 55(100%).
					Qualitative: Cisgender: Pre-webinar: Unable to provide a definition or mistook cisgenderism for cisgender n = 48(87%). Post-webinar: Able to give a definition n = 55(100%)
					Transgender: Pre-webinar: Definition of transgender that constituted cisgenderism n = 32(58%). Transgender as a transition related process or an identification related process n = 13(42%). Post-webinar: n = 40(73%) of participants identified transgender n = 15(27%) definition that was constituted as cisgenderist.
					Non-binary: Pre-webinar: Non-binary as a continuum or in the context of not being female or male (n = 40, 73%). Unable to provide any definition (n = 15, 27%). Post webinar: Non-binary in the context of a continuum or being neither male nor female (n = 55, 100%).
Sequeira et al. (2022) “…to conduct a 2 year quality improvement project to increase affirmed name and pronoun documentation in the pediatric ED” p. 995	TGD youths (n = 196)	Quality improvement project	3 Plan-Do-Study-Act (PDSA)cycles		Percentage of ED visits with pronouns documented: Baseline: 13.8% PDSA cycle 1: 20.1% PDSA cycle 2: 20.1% PDSA cycle 3: 47.8% Increase in PDSA cycle 3 following dissemination of a near miss case study.
Staggs et al. (2022) ‘To understand the baseline state of name and pronoun use at our institution and develop strategies for improvement based on findings’	TGD youths and parents baseline (n = 55/328) TGD youths and parents follow up (n = 180/721) Hospital employees n = 11,090 (99.4%)	Mixed-methods Quality improvement project	Mandatory online LGBTQ + training module containing 14 interactive slides with a final quiz. The SOGI Epic form was piloted. Providers were given a 4–5 min training video and a tip sheet with FAQs.		n = 1662 (97.3% of physicians and APP completed the SOGI training n = 11,090 (99.4%) of hospital employees completed the Understanding Gender and Sexual Orientation module. 85% of hospital employees strongly agreed or agreed that the course was helpful to their role. 81% strongly agreed and agreed they learned something new Affirming documentation of name and pronouns: Gender diversity clinics Check-in, p < 0.0001 Medical assistant/nurse/technician interactions, p = 0.003
Vance et al. (2017) “To enhance pediatric trainees’ and students’ knowledge of the psychosocial and medical issues facing transgender youth through a comprehensive curriculum.” p. 1	Healthcare providers (n = 20)	Quasi experimental Retrospective pre-post design	Transgender youth curriculum based on a comprehensive literature review and expert consultations. Two elements: Online modules Observational experience at a child and adolescent gender clinic.		Knowledge/awareness measures: Components of gender: M: Pre: 3/5, Post: 5/5, p < 0.001 Difference between gender and sexuality: M: Pre: 4/5, Post: 5/5 p = 0.002 “Transgender” as an umbrella term: M: Pre: 3/5, Post 4.5/5, p = 0.001 Variability in age of presentation of transgender youth: M: Pre: 2.5/5, Post: 4/5, p = 0.001 Questions to ask transgender youth about gender identity: M: Pre: 2/5, Post: 4/5, p < 0.001 Ways to ask about preferred name: M: Pre: 3/5, Post: 4/5, p < 0.001 Questions to ask about gender history: M: Pre: 2/5, Post: 4/5, p < 0.001 Manifestations of gender dysphoria: M: Pre: 3/5, Post: 4/5, p < 0.001 Role of family rejection in poor psychosocial outcomes: M: Pre: 3/5, Post: 5/5, p < 0.001 Questions for transgender HEADSS assessment: M: Pre: 3/5 Post: 4/5 p < 0.001 How to sensitively approach Tanner staging transgender youth: M: Pre: 2/5, Post: 4/5, p < 0.001 How puberty can trigger gender dysphoria in transgender youth: M: Pre: 2/5 Post: 4/5, p < 0.001 Methods used to conceal unwanted secondary sexual characteristics: M: Pre: 2.5/5, Post: 4/5, p < 0.001 Methods used to simulate desired secondary sexual characteristics: M: Pre: 2/5, Post: 4/5, p < 0.001 Types of psychosocial support for transgender youth: M: Pre: 2/5, Post: 4/5, p < 0.001 Role of gender specialist mental health provider: M: Pre: 2/5, Post: 4/5, p < 0.001 Benefits of pubertal blockers: M: Pre: 2/5, Post: 4/5, p < 0.001 Irreversible effects of estrogen: M: Pre: 2/5, Post: 4/5, p < 0.001 Irreversible effects of testosterone: M: Pre: 2/5, Post: 4/5, p < 0.001 PCP role in reducing gender dysphoria: M: Pre: 2/5, Post: 4/5, p < 0.001
					Expected usefulness: Caring for transgender youth: 4.7/5 Use the information gained from this curriculum: 4.8/5
Wahlen et al. (2020) To explore “the knowledge and attitudes of medical students regarding LGBT people,” and to assess “the impact of a 1-h lecture targeting adolescent LGBT health needs.” p. 1	Medical students (n = 157)	Quasi experimental	One-hour mandatory lecture focusing on healthcare needs of LGBT adolescents.		Attitudes: M(SD): Baseline = M: 84.8/100(13.6), Post = 86.8/100(15.4), p < 0.001, d = 0.14 Knowledge: M(SD): Baseline = 73.7/100(18.1), Post = 87.9/100(15.7), p < 0.001, d = 0.84
					Swiss vs. foreign students knowledge: M: foreign students = 59.2/100, Swiss students = 73.1/100, p = 0.05
					Active religious practice: Attitudes (M = 75.3/100 vs. 84.7/100, p = 0.05) Knowledge (M = 63.1/100 vs. 73.2/100, p = 0.08).
Walia et al. (2019) “… to gauge the impact of providing education and cultural competency training regarding caring for patients who identify as LGBTQ.” p. 1098	Pediatric perioperative staff (n = 253)	Quasi experimental Pre-post test design	Two-part educational series focusing on LGBT + education and cultural competence.		knowledge Language use: M: Pre = 4/5, Post = 4/5, p = 0.292. Assuming identity: M: Pre = 3/5, Post = 4/5, p = 0.236. Awareness of multiple minority status: M: Pre = 4/5, Post = 4/5, p = 0.074

Figure 1. PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers, and other sources (Page et al., 2021).

Table 4. Study characteristics of included studies (n = 9).

Country	USA: n = 6 (66.6%) Australia: n = 2 (22.2%) Switzerland: n = 1 (11.1%)
Intervention aim	Increase healthcare providers knowledge and cultural competence of LGBTQ people: n = 1 (11.1%) Improve healthcare provider knowledge of LGBT adolescent healthcare needs: n = 1 (11.1%) Improve healthcare providers knowledge of TGD youths’ healthcare needs: n = 1 (11.1%) Educate healthcare providers on the psychosocial and medical issues facing transgender and gender-diverse youths: n = 1 (11.1%) Provide psychologists with affirming approaches to use when working with TGD youths: n = 1 (11.1%) Increase knowledge and affirming practices of healthcare providers when working with TGD youths: n = 1 (11.1%) Identify baseline use of affirmed name and pronouns and develop strategies to increase this: n = 1 (11.1%) Improve levels of affirmed name and pronoun documentation: n = 1 (11.1%) Identify the impact of a first assessment single session triage assessment on the mental health and wellbeing of TGD youth: n = 1 (11.1%)
Design	Mixed Method: n = 4 (44.4%) Quasi Experimental: n = 4 (44.4%) Randomized Control Trial: n = 1 (11.1%)
Target population	Healthcare Providers: n = 7 (77.7%) TGD Youths: n = 1 (11.1%) Healthcare Providers and TGD youths: n = 1 (11.1%)*
Delivery method	In Person: n = 5 (55.5%) Online: n = 2 (22.2%) Hybrid: n = 2 (22.2%)
Intervention type	First assessment single session triage assessment: n = 1 (11.1%) One-hour online training, 2-h in person training and technical assistance post training to develop inclusive healthcare systems: n = 1 (11.1%) Four 90 min online synchronous education sessions: n = 1 (11.1%) Two-part education series: n = 1 (11.1%) Mandatory Lecture: n = 1 (11.1%) Two-part online module, and an observation experience: n = 1 (11.1%) Mandatory online LGBTQ + training module, and the introduction of the SOGI Epic form: n = 1 (11.1%) Three PDSA cycles including nurse, medic, and social work education on the use of affirmed name and pronouns, Regular chart reviews, development and distribution of toolkits, and the distribution of a real-world case study: n = 1 (11.1%) Provision of teaching materials and videos produced in collaboration with TGD youths: n = 1 (11.1%)

*Staggs et al. (2022) conducted their intervention with healthcare providers and assessed some outcomes based on TGD youths however the sample age included those aged over 18 so outcome data could not be included for TGD youth.

Table 5. Critical appraisal mixed methods appraisal tool (MMAT; Hong et al., 2018).

	Author(s) and	Quality appraisal items
Study designs	year	1*	2*	3	4	5	6	7	8	9	10	11	12	13^****	14^****	15^****	16^****	17^****	18	19	20	21	22
Randomized Control Trial**	Martin et al. (2022)	Y	Y	CT	Y	N	CT	Y
Quantitative non-randomized***	Sequeira et al. (2022)	Y	Y						Y	Y	CT	CT	Y
	Vance et al. (2017)	Y	Y						Y	N	N	N	Y
	Wahlen et al. (2020)	Y	Y						Y	Y	N	Y	Y
	Walia et al. (2019)	Y	Y						Y	N	N	N	Y
Mixed Method^*****	Dahlgren Allen et al. (2021)	Y	Y						Y	Y	CT	N	Y	Y	Y	Y	Y	Y	N	Y	Y	Y	Y
	Jadwin-Cakmak et al. (2020)	Y	Y						Y	Y	Y	N	Y	Y	Y	Y	CT	Y	Y	Y	Y	Y	Y
	Riggs (2021)	Y	Y						Y	Y	Y	N	Y	N	N	Y	Y	Y	N	CT	N	Y	Y
	Staggs et al. (2022)	Y	Y						Y	Y	N	N	Y	N	N	CT	CT	CT	N	N	N	Y	N

CT: can’t tell; Y: yes; N: no.

*All studies: 1 = Clear research questions/aims, 2 = Data collection addresses the research question.

**Quantitative randomized controlled trial: 3 = Randomization is appropriately performed, 4 = Groups comparable at baseline, 5 = Complete outcome data, 6 = Outcome assessors blinded to the intervention, 7 = Participants adhered to assigned intervention.

***Quantitative non-randomized studies: 8 = Participants representative of target population, 9 = Measurements appropriate regarding both the outcome and the intervention, 10 = Complete outcome data, 11 = Confounders accounted for in the design and analysis, 12 = The intervention administered as intended.

^****Qualitative: 13 = The qualitative approach is appropriate to answer the research question, 14 = The qualitative data collection method is adequate to address the research question, 15 = Findings adequately derived from the data, 16 = Interpretation of the results is substantiated by data, 17 = Coherence between data sources, collection, analysis, and interpretation.

^*****Mixed-methods: 18 = Adequate rationale for using a mixed-methods design, 19 = Components of the study effectively integrated to answer the research question, 20 = Outputs of the integration of qualitative and quantitative components adequately interpreted, 21 = Divergences and inconsistencies between quantitative and qualitative results adequately addressed, 22 = Components of the study adhere to the quality criteria of each tradition of the methods involved.

Figure 2. Risk of bias assessment of randomized and non-randomized controlled trials.

Dahlgren Allen, S., Tollit, M. A., McDougall, R., Eade, D., Hoq, M., & Pang, K. C. (2021). A waitlist intervention for transgender young people and psychosocial outcomes. Pediatrics, 148(2), e2020042762. https://doi.org/10.1542/peds.2020-042762

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