Transgender Health between Barriers: A Scoping Review and Integrated Strategies

: Transgender people have garnered attention in recent years. They have different health problems; the fact, however, that they belong to a minority means that this is characterized by complex mechanisms of stigmatization. This paper aims to analyze the current literature on the barriers to health services encountered by transgender people. This scoping review is based on the following research questions: (1) What are the main barriers to health care encountered by transgender people? (2) Is it possible to organize these barriers according to a macro-, meso-and microanalysis approach? (3) What are the main characteristics of the barriers to health care encountered by transgender people? (4) Are there signiﬁcant relations between the different types of barriers? The review was undertaken following the PRISMA extension for scoping reviews. In total, 32 studies were included from which three types of barriers with different subcategories were identiﬁed: health system barriers, social barriers, and individual barriers. In conclusion, due to the complexity of gender issues and barriers to health care, a multidisciplinary approach is necessary. In this regard, some integrated strategies to reduce barriers to health care for transgender people are proposed.


Introduction
Transgender people have garnered attention in recent years. "Transgender" is an umbrella term that describes people whose gender identity or expression does not match the sex they have been assigned at birth (p. 1, [1]). Transgender people have different health problems; the fact, however, that they belong to a minority means that this is characterized by complex mechanisms of stigmatization. In fact, transgender people have health problems related to the delivery of health services [2] and have also particular health concerns [3]. This is a known aspect of the field called the Minority Stress Model (MSM), which relates to theories considering factors in the community that cause stress and explains how minority groups are immoderately affected by stress due to their status in society [4]. Specifically, these are the elements that form multiple barriers to health care for transgender people, that is, factors that do not allow individuals, a group of individuals or a population and/or community to access health services and/or to achieve or improve health status [5]. All this means that transgender people experience victimization phenomena that alter their state of health.
Factors such as violence, stigma and discrimination, along with other social, political and economic issues, are able to affect the physical, mental and behavioral health of transgender people [6]. Several studies showed that, compared with the general population, transgender people suffer from more chronic diseases and experience higher rates of health issues related to HIV/AIDS, substance use, mental illness and sexual and physical violence, as well as higher prevalence and earlier onset of disabilities that can also lead to health issues [7]. In addition to poorer health outcomes, transgender people also encounter unique challenges and inequalities in the context of accessing health insurance and appropriate care [8]. The public health and economic crises have also increased existing disparities and barriers to health care for transgender people [9]. For these reasons, considering the health of transgender people and possible barriers to health care, there is no clear distinction between the context of meeting health services and social phenomena, such as discrimination (i.e., access to employment, status, income, etc.), and how these affect health outcomes; on the other hand, there is a constant influence between all these dimensions [7,10,11].
In turn, this increases the possibility of poor health conditions for transgender people with a further increase in barriers to health care [12]. As far as barriers to health care, in general, are concerned, there are different analysis models, such as the Health Care Access Barrier (HCAB), in which there are three types of barriers: financial (concerning insurance, financial protection, economic access to care, etc.), structural (concerning the physical and social environment of health care contexts) and cognitive (relational and psychological of the individual subject) [13]. This is a model based on a macrosocial type approach, i.e., concerning systematic issues. Another model of barriers to health care has been proposed by Andersen [14], known as the behavioral model of health care use. In this model, the level of analysis is microsocial, i.e., from the point of view of a single individual whose access to health protection depends on a series of factors or determinants, such as the social dimension (occupational, scholastic, physical, social, etc.), demographic factors (age, gender, etc.) and health beliefs (behaviors, attitudes and knowledge that can impact perceptions of health and illness and their support for health services) [14].

Transgender Health and Ecological Theory of Human Development
Bronfenbrenner's ecological theory of human development [15,16] turns out to be very useful for this article. According to Bronfenbrenner's [15,16] conceptual model, human development is considered a manifold system of interactions impacted by several levels of systems. Individuals and processes are pivotal to human development; individuals are the persons and how their characteristics impact social interactions across life, while processes are the reciprocal relationship between the individuals and others, objects and symbols in their environment.
The first level is the microsystem and refers to the complex relationships between an individual and their setting. In the case of transgender people, it refers to long-term care homes, hospitals and clinics, use of inclusive pronouns (language), etc. [15][16][17][18].
The mesosystem also impacts individuals directly, but is composed of the interactions which occur between two or multiple system levels. The mesosystem can be lasting, such as an ongoing relationship with a general practitioner [15,16]. Moving from a familiar community to a health care environment may include moving to a heteronormative environment [17,18].
The exosystem includes environments (informal and formal social structures) where individuals are a part of without an interaction on a regular basis. In the case of transgender people, the broader health care system, agencies of government and mass media may be considered examples of this level [17,18].
The macrosystem is the culture and/or subculture that creates patterns, activities and structures that are community-based. It is informal and implicit [15,16]. The culture that an individual inhabits can be even more powerful to the transgender experience than policies and protocols [17,18].
The chronosystem includes the historical events influencing the contexts of the other systems. Regarding transgender people, their history is based on the experience of stigmatization and exclusion in society and in a health care context. This causes cumulative negative experiences acting as causative factors that result in distrust of health care systems [15][16][17][18].
Furthermore, these systems are presented as concentric. These systems are nested and interrelated to an extent that influence flows bidirectionally [15,16].
The use of Bronfenbrenner's Ecological Model [15][16][17][18] is important to understand the health needs of transgender people that were effective in identifying potential practice changes in order to better support this people in several contexts: incorporating consistent transgender cultural competence training into one's continuing education regime, including recognizing and de-escalating conflict related to sexual orientation, positionality/critical reflection of the clinician, positive communication and relationship building [15,16]; programming inclusive services for transgender people [17,18], etc.

The Aim and the Research Questions of the Review
This review aims to analyze the current literature on the barriers to health care encountered by transgender people in the context of health services to understand the interaction between different barriers and their influence on the health of transgender people.
This review is based on the following research questions: (1) What are the main barriers to health care encountered by transgender people? (2) Is it possible to organize these barriers according to a macro-, meso-and microanalysis approach? (3) What are the main characteristics of the barriers to health care encountered by transgender people? (4) Are there significant relations between the different types of barriers?

Study Design
The review was realized undertaken following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, extension for scoping reviews (PRISMA-ScR) [19], and Arksey and O'Malley's methodological framework for conducting scoping studies [20].

Search Strategy
A systematic literature search was performed using the Medline (via PubMed), Scopus and Web of Science electronic databases, with combinations of search terms, tailored to the syntax and functionality of each database. Searches were conducted from December 2022 to February 2023, with no date limitation. The search query used is detailed in Table 1. Subsequentially, the grey literature was identified through specific searches using Google Scholar's search engine up to page 20 [21]. Only English-language documents were considered eligible for inclusion.

Inclusion and Exclusion Criteria
The criteria for the articles' inclusion/exclusion were decided using the modified PICOTS framework (population, interventions, comparators, outcomes, timing and setting) [22] are described in Table 2. The parameter "Patients" was adapted to "Source", "Setting" to "Study type" and we included "Language".

Review Team
Considering that the article has only one author, it was necessary to set up a review team made up of three members. These three members participated only in the study selection and data extraction activities. As they did not participate in the other stages of writing and elaboration of the article, these members were not eligible as authors.

Study Selection
According to the inclusion and exclusion criteria, the author and the review team retrieved and independently investigated the complete texts of the screened publications and the complete list of titles generated by the search procedure, and they constructed a preliminary classification list of the articles. These articles were subjected to an abstract review, and the full texts of potentially relevant articles were obtained. The author and the review team independently assessed their eligibility for inclusion. Then, the author searched the references of the articles selected to identify other relevant studies. Any difference in opinion about the paper inclusion was solved through a discussion until the author and the review team achieved a consensus.

Data Extraction and Synthesis
From the included articles, the following data were extracted: (1) Authors, (2) Title, (3) Year, (4) Country, (5) Methods/Study design, (6) Population, (7) Study content and (8) Type of barriers. For the selected articles, the data sheets were organized in such a way to extract all data of potential relevance. The author and a member of the review team performed the filtering independently and the author ensured the accuracy of the selected, reviewed results. The extracted form contained the following elements: reference, title, journal, publication year, type of study, aim/research questions, type of barriers identified and key findings. Missing data were filled in, when possible, by email correspondence with the studies' authors. Risk of bias or methodological quality of the included articles was not used because it was not necessary for a scoping review [13]. Results are presented narratively: a synthesis was the best choice for showing several results of the included studies.

Quality Assessment
The quality assessment was performed using AMSTAR 2: a critical appraisal tool for systematic reviews, which include randomized or nonrandomized studies of health care interventions, or both [23]. The related questionnaire is included in the supplementary material (Questionnaire S1).

Selected Studies
A total of 1980 articles were identified, 1007 in Scopus, 602 in Web of Science, 171 in PubMed and 200 in Google Scholar. After duplicate removal (n = 382), 1598 articles remained for screening. Subsequently, through the screening phase, 1321 articles were excluded and 277 articles were assessed for eligibility. In total, 245 papers were excluded because they did not meet the inclusion criteria; thus, 32 articles were included in the review. A flow diagram providing the number of articles included and excluded at each stage is provided in Figure 1.

General Characteristics of the Included Studies
In total, 32 articles were included in this review and the general characteristics of the included studies are summarized in Table 3.

General Characteristics of the Included Studies
In total, 32 articles were included in this review and the general characteristics of the included studies are summarized in Table 3.      To explore pre-exposure prophylaxis awareness and identify trans-specific perceived barriers and facilitators of pre-exposure prophylaxis uptake Structural barriers  To explore barriers and facilitators that arose during an initiative to improve care for transgender patients in federally qualified health centers from the perspectives of staff Institutional barriers

Temporal Extension of the Included Studies
In the included set of articles of the present review, the review team found one study published in 2005, two studies were published in 2011 and 2012, while the rest of the studies were published between the years 2014 and 2020. In the period 2021-2022, the review team found two studies each. Figure 2 shows the details of the publication years of these studies.

Temporal Extension of the Included Studies
In the included set of articles of the present review, the review team found one study published in 2005, two studies were published in 2011 and 2012, while the rest of the studies were published between the years 2014 and 2020. In the period 2021-2022, the review team found two studies each. Figure 2 shows the details of the publication years of these studies.

Journal Distribution of the Included Studies and Their Research Areas
The analysis shows, as demonstrated by 32 papers published in 29 different journals, that barriers form a part of the research field of several different journals which relate to different areas: from biomedical ones to those typical of the social sciences. Regarding the research area, most of the journals are public environmental journals, occupational health journals or social science journals. Table 4 shows the journal distribution and the research areas of the included studies.

Journal Distribution of the Included Studies and Their Research Areas
The analysis shows, as demonstrated by 32 papers published in 29 different journals, that barriers form a part of the research field of several different journals which relate to different areas: from biomedical ones to those typical of the social sciences. Regarding the research area, most of the journals are public environmental journals, occupational health journals or social science journals. Table 4 shows the journal distribution and the research areas of the included studies.

Geospatial Distribution of the Included Studies
A geospatial analysis of the included papers showed that 32 studies were conducted in the context of nine countries, of which the majority of the studies were conducted mainly in the United States(21 articles), followed by India(3 articles) and Africa(2 articles). Only one article was conducted in Brazil, European countries, China, etc. Figure 3 shows the details of the geospatial distribution of the papers included.

Barriers Extracted from the Included Papers
From the analysis of the articles included, different types of barriers emerged, which are reported in Table 5, and it represents the general list of barriers to health care encountered by transgender people.

Barriers Extracted from the Included Papers
From the analysis of the articles included, different types of barriers emerged, which are reported in Table 5, and it represents the general list of barriers to health care encountered by transgender people. Internal barriersconcern for confidentiality; fear of discrimination; feeling that the treatment is useless; thinking that the symptoms will go away; fear of treatment. External barriers: cost concern; lack of access to qualified doctors; lack of time; negative experience of mental health services. Structural barriersconcern discrimination from health care providers; lack of trans-inclusive services; mental health; struggles that limit the ability to access health services and concerns about the potential side of effects of drug interactions with hormone therapy and lack of services; protection from sexually transmitted diseases.

7.
Ziegler E. et al., 2020 [49] Organizational barriersconcern of a lack of transgender-friendly spaces; gender-neutral spaces and toilets; gender documentation in electronic health records, and inappropriate reference ranges for laboratory systems; the lack of policies for welcoming transgender individuals and lack of training of health professionals in this regard. Structural barriersfailure of the health care system to provide an inclusive environment, such as unisex bathrooms and appropriate arrangements for inpatient transgender patients. Systemic barriersinclude erasure through a failure to acknowledge the existence of the transgender population as patients within the health system. This erasure can be passive, through lack of knowledge, data, policies and practice guidelines relating to the transgender population, resulting in a paucity of programmers that cater for transgender patients; however, this erasure can also be active exclusion in the form of hostility and verbal abuse intended to cause discomfort and harm to transgender patients, thereby alienating the transgender population and, eventually, resulting in their avoidance of health care facilities. Structural access barriersto medical transition generally described among transgender people consist of costs, lack of service availability, stigma, difficulties with the supply of drugs from female hormones to antiretroviral therapy and the lack of information on drug interactions. Interpersonal barriers: transphobia, stigma and nonacceptance. Institutional barriers: lack of knowledge about transgender health.

Aylagas-Crespillo M. et al., 2017 [39]
Individual barriers: health status: being affected by HIV; age: youth in transgender people; perception of refusal declared by transgender people; perception of the lack of rights declared by transgender people; lack of training and skills of professionals. Organizational barriers: lack of information from transgender people about available resources; poor computerized assistance programs. Community barriers: the taboo of being transgender. Barriers at the political level: lack of legal standards, concrete policies, etc.
toward the protection and safeguarding of transgender health.

Authors Definition
14. Tagliamento G. and Paiva V., 2016 [32] Programmatic barriersare due to cultural standards that are difficult to modify; negative stereotypes and stigmas associated with transsexual identity, which may lead to discontinuation of ongoing clinical activity treatment. They are related to AIDS and stigmatization and discrimination of transgender people.
15. Szydlowski M., 2016 [33] Direct barrierssystematically limit access to certain services through eligibility requirements, medical necessity criteria, prohibitive costs, and restrictions on gender-specific medical services. Indirect barriers,such as stigma and discrimination, can hinder or delay the delivery of care or compromise its quality.

Shaikh S. et al., 2016 [34]
Social barriers: experience of high levels of both perceived and internalized social stigma, social isolation, discrimination, and victimization. Extreme social exclusion and lack of acceptance of transgender populations in different settings diminishes their self-esteem and ability to participate in social events. Structural barriersare factors that contribute to poor health and HIV risk among transgender populations. For example, medical training often excludes transgender health and, as a result, health professionals lack the appropriate skills and competencies to provide tailored services to transgender populations

Tanner A.E. et al., 2014 [27]
Macrolevel barriers: barriers at the health care level, distance from the nearest clinic, lack of transportation and state immigration. Mesolevel barrier: barriers at social level, availability/hours, language, time to get an appointment, too long, previous visit and high cost. Microlevel barriers: barriers at personal level, health insurance status, inability to get permission to work, lack of knowledge on where to get services, concerns about being badly treated, perception of suitability for service health and privacy issues

Singh Y. et al., 2014 [28]
Barriers from the health system: lack of availability of free sex reassignment surgery and hormone therapy in public hospitals; lack of experience among health professionals regarding gender transition services. Policy barriers: lack of national policy/practice guidelines for gender transition; lack of clarity on the legal status of sex reassignment surgery by qualified surgeons.
Community level barriers: preference for traditional surgery among some sections of the transgender community; relative nonacceptance of surgeon-performed sex reassignment surgery (involving vagina creation) among some senior transgender gurus, as they disagree with the need for transgender identification by people with a vagina. Personal Barriers: lack of awareness among transgender people about sex reassignment surgery offered by qualified surgeons; inadequate resources to pay for gender transition services, sex reassignment surgery, breast increase and hormone therapy available in private hospitals.

Snow A. et al., 2019 [45]
Psychotherapeutic barrierscompounded by an incongruous financial burden: having to pay to educate their therapist.

Chakrapani V. et al., 2011 [25]
Family/social-level barriers: lack of family support; discrimination and lack of support within other communities; unmet basic needs. Health care system barriers: negative experiences with health care providers; lack of transgender-friendly registration and admission procedures; inadequate counseling services and lack of confidentiality; perceived lack of focus on antiretroviral treatment in HIV/AIDS interventions. Individual-level barriers: delay in HIV testing; fatalism; insufficient knowledge about antiretroviral treatment and beliefs in alternative cures; alcohol use. Structural barrierssuch as restroom access; uncomfortable with public restrooms; electronic health records, billing/coding systems and laboratory information systems have implemented a binary male/female identification system; failure to be identified by a preferred name or pronoun can cause discomfort, leading to a poor rapport with providers and impacting quality of care. Financial barriers: insurance issues; disproportionate levels of unemployment within the trans community; individual insurance market, trans identity has long been considered a preexisting condition disqualifying trans persons for coverage; "transition-related care" is excluded by insurance companies. Interpersonal barriers: health care providers with low knowledge and health care providers and their low sensitivity and appropriateness attitudes. Physical environment barriers,such as a lack of gender-neutral washrooms; exclusion of trans-related information in health care settings; feeling that the physical environment within the health care setting was not conducive to privacy; feeling uncomfortable when filling out gender-binary medical forms and identifying these forms as a physical barrier to care. Social environmental barriers: ignoring or being blind to trans identity; barriers to pursuing hormone replacement therapy and mental health care; lack of trans-friendly clinics and resources and incessant experiences of 'discrimination' throughout that are simply untrue; fallacious social discourses incorporated into the social environments of health care settings. Social barriers: forms of victimization, such as 1) the doctor/health care provider used harsh or abusive language, 2) the doctor/health care provider was physically rough or abusive, 3) the patient was verbally harassed in the health care setting and 4) patient experienced unwanted sexual contact in a health care setting; Policy barriers: lack of policy protections against denial of transgender patients; Health care barriers:transphobic discrimination results in elevated rates of denial of care, receipt of substandard care (e.g., rough exams); forced care (e.g., being forced to undergo procedures); Structural barriers: lack of legal documentation discourages transgender patients from seeking appropriate and adequate care.
For a better understanding of the findings as presented in the previous sections, the barriers were organized according to the macro-, meso-, and microlevels of social analysis [56].

Macrolevel: Health System Barriers
The barriers to health care encountered by transgender people concern the health system. Health system barriers have been studied by 11 papers [25][26][27][28]31,36,[41][42][43]52,53]. They are denominated in various ways: systemic barriers [42,44], macrolevel barriers [27], barriers to the health system [28], health care system barriers [25] and health care barriers [26,31,36,42,52,53]. Through a synthesis of these studies, it is possible to define health system barriers as the failure to acknowledge the existence of transgender people as patients within the health system [41][42][43]. An important aspect of these types of barriers regards the victimization and health care setting, such as denial of services, misgendering, verbal abuse, etc. [52,53]. This type of barrier includes some subcategories of barriers, such as institutional barriers, defined as lack of knowledge about transgender health [35,44,55], psychotherapeutic barriers, compounded by an incongruous financial burden, i.e., having to pay to educate their therapist [46], and structural barriers, which will be analyzed in detail later, as they are among the most studied barriers in the included papers [24,[29][30][31]34,35,[37][38][39][40][41]43,44,[46][47][48][49][50][51][52][53]55]. Health system barriers, according to the included studies, are influenced by other types of barriers, i.e., policy barriers, which allow a lack of national policy/practice guidelines for gender transition and a lack of clarity on the legal status of sex reassignment surgery by qualified surgeons [28,51,53], barriers at the political level, such as a lack of legal standards, concrete policies, etc. on the protection and safeguarding of transgender health [41] and financial barriers, that is, insurance issues, disproportionate level of unemployment within the transgender community and an individual insurance market, as transgender identity has long been considered a preexisting condition disqualifying transgender people for coverage; it is all too easy for insurance companies to exclude "transition-related care" [29,31,50,52]. These are considered direct barriers that systematically limit access to certain services through eligibility requirements, medical necessity criteria, prohibitive costs and restrictions on gender-specific medical services [31,33].

Mesolevel: Social Barriers
The social barriers faced by transgender people are analyzed in seven studies [25,27,28,32,39,51,53]; they can be defined as experiences with a high level of both perceived and internalized social stigma, social isolation, discrimination and victimization [30]. Social barriers can also be referred to as community barriers [39], community level barriers [28] and mesolevel barriers [27]. Within the social barriers, it was possible to detect the following subcategories: programmatic barriers, which are due to cultural standards that are difficult to modify, negative stereotypes and stigmas associated with transsexual identity, which may lead to discontinuation of ongoing clinical activity treatment. They are also related to AIDS and stigmatization and discrimination of transgender people [32]. Family/social-level barriers consist of a lack of family support, discrimination and lack of support within other communities, unmet basic needs, etc. [25], while interpersonal barriers are health care providers with low knowledge and low sensitivity and appropriateness, attitudes, transphobia, nonacceptance and stigma [34,35,44,55]. These barriers are related to intersecting marginalized identities, for example, low socioeconomic status, and with forms of victimization, such as (1) the doctor/health care provider used harsh or abusive language, (2) the doctor/health care provider was physically rough or abusive, (3) the patient was verbally harassed in the health care setting and (4) patient experienced unwanted sexual contact in a health care setting [52,54].
The subcategory of social barriers is social environmental barriers and consists of ignoring or being blind to transgender identity, barriers to pursuing hormone replacement therapy and mental health care, a lack of trans-friendly clinics and resources and incessant experiences of 'discrimination' throughout that are simply untrue and fallacious social discourses incorporated into the social environments of health care settings [34]. However, these latter barriers arise from the overlap between elements of social barriers and elements of structural barriers.
Furthermore, many of the social and individual barriers are also defined as indirect barriers, i.e., stigma and discrimination, because they can hinder or delay the delivery of care or compromise its quality [31,33].

The Point of View from Which the Barriers Were Detected
Regarding the point of view from which the barriers encountered by transgender people were detected, from the analysis of the 22 research articles included out of 32 total studies, 19 papers found barriers from the point of view of transgender people and only 3 studies found barriers from the point of view of health providers.

The Methods and the Research Instruments Used to Study the Barriers
Of the 32 articles included, 22 are research articles. Most of the articles included (11) have used qualitative approaches to analyze the barriers encountered by transgender people, 10 studies have used quantitative approaches and 1 has used mixed methods. The data collection instruments used in the paper included interviews (10), focus groups (5), surveys (7), participant observations (1) and content analysis (1).

Discussion
This study included a scoping review in order to identify the barriers to health care faced by transgender people in the context of health services. Due to the complexity of the results, the discussion was divided into subsections.

Barriers to Health Care: An Overview
The findings show the complexity of the health status of transgender people. The health needs of transgender people concern medical (e.g., hormone therapy) and sociopsychological (e.g., mental health care) interventions [57]. This review clearly highlights the stigma as barriers at all levels (macro, meso and micro) are very dangerous to the health of transgender people. Therefore, the various barriers encountered are an expression of a society that is still dominated by the stigma towards transgender people, which is reflected by the individual to the systemic dimension of the health system [58]. Moreover, the various barriers identified can be summarized by three needs: (1) lack of training on transgender people starting from health providers up to health professionals [24,28,51,53,54], (2) relational and organizational difficulties in accessing health care (e.g., access to the costs of surgical and hormonal therapy) [39][40][41][42][43] and (3) physical spaces (bathrooms, filing systems, etc.) and social spaces (individual, parental and professional relationships) [48,49,52,53] still with prejudices and stereotypes regarding transgender people [20][21][22][23][24]. The results highlighted the need to introduce training courses for health professionals, health professionals, policy makers, etc. specific to the health of transgender people. Thus, the needs of transgender people, their health, like everyone else's, depends on who the people are (individual characteristics) and where they live (community characteristics) [59]. Thus, more inclusiveness is needed from the macrolevel to the microlevel. Inclusivity consists of the use of gender-affirming language, attitudes, etc. [60]. The consolidated presence of barriers to health care for transgender people is clear proof of the necessity to talk about specific social determinants of health (SDHs) for these people [61]. While in the past, gender inequality was referred to as SDHs of cisgender women, recently, gender SDHs have been applied to the identity and health of transgender people [62,63].

The Relationships between the Different Levels of Barriers and Their Health Implications
According to the model proposed by Bronfenbrenner [15,16], it is possible to detect a series of interactions between the different types of barriers identified.
Considering the dimensions of the individual barriers from a microsocial perspective, the individual ones highlighted in this article would require an intersectional approach that encompasses multiple aspects, i.e., physical, biological, demographic and socially constructed identities that an individual claims or that are attributed to them by others. These identities may include, for example, age, gender identity, culture/ethnic identity, racial identity, sexual identity, ability status, class, national origin and religion or spiritual background affiliation. This set of identities affects the way people present themselves or the way they are regarded by others, which in turn affects how a person interacts with the wider network of systems. The results of this review concerning barriers at the individual level are very much similar to the study by Kidd et al. [64], in which transgender people consider themselves ill-suited to different contexts, feeling outcasts in general due to their gender identity and within the transgender community due to health issues. It is important to remember that the experience of suffering from a disease, for transgender people, is shaped by a history of psychiatrists confusing gender dysphoria as a symptom of schizophrenia [65], effectively invalidating and pathologizing transgender people. All of this has a number of implications for individual health. This review suggests that health professionals should know the influence of the different sociocultural identities of the single transgender person as tools of resilience and/or as stressors, based on the needs of the individual transgender person. To do this, all health professionals should have a thorough education of the theory of intersectionality [66,67]. This is an example of interaction between different barriers.
At the mesosocial level, the barriers identified present a series of typifying characteristics, and are also interrelated with both the micro-and macrosocial ones. Therefore, the mesolevel is composed of organizations such as workplaces, school systems, law enforcement, mental and physical health systems and other general community associations. For transgender people, interacting with community systems presents unique welfare risks due to the sheer amount of transphobia that permeates these systems. The different papers included in this review demonstrated how at this level there is gender-based violence, harassment and discrimination experienced by transgender individuals in community systems. The negative effects of discrimination by society systems have also been shown to impact the well-being of cisgender people in relationships with transgender partners, with consequences on the health status of transgender people. In this case, the implications in terms of health status are indeed transversal between macro-, meso-and microdimensions, since the health implications concern both the individual transgender people as well as couples and families with transgender members. Therefore, being aware of barriers at the mesolevel can help expand inclusive communities organizations, some local and some national, provide legal services, physical health care services and transition-related services [68].
Finally, as regards the barriers to health care at the macrosocial level, the health systems are the most responsible. In fact, lack of knowledge or rejection of transitionrelated health services, unnecessarily invasive questions, having to educate health care professionals, verbal harassment and physical and sexual violence constitute the most critical barriers to maintain health. Moreover, completing hormonal and/or surgical transition puts transgender people in dangerous situations. These aspects are identified above all at the structural level: bathrooms, bedrooms, exclusively cisgender symbols, etc. Experiences of discrimination in health care settings operate as one of the many barriers for transgender individuals hoping to access health services. Other barriers to health care for transgender people include ill-trained health care workers, institutional cisnormativity in medical/medical record systems facilities and financial hurdles, such as limited insurance coverage and lack of income. It should be highlighted that the barriers mentioned also act at the working level, thus determining greater economic instability and a reduction in access to health insurance. This is another example of the health care barriers of transgender individuals, which can lead to health inequalities for transgender people. Thus, the interconnectedness of these barriers to health care explains why those in the transgender community report low levels of health care use, including prevention services [69], general medical services [70] and transition services.
All these barriers often cause the search for alternative pathways for the affirmation of one's gender. These pathways concern the use of loopholes in transition insurance policies procedures [71], access to hormones for transition through illegal trade [72] and self-performed surgeries or surgeries performed by unauthorized personnel [73].
A brief reflection on the relationships between the different levels of barriers identified in this article concerns how the other levels of barriers influence the microlevel of analysis on searching and obtaining help (or not) from health care services and health care professionals. In this regard, the results obtained are in line with the fact that transgender people, even in health care contexts, encounter transphobia which consists of a set of ideas and phenomena that encompass a range of negative attitudes, feelings or actions towards transgender people or transness in general [74]. This makes transgender people more vulnerable to marginalization both in terms of access to care and in health care settings [75]. Thus, the effects on the microsetting level make that transgender people are also victims of forms of microaggressions, or common everyday verbal, behavioral or environmental insults, intentional or unintentional, which communicate hostile, derogatory or negative attitudes towards stigmatized or culturally marginalized groups. One of the most common forms of microaggressions experienced by transgender people, also in health systems, is "misgendering" (i.e., referring to a person using an incorrect pronoun/name) [75]. Thus, stigma, which transversally affects all the identified barriers, is a negative health issue for these people both because it causes stress in relating to others and because it acts as a real barrier to health [76]. Stigma also acts as a significant factor in increasing the incidence and prevalence of anxiety, depression, suicidal ideation and suicide [77]. This results in negative health care provider interactions and can also include providers not understanding the health care needs of transgender individuals, or the difference between sex, gender and sexual orientation, which can lead to providers pathologizing their patients and denying care, and negative experiences with health care may correlate with reduced quality of life and higher rates of self-reported disability among transgender people [78].
Thus, the three levels of barriers mean that health systems, personnel and places have a different structure, since all personnel, health professionals and care environments can play a role in identifying the health care needs of transgender people [79]. Health care is considered transgender-friendly when it respectfully supports the self-identified gender identity of transgender people. Breaking down barriers, starting with the microsetting, resulted in positive experiences in receiving health care when providers used inclusive and respectful language and allowed their patients more control over their own proce-dures [80]. Health care that protects and respects transgender people can significantly improve transgender people health [81].

Countries of Included Studies
A brief consideration concerns the countries in which the studies included in this review were conducted. In total, 21 were conducted in the United States, where access to care depends on insurance. In fact, in the United States, transgender people are denied coverage for treatments specific to their gender needs, such as screening services, hormone therapy, etc.; this is because insurers consider these interventions unnecessary or unsuitable [59]. Three studies were conducted in India and two in Africa, where the degree of stigmatization and nonacceptance of transgender people is still very high [82,83].
Since 21 studies included in this review were conducted in the United States, most of the considerations related to the identified barriers, public health aspects and recommendations are related to the American cultural context, in which the number of transgender people out of the general adult population it is about 1.6%, while in young people the number comes close to 5.1% [84], and therefore, there is a growing interest in the study of health and the health barriers encountered by transgender people in the US.

Barriers, Transgender People and Public Health
The results obtained from this review confirm the need for greater equity towards transgender people. In this context, public health research goes toward policies that can protect and promote transgender health. Several barriers are related to the fragmentary nature of nondiscrimination laws across work, education, housing, public health rights, etc. [85]. Considering SDHs, and all issues related to gender identity should be included in social movements for health equity, civil rights and health reform. The prevalence of poverty among some transgender groups affects significatively the well-being of transgender people [86]. In this regard, although the World Health Organization (WHO) in their program includes the aim that more than one billion people will have universal health access, including transgender people, the actual outcomes of the included studies underline that several transgender people still encounter health barriers and related problems [87][88][89].
Research on barriers to the health of transgender people are growing; however, to improve transgender health care, more culturally and specific operational training is needed. Health systems should consider several existing flaws to ensure inclusiveness of care to transgender people and improve the related transformations. The lack of appropriate training and knowledge of health care professionals should be highlighted. An adequate and important institutional intervention for training and professional development is essential in this context in order to implement routine medical care to transgender people and to assure that health services could be provided in a nonstigmatizing, nondiscriminatory and informed setting [90,91]. Therefore, the results obtained underline the need to increase the empowerment of transgender people, in order to improve their quality of life, i.e., it is pivotal to improve information, training and specific processes, using appropriate tools and promoting active involvement in decisions related to the health of transgender people [92]. The existence of barriers to health care could be eliminated by resorting to the concept of empowerment, because transgender people would achieve appropriate control and protection over their lifestyle and activities that are important for their quality of life. Empowerment would be a tool for prevention and training [93]. The presence of barriers to health care may also underline the need for more effective civic participation of transgender people, an issue that would implement social integration, economic progress and formal acceptance of their psychosocial and even legal equality. It can immeasurably support their empowerment and act as an acknowledgment of their human dignity and change the way they are perceived by several individuals in society, such as family, police, government actors and health care personnel, that are encountered in their daily lives [94,95].

Strengths and Limitations of the Research
This paper has strengths and limitations. The first limitation is represented by having excluded papers not in English, which has led to a probable loss of information. A strong point, however, is that the search strategy was complete, having been carried out on the three main databases. Another strength is the use of the PICOTS method to identify the inclusion and exclusion criteria. The studies, independently of the methods used, were included to jointly present the findings, which may also be considered a limitation. This study did not include the analysis of nonbinary, gender-fluid and other gender-diverse terms for the difficulty to link these heterogeneous terms to health barriers and their specific denominations. Moreover, for the same reasons, in the search strategy, terms such as two-spirited, brotherboy, sistergirl, hijra, fa'afafine and others were not included. This represents a limitation of this study. Another limitation regards that the following databases CINAHL and PsychInfo databases were not used, as they were not accessible at the author's institution. The design of the study does not allow to explore specific issues on health personal's competence and attitude to treat transgender people as treatments used in transgender health care are very different all over the world, also because of the heterogeneity in the current literature. Possibly, further research subdivided per world region may help to achieve this goal. However, this review aimed to summarize the scientific evidence regarding the barriers to health equity for transgender people; therefore, all identified articles were included to facilitate the overview of the key factors influencing the health status of transgender people.

Conclusions
This study updated the main barriers to health care faced by transgender people, from which a tripartition of these barriers emerged. Due to the complexity of gender problems and health barriers, a multidisciplinary and complex approach [96] is necessary, capable of grasping all critical issues that health needs, and the barriers connected to them, that transgender people encounter during their lives.
The evidence and arguments presented address a specific gap in the field as well as the main questions posed. In this regard, Figure 4 summarizes a series of integrated strategies to reduce barriers to health care for transgender people. Figure 4 on the left shows the main stakeholders that should be involved in managing and reducing barriers. At the center, there are the health system, social and individual barriers. Between stakeholder and barrier types, there are a number of relationships indicated with double-headed arrows to indicate the mutual influence between all these dimensions. Some proposed strategies are shown on the right. Clearly, the list is not exhaustive, but it is only a starting point for possible extensions. The main element of these strategies is multidisciplinary and the integration of knowledge and skills, emphasizing the role of the social sciences, which, on issues of gender, stigma, nondiscrimination, etc., constitute training and information tools at any level of activity in favor of transgender people. Strategies and barriers have been considered in mutual relationships and influence, being considered in an integrated perspective.
Further research on this topic is needed in order to provide more awareness and insight into the realities of the lives of these people, as well as the social taboos and stigma surrounding their lives. In this way, the aforementioned problems need to be eliminated in the near future in order to ensure transgender people are accepted by their families and in general by society, just like other citizens.  Figure 4 on the left shows the main stakeholders that should be involved in managing and reducing barriers. At the center, there are the health system, social and individual barriers. Between stakeholder and barrier types, there are a number of relationships indicated with double-headed arrows to indicate the mutual influence between all these dimensions. Some proposed strategies are shown on the right. Clearly, the list is not exhaustive, but it is only a starting point for possible extensions. The main element of these strategies is multidisciplinary and the integration of knowledge and skills, emphasizing the role of the social sciences, which, on issues of gender, stigma, nondiscrimination, etc., constitute training and information tools at any level of activity in favor of transgender people. Strategies and barriers have been considered in mutual relationships and influence, being considered in an integrated perspective.
Further research on this topic is needed in order to provide more awareness and insight into the realities of the lives of these people, as well as the social taboos and stigma surrounding their lives. In this way, the aforementioned problems need to be eliminated in the near future in order to ensure transgender people are accepted by their families and in general by society, just like other citizens. Supplementary Materials: The following supporting information can be downloaded at: https: //www.mdpi.com/article/10.3390/soc13050125/s1, Questionnaire S1 quality assessment performed using AMSTAR 2.
Funding: This research received no external funding.

Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable. Data Availability Statement: All data generated or analyzed during this study are included in this published article.