Barriers and facilitators to publicly-funded gender-affirming surgery: the perspectives amongst a cohort of Australian clinicians

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Abstract
Introduction: Barriers to publicly-funded gender-affirming surgery (GAS) in Australia have been identified as costly with limited availability of qualified providers and lack of public hospital systems performing/offering these services. Our study explores barriers, facilitators, and potential implications for expanding, and improving publicly-funded GAS in Australia from the perspectives of an Australian cohort of gender-affirming clinicians. Methods: We conducted semi-structured interviews with eight clinicians in 2021 who currently work within gender-affirming health services in Australia. Through ecological systems theory, gender minority stress framework, and reflexive thematic analysis, themes and subthemes were developed. Results: Our study identified three themes and five sub-themes exploring the barriers and facilitators to publicly-funded GAS in Australia. Gender-affirming clinicians indicated establishing a surgical center for excellence in trans and non-binary healthcare is an essential facilitator needed to implement publicly-funded GAS. This would allow for a best-practice decentralized model of gender-affirming care to be realized in future to optimize health and wellbeing among trans and non-binary persons. Conclusions: There remain substantial barriers, specifically at exosystem and macrosystem levels, within the public health service needing urgent attention. Implications of findings are relevant to funding, clinical practice, research, and policy within and beyond Australia. Policy Implications: The substantial barriers within the public health service sector could be improved through a growing support, and a changing socio-political-cultural milieu; ultimately informing publicly-funded GAS as the most sustainable course of action and policy reform.

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