Transgender and gender diverse individuals face significant institutional harms in in-patient psychiatric care, leading to high rates of care avoidance and poor post-discharge follow-up. Our mixed-methods study found that experiences of misgendering, lack of affirming resources and structural marginalization contribute to disengagement from mental health supports after hospitalization. Integrating qualitative insights with population-based data revealed that current practices fall short of Ontario's own gender-affirming care standards. Policy efforts must move beyond broad principles to mandate concrete, measurable actions that ensure continuity, safety and affirmation across the full spectrum of mental healthcare.

Introduction

Ontario Health recently published the first Canadian provincial quality standards for gender-affirming care, articulating what high-quality care looks like for transgender and gender diverse (TGD) adults (Ontario Health 2024). Quality standards are needed “for conditions or processes where there are large variations in how care is delivered, or where there are gaps between the care provided in Ontario and the care patients should receive” (Ontario Health 2024: 2). Two of the five quality statements recommend that TGD patients have access to gender-affirming healthcare environments and mental healthcare, as substantial evidence indicates that current access to such care is poor.

Why Do TGD Patient Experiences in the Acute Care Setting Matter?

Despite evidence of two- to fivefold increases in the rates of depression and anxiety disorders, and 10-fold increases in the rate of suicide attempts in the TGD population compared with the general population globally (Winter et al. 2016), TGD patients experience many barriers to care related to stigma. This extends to the acute psychiatric care setting, which includes emergency department (ED) visits and hospitalizations. Twenty-one percent of TGD Ontarians in one study avoided ED care due to a perception that their TGD status would negatively affect their visit, despite one-third reporting a need for ED care in the past year (Bauer et al. 2010).

Still, many TGD Ontarians present to the ED as one of the few remaining doors available to access mental healthcare due to multiple barriers navigating outpatient care; however, their experiences in the acute care setting will impact their subsequent engagement with or avoidance of the mental health system (Lam et al. 2025b). Early post-discharge follow-up care after an acute psychiatric care visit is an important health equity indicator, as it has been shown to reduce substance use, future need for acute care and even mortality (Lam et al. 2025a). While post-discharge follow-up is poor overall (MHASEF Research Team 2018), it is a quality-of-care measure that had not been examined with TGD individuals (Health Quality Ontario 2018).

Findings

What leads TGD individuals to present for acute mental healthcare?

A population-based study of TGD individuals who had a mental health-related ED visit (n = 728) or hospitalization (n = 454) in Ontario between 2012 and 2018 was compared with samples of cisgender ED and hospitalization users matched on age, region of residence and mental healthcare use history (Lam et al. 2022). TGD acute care users were more likely than cisgender matched controls to live in areas of low income, high residential instability and high material deprivation.

Findings were consistent with the minority stress theory, which posits that interpersonal and structural discrimination contribute to the disproportionately high rates of physical and mental illness in marginalized communities (Testa et al. 2015). These intersecting barriers contribute to both the onset and exacerbation of mental health conditions while limiting access to preventive and community-based care. We explored this further with interviews of TGD participants with lived experience of acute psychiatric care. This led to the creation of a healthcare access model explaining the direct link between gender-related discrimination and minority stress, social determinants of health challenges, inability to access outpatient care, worsening mental health and the eventual need for acute care when in crisis despite a desire to avoid such care (Figure 1) (Lam et al. 2025b).

How does the acute care environment impact TGD patients' post-discharge care?

In our retrospective population-based cohort study, 55% of TGD individuals had outpatient mental health-related physician (primary care physician or psychiatrist) follow-up in the 30 days after discharge from the ED, compared with 38% for the general population (Lam et al. 2025a). This increased access to mental health supports likely reflects increased need in the TGD cohort.

Despite the increased access to care following ED visits, TGD individuals were 20% less likely to receive follow-up care in the month after a psychiatric hospitalization, after accounting for other factors. If the increased access in TGD patients after ED visits represents increased need, the decreased access following a hospitalization suggests a systemic failure to ensure continuity of care for a structurally marginalized population.

Table 1 illustrates how qualitative data from lived experience explained the stark drop-off in care within 30 days of discharge from a psychiatric hospitalization in TGD individuals compared with the general population.

Results point not to low need but to active avoidance of a system perceived as harmful or untrustworthy. Many TGD individuals report feeling pathologized, invisible or re-traumatized during in-patient care. Hospitalizations were often settings for daily experiences of invalidation and lack of agency, reminiscent of prior negative experiences in multiple domains of their life outside of the healthcare system. Their stories reflect how acute psychiatric services, when not gender-affirming, become sites of trauma rather than healing. These experiences deter re-engagement and leave individuals without support during vulnerable post-discharge periods.

Gender-Affirming Care Standards for In-Patient Settings

Existing recommendations for gender-affirming mental healthcare often lack specificity on how to make in-patient care settings more affirming and trauma-informed (Britt-Thomas et al. 2023; Ontario Health 2024). Our mixed-methods study highlighted specific elements of the in-patient environment that could be targeted to improve post-discharge engagement with care. While our study was carried out in the Ontario context, it is likely that TGD individuals in other provinces and territories share similar experiences. Thus, the Ontario recommendations may be applicable to other jurisdictions in the country.

Core recommendations to improve in-patient psychiatric settings based on TGD patient-identified priorities are given in Table 2.

Together, these recommendations reflect a call for institutional change grounded in the real-world experiences of TGD individuals.

Long-Term Change and Policy Recommendations

To move from crisis to continuity, policy makers must embed lived experience in service design and mandate gender-affirming standards across the continuum of care, with targeted, measurable implementation.

First, Ontario's mental health system lacks consistent gender identity data collection across services. As a result, disparities remain invisible in system scorecards and quality indicators, and accountability is impossible. The integration of gender identity data should be mandated across hospital and outpatient reporting systems, such as with Community Health Centre data available at ICES. This will facilitate monitoring of crucial health equity outcomes, such as parity of post-discharge care. Second, discharge planning protocols should require a gender-affirming lens, including access to peer support and practical transition supports such as housing and transportation. These should be standardized and linked with community-based care organizations to reduce drop-off post-hospitalization. Third, in-patient psychiatric units should implement routine quality audits for trans inclusion, including documentation reviews (e.g., use of chosen names/pronouns), staff training compliance and environmental safety assessments for TGD patients. These audits should be tied to existing accreditation and quality improvement processes. Together, these actions can operationalize the Ontario Health standards and transform affirming care from aspiration to reality.

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