Primary care plays a crucial role in addressing the evolving health needs of diverse populations. However, data on the health and healthcare experiences of trans and non-binary adults remain limited. This research addresses this gap by leveraging data from the 2021 GP Patient Survey, a nationally representative survey in England that, for the first time, included questions about both gender and trans status. The study aims to describe the demographic characteristics, long-term health conditions, and healthcare experiences of trans and non-binary adults in England. This is vital for informing healthcare planning and quality improvement programs, particularly within primary care, and for addressing health inequalities experienced by this population. Existing literature suggests significant disparities in health access and outcomes for minority groups, including those with protected characteristics like gender reassignment. The NHS long-term plan prioritizes addressing these inequalities, and primary care is central to these efforts. However, current clinical guidelines primarily focus on transition-related care or HIV, neglecting broader aspects of mental health and primary care. While some research exists on specific areas like equitable screening access and service gaps, comprehensive evidence on healthcare access, patient experience, and the epidemiology of long-term health conditions for trans and non-binary adults remains scarce. The inclusion of relevant questions in the GP Patient Survey offers a valuable opportunity to gather this much-needed data.

Prior research indicates significant health disparities experienced by transgender and gender diverse individuals. Studies have shown higher rates of mental health conditions and poorer healthcare experiences among these populations. However, existing evidence is often based on smaller, non-representative samples, limiting generalizability. There's a scarcity of population-level data on long-term health conditions and the nuances of healthcare experiences within primary care settings. Previous research on sexual minority populations also highlights disparities in health and healthcare experiences, providing a relevant context for understanding potential overlaps and unique challenges faced by trans and non-binary individuals. This study bridges this gap by providing nationally representative data, informing a more comprehensive understanding of the health needs and experiences of trans and non-binary adults in England.

This study employed a cross-sectional secondary data analysis of the 2021 GP Patient Survey. The survey was administered to 2,408,303 adult patients registered with a GP in England, with a 35% response rate. Data were weighted to account for design effects, non-response, and calibration to the population of eligible patients. This ensures nationally representative estimates for England. The survey included questions on gender identity, trans status, long-term health conditions (17 options), and patient experience (18 items across five domains: overall experience, access, continuity, communication, and experiences before appointment). Gender identity was assessed via two questions: one on self-described gender (Female, Male, Non-binary, Prefer to self-describe, Prefer not to say) and one on congruence between gender identity and sex registered at birth. For analysis, trans and non-binary individuals were defined as those who selected 'Non-binary' or 'Prefer to self-describe' for their gender, or affirmed their gender identity differed from their registered sex at birth. Weighted descriptive statistics were calculated for demographic characteristics. Logistic regression was used to explore the association between being trans/non-binary and 15 long-term physical and mental health conditions, adjusting for age, deprivation, and ethnicity. The analysis also examined 18 patient experience items, using logistic regression to compare experiences of trans/non-binary adults with all other respondents, adjusting for relevant factors. The study protocol was developed collaboratively with a trans, non-binary, and queer patient and public involvement panel, ensuring engagement throughout the research process. Data analysis was conducted using Stata V.15.3.

The analysis of 6333 trans and non-binary respondents from the 2021 GP Patient Survey revealed several key findings: **Demographic Characteristics:** Trans and non-binary adults were significantly younger than the general population and over-represented in Asian, Black, Mixed, and Other ethnic groups. They were also more likely to live in deprived areas and less likely to identify as heterosexual. **Long-Term Health Conditions:** After adjusting for age, ethnicity, and deprivation, trans and non-binary adults showed a higher prevalence of several long-term conditions compared to the general population. The most significant disparities were observed for autism/autism spectrum conditions (OR 5.8, 95% CI 5.0–6.6), dementia (OR 3.1, 95% CI 2.5–3.9), learning disabilities (OR 2.8, 95% CI 2.4–3.2), and mental health conditions (OR 2.0, 95% CI 1.9–2.2). Analysis of age-stratified data revealed four distinct patterns of age-related prevalence differences across conditions, suggesting complex interactions between various factors. For some conditions, disparities increased with age, while for others, the gap was most pronounced in younger age groups. **Patient Experience:** Trans and non-binary adults reported slightly poorer overall primary care experiences and were more likely to report both very positive and very negative experiences compared to the general population. The most striking disparities were found in interpersonal communication, where trans and non-binary individuals were significantly less likely to report positive experiences. Conversely, they exhibited a significantly higher preference for continuity of care, although there was no difference in their ability to see their preferred GP. They were also more likely to report mental health needs during appointments but less likely to feel those needs were met.

This study provides nationally representative data that confirms and extends previous findings regarding health disparities among trans and non-binary individuals. The higher prevalence of autism, dementia, learning disabilities, and mental health conditions underscores the need for targeted interventions and support services. The significant disparities in communication highlight the critical role of provider training and cultural competency in improving healthcare experiences. The greater preference for continuity of care suggests a potential benefit from identifying and supporting providers with demonstrated expertise in trans healthcare. The finding that trans and non-binary individuals report both extremely positive and extremely negative experiences points to variability in care quality and suggests the need for systematic improvements across the healthcare system to ensure consistent, affirmative care. The age-related variations in condition prevalence warrant further investigation to unravel the complex interplay of factors, including minority stress, biological effects of hormones, and cohort effects related to changing social contexts and access to healthcare. Future research should explore these factors in more detail and investigate strategies for improving healthcare access and quality for this population.

This study offers valuable insights into the demographic characteristics, health conditions, and healthcare experiences of trans and non-binary adults in England. The findings highlight significant disparities in mental health, long-term conditions, and patient experience, particularly concerning communication. These findings underscore the importance of addressing health inequalities within primary care by improving provider training, cultural sensitivity, and access to specialized care. Future research should utilize longitudinal data to better understand causal relationships, evaluate the impact of interventions, and explore subgroup differences within the trans and non-binary population.

The study's limitations include the potential for non-differential misclassification of trans and non-binary status, the exclusion of respondents who did not answer or chose 'prefer not to say' to gender questions, and the focus solely on individuals registered with a GP. While the survey methods were designed to minimize bias, these factors may still influence the results and should be considered when interpreting the findings. Longitudinal studies are needed to better establish causal relationships and assess the effectiveness of interventions aimed at reducing these disparities.