Western societies often presume that individuals’ gender identity always aligns with the gender assigned at birth, which can be challenging for those whose identity differs. They must navigate a path to affirm their true selves and seek recognition and respect (Dorsen et al., 2022). Transgender individuals are those who identify with a gender that differs from their assigned gender at birth. This label includes transgender women, transgender men, and non-binary individuals. Research suggests that not all individuals who identify as non-binary also identify as transgender (Rosati et al., 2022). To ensure inclusivity in this article, we have opted to employ the terms “trans” and “gender-diverse” (TGD), which encompass a diverse range of gender identities and experiences (Coleman et al., 2022).

This paper aims to shed light on the challenges encountered by TGD individuals in Italy throughout their gender-affirming pathway (GAP). The GAP encompasses not only medical and legal facets but also sociocultural and individual dimensions. To comprehensively explore the complexities of the GAP, the ecological framework is utilized. Moreover, the paper advocates for potential GAP reforms by amplifying the perspectives of activist participants who have developed a critical understanding from their own first-hand experience of the GAP. It emphasizes the limitations identified by activists within the current GAP, as well as their efforts to enact changes. Ultimately, the article proposes a model for the desired GAP based on participants’ proposals and voices.

Gender-Affirming Pathway(s)

The GAP has a distinct and personalized meaning for each TGD individual, holding dual significance (Dorsen et al., 2022). Firstly, it refers to the medical and legal dimensions, encompassing options such as hormonal treatments and surgical interventions, as well as potential changes to birth names and/or sex markers on official identification documents. Secondly, GAP extends to a broader sense of feeling acknowledged, respected, and seen in one’s TGD identity, encompassing social and psychological aspects. The social aspect involves using a chosen name, preferred pronouns, and expressing gender through clothing and accessories. The psychological aspect encompasses accepting one’s own gender identity, challenging internalized transphobia, and navigating feelings of gender euphoriaFootnote 1 and gender dysphoria related to gender experiences. This broader meaning highlights the significance of social acceptance and validation in affirming one’s gender identity (Dorsen et al., 2022). The GAP involves both informal settings, like gender affirmation within the LGBTQIA + community, and formal settings, where TGD individuals interact with professionals, institutions, and society. Navigating societal perceptions and legal frameworks are integral aspects of this journey (Koch et al., 2020).

Unfortunately, the GAP for TGD individuals is frequently framed solely from a medical perspective, emphasizing a diagnostic approach (Riggs et al., 2019). To address this limitation and move beyond reductionist understandings of health for LGBTQIA + individuals, several authors have proposed the utility of using an ecological approach (Jones, 2023a, b; Mann & Jones, 2022). This approach highlights the importance of considering, not only individual-level factors, but also the impact of other social determinants on TGD people’s well-being (Mocarski et al., 2019).

The Ecological Framework

The original ecological model of individual development, proposed by Bronfenbrenner (1974, 1979) and Bronfenbrenner and Crouter (1983), considers individuals as developing within different overarching systems, including the individual (and all their characteristics), the microsystem, the mesosystem, the exosystem, and the macrosystem. It suggests that a person’s development is influenced by interactions across various levels, and factors at each level can significantly impact individuals’ health and well-being.

This comprehensive model has been applied to the LGBTQIA + population (Jones, 2023a, b; Mann & Jones, 2022), and its application offers valuable insights into understanding the complex interplay of factors affecting TGD individuals’ well-being. Building on the ecological framework, the GAP can be understood as a complex experience involving overlapping and mutually influencing factors, including both internal and external validation (Dorsen et al., 2022). Internal self-affirmation encompasses recognizing and accepting one’s own gender identity, navigating through the processing of emotions related to their body, self-identity as a TGD person, and ultimately achieving self-acceptance (Dorsen et al., 2022). On the other hand, external affirmation involves being recognized and seen by significant figures in a TGD person’s life, including family, friends, the LGBTQIA + community, and professionals, as well as receiving formal recognition in society (Dorsen et al., 2022).

In addition, the ecological framework offers several strengths for exploring the experiences of TGD individuals in affirming their identities. Firstly, it avoids a narrow medical or legal perspective on the GAP. Secondly, it recognizes that the GAP is influenced by external relationships and social context, not solely an individual’s journey (Dorsen et al., 2022). Thirdly, it highlights the impact of policies and cultural systems on the TGD individual’s affirmation process (Jones, 2023a; Mann & Jones, 2022). Finally, it helps avoid a heteronormative view of identity development (Allen & Demo, 1995). The development of TGD identity begins to take shape during childhood and adolescence (Dorsen et al., 2022). However, self-awareness may not always align completely with full gender affirmation, as it is influenced by the context in which an individual is raised. The affirmation of one’s identity is favored by a context that includes both a supportive environment and a societal framework that facilitates easy access to medical resources and legal gender acknowledgement (Koch et al., 2020). The presence or absence of cultural references can also impact the timing of self-identity awareness and its validation (Jones, 2023a, b). Finally, the ecological framework proves highly valuable in providing comprehensive insights into specific national contexts due to its multilevel and contextual analysis of interactions between individuals and their environment (Mann & Jones, 2022).

The Italian GAP from an Ecological Perspective

In this paragraph, we take an ecological standpoint to approach the Italian GAP, exploring the dimensions of gender affirmation that are present or absent at different levels. The macrosystem includes cultural beliefs and ideas about gender, as well as social representations of TGD individuals in society. The ability to affirm oneself is influenced by the prevailing laws in a country, which may or may not support self-determination or legal recognition for all gender-diverse identities, including non-binary individuals (Köhler, 2022). In Italy, LGBTQIA + people face marginalization in the political agenda (Sodano, 2021), and the country also had the highest rate of trans murders in Europe in 2020 (TvT Research Project, 2020). Italian TGD people’s experiences are often associated solely with sex work or portrayed within a pathologizing framework (Lorusso & Albanesi, 2021). In the clinical care of TGD individuals, psychologists and psychiatrists often promote normativity, fueling the concept of transnormativity (Riggs et al., 2019). Transnormativity involves dominant narratives pressuring TGD people to conform to specific tropes, such as the belief that they must describe their gender through a “wrong body narrative,” necessitate medical treatment, and strive to appear cisgender (Johnson, 2015, 2016). This construct is evident in societal views and perspectives at both the structural and individual levels, historically fostering stereotypical and pathologizing attitudes toward TGD individuals (Bradford & Syed, 2019; Mocarski et al., 2019).

The exosystem includes broader institutional influences on individuals and their microsystems, such as legal environments and welfare systems. Specifically, we focus on access to medical and legal affirmation in Italy, referred to as the institutional GAP. In Italy, the institutional GAP is accessed through public and private centers and professionals, such as psychologists, psychiatrists, endocrinologists, surgeons, and lawyers.

To begin a medical GAP for hormonal treatment and surgeries, TGD individuals must first receive a diagnosis of gender dysphoria or gender incongruence. This requires a psychological pathway with mental health professionals. For gender-affirming surgeries, they need to present medical records and receive a favorable legal opinion, typically from a judge (Voli, 2018). With the judge’s consent, TGD individuals can choose to undergo surgery at a public hospital, join a surgery waiting list, or rely on a private surgeon. Changing their identification card with their chosen name and sex marker also requires the consent of a judge. However, the current law only allows for the legal affirmation of binary and medicalized experiences, excluding de facto non-binary identities and non-medicalized paths. The institutional structure of the Italian GAP reinforces passing from a cisnormativeFootnote 2 perspective, contributing to the transnormative norm, which is also internalized by the transgender community itself (Pignedoli, 2021).

The mesosystem consists of connections between microsystems. However, exploring the entire ecological system within one study is not feasible due to the wide-ranging environmental contexts that can influence an individual’s GAP (Mann & Jones, 2022). Therefore, this study focuses on the characteristics of relationships with professionals and LGBTQIA + individuals. Professionals represent the out-group, in charge of institutional GAP procedures and identification, while LGBTQIA + individuals represent the in-group, legitimizing different GAPs and belongings. Interactions between the LGBTQIA + community and professionals, such as updating knowledge or meeting TDG clients’ needs, exemplify mesosystem interactions. Professionals play a significant role in the GAP for TGD individuals, acting as gatekeeper (Morris et al., 2020; Riggs et al., 2019). This may lead individuals to conform to transnormative narratives to meet institutional criteria (Johnson, 2019). Transnormative narratives may also be strategically used to gain approval from professionals (Applegarth & Nuttal, 2016; Johnson, 2015, 2019). However, psychotherapy, as a space for listening and acceptance, can be significant for TGD clients (Anzani et al., 2019). Negative gender beliefs and transphobia exist within the LGBTQIA + community in Italy, specifically targeting TGD identities (Compare et al., under review). A segment of the trans community exhibits a hierarchical approach to identities, influenced by a transnormative attitude, wherein those with more cis-passing experiences are considered more valid (Pignedoli, 2021).

At the individual level, affirming one’s gender may still leave space for normative narratives centered on the “wrong body” narratives and gender dysphoria diagnosis as criteria for self-identification as trans (Lorusso et al., in press). The ecological perspective also acknowledges the significance of gender euphoria for sexual and gender minority identities (Jones, 2023a). However, TGD individuals are not passive recipients of stereotypical narratives and transnormativity prevalent at all levels. One way to resist these norms is through activism (Bradford & Syed, 2019).

Staying at the Margins and Resisting Oppression: the Role of Activism

Stigma and social neglect expose LGBTQIA + individuals to minority stress. The minority stress model explains how marginalized LGBTQIA + people face unique stressors (Meyer & Frost, 2013). This is particularly pronounced for TGD individuals, who face an elevated risk of psychological issues due to daily stressful experiences (Lefevor et al., 2019; Matsuno et al., 2022). Research indicates that activism and collective action serve as resistance to oppression, contributing to resilience (Roberts & Christens, 2021) and benefiting the well-being and mental health of TGD individuals, reducing gender-related stress. (Frost et al., 2019; Lindley & Budge, 2022). It is helpful for coping with oppression and fostering resilience and empowerment at individual, community, and societal levels (Frost et al., 2019; Hagen et al., 2018; Lindley & Budge, 2022). Through activism, people can reverse the narrative of marginality, turning the margins into spaces to be reclaimed, and to find a prospect for change (hooks, 1989). As such, activism represents a collective strategy to counter stigma and isolation resulting from minority status, valuable both for individuals and their communities (Lindley & Budge, 2022; Rosati et al., 2021). Activism as a coping strategy can have a twofold purpose for TGD individuals. Firstly, it helps resist cisnormative experiences through raising awareness and challenging gender norms (Lindley & Budge, 2022). Secondly, it offers TGD individuals the opportunity to be mentors, providing support, educating about gender-affirming processes, and assisting in accessing resources (Budge et al., 2017; Matsuno & Israel, 2018) for their own community and in different settings such as educational (Golberg et al., 2020) and clinical ones (Hostetter et al., 2022). TGD individuals link gender affirmation rights to broader social implications, recognizing the intersectionality of gender norms, race, capitalism, and class in the GAP (Dorsen et al., 2022). They engage in collective struggles for social justice beyond personal goals (Hagen et al., 2018). Indeed, activism leads to social change and political queer generativity, particularly for young adults (Rosati et al., 2021). In an Italian study, LGBTQIA + individuals engaged in activism demonstrated more inclusive attitudes toward TGD individuals rather than non-activists and higher level of social justice and sense of community (Compare et al., under review). In fact, activists exhibit critical consciousness and health literacy, challenging oppressive systems (Hagen et al., 2018; Schulz & Nakamoto, 2013) and fostering community connections and improving psychological well-being (Roberts & Christens, 2021). Yet, they perceive a lack of understanding and recognition in their GAP from institutions and professionals (Hostetter et al., 2022).

The Present Study

This research is grounded in critical social community psychology, rejecting traditional approaches that neglect the experiences of minority identities and perpetuate negative views among them (Mann & Jones, 2022; Worth & Smith, 2017). For TGD individuals, whose experiences have been pathologized, the clinical perspective often takes precedence over the ecological perspective (Jones, 2023a; Mann & Jones, 2022; Riggs et al., 2019). Critical social community psychology focuses on identifying unmet needs and providing targeted support (Worth & Smith, 2017). While activism is recognized for resisting oppression, its potential to transform contexts and influence policymaking requires further attention.

This study aims to define the GAP experiences and explore the potential of activism by using the ecological framework (Jones, 2023a, 2023b; Mann & Jones, 2022) to develop a transformative model for the Italian GAP, based on the experiences of TGD activists in both formal and informal settings. The underpinning research questions are as follows:

  1. 1.

    What are the potentials and shortcomings of the current GAP? (RQ1).

  2. 2.

    Should it change? Why? Why not? What would the desirable GAP be? (RQ2).

  3. 3.

    How does activism contribute (or not) to transforming the current framed GAP? (RQ3).

Method

Instruments and Procedure

To collect data, in-depth semi-structured interviews were conducted. These interviews aimed to investigate participants’ experiences using an ad hoc guide with five main sections: (1) personal gender identity experience; (2) GAP experience within the social, psychological, medical, and legal dimensions; (3) potentials and shortcomings of the GAP; (4) possible GAP implementations and changes; and (5) the activism dimension.

Ethical clearance for the research was obtained by the University of Bologna, Ethics Committee [Prot. n. 201,357, 26/08/2021] and signed informed consent was collected. Interviews for this study were conducted online via Zoom between June and November 2021. The first author conducted the interviews in Italian, and each interview lasted approximately 95 min. Quotations from the interviews were translated into English for this article. To ensure accuracy, a translation-back-translation process was adopted. Participants were eligible for inclusion in the study if they (1) were 18 years or older, (2) self-identified as TGD person and, (3) were an activist. To recruit participants, a call containing the study’s aims and inclusion criteria was posted on social media.

Participants

The participants were 25 Italian TGD activists. Participants were mainly White (92%, n = 23), with one African Italian and one Multiracial individual. Participants could be considered part of Generation Z or Millennials, as their ages ranged between 18 and 38 years (Mage = 24.7; SD = 5.45). Most participants were students (48%, n = 12), 40% (n = 10) employed, and 12% (n = 3) unemployed. They mainly had a high school diploma (60%, n = 15), 32% (n = 8) had a higher education degree, and 8% (n = 2) middle school diploma. Regarding their gender identity, participants mainly self-identified as non-binary (52%, n = 13), followed by trans men (32%, n = 8), trans women (8%, n = 2), and gender questioning (8%, n = 2). The majority were assigned female at birth (84%, n = 21), 13% (n = 3) were assigned male at birth, and one participant preferred not to say. The majority were out as TGD person within every life context (68%, n = 17), while 32% (n = 8) were out only within specific contexts. Participants’ actions as activists were distributed as follows: 72% (n = 18) to educate people about LGBTQIA + issues, 56% (n = 14) to create and/or share LGBTQIA + content online, and 52% (n = 13) to be part of associations. All participants socially affirmed their gender (e.g., using pronouns, chosen name, clothing, make-up). Moreover, all the participants shared similar feelings related to the psychological dimensions of their GAP (i.e., perception of their identity, gender euphoria, gender dysphoria). Regarding the interaction with the professionals and their experiences within the institutional GAP, 52% (n = 13) of the participants have started a psychological pathway, 40% (n = 10) experienced the medical dimension (i.e., hormonal therapy or surgery), and 32% (n = 8) the legal dimension (i.e., change the birth name and/or the sex marker).

Positionality and Reflexive Statement

The research team consists of individuals with diverse identities, including White, trans non-binary and cisgender, queer and heterosexual, and transfeminist activists and researchers. The authors recognize the significance of avoiding neutrality when conducting fieldwork, particularly when studying marginalized groups. Critical consciousness led the authors to reflecting on psychology’s historical role for TGD individuals (Riggs et al., 2019) in line with critical psychology aims (Worth & Smith, 2017). The research aims to avoid creating a knowledge hierarchy between researchers and activists, benefiting the TGD community and addressing activists’ needs with various methodological considerations and efforts to deconstruct imbalances between researchers and professionals. The interview process was carefully designed to actively listen to participants’ self-expression concerning their identity and emotions, using the language consistently as participants did. Participants were encouraged to share their experiences and discuss additional questions or themes, allowing for their input and integrating their perspectives and feedback into subsequent interviews. Moreover, during the debriefing, participants expressed that the presence of a non-binary interviewer created a safer space during the interviews. Participants received the main results through email after the analysis (i.e., member check). Feedback showed they appreciated seeing their experiences reflected and gaining insight into others’ experiences.

Analytical Approach

Constructivist Grounded Theory (CGT; Charmaz, 2014) was identified as the best theoretical and analytical approach, as it views research as a collaborative space where investigators and participants co-create knowledge. This approach deconstructs the notion that the interviewer is the sole expert on the issue and recognizes the crucial role of both researchers’ and participants’ positionalities (Charmaz, 2014; Hagen et al., 2018).

Following the CGT, we approached data inductively, moving back and forth in an iterative way (Charmaz, 2014). Coherently, we followed six main phases to analyze data. (1) The authors read all interviews and started to take notes of possible ways to frame the content. (2) Additional interviews were collected focusing on the phase 1 insights to reach data saturation (Charmaz, 2014). (3) The first and second authors started to code data while consulting additional existing literature on the topic; five interviews were identified to delineate potential codes. Moreover, the authors found that codes could be organized into ecological levels (i.e., macrosystem, exosystem, mesosystem, microsystem, and individual level). (4) The authors discussed the codes to orient the remaining data analysis. Seventeen codes emerged. (5) The first and second authors coded all transcripts with the identified codes, verifying the salience and accuracy of the codes by comparing the transcripts. (6) The authors discussed the final dataset containing the seventeen codes.

Results

A visual model was created to facilitate the overall interpretation of the results (Fig. 1). As shown in Fig. 1, the 17 codes were divided into two distinct columns: the left one shows the current top-down binary structured GAP, and on the right, the desired one, the GAP is a bottom-up and non-unidirectional process. The codes were arranged into five ecological domains, building on the ecological model (Bronfenbrenner, 1974, 1979; Bronfenbrenner & Crouter, 1983). The domains are discussed in the following paragraphs. Excerpts of participants’ interviews are provided; participants’ names, ages, and gender identities are anonymized and presented in brackets.

Fig. 1
figure 1

The figure summarizes graphically the results. On the left it is shown the current GAP, and on the right the desired one. The first eight codes in the left column portray the top-down (expressed by the unidirectional vertical arrows) and binary structure of the current GAP, as reported by participants. The latter nine codes in the right column refer to a top-down and bottom-up structures where outer systems influence and are influenced by inner systems (expressed by the bidirectional vertical arrows) of the desired GAP, as delineated by participants. To connect the columns, we used horizontal arrows that represent the queer generative actions implemented by the participants as activists. Solid arrows refer to concrete and direct actions performed by participants (e.g., the creation of new territorial GAP centers). Dashed arrows are the indirect actions that can stimulate a change (e.g., a series of informative actions can change society at the macro level over time). Dotted arrows represent potential actions for change that have not been implemented yet (e.g., formally including TGD individuals to design a new GAP model).

Full size image

Macrosystem

References to the broader social context are reported in this domain. The society in which the current GAP is implemented is very binary, cis-normative, and with entrenched prejudice against TGD people. Indeed, “trans identities are connected to the mainstream Italian narrative, where trans people are mainly sex workers, drug addicts, or victims of crimes” (S., 32, non-binary). Gender stereotypes characterize participants’ experiences. They remark on how these factors also foster transnormativity in GAP, which negatively impacts both trans and non-binary’s people experiences.

If you do not like pink or play with dolls but you feel like a woman, they say something is wrong. You are not woman enough and you need to extend the GAP or end it because of these very narrow, binary, and wrong canons. (F., 25, non-binary).

Society pushes people to think “I am more trans than a gender-fluid person because my [binary] identity is defined and therefore I have more of a say.” (G., 23, non-binary).

The desired GAP could benefit from questioning gender roles and stereotypes and systematizing TGD identities at the legal level (e.g., giving the possibility to introduce pronouns into official documents). As one participant stated, being a TGD person is not only an individualistic pathway:

It is a journey to be aware of yourself and to start doubting what others take for granted. We need this cultural change. (K., 29, non-binary).

References to different actions questioning gender roles and stereotypes of TGD identities are reported by all participants, such as educational activities on TGD issues performed online (i.e., social media and personal blogs) and in community contexts (e.g., at work or school); organizational activities (e.g., the implementation of new medical GAP centers or the adoption of more inclusive practices in LGBTQIA + associations); and political activities (e.g., public demonstrations and events). Being visible and sharing knowledge to deconstruct TGD representations are also ways to fight against injustice, creating new possibilities for future generations:

When I came out ten years ago no one used to talk about trans identities, there was no information or support; people were ashamed to be out. It was not nice what I and many others went and go through, even today. I fight for that. (M., 21, trans woman).

At this level the model contains the identified grassroots initiatives that contribute to the transformation of the broader society by informing and shifting the narratives around GAP and TGD identities.

Exosystem

References to the psychological, medical, and legal procedures and their interconnections are reported in this domain. The current medical procedures of the GAP are described by participants as very stereotypical, binary-oriented, and highly pathologizing. The diagnosis is set as a requirement to access the GAP, which participants consider “something useless and pathologizing, detrimental for people to receive it” (E., 23, non-binary) and a form of oppression for participants, a gatekeeping system that fails to include TGD perspectives.

We are rarely asked how we would like the GAP to be. It is a matter of oppression, I would say. We are not treated as equals; it is like we are unstable and they “have to be sure you do not change your mind.” It is important to make sure we know everything that comes with the path, but it could be done differently. (Z., 19, trans man)

The actual legal procedures are defined as binary-oriented and particularly problematized by non-binary participants, who stress the absence of the non-binary gender option for the identification documents and the lack of tailored institutional GAP for non-binary people.

They expect you to go from pink to blue, from F to M. There is no possibility for example that I do not want to start a hormonal treatment but that I want to do a top surgery, and that does not necessarily mean that I will be a man. (S., 32, non-binary)

The institutional GAP is partially provided by the national health system (i.e., Sistema Sanitario Nazionale, SSN), but there are few centers present in the country and with long waiting lists. For surgery affirmation, activists chose to go abroad to skip both the gatekeeping and the waiting list.

Economically is a difficult path, because not everyone can afford it. Fortunately, I saved some money up and then went to work, because even though my parents supported me, I do not want to be a burden. So, I saved up some money so that I could also afford the operations that I will do abroad for sure because I cannot wait for the Italian times. But it is an expensive journey because of visits cost, hormones and so on. (G. 29, trans man)

From the participants’ account, welfare perpetrates a form of economic injustice. Participants suggest a more equitable and just welfare system that includes GAP steps (e.g., surgery and hormones) free of charge even for non-diagnosed trans and non-binary people or to have a payment system that is proportionate to people’s income levels.

The legal procedure is strongly intertwined with the medical procedure (e.g., it is judges who authorize surgery): its main pitfall is that the lawyers and judges have limited knowledge of the TGD people’s lived experiences with the GAP. From participants’ accounts “there is no need for judges who give or deny the consent for your surgeries or changing your name, especially when you need to explain to them how the GAP works” (N., 31, trans man).

The participants’ desired an institutional GAP that reimagines and reframes the medical procedures to be more inclusive, tailored, and devoid of pathologization, leaving it to TGD people to decide and elect to follow some steps (e.g., psychotherapy to support coming out/questioning process), thus diminishing the power of the practitioners’ gatekeeping role. Furthermore, participants underscore the potential of therapy as a valuable and desirable tool when transformed into a space for exploration and support “to become who you are” rather than a mere diagnostic step. In turn, the centrality of gender dysphoria should be downsized, giving more space for the exploration of gender euphoria, which, according to several participants, was what made them embrace their TGD identity.

Therapy can give you the tools to understand yourself, start a path to fulfil yourself and achieve gender euphoria, which is much more indicative than dysphoria in some ways. (G., 23, non-binary)

Moreover, participants advocate for a GAP that includes TGD identities’ desire for partial and tailored body interventions (e.g., micro-dosing or top surgery only) or non-medicalized experiences (e.g., social and legal affirmation), all moving away from the diagnostic paradigm. The legal procedures are the most stressful and anxiogenic according to participants that are “afraid of this step. I think it is unfair for teenagers to find a lawyer to live their lives as if they committed a crime” (W., 18, trans man). To transform this step, participants suggest a simplification of the practices (e.g., turning the legal procedures into administrative procedures), “as if you need to renew your ID because is expired or you have lost it” (Y., 20, non-binary), and the inclusion of non-binary options in the identification documents.

Despite activists’ efforts to train and educate practitioners using “first-hand experiences,” the need for more TGD perspectives in the institutional GAP discourses and practices, from its design to its on-the-ground implementation, remains unfulfilled. None of the actions deployed by the participants addressed this need, underscoring that TGD people are excluded from the decision-making that concerns their affirmative care at the institutional level.

Mesosystem and Microsystems

Mesosystem, in this context, was intended as the container space where different microsystems interact. Two microsystems were outlined as particularly relevant to GAP, (a) professionals and (b) LGBTQIA + community members.

Relationships with Professionals

Participants reported various experiences with different professionals, mainly characterized by rigidity in the application of protocols, following stereotypical and transnormative patterns in the representation of TGD identities. Therefore, these experiences are considered negative and intrinsically limited to the point of “perceiving this moment as useless. I was talking to a therapist that was asking for things that had nothing to do with my gender identity, like if I used to wash the dishes when I was younger” (E., 23, non-binary).

The experiences with therapists were presented in ambivalent ways by participants. For some participants, this relationship was extremely negative; microaggressions turned therapy into a corrosive path or led to dropping out.

It was a disappointment. After one year my therapist called me by my dead name. I was shocked. (R., 34, trans woman)

Other participants reported how therapy represented a moment of growth and support for their gender affirmation. Most of these positive experiences were with professionals who were not part of the institutional GAP procedure and were not involved in a gender dysphoria diagnosing pathway.

My therapist is helping me to navigate my identity. It is very helpful to have someone open to hearing all the things you have in your mind, without judgment. I am not afraid to share doubts, fears, desires, and thoughts because I know it is a safe space. (S., 32, non-binary)

Participants proposed having new specialized professionals (e.g., gender therapists) receiving specific training legitimizing every TGD experience as authentic and unique.

It could be useful to update the GAP to include non-binary identities and gender therapists like in the US, overcoming this idea of FtM and MtF. (M., 21, gender questioning)

Since direct contact with institutions to reform the GAP is challenging for activists, they opt to engage in dialogues with individual professionals who demonstrate a genuine interest in the needs of the TGD community. This approach aims to bridge the gap by addressing professionals’ requirements, such as integrating their knowledge of TGD issues via comprehensive narratives and incorporating new perspectives like non-binarism and intersectionality. Through these meaningful collaborations, activists strive to raise awareness and promote positive changes in the way professionals work with TGD individuals.

With my collective, we created a public festival in our city with workshops and discussions, addressing queer issues with an intersectional approach. It happens that some allied professionals ask for our opinions on various topics. For instance, we organized an event in collaboration with a group of psychologists on the topic of sexuality from an intersectional perspective. (S., 32, non-binary)

Relationships with LGBTQIA + Community Members

Overall, participants depicted an ambivalent connection to the larger LGBTQIA + community: being a member does not necessarily imply being trans-inclusive. While they found support within the TGD community, they also described a friction with stereotypical views and misconceptions about the trans experience, exclusive behaviors—such as ableism and cis-normativity, hegemonic concepts of masculinity and femininity, and exclusion of non-binary experiences.

I am always afraid that other people will not give me credibility. Some groups are very stereotypical and rooted in the binary logic of “men must do men”, to the point they think I am not trans enough. (P., 22, non-binary)

Participants call for a more inclusive and supportive community where the deconstruction of cis and transnormativity can take place. The highlight is the importance of embracing diverse narratives and identities, in line with the principle of intersectionality. After all, having a place and a community to belong to can sustain TGD people and allow them to flourish during their GAP and “feel like you have another family outside your home, where you can be understood” (N., 31, trans man).

However, participants reported experiencing mixed emotions concerning the responses of the LGBTQIA + community to their activist efforts. While some participants have been able to successfully initiate new inclusive procedures (e.g., remove the obligation to declare gender markers in the subscription form for an LGBTQIA + association) and start intersectional discussions within their groups (e.g., talking about ableism, fatphobia, and TGD identities). Nevertheless, transnormativity is hard to challenge since it is highly reinforced and legitimized by the GAP institutions.

At a party, I wanted to enroll in my association [LGBTQIA+], and they asked me to use my legal name. I couldn’t believe it. I cried and got angry, but then a person from the association told me to use my chosen name and we made a formal request to the national head office. Now, to become a member, you don’t need your legal name; you just need your tax code. It was an important achievement because something good came out of a difficult situation. (N., 31, trans man)

The quote presented underscores the difficulties in transforming procedures and perspectives. Activists often face significant challenges when attempting to change the rules, especially when the resistance comes from within the LGBTQIA + community itself. Challenging transnormativity can be particularly arduous, making the pursuit of inclusivity an even greater endeavor.

On a Facebook group for trans women, an older trans woman suggested that “to be a woman, you have to have huge breasts.” I took a screenshot of this post, removing her name and, I reposted it in another group, stating that we should combat these stereotypes rather than embracing them. As a result, the older trans woman contacted me privately, threatening me and stating, “you are not a woman,” “you look like a man, you are a faggot” Sometimes, it feels like a competition to prove who is more woman or more man. [...] We desire to be part of a community, to belong somewhere. Consequently, when you exist on the margins, there comes a point where you may do anything to fit in. (M., 21, trans woman)

Individual Level

From participants’ accounts, all institutional procedures are intended to legitimize and sustain the GAP experience within the framework of gender dysphoria exclusively. This further reinforces the trans rhetoric of being born in the “wrong body,” which is a source of suffering and a sense of inadequacy.

It makes me sad that in Italy we still need a diagnosis, to be pathologized. This prevents non-binary people from accessing surgeries or [hormonal] micro-dosing. We are healthy people, we are medicalized, but we have no pathologies. I do not feel in the wrong body. It is true, I take hormones and my body changes, but it is still my body. The same body. This narrative of the wrong body must be abandoned. (G. 29, trans man)

In the desired GAP, participants envision experiencing a validating dialogue between feelings of dysphoria and euphoria. This dialogue, experienced and sustained within the institutional setting, would allow an awareness of the TGD experience that is coherent with everyday life outside the clinical contexts.

Gender euphoria was the feeling that unlocked me realizing who I was. (P., 22, non-binary)

Participants are actively involved in generating new narratives about the TGD experience through an educational process in various aspects of their lives. This primarily involves sharing their perspectives in online and community settings, as well as engaging in exchanges with other TGD individuals. Participants express the need of starting a dialogue between the scientific knowledge and the embodied experiences of the TGD community.

I have a public profile where I discuss non-binarism and LGBTQIA+ issues in general. Additionally, I am writing a book; I have asked several non-binary people to share their stories with me. Hopefully, a publisher will decide to publish it. I have noticed that, at least in Italian, there are not many books on this subject, and the ones that have been published do not address the topic adequately. (B., 19, non-binary)

I do not use online networks very much. Whenever I can, I get involved, aiming to shed light on the TGD experience. I believe that sharing one’s own story is fundamental; that’s my activism. Additionally, I am part of a film festival that focuses on queer cinema, and I strive to contribute my experience to ensure a diverse representation of bodies and life experiences in the films we select. (F., 25, non-binary)

To recap, the GAP as it is now, throughout all the levels presented, contains no communication between levels (Fig. 1, left section). Instead, in the transformative GAP, levels are in communication with each other (Fig. 1, right section). The current GAP is a top-down structure, with no openness to the contribution of activists; it is a rigid path and reluctant to proposed changes. At all levels, there is a distance between the current situation and the desired one. Participants ask for space for TGD people to build change, where they can be formally included as educators and professionals, not leaving the work of education solely in the individual relationship with providers.

Discussion

The present study aimed to design a transformative ecological model of the Italian GAP, prioritizing and building on the subjective experiences and perceptions of TGD people. A hostile social climate, cisnormative societal values, and stereotypical social representations of TGD identities provide the landscape where participants’ experiences are situated.

Regarding the first research question (RQ1), the results revealed numerous shortcomings in the actual GAP across all five ecological domains, with limited potentials identified. The Italian institutional GAP follows standard steps for all individuals, disregarding their unique needs and preferences. TGD individuals are required to undergo a psychological pathway, even if they do not wish to, with professionals assigned directly by the centers. Unfortunately, the psychological consultation often serves as a formality to prove their identities rather than an exploratory process (Morris et al., 2020; Applegarth & Nuttall, 2016). This search for identity is further hindered by professionals with transnormative perspectives and stereotypically binary gender views (Johnson, 2019). Therefore, many patients fear that expressing their subjective and unique TGD identity may result in denial of necessary medical treatment for their GAP (Applegarth & Nuttall, 2016). It is even more complex for non-binary individuals to express their subjective and unique identity: they can legally change their gender, but they must choose the “opposite” sex marker and they also feel apprehensive about coming out even within the trans community, as it is perceived as not fully inclusive (Pignedoli, 2021). The positive aspect of the GAP is that, if it is carried out in public centers, it is fully covered by the national health system (i.e., SSN). However, this advantage is counterbalanced by the long waiting lists with the SSN, limited availability of structures and services locally, and outdated training of professionals. As a result, most people who are affluent enough bear the cost of travel or resort to the private sector, either in Italy or abroad.

RQ2 highlights the need for several changes in the Italian GAP to address the needs of TGD individuals. Participants emphasize the importance of a tailored institutional GAP with well-trained professionals acting as supportive figures rather than gatekeepers. The medical and legal systems as it is now can hinder the achievement of GAP-related goals, leading to significant stress and adverse mental health outcomes for TGD individuals (Koch et al., 2020).

TGD individuals feel subordinate in their interactions with professionals and report being treated as patients to be diagnosed, infantilized, and questioned about their choices, rather than receiving the support they require (Applegarth & Nuttall, 2016). They also experience the need to educate every professional they consult (Hostetter et al., 2022), thus contributing to additional stress as it places a considerable burden on individuals to simultaneously educate and receive treatment (Wolf-Gould & Wolf-Gould, 2020).

In their interactions with psychologists, they encountered various forms of verbal microaggressions (Morris et al., 2020). Particularly, non-binary individuals may avoid seeking psychotherapy due to professionals’ lack of expertise (McCullough et al., 2017) and the risk of experiencing misgendering with gendered language that erases their identities (Rosati et al., 2022). However, participants stressed that voluntary psychotherapy could be valuable if it authentically supported their gender-affirming pathway (Anzani et al., 2019).

The role of judges is particularly criticized, and participants propose replacing the judicial pathway with an administrative procedure, granting individuals the right to change gender markers and names without a judge as a gatekeeper. They also demand the recognition of non-binary gender in official documents. Participants advocate for depathologizing TGD experiences to access the institutional GAP. The current model centers on diagnosis and treatment, limiting autonomy and active involvement of TGD individuals in medical and legal pathways (Davy & Toze, 2018; Riggs et al., 2019). Depathologization entails recognizing the active role of TGD individuals in decision-making concerning their bodies (Köhler, 2022).

Our participants demonstrate significant capacity for health and critical literacy (Schulz & Nakamoto, 2013), putting them in a position to negotiate treatment conditions based on their knowledge. This capacity is such that they often find themselves educating professionals yet live their knowledge and expertise as a paradox. It is also crucial to acknowledge that the opportunity for strategic engagement with medical authority may not be equally accessible to all TGD individuals in every context (Johnson, 2019). Activists have the competence to build a transformative GAP, but there is structural oppression and power asymmetry that hampers this possibility. To transform the institutional GAP a paradigm shift in the reading of TGD identities’ experiences is needed at every level, moving from a pathological view to one in which TGD identities is one of many possible life trajectories, including heterogeneous and fluid narratives (Mocarski et al., 2019).

RQ3 shows participants are engaged in actions for social change, with the aim of transforming the current institutional and informal GAP and supporting the TGD community. Their activism became a space of social empowerment and resilience (Lindley & Budge, 2022); having a limited space at the institutional level did not prevent activists’ work in changing social representations of TGD identities’ experiences in society and personal relationships.

TGD activist actions have, as interlocutors, both professionals and the LGBTQAI + community. With regard to professionals, activists provide education as experts, relieving them from the effortful task of educating within the provider–client relationship (Hostetter et al., 2022). As for the community, they create safe spaces through online meetings or surveys where TGD people can share their positive and negative experiences with professionals and use them to advocate for a better gender-affirming care system (Budge et al., 2017; Matsuno & Israel, 2018) as well as help others to avoid inadequately trained professionals (Lindley & Budge, 2022). Information received from other TGD individuals and through networking plays a crucial role in “learning” how to interact with professionals strategically, to deal with their transnormativity, which can also be internalized within the TGD community (Johnson, 2019; Pignedoli, 2021). Activists are committed to a process of collective resistance to transnormativity, wherein they collaboratively construct intersectional, alternative, and divergent narratives (Bradford & Syed, 2019; McLean et al., 2017). Participants, understanding the impact of societal oppressions (Hagen et al., 2018), deconstruct the idea that there should be criteria for being “trans enough,” especially ones imposed by the transgender community itself (Bradford & Syed, 2019). They share experiences also embodying gender euphoria narratives and information on gender issues and TGD experiences to challenge prejudice and stigma (Lindley & Budge, 2022), through personal networks, public events, both online and in person with their associations, clearly showing queer generativity (Rosati et al., 2021). Indeed, activists claim that education and information are central to transforming society at this level and work actively to contribute to change in both the LGBTQIA + community and wider society, to contrast ignorance, and systemic transphobia of the country (Lorusso & Albanesi, 2021).

Our results clearly highlight that societal transformation would require a dialogue at the institutional level with activists. In the desired GAP, TGD people would have an active role in reforming the pathway and working as experts. Activists are aware of intersecting oppressions and view their call for changing the GAP as a broader call for societal reform at multiple levels (Dorsen et al., 2022; Hagen et al., 2018).

The current GAP operates as a top-down structure, with little openness to the input of activists, and it is characterized by rigidity and resistance to proposed changes. There is a noticeable discrepancy between the current situation and the desired one across all levels. Participants advocate for providing space for TGD individuals to drive change actively, where they can be formally included as educators and professionals, rather than solely relying on individual interactions with providers for education.

The Desired GAP Model and Recommendations for Supporting Transgender and Gender-Diverse Individuals: a Multilevel Perspective

Our study adheres to an ecological perspective, emphasizing that the health and gender affirmation journey of TGD individuals cannot be solely understood at an individual level and should not be limited to clinical settings (Dorsen et al., 2022; Jones, 2023a, b; Mann & Jones, 2022; Mocarski et al., 2019).

Our research highlights how transnormativity, gatekeeping, and discrimination are prevalent across various ecological levels. This normative perspective poses a threat to the well-being of individuals, both in their personal lives (informal settings) and in the context of GAP services (formal settings). However, participants’ advocacy against injustice and pathologization has contributed to the development of a potential model that can transform narratives, practices, and recognition.

The ecological framework, as previously employed in LGBTQIA + literature (Jones, 2023a, b; Mann & Jones, 2022), unveils the multifaceted nature of the GAP shaped by interconnected dimensions. This process encompasses both internal and external affirmation (Dorsen et al., 2022). Our work not only highlights this dynamic but also provides invaluable insights into how each ecological level contributes to the GAP. Furthermore, the ability to self-determine one’s life should not be controlled by policies that have historically constrained, and continue to do so, the possibilities for LGBTQIA + individuals to pursue paths of euphoria (Jones, 2023a).

As Fig. 2 shows, the GAP model proposed by the participants dismantles the transnormative view that permeates all levels (Mocarski et al., 2019), thereby making room for a self-determined GAP that is unique and based on the pride and euphoria of being a TGD person (Jacobsen & Devor, 2022).

Fig. 2
figure 2

The ecological model of the desired gender-affirming pathway. Dashed lines were employed to represent the permeability of layers and the potential for bidirectional top-down and bottom-up interactions

Full size image

At the macro level, we need genuine legal reforms to protect LGBTQIA + individuals. Additionally, cultural work is required to dismantle stigmatizing views of TGD people’s lives. The ecological model emphasizes that identity development is closely linked to the sociocultural context (Jones, 2023a, b; Mann & Jones, 2022). Therefore, it is crucial to create inclusive narratives of TGD experiences and officially recognize all identities, including non-binary ones. Participants also highlight the connections between the GAP and social change, seeing living as a TGD person as a radical act and gender affirmation as part of a broader sociopolitical and cultural paradigm shift (Dorsen et al., 2022).

At the exosystem level, we should reform the institutionalized GAP to bring about these changes. Participants propose an equitable welfare system, offering free GAP procedures for all or a payment system based on income levels for fairness. They stress the importance of reducing waiting lists, improving professional training, and expanding services. Economic, geographic, and class-related factors must also be considered, as they impact the well-being of TGD individuals (Koch et al., 2020). Access to medical and legal procedures in the GAP should be based on self-determination, fully depathologizing TGD identities (eliminating the need for diagnosis or gatekeeping), and explicitly including non-binary identities both in legal aspects and medical procedures (Köhler, 2022). It should be a tailored process that avoids reinforcing stereotypical and transnormative views. These changes will bring benefits to both professionals and the LGBTQIA + community. From the interactions between professionals and TGD individuals (mesosystem level), we can see a shift in the hierarchy of knowledge, where those directly involved are recognized as experts. This collaboration will improve the relationship between professionals and TGD clients, fostering a joint effort to improve their health (Kerr et al., 2022). This is also evident in relationships at the micro level, where TGD individuals can interact with accepting professionals, sharing their own personal narrative. Moreover, they can be part of an LGBTQIA + community that is inclusive of diverse and fluid narratives. This positive change will impact the individuals, providing space for them to share their experiences of both euphoric and dysphoric feelings, finding acceptance without being interpreted within a pathological and diagnostic framework.

The desired model proposed by the participants (Fig. 2) provides insights for clinical and research practices. TGD individuals wish to have a voice in decisions concerning their lives and health (Applegarth & Nuttall, 2016; Hostetter et al., 2022). Therefore, we believe it is crucial for every professional association and team to engage with members of their local LGBTQIA + community, working collaboratively to improve their services and reduce the feeling of not being heard that TGD individuals experience (Koch et al., 2020). Moreover, professionals must question their gatekeeping role and abandon it, allowing safe spaces to be established, where TGD individuals can authentically share their narratives without the fear of seeing their legal or medical pathway negated. By moving in this direction, the relationship with medical and psychological professionals will become a space where doubts and concerns about treatment choices can be openly discussed. Lastly, as we have highlighted, supporting a TGD person in their GAP does not solely involve considering individual medical and psychological factors; it means understanding the social context in which the person is immersed. Therefore, professionals need to be aware that TGD individuals may have fears more related to living in a hostile social context than to their identity. This understanding is essential because internalization of transnormativity should be interpreted and addressed as a social process and not as intrapsychic individual one (Mocarski et al., 2019).

Limitations and Future Directions

This research comes with limitations. There is a low representation of identities that have experienced all dimensions of the institutional GAP (4 people out of 25 had affirming-surgeries, and 6 out of 25 had changed their documents). Due to the complexity of the GAP in Italy, the paper did not provide an analysis of the differences between undertaking a GAP with private professionals and a GAP at a public center; instead, we preferred to focus on the common points of these two paths. Future research could investigate the experiences of TGD people with different kinds of services for the affirmation of gender in Italy and/or in other countries. Furthermore, our study does not consider the chronosystem level, which could be an interesting perspective for future research, highlighting how the possibility of affirmation changes over time. Investigating generational differences in this sense could provide interesting insight. Indeed, the age of our participants, which is very homogeneous, probably partly due to the online sampling methods, did not allow to explore differences related to age of participants. For future research, it would be also important to consult other actors directly of the microsystems that are part the ecological model such as family members and professionals.

Despite the limitations, our research suggests that the current institutional Italian GAP is far from meeting the needs of the TGD population and, at times, can be an additional source of stress that negatively impacts mental health and well-being of TGD population. GAP should be a pathway based on self-determination capable of giving supportive tools for well-being, rather than posing additional challenges. The GAP should be a turning point in addressing the medical, psychological, and social needs of this population.