Addressing rural mental health inequities for transgender communities in Aotearoa

Gender diversity is expressed through a wide range of terms, including culturally grounded identities used within Māori and Pacific communities in Aotearoa New Zealand and across the Pacific.^1,2 In this commentary, the term “transgender” is used to describe individuals whose gender identity does not align with the sex assigned to them at birth. For clarity and inclusivity, we use transgender as an umbrella term throughout, encompassing identities such as non-binary, whakawahine, fa’afafine and genderqueer, among others. For perspective, the 2023 New Zealand Census reported that around 26,000 adults (0.7% of the adult population) identified as transgender;³ however, currently there are no reliable data on rural versus urban distribution.

Access to mental health services is a well-recognised challenge in rural Aotearoa, where specialist services are limited, wait times are often longer and distance creates additional barriers.^4,5 These challenges have been linked to inequities in service access and persistently higher suicide rates in rural communities. This broader context highlights the additional barriers faced by transgender and gender-diverse people who live in rural areas of Aotearoa.

As a minority group, people from the transgender community face significant mental health challenges, exacerbated by ongoing barriers to accessing appropriate healthcare.^6–8 These barriers include discrimination, stigma, lack of transgender-competent healthcare providers and insufficient access to gender-affirming care (GAC)—an affirming approach to healthcare that may include puberty blockers, hormones, surgery and psychosocial support—particularly in rural regions like Whanganui.^8–15 Access issues are associated with higher levels of psychological distress, self-harm and suicidality among transgender people, with Indigenous populations experiencing even greater disparities.⁹ The recent Aotearoa-based Counting Ourselves survey^7,8—a nationwide community-led health survey of transgender and non-binary people—found that over half of the participants had seriously considered suicide in the past year, with more than a third having attempted it at some point.^7,8 These insights point to an ongoing need for inclusive, accessible healthcare that better meets the specific needs of transgender communities.

In rural areas, such as Whanganui, access to GAC is hindered by a lack of designated gender health services and a limited number of healthcare providers with adequate knowledge of transgender issues.^9,14,16 Moreover, many transgender individuals face navigating their healthcare alone, further increasing their risk of negative mental health outcomes.¹⁶ Historically, gender diversity was pathologised, with transgender identities often framed as disorders rather than recognised as valid expressions of self.^13,15 This history has shaped a health system where transgender people still encounter systemic barriers to care and support. While there is no single agreed definition of “transgender competence” comparable to cultural competence frameworks, several key factors are consistently described. These include using correct names and pronouns, creating inclusive environments, understanding GAC pathways and recognising the impact of stigma and minority stress on health. Both international standards¹⁷ and Aotearoa guidelines¹⁸ emphasise that this competence is ongoing and built through clinical knowledge, respectful communication and culturally safe practice.

Positive mental health outcomes are closely tied to the presence of supportive environments and affirming care practices.^7,11,13 For instance, transgender individuals within Aotearoa who receive strong support from their whānau are nearly half as likely to attempt suicide compared with those who lack such support.⁷ Of concern, a Canadian study found that only 13% of transgender youth reported having supportive parents, highlighting the critical role of non-familial external support networks.¹³ Primary care providers, including general practitioners (GPs), play a crucial role in initial and ongoing GAC access. Yet many transgender individuals report negative experiences within primary care, such as having to educate their providers, being misunderstood or stigmatised and facing long wait times for transgender-friendly services.^11,16,19

This commentary draws on findings from a qualitative study conducted in the Whanganui Region in 2023–2024, which explored healthcare experiences of transgender and gender-diverse people and their whānau, alongside perspectives from primary care clinicians.⁹ Although the study was designed to examine access to gender-affirming healthcare more broadly, mental health needs and barriers to support emerged as dominant themes throughout the interviews. This commentary draws attention to mental health concerns raised throughout the study and outlines practical steps to strengthen access to appropriate support for transgender and neurodiverse individuals. Recently, the Whanganui Region has introduced a specific transgender health clinical pathway and opened a clinic that specialises in GAC, addressing critical gaps in transgender healthcare; however, there remains a pressing need for further action. For example, enhancing the availability of mental health support and safe spaces for physical activity is essential to the overall wellbeing of transgender individuals. This commentary will explore these challenges and emphasise the importance of adopting an asset-based approach that leverages community strengths to improve healthcare access and outcomes for transgender populations in Whanganui.

Mental health challenges and barriers

Transgender people living in rural areas, such as Whanganui, face numerous challenges that significantly impact their mental health and wellbeing. Recent research with transgender participants from the Whanganui Region highlighted the significant role of mental health on the transgender journey.⁹ 

Negative impacts on mental health

The Whanganui-based research revealed high rates of mental health–related problems, including anxiety, depression, post-traumatic stress disorder (PTSD), dissociation and suicidal ideation.⁹ These mental health challenges stemmed from both transgender-related and non-transgender-related circumstances, such as early childhood trauma, neurodiversity and difficulties with family acceptance. Together, these factors create a complex landscape in which accessing appropriate support is often difficult and inconsistent. Participants discussed the profound impact of gender dysphoria, where the discrepancy between the physical body and gender identification was often intertwined with mental health, highlighting, as in previous research, the importance of access to GAC.¹⁵

One of the most prominent barriers identified was the limited availability of accessible mental health services in the Whanganui Region. Participants reported that access to counselling or therapy is limited, with those who were able to find support often receiving it for reasons unrelated to their gender identity. Many participants found that their counselling sessions could not be used for gender-related support due to funding restrictions (e.g., Accident Compensation Corporation [ACC] sexual abuse claims) or the counsellor’s lack of expertise in transgender issues. As a result, individuals were often unable to fully engage in therapy, limiting its effectiveness and adversely impacting their mental health.

Additionally, participants faced challenges in finding transgender-competent mental health providers. A strong preference for counsellors with lived experience was emphasised, but the absence of transgender and gender-diverse counsellors in the Whanganui Region limited this potential access to gender-related mental health care. Participants differed in opinion around how to choose a counsellor, with a strong preference for face-to-face, in-person appointments. For some, this meant seeing a counsellor with minimal knowledge or education about transgender issues. For others, it meant compromising on their preference for in-person sessions and resorting to online appointments with transgender clinicians.

Some participants reported that therapy was further complicated by therapists’ personal or religious beliefs, which at times undermined the therapeutic relationship. Participants described feeling judged or misunderstood, particularly when their therapist held conservative views on gender or attempted to pathologise transgender identities. Such experiences left some participants feeling alienated or stigmatised, leading to disengagement from care.

Another significant impact on mental health was the experience of living “stealth”—concealing one’s transgender identity. This lifestyle often resulted in heightened stress due to the secrecy and the need to conform to cisgender norms. Participants reported that, while they enjoyed gender-affirming activities in safe spaces, returning to a non-affirming environment afterwards led to negative thoughts and low mood, exacerbating their mental health struggles.

Finally, financial stressors were highlighted as significant contributors to poor mental health. Many transgender individuals struggled to afford basic needs (e.g., clothing or haircuts), let alone the additional costs associated with GAC, such as hormone therapy or surgeries. The cost of accessing GAC, alongside employment challenges linked to discrimination or gendered expectations, contributed to financial instability and added strain on mental wellbeing.

Positive impacts on mental health

Conversely, participants noted several factors that positively impacted their mental health and wellbeing. Access to supportive GAC, including hormone therapy and surgeries, was frequently cited as a key contributor to improved mental health. Having access to GAC allowed individuals to align their physical appearance with their gender identity, significantly alleviating gender dysphoria and improving overall wellbeing. Whether through social transition, hormone therapy or surgery, participants described a strong desire for access to these services and noted poorer outcomes when care was unavailable.

Participants also emphasised the importance of “rainbow safe” counselling and trans-friendly sport and recreational activities. Access to such inclusive activities in Whanganui was acknowledged to be poor. Engaging in environments that supported their gender identity provided a sense of safety and connection. Community support—including peer connection and belonging within LGBTQI+ spaces—was described as vital to mental wellbeing. Peer support, especially in early stages of transition, offered lived experience, practical advice and emotional connection often missing in formal services. This is in line with previous Aotearoa findings.

Preferences around therapy and challenges

The interviews revealed a clear preference among transgender individuals for therapy that is affirming, accessible and delivered by someone who understands the unique challenges of being transgender. In-person therapy was valued for its direct human connection, seen as essential for building trust and rapport. However, due to the scarcity of qualified transgender therapists in rural areas, many participants turned to online sessions, which, while helpful, did not always meet their needs for personal connection and depth.

Neurodivergent participants, including those with attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD) or other cognitive differences, described additional barriers in accessing GAC. Many lacked a formal diagnosis due to fears it could jeopardise their access to GAC or because assessments were financially out of reach. Neurodivergence shaped how participants engaged with healthcare, with challenges in planning ahead to avoid prescription lapses, attending appointments and navigating social interactions often resulting in delays or avoidance. These findings highlight the need for flexible, inclusive care pathways that accommodate the diverse needs of neurodivergent transgender individuals.

Implications for policies, legislation, and future directions

There is a need for greater investment in transgender-affirming mental health services that are accessible across both urban and rural areas. Improvements could be made by broadening telehealth access, enhancing rural clinician training and ensuring streamlined pathways to GAC without imposing unnecessary psychological assessments.^15,20

Future research and advances in rural health practice

Further research is needed to examine how locally tailored GAC models affect mental health outcomes in rural settings. In particular, studies should investigate the impact of culturally grounded, community-led services on rates of distress, disengagement and suicidality among transgender populations. Future research should focus on evaluating sustainable mental health support models that incorporate Kaupapa Māori values, peer-led strategies and digital delivery tailored to areas with limited clinical infrastructure.

Recommendations

• Fund and integrate affirming mental health services in rural care models: Ensure mental health support is not treated as an adjunct, but as a core component of GAC pathways.
• Build capacity through training and shared learning: Develop and deliver targeted mental health education for rural clinicians, incorporating transgender-specific and culturally responsive competencies.
• Support peer and community-based mental health initiatives: Expand roles for peer support workers and community navigators in providing early, easy to access mental health assistance.
• Strengthen cross-sector and iwi partnerships: Foster collaboration between primary care, iwi providers and community groups to expand culturally grounded mental health services.
• Prioritise service integration and sustainability: Develop enduring rural mental health strategies that include transgender-specific pathways, informed by both clinical and lived experience.
• Expand access to inclusive and affirming physical activity environments: Support the development of safe, community-based spaces that enable transgender individuals to engage in physical activity without fear of discrimination or harm. Recognise the role of such spaces in promoting mental health, social connection and long-term wellbeing, particularly in regions where access to clinical support may be limited.

Conclusion

Mental health emerged as a central concern for transgender participants and clinicians in this rural study, highlighting the importance of improving accessibility, affordability and GAC. We propose a community-informed approach for improving mental health support for transgender people in rural Aotearoa. It highlights ongoing service gaps, including the limited availability of affirming, culturally appropriate care. Addressing these gaps through regional health planning, integrated service delivery and targeted mental health initiatives is essential to reducing inequities. With greater investment and collaborative planning, rural health systems can improve access to timely, affirming mental health support for transgender communities.