Feedback Structures Generating Policy Exposure, Gatekeeping, and Care Disruption in Transgender and Gender Expansive Healthcare

Transgender and gender-expansive (TGE) communities face persistent health inequities that are reproduced through everyday administrative and clinical encounters across care systems. A feedback-focused lens can clarify how those inequities are generated and sustained. Objective: To identify and validate feedback loops that create policy exposure and institutional gatekeeping in TGE healthcare and to surface leverage points to stabilize their continuity of care. Methods: Two facilitated, Zoom-based Group Model Building (GMB) sessions were conducted in March 2021 with eight TGE participants (mean age 38 years; range 22–63; transfeminine and transmasculine identities; multiracial, White, and SWANA racial identities) recruited through a Lesbian Gay Bisexual and Transgender (LGBT) community center, followed by a participant member-checking session to validate loop structure, causal direction, and interpretive accuracy. Analysis focused explicitly on identifying reinforcing and balancing feedback structures, rather than isolated barriers, to explain how policy exposure and institutional gatekeeping are generated over time. Results: Participants co-constructed a nine-variable Causal Loop Diagram (CLD) with six feedback structures, four reinforcing and two balancing that interact dynamically to amplify or dampen policy exposure, institutional gatekeeping, and continuity of care, which were organized across structural, institutional/clinical, and individual/community tiers. Reinforcing dynamics linked structural stigma, exclusion from formal employment, institutionalized provider bias, and enacted stigma to degraded care experience, increased trauma and distrust, and disrupted continuity, manifesting as policy exposure (e.g., coverage volatility, denials) and gatekeeping (e.g., discretionary documentation, referral hurdles). Community-based supports and peer/elder navigation functioned as balancing loops that reduced trauma, improved continuity and encounters, and, over time, dampened provider bias. A salient theme was the visibility/invisibility paradox: symbolic inclusion without workflow redesign can inadvertently increase exposure and reinforce harmful loops.