Abstract
Suicide rates are particularly high among transgender and gender-diverse (TGD) youth. Although gender-affirming care is increasingly incorporated into crisis services, little is known about how its delivery across crisis-care touchpoints may support or undermine safety and affirmation. This study used a youth-centered, iterative, qualitative design to examine practices shaping TGD youths’ experiences of gender-affirming care across crisis encounters. The study included 12 TGD youth aged 13–17 years (M = 16.3), all of whom reported suicidal-related thoughts and behaviors within the past month. Participants completed 22 semi-structured interviews across two iterative waves. Wave 1 explored experiences across crisis-care touchpoints and informed prototypes of gender-affirming practices, which participants reviewed and refined in Wave 2. Data underwent two-phase inductive-deductive analysis, with Wave 1 interviews coded to identify themes, and Wave 2 interviews coded to examine responses to emerging findings and practices. Across in-person acute care and virtual touchpoints, three themes described a mismatch between crisis response and gender affirmation: (1) standardized gender-affirming practiced could feel scripted; (2) agency and control over disclosure and decisions about care, shaped whether encounters felt affirming; and (3) direct and indirect experiences shaped trust and future use of crisis-care resources. A fourth theme focused on proposed improvements to gender-affirming care; across waves, participants favored approaches that adapted affirmation to individual identities, knowledge, and preferences rather than applying standardized practices uniformly. Findings highlight the need for crisis care that addresses immediate safety while tailoring gender-affirming practices to youths’ identities, knowledge, preferences, and disclosure control.