Systemic oppression of transgender and gender diverse (TGD) individuals is fueled by societal stigmas derived from normative perspectives on sex and gender (Sevelius, 2013; Testa et al., 2012). Prior research indicates that the marginalized status of TGD youth may negatively impact their health and healthcare access (Hendricks & Testa, 2012). Overcoming barriers to equitable healthcare access for TGD youth requires an awareness of the oppressive power structures that impede their well-being and ability to flourish. Researchers have inadequately studied the manner in which gender shapes TGD youth's ability to seek out needed healthcare services safely and on how gender-based oppression impacts TGD youth's health and well-being told from youth's perspectives.Using Walker and Pratto's (2004) theory of gendered power and a sequential mixed-methods participatory design, I collaborated with a TGD youth research and advisory team to explore gendered power and healthcare access in two unique samples of TGD youth. I intentionally used a participatory approach because researchers have historically excluded youth's perspectives on their social and structural marginalization and its impact on access to healthcare. Findings revealed a framework of gendered power composed of three distinct mechanisms that limited youth's power over their gender expression and identity. The framework's restrictive mechanisms-gatekeeping, violent control, and reification of heteropatriarchy-mirror extant theory on gender and power. These mechanisms of control were enacted differently than in the case of cisgender women on whom prior theories were developed. Restrictive mechanisms of power also impacted youth's willingness to engage with and have confidence in healthcare providers. Further, among the sample of TGD youth living with HIV (n=28), I found the restrictive mechanisms of gendered power undermined TGD youth's steady engagement in HIV care, despite also finding that HIV care was the sole source of affirmation within medical environments. Mechanisms operated differently as a function of youth's age, race, gender identity, gender presentation, and socio-economic status. Finally, we identified restorative mechanisms for reclaiming control of and enacting autonomy over identity (e.g., educating and advocating for rights, lifting up the self and the TGD community, disrupting power imbalances, enacting physical expression).The findings from this research provide an empirically based theoretical framework of gendered power that is developmentally appropriate for TGD youth. This study also underscores the importance of theories of gendered power in understanding healthcare access and general well-being among TGD youth. The results suggest the need to support youth reclamation of gendered power at individual interpersonal, and community levels. Findings also point to policy and practice interventions that would promote TGD youth's engagement in care, including revised medical training curriculum for practitioners of family medicine, pediatrics, and reproductive health on gender diversity and affirming TGD care. Finally, results highlight the need for gender affirming policies within youth-serving institutions that promote the validation, inclusion, and safety of TGD youth.
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