Introduction: Close to 2 million transgender (trans) individuals live in the United States and Canada. Trans communities frequently report emergency care avoidance and negative health care experiences. Of note, there is currently no research on the paramedic perspective of caring for trans populations. Our objective was to explore paramedic comfort, confidence, and cultural competency in providing emergency care to trans individuals. Methods: A cross-sectional, semi-structured electronic survey was administered by email to paramedics registered with the College of Paramedics of Nova Scotia (n = 1225) from April 9th to May 7th, 2018. The survey included previously validated questions from other medical settings. Three survey reminders were sent at weekly intervals following survey initiation. A 4-point Likert scale and qualitative open-ended questions were included to evaluate paramedic comfort, confidence, and cultural competency. Descriptive statistics were used to describe respondent characteristics. Open ended questions pertaining to paramedic needs were evaluated using constant comparative analyses consisting of open coding to identify themes. Results: Of the 387 paramedics who participated (response rate = 32%), 77.8% (n = 301) worked ground ambulance in a mixed rural/urban location (32.6%, n = 126) within Nova Scotia (94.5%; n = 365). Most respondents were between the ages of 41-50 (29.5%; n = 114), with > 20 years’ experience (25.1%; n = 97), and male sex assigned at birth (56.1%; n = 217). Over half (54.8%; n = 212) identified as cisgender men. The majority (66.1%; n = 256) reported caring for a patient who identified as trans. 74.7% (n = 289) have never had formal education on trans health. Only 4.1% (n = 16) felt very knowledgeable about providing optimal care to trans communities and 26.6% (n = 103) felt very comfortable in providing optimal care. Most (70%; n = 271) were interested in obtaining formal education. 41.9% (n = 162) reported observing transphobia in the work place. Conclusion: The frequency of trans patient contact by paramedics is perceived to be high. Although comfort and knowledge are relatively low and transphobia witnessed in the work place relatively high, there was strong interest and expressed need for education on trans related health.