Thomas Lawrence Long, Christine Rodriguez, Marianne Snyder, & Ryan Watson

Background

It should come as no surprise that the transgender and gender nonconforming community has suffered, often in silence. Numerous studies have depicted the various barriers these patients face in respect to healthcare, which include mistreatment by healthcare providers, providers’ discomfort or inexperience regarding patient’s healthcare needs, as well as patients’ lack of adequate insurance coverage for healthcare services (Konsenko et al., 2013; Poteat et al., 2013; Radix et al., 2014; Roller et al., 2015; Sanchez et al., 2009; Sevelius et al., 2014). Due to these barriers, transgender and gender nonconforming patients are often left to navigate health care on their own.

For example, the National Center for Transgender Equality (2016) reported that 33% of respondents who had seen a healthcare provider in the past year suffered at least one negative experience related to being transgender, while 23% of respondents did not even seek a medical provider when they needed for fear of being mistreated. Additionally, a staggering 39% of respondents experienced psychological distress, and 40% have attempted suicide in their lifetimes, which is nearly 9 times the 4.6% rate of the general population (James et al., 2016). Seeking routine or preventative physical and mental health care, let alone transition-related services for those who seek to transition, is difficult.

Epidemiology

Several attempts have been made to determine how many individuals identify as transgender within the United States (Institute of Medicine, 2011; Zucker & Lawrence, 2009). Recent estimates postulate that 0.6% of the population, or 1.4 million Americans, are transgender (Flores et al., 2016). However, one must also consider the complexity of the gender construct because more rigorous epidemiological studies are needed on a global scale to delineate the incidence (percentage of the population) and prevalence (total number of people) of this experience. Historically, transgender and gender nonconforming individuals have been marginalized, and the disparities we have discussed earlier in this chapter may instill a sense of fear within the community, thus leading to greater difficulty in obtaining an accurate estimate. Additionally, cultural differences in different societies shape the behavioral expressions of gender identities, masking gender dysphoria (Coleman et al., 2012). For instance, certain cultures may revere and consider as sacred such gender non-binary behaviors, leading to less stigmatization (Coleman, Coren, & Gooren, 1992; Kessler & McKenna, 1978; Wilson, 1996).

Moreover, as the literature suggests, the prevalence of a diagnosis of gender dysphoria is unknown. There has been great controversy within the transgender and gender nonconforming community regarding this diagnosis because in earlier years the phenomenon was deemed as psychopathological (McHugh, 1992). On the one hand, gender nonconformity refers to “the extent to which a person’s gender identity, expression, or role differs from the cultural norms that designate for people of a particular sex” (Institute of Medicine, 2011). On the other hand, gender dysphoria was first described by Fisk (1974) as “the discomfort or distress that is caused by a discrepancy or incongruence with a person’s gender identity and that very same person’s sex that was assigned at birth.” Therefore, not every transgender and gender nonconforming individual experiences gender dysphoria. As a result, the World Professional Association of Transgender Health (WPATH) released a statement in 2010 that urged for the de-psychopathologization of gender nonconformity worldwide. It is thereby the goal of the healthcare professional to assist transgender and gender nonconforming patients who suffer from gender dysphoria by affirming their gender identity and collaboratively investigating the array of options that are at their disposal for expression of their gender identity.

Therapeutic Options for Transgender and Gender Nonconforming Patients

An array of therapeutic options must be considered when collaboratively working with transgender and gender nonconforming patients. For those who seek it, transition does not follow a linear model but is rather an individualized process based upon the patient’s specific needs. Such interventions may differ from person to person, as well as when the sequence of such events occurs. Therefore, a collaborative approach between the healthcare professional and patient is of the utmost importance. Additionally, a multidisciplinary approach, one that encompasses primary care providers, mental health clinicians, and surgeons, as well as speech pathologists, results in the best outcomes. Below are the various therapeutic options that the transgender and gender nonconforming patient may undertake:

• Changes in one’s gender expression or role, whether it be living full-time or part-time in the gender expression that aligns with one’s current gender identity; this may also involve chest binding in order to create a flat chest contour, padding of the hips and buttocks, genital tucking, gaff underwear, and wearing a prosthesis.
• Changes to one’s name and gender marker on various identity documents.
• Psychotherapy in order to understand and investigate the constructs of gender: gender identity, gender role, gender attribution, and gender expression; address the positive/negative impacts of such feelings, stigma, as well as address internalized transphobia, if present in the individual.
• Gender affirming hormone therapy to either feminize or masculinize the patient’s body.
• Gender affirming surgeries to alter primary and/or secondary sex characteristics.
• Peer-support groups and community organizations that provide social support, as well as advocacy.
• Speech/voice and communication therapy that assists in facilitating comfort with one’s gender identity or expression and ameliorate the stress associated with developing verbal and non-verbal behaviors/cues when interacting with others
• Hair removal through laser treatments, electrolysis, waxing, epilating, or shaving.

Although the numerous options may seem overwhelming to review, it is the goal of the healthcare professional to assist and facilitate the patient through their journey, regardless of what therapeutic options the patient ultimately chooses. Moreover, access to those services requires that the transgender person lives in an area where they are available and has adequate health insurance, which is usually provided by employers. Transgender people, particularly those of color, however, are less likely to be employed than cisgender LGB people, thus often deprived of the health insurance that they need.

Criteria for Gender Affirming Hormone Therapy

Gender affirming hormone therapy consists of the administration of exogenous endocrine agents in order to elicit feminizing or masculinizing changes. While some transgender and gender nonconforming patients may seek maximum changes, others may be content with a more androgynous presentation. The fluidity of this construct should not be minimized because hormonal therapy must be individualized based upon a patient’s goals, with their thorough understanding of the risks and benefits of medications, as well as in-depth overview of a patient’s other existing medical conditions. Furthermore, initiation of hormonal therapy may “be undertaken after a psychosocial assessment is conducted and informed consent is reviewed by a qualified healthcare professional” (Coleman et al., 2012). The criteria for gender affirming hormone therapy are:

1. Persistent, well-documented gender dysphoria.
2. Capacity to make a fully informed decision and consent for treatment.
3. Age of majority in the given county.
4. If significant medical or mental health concerns exist, they must be reasonably well-controlled.

Common agents used for feminization regimens are estrogen and antiandrogens, while the common agent used for masculinization regimens is testosterone. Progestins have been deemed controversial in feminizing regimens, with clinicians citing only anecdotal evidence for its use in order to allow for full breast development. Despite such a view, a clinical comparison of feminizing regimens with and without the use of progestins found that these agents did not enhance breast growth or reduce serum levels of free testosterone (Meyer et al., 1986). Additionally, progestins’ adverse effects outweigh their benefits because depression, weight gain, and lipid changes have been seen with these agents (Meyer et al., 1986; Tangpricha et al., 2003). However, progestins do play a role in masculinizing regimens, so they may be used in early stages of hormonal therapy to assist in the cessation of menses.

Physical Effects of Gender Affirming Hormone Therapy

A thorough discussion regarding the physical effects of gender affirming hormone therapy by the healthcare professional with the patient is warranted. The use of endocrine agents for the purpose of congruency with a patient’s gender identity will induce physical changes, which may be either reversible or irreversible. Most physical changes occur within the course of two years, with several studies estimating the process to span five years. The length of time attributed to such changes is unique to each individual.

Tables 2 and 3 below outline the estimated effects and the course of such changes.

Table 2: Effects of Gender Affirming Hormone Therapy with Masculinizing Agents

Table 3: Effects of Gender Affirming Hormone Therapy with Feminizing Agents

Due to the masculinizing/feminizing effects of endocrine agents used in transitioning, one must also take into account that the coming out process for someone who identifies as transgender or gender nonconforming may be challenging and may differ from the coming out process of lesbian, gay, and bisexual individuals. LGB individuals may keep their sexual orientation concealed, but the effects of hormonal agents on the transgender person are noticeable to others. Transgender and gender nonconforming individuals may have to come out during social interactions, unless they wish to relocate to a new area, where they may choose not to disclose their transgender identity, often referred to in the community as “living stealth.”

The coming out process may seem daunting to endure and may encompass numerous challenges. A lack of support throughout this process or “experiences of being mistreated, harassed, marginalized, defined by surgical or chromosomal status, as well as being repeatedly as probing personal questions may lead to significant distress” (Deutsch, 2016). Additionally, the persistent and chronic nature of minority stress and the suffering of microaggressions, have led some researchers to apply the Minority Stress Model to transgender and gender nonconforming individuals (Hendricks & Testa, 2012; IOM, 2011). Due to such experiences, there exists a potential increase in the rate of certain healthcare conditions, such as clinical depression, anxiety, and somatization (Bockting et al., 2013).

Transgender people, like all other LGBTQ people, need to learn how to become informed consumers of healthcare services and make informed choices about their own physical and mental wellbeing. Our final section in this chapter explains how to become such a knowledgeable patient.