‘A little bubble of utopia’: constructions of a primary care-based pilot clinic providing gender affirming hormone therapy

ABSTRACT

The provision of gender affirming hormone therapy for transgender and non-binary people is a rapidly developing area of gender affirming healthcare. While research indicates the benefits of providing gender affirming hormone therapy through interdisciplinary primary care-based models, less is known about how service users and providers construct their understandings of affirmative approaches. In this paper, we present findings from a discourse analysis of four service users’ and four healthcare professionals’ talk about a primary care-based pilot clinic providing gender affirming hormone therapy in Aotearoa New Zealand. Participants employed notions of pathologisation, time, and agency in their talk to construct the clinic as a personal setting which gave service users time to make their own health decisions, while constructing hospitals as impersonal with lengthy wait times. The assessment-driven nature of best practice guidelines that governed clinicians’ decision-making was constructed as constraining users’ agency. Findings highlight the ongoing importance of aligning gender affirming hormone therapy with other non-disease types of healthcare, and suggest new ways for achieving this through affirmative approaches to healthcare.

KEYWORDS:

• Gender affirming hormone therapy
• primary health care
• transgender
• medicalisation
• depathologisation
• discourse analysis
• informed consent

Many transgender and non-binary (trans) people, whose gender does not align with that presumed for them at birth, view gender affirming hormone therapy as medically necessary. Despite research demonstrating the positive effects of gender affirming hormone therapy on trans people’s wellbeing (Bockting, Miner, Swinburne Romine, Hamilton, & Coleman, 2013; Hughto, Reisner, & Pachankis, 2015), many people around the world have had difficulties accessing hormones due to the lack of trained healthcare professionals (Dewey, 2015; McPhail, Rountree-James, & Whetter, 2016; Safer et al., 2016; Snelgrove, Jasudavisius, Rowe, Head, & Bauer, 2012), lengthy wait times (Clark, Veale, Greyson, & Saewyc, 2018; Erasmus, Bagga, & Harte, 2015; Fraser, 2020) and lack of dedicated funding and clear information on how to access care (Veale et al., 2019). Such barriers are typically underpinned by dominant understandings of gender that privilege cisgender (non-trans) interpretations (Pearce, 2018). These systems, which tend to position gender affirming healthcare as elective or non-urgent (Stryker, 2008; Wi-Hongi, Grieg, & Hazenberg, 2017) are being increasingly challenged by trans health advocates who frame access to gender affirming healthcare as a human rights issue (Davy, Sørlie, & Schwend, 2018; Schwend, Winter, Chiam, Smiley, & Cabral Grinspan, 2018).

Medicalisation and (de)pathologisation

The evolving discourses about gender diversity both construct, and are constructed by, medical discourses around gender dysphoria and transitioning (Riggs et al., 2019). As such, medicalisation and (de)pathologisation are both useful concepts to assist in understanding gender affirming healthcare. Medicalisation refers to the process by which human experiences and conditions become framed as medical issues that require intervention or treatment (Illich, 1975; Szasz, 1970). Though some earlier sociologists describe medicalisation as a process of diagnosing and exerting social control (see Conrad, 1992; Zola, 1972), some scholars (e.g. Cannoot, 2019) have more recently asserted that access to healthcare should not require that a person’s experience is legitimised through only being understood as a disorder or illness. This highlights the usefulness of distinguishing between medicalisation and pathologisation more closely.

In this article we draw on Sholl’s (2017) distinction between medicalisation (referring to intervention and treatment) and pathologisation (relating to diagnosis and illness-related issues) to ask how gender affirming healthcare can be made accessible to trans people in medical settings, yet not reinforce the construction of gender diversity as a disorder. This is consistent with the trans depathologisation movement’s efforts to ensure trans people have self-determination with regards to accessing healthcare (Sheherezade, 2017). Notably, the shift in medical discourses from narrow deficit constructions of gender dysphoria to affirmative framing of gender diversity—evident in recent revisions to the placement of and criteria for gender incongruence in the International Classification of Disorders, 11th Edition (ICD-11; World Health Organisation Europe, n.d.)—signals a need for healthcare providers to align their practice with affirmative approaches and principles of depathologisation.

Variations in gender affirming hormone therapy provision

The World Professional Association for Transgender Health’s current Standards of Care, version 7 (WPATH SoC), on which Aotearoa NZ’s national guidelines on gender affirming healthcare are based (Oliphant et al., 2018), are ‘intended to be flexible in order to meet [trans people’s] diverse health care needs’ (Coleman et al., 2012, p. 2). Consequently, models of gender affirming hormone therapy differ across healthcare systems globally, depending on dominant understandings of gender, availability of resources, and healthcare providers’ ability to provide gender affirming healthcare (Bonifacio, Maser, Stadelman, & Palmert, 2019; Mamoojee, Seal, & Quinton, 2017). Within the traditional diagnostic model of gender affirming hormone therapy provision, people require a formal diagnosis of gender dysphoria (American Psychiatric Association, 2013) or gender incongruence (World Health Organisation Europe, n.d.); this requirement has historically constructed and reinforced the pathologisation of trans people’s experiences (Pearce, 2018; Wi-Hongi et al., 2017).

A growing number of primary healthcare services are implementing informed consent-based models to provide gender affirming hormone therapy (Cavanaugh, Hopwood, & Lambert, 2016; Schulz, 2018). In such services, primary care physicians typically work within an interdisciplinary team to offer individually tailored support to service users, and perform a mental health screening instead of a formal assessment (Bourns, 2019; Callen-Lorde, 2014; Cundill & Wiggins, 2020; Fenway Health, 2015). With sufficient provider knowledge of gender diversity, primary care settings are generally well set up to provide gender affirming hormone therapy through interdisciplinary teams (Bauer, Zong, Scheim, Hammond, & Thind, 2015; Guss et al., 2019; Wylie et al., 2016; Ziegler, Valaitis, Yost, Carter, & Risdon, 2019). An initial study of the pilot clinic on which the present study is based (Ker, Fraser, Lyons, Stephenson, & Fleming, 2020) indicated that service users were highly satisfied with the care they received in primary care. However, external understandings of medical providers as ‘gatekeepers’ still affected how some services users talked about their health needs with clinic staff.

The Aotearoa New Zealand context

The national healthcare system in Aotearoa New Zealand is governed by twenty district health boards, each responsible for allocating resources and funding to health services in their region (Ministry of Health, 2020). Because of this, there is no standardised pathway to accessing gender affirming healthcare across the country. The under resourcing of gender affirming healthcare in Aotearoa NZ, like in many countries, is a key determinant of unmet health needs among trans people and has created lengthy wait times for care (Fraser, 2020; Veale et al., 2019). However, there is a growing recognition of the importance of providing affirming and equitable healthcare across the country; for example, the Professional Association of Transgender Health Aotearoa (PATHA) was established in 2019 to improve healthcare for trans New Zealanders.

Gender affirming hormone therapy in Aotearoa NZ has traditionally been provided through hospital-based secondary care services (Delahunt, Denison, Sim, Bullock, & Krebs, 2018). People seeking gender affirming hormone therapy are generally required to obtain a ‘readiness assessment’ conducted by a qualified mental health professional in accordance with WPATH’s recommendations. This assessment is usually conducted in one appointment, and the inability to provide service users with ongoing support is attributed to resource constraints. As of 2018, the growing demand for gender affirming hormone therapy in many regions meant an average wait time of one year to receive a mental health assessment through the public healthcare system (Fraser, 2020).

While some overseas studies have addressed how dominant understandings of gender and medicine affect trans people’s experiences of general healthcare (e.g. Bauer et al., 2015; Hilário, 2019; Johnson, 2015a), little research has examined how gender affirming healthcare is constructed and understood by those accessing or providing gender affirming hormone therapy. The present study therefore aimed to explore how both service users and healthcare professionals constructed the pilot clinic in their talk, examining the discourses they drew on, and the implications of their constructions for understanding gender affirming hormone therapy in primary care settings. We use the term ‘service users’ instead of ‘patients’ to emphasise participants’ agency in accessing care, and to resist the connotations attached to patients as unwell or passive.

Methodology

This study was informed by trans epistemology, an affirmative framework which can be used to interrogate how cisgender experiences are privileged in knowledge production (Johnson, 2015b). Accordingly, we use language and framing which acknowledge trans people as the experts in and on their own lives, rather than as ‘objects and instruments of study’ (Radi, 2015, p. 48). A majority of participants were trans, and the first author (who also led the present study) is trans. The study also drew on a social constructionist framework which posits that social phenomena are both constructed by the sociocultural contexts in which they are situated, and also function to construct social realities (Phillips & Hardy, 2002). The study involved in-depth individual interviews with service users and health professionals. Ethical approval was granted by the University's Human Ethics Committee.

Study location and pilot clinic

This location specific study was conducted in a clinic located in a tertiary education setting, which was established in response to growing need for gender affirming hormone therapy provision in the region to alleviate wait times in secondary care (Delahunt et al., 2018). This approach is consistent with the growing trend globally to shift gender affirming hormone therapy provision into primary care settings. Staff at a university healthcare service developed a pilot clinic in 2017 in collaboration with trans community members, students, and healthcare professionals. The clinic was supported by community organisations in the region who provide crucial support to trans community members outside of the healthcare service. As the campus-based clinic was considered one of the first of its kind in Aotearoa NZ, a small research project was conducted to gain insight to aid future provision development (see Ker, Fraser, Lyons, Stephenson, & Fleming, 2019). The pilot clinic was funded by the health service in which it was located.

The procedure within the clinic involved service users meeting with a GP to discuss the clinic process before attending an average of five counselling sessions to ensure the service user had sufficient support and information to make their decision. In an effort to enabling service users to give greater informed consent, the counsellor wrote a referral letter, and service users met with the same GP and an endocrinologist who prescribed gender affirming hormones. Although some primary healthcare providers in Aotearoa NZ are able to provide gender affirming hormone therapy without an endocrinologist present, the endocrinologist’s role in this clinic was to oversee the initial appointments as the GP increased their competence in prescribing hormones. The clinic offered support between sessions, as well as after service users had been prescribed gender affirming hormone therapy. Service users who graduated or left the university were assisted by clinic staff to find a trans-friendly primary care provider. The clinic process took an average of four months from service users’ initial GP appointment to starting gender affirming hormone therapy. This primary-based model adheres to Aotearoa NZ’s national guidelines for providing gender affirming healthcare (Oliphant et al., 2018).

Participants and interviews

Potential participants were identified by staff at the healthcare service, including all six service users who completed the clinic at the time of the study, and four of the health professionals involved in the clinic. They were invited via email to take part in interviews about the clinic. Four service users (aged 18–26) agreed to be interviewed, two of whom were undergraduate students, and two who were taking a break from study; three defined their gender as female, and one as non-binary/neutrois. Four health professionals agreed to be interviewed; three were members of the clinic’s multidisciplinary team, and one was a trans community adviser to the pilot clinic. Two health professionals were cisgender, and two were trans or non-binary. Seven participants identified as Pākehā (New Zealand European); one participant did not disclose their ethnicity. Seven participants were interviewed in person at the university, while one was interviewed by telephone. Interviews were conducted between July and September 2018 by the first author who identifies as trans. Interviews lasted between 39 and 80 min, with health professionals’ interviews being slightly longer than those of service users, on average. Recordings were transcribed verbatim using a standard, basic transcription notation (from Silverman, 2001) and anonymised. All names reported here are pseudonyms.

Approach and analysis

Transcripts were analysed by the first (trans, Pākehā) and last (cisgender, Pākehā) authors, using Foucauldian discourse analysis. Discourse analysis is an approach that views language and talk as functional and achieving particular outcomes, rather than merely a neutral transmitter of information (Potter & Wetherell, 1987). Foucauldian discourse analysis similarly focuses on language, but also attends to power relations within society, and how realities are created, reinforced and sustained through dominant understandings (Willig, 2001). People employ various patterns within their talk, or coherent systems of meaning, known as discourses. Discourses may include metaphors, representations, and statements that together produce a particular meaning, or version of reality (Parker, 1990). Discourses are linked to social, historical and cultural contexts and can have connections to other discourses, all of which may construct an object in different ways (Burr, 2003). Particular discourses – or constructions in talk – can make certain ways of seeing (and being in) the world available, while closing down other ways.

Speakers draw on a number of discourses during talk, and there are often inconsistencies and contradictions between these discourses which, when identified, can provide useful analytic insight and highlight their different functions. Discourses also construct and position people in various ways, and speakers may take up or resist certain subject positions, while positioning others in other ways (Parker, 1990). Our analysis focused on identifying metaphors, phrases, grammatical features such as pronouns, and binary oppositions in participants’ talk. We then identified contradictions and complexities in the patterns of meaning, which were discussed among the research team throughout the analytic process.

Findings

Participants drew on common notions of pathologisation, time, and agency to construct the clinic as an affirming process compared to the hospital system, where trans people were positioned as passive recipients of care. The clinic, however, was also constructed as inevitably constrained by the same structures apparent in the hospital system which have historically been associated with illness. This construction limited two service users’ ability to discuss their mental health openly, due to concerns that existing mental health conditions may prevent or delay care. Overall, the clinic was constructed as a space in which gender affirming hormone therapy can be accessed as a necessary yet non-pathologised aspect of healthcare.

Pathologisation and power: hospital as scary, primary care as comfortable

Participants frequently drew on and resisted a discourse of pathologisation to position the clinic in opposition to secondary care models. Binary opposition is a dominant ordering principle of Eurocentric (male) thought and culture, rather than a reflection of reality (Sheets-Johnstone, 2000); although primary and secondary care are rarely delivered in binary ways, participants’ dichotomising of the clinic and hospital settings was stark and functioned to position the clinic positively. Participants notably drew on similar patterns of talk through their informal and affective descriptions of therapeutic relationships and contrasted these with their formal descriptions of the hospital as a ‘format’ or ‘procedure’ associated with illness. Associating the hospital with negative affect and power imbalance functioned to conversely position gender affirming hormone therapy in a primary care-based setting as a way of normalising gender affirming healthcare.

Some participants highlighted the importance of accessing gender affirming hormone therapy in a familiar environment, constructing talk about their identity and mental health as easier with healthcare professionals with whom they had existing therapeutic relationships.

I mean that was useful, you know, having a place I was familiar with and someone I was familiar with there, and also just being able to come up to campus and do it, it was much easier I think than- hospitals are scary! Um, than, you know, wandering through the hospital and going to the scary room and speaking to this doctor (Eli, service user)

Going into the hospital kind of makes it seem like a bigger deal and (.) the single meeting with the hospital psychiatrist format, I think I found quite intimidating as a prospect because it’s like you have this one chance to convince this person that you, that this treatment is right and you don’t know [the healthcare professional] at all going in (Sam, service user)

Both Eli and Sam drew on negative affect-type terms (e.g. scary/intimidating) to describe the hospital and de-personalised terms to describe medical professionals (e.g. this doctor/this person), which constructed the hospital as an uncertain space. The familiarity of the space and the clinic staff, on the other hand, was ‘useful’ for Eli; others also described the clinic as useful, helpful, or supportive. These descriptions emphasise service users’ agency to use the service to meet their needs, rather than having little control over being ‘sent’ to the hospital or proving themselves as ‘trans enough’ to access gender affirming healthcare.

Sam’s talk about the hospital process as a ‘test’ alludes to a narrative commonly shared among trans communities about diagnostic models of care as gatekeeping processes (Ashley, 2019; Johnson, 2019; Pearce, 2018). Some participants resisted this dominant narrative throughout their accounts by mitigating perceived power imbalances in doctor/patient relationships, and instead drawing on a discourse of support. Michael the endocrinologist, for example, described ‘this whole [clinic] process’ as ‘about supporting people […] to do what they want to do, you know, it's not like other aspects of healthcare where we're gatekeeping’. A similar resistance to the clinic as a gatekeeping process was evident in Monty’s (service user) account:

[in the clinic] it was refreshing not to have to go through a gatekeeping process of saying, ‘are you masculine enough or are you feminine enough?', it was simply a matter of, ‘you want hormones, okay let’s figure out the best way to give them to you'

Monty’s use of the adjective ‘refreshing’ constructs the experience of not having to prove one’s gender as something new or different, in contrast to the secondary care model. Further, his emphasis on collaboration in the healthcare professionals’ response (i.e. ‘let’s figure out’) positions himself and clinic staff as shared decision-makers, rather than the staff as deciding for Monty in their positions of authority.

Participants further resisted the pathologisation of gender affirming hormone therapy by positioning trans people as ‘healthy’. In describing the traditional pathway of accessing gender affirming hormone therapy through the hospital, Michael (endocrinologist) shared that:

obviously [gender affirming hormone therapy] is a very different situation altogether, we’re dealing with- with um generally very healthy, generally very young individuals, y’know, who don’t have diseases and we’re simply supporting [them] with their healthy transition, and so we’ve acknowledged for a while now that this, doing this in hospital settings for that reason is not ideal.

Here, Michael’s construction of healthcare professionals as supportive and the process as simpler than illness-related healthcare resists dominant constructions of gender affirming hormone therapy provision as a complex or gatekeeping process. Michael’s use of the adjective ‘healthy’ to describe both people and their transitions alludes to a broader definition of health which includes complete social, mental and physical wellbeing, as well as the absence of disease (World Health Organisation, 2020 [1948]). According to this framing of health, people access healthcare for many reasons other than being ‘unwell’. At the same time, Michael’s association with hospital-based settings and illness suggests that the spaces in which people enter to access care, regardless of their level of health, can reinforce messages about what it means to need healthcare. These discursive manoeuvres function to locate primary care-based gender affirming hormone therapy provision as a process of resisting the historic pathologisation of trans people, which in contrast may be reinforced through requiring ‘healthy’ trans people to enter a space associated with illness such as the hospital. Connor, the community advisor, further resisted the pathologisation of trans people accessing healthcare:

The advantage of having a multidisciplinary team [in the clinic] is that there's nothing wrong with us as trans people, we have got nothing wrong with us. We might have a thyroid [problem] but that's not because we're trans, we might have diabetes but it's not because we're trans, so a multidisciplinary team helps the team of health professionals stay within constructs of that person's care, not in society's views of our pathologisation.

In distinguishing someone’s transness from receiving any other aspect of healthcare, Connor constructed gender affirming hormone therapy as part of a person’s general healthcare as opposed to their pathologisation, a process which he frames as being ‘done’ to trans people. Participants frequently discussed gender affirming hormone therapy as medication distinguished from that needed to treat illnesses; this resistance to pathologising trans experiences frames gender affirming hormone therapy as a less stigmatised form of healthcare.

The importance of time when accessing gender affirming hormone therapy

Participants frequently drew on notions of time throughout their accounts in ways that constructed the clinic as quicker and with less delays than secondary care. Jordan’s (service user) metaphoric description of the clinic as a ‘little bubble of utopia where you can get all these appointments within a short amount of time for free’ illustrates how most participants positioned the clinic as distinct from the secondary care model, which was also discussed using historical temporal markers such as ‘old-fashioned’ (Monty, service user) or ‘behind the times’ (Michael, endocrinologist). The relative timeliness of the clinic was juxtaposed with participants’ perceptions of lengthy wait times for appointments in secondary care. As Monty mentioned:

I think paradoxically even being on the [hospital] waiting list can make it worse because you’re that much closer to your goal, but there’s a kind of arbitrary bureaucracy standing in the way between getting you the medication that you need to continue living

Here, Monty’s description of the hospital wait times as a barrier to someone’s transition, further highlights how time was constructed as important to allowing people to continue with their lives, and not be in the limbo being on ‘the waiting list’. Time in the hospital system was constructed as an exercise of power or a structural barrier, whereas having the time to ‘just talk things through’, as Monty also mentioned, suggests that time can be seen as a resource which can be used to support service users achieve their transition goals. Monty discussed the goal of the medication as enabling trans people ‘to continue living’, similar to Jordan’s desire to ‘get on’ with their life, reinforcing minimal wait times as critical.

In contrast to waiting months for care, most participants described time throughout the clinic both metaphorically as a ‘luxury’ (Sarah, GP), and practically as ‘having constant kind of contact through the [clinic] process and someone to talk to about anything I wanted to talk about’ (Sam, service user). Many participants highlighted the variability of service users’ health needs and the points they were at in their transitions, which served to reinforce the importance of building relationships with clinic staff over time. Constructing the clinic as having faster or ‘smoother’ timeframes allowed time service users to position themselves as having a ‘long lovely relationship building with the clinician as well, so it's not a one-off assessment with someone that you don't know’ (Sarah, GP). Sarah’s juxtaposition between constructions of the ‘long’ clinic time and ‘one-off’ assessment in the hospital, further reinforces the hospital/clinic binary and importance of familiarity and certainty in gender affirming care.

This temporal construction of longitudinal support was further emphasised in Eli’s account that, even after finishing the clinic, ‘[I] still feel like that support's there and you know, I still feel like I'm part of the system’, rather than ‘this medical thing that you go through and they spit you out and you've got your pills, and that's it’. Eli’s vivid contrast, and a system ‘spitting’ service users out, constructs the hospital process as impersonal with an abrupt end-point, and unable to provide the type of ongoing holistic support available through the clinic. Because having time in healthcare interactions is often considered rare due to limited resources, this feature of the clinic was presented as enabling service users and healthcare providers to build trust. In this way, the value of time was used to resist the dominant narrative of mistrust between healthcare professionals and trans people in healthcare encounters (Lambrou et al., 2020).

Participants’ extended use of journey and movement metaphors further worked to construct the clinic as an exploratory process which acknowledged the time service users had spent considering gender affirming hormone therapy prior to entering the clinic. Sarah (GP) explained that:

I think quite often there is a really long journey before people actually get into the doctor's room and say, ‘I'd like to start some hormone therapy now’, and it's not a week, you know, it has sometimes been years and years and years to get to that point

Sarah and Joella similarly emphasised the work trans people had done exploring their gender or attempting to access healthcare services. This discourse of time enabled participants to account for the contradictions between service users wanting time to talk about the complexities of their identity with the counsellor, while at the same time discussing the urgency of gender affirming hormone therapy, or needing it ‘ASAP for [a person’s] own peace of mind’ (Monty, service user). Employing the metaphor of a journey further positioned service users as capable of directing their own care throughout the clinic. Joella spoke about their role as a counsellor to keep service users in ‘the driver’s seat’ throughout the sessions, while Sarah positioned healthcare professionals as ‘pointing [trans people] in the right direction’. The participants’ use of the journey metaphor constructed service users as agents, but agents who were still needing some direction, which functions to shift the healthcare professional from ‘expert’ to ‘guide’. This has implications for how participants view power relations in healthcare settings, in which service users are traditionally considered passive recipients of care.

Bureaucracy, assessments and agency

While participants predominantly constructed the clinic as a unique and person-centred process, it was somewhat contradictorily also constructed as part of a wider medical system. Guidelines around obtaining a mental health assessment, and external constructions of accessing gender affirming hormone therapy as a gatekeeping process, functioned to limit both clinic staff and service users’ agency. Most participants discussed how the pilot clinic sought to de-centre assessment from the informed consent process and positioned clinic staff as ‘supporters’ rather than ‘assessors’. However, some participants described the requirements which clinic staff adhered to as counteracting services users’ agency to determine the support they needed throughout the clinic process. The tension between the ‘structural impositions’ (Jordan, service user) constructed as part of an otherwise flexible pilot clinic was evident through the way participants discussed the assessment aspect of the counselling process. Most participants positioned the counsellor as an ally to service users, yet constrained by the requirement to assess service users’ readiness:

it felt like there was a procedural requirement that I got through a lot of stuff with [the counsellor] so [they] could fill in lots of paperwork and write a big letter and things, which all of which seemed excessive because [they] seemed to recognise- [they] seemed to basically be confident that in what I needed and things early on (Jordan, service user)

there has been a tension sometimes between doing the clinical assessment, which is required-which the need for a clinical assessment, I hope one day will change, and actually just doing what might be deemed as counselling work which is attending to what the client wishes to bring (Joella, counsellor)

Here, Jordan and Joella both constructed the required assessment or readiness letter as distinct from counselling driven by service users’ wishes, which participants discussed as a more valuable aspect of the clinic. Jordan framed the paperwork as serving the ‘procedural requirement’ rather than benefitting her as a service user, and positioned the counsellor as personally believing her needs. This constructs the perceived requirements as constraining for both the healthcare professional and service user. As shown above, Joella distanced themself from the clinical discourse they initially drew on by emphasising its requirement within the current system, and their desire for it to change ‘one day’. This enabled them to prioritise the clients’ needs and align herself with the counselling process, affirming service users’ agency. As a member of the rainbow community themself, Joella frequently drew on trans-affirmative discourses to critique the cisnormativity of assessment-driven aspects of accessing gender affirming hormone therapy. Sam (service user) reproduced Joella’s positioning in her account:

[The counsellor] always emphasised that [they] thought the process was over-medicalised and that it shouldn’t be treated as a disorder, which was nice since it had bothered me that it was treated as a disorder and I think going through the hospital […] without that sense that the people um, there, understood the process in the same way that I did, it would have been a lot harder.

Here, Sam used Joella’s statement against the pathologisation of gender dysphoria to construct her own preference of the clinic over the hospital; this shared resistance and allyship implies that Sam found it easier to access care through the pilot clinic. Sam also constructed Joella’s role as a mental health professional as representing a wider system which was seen to limit Sam’s ability to get the support she needed at the time:

I did feel some pressure to pretend that my mental health was better than it was […] because I knew that, um, they weren’t meant to prescribe hormones to people who were potentially um suicidal or inclined to self-harm […] I don’t know what one could do about that, I do feel like the system as it is encourages people to lie and so not get access to the support that they need

Sam constructed the pressure to ‘pretend’ as due to ‘the system’, a generalised term referring to the clinical requirements for providing gender affirming hormone therapy that govern clinicians’ actions. This enabled Sam to deflect blame from individual clinicians. Similarly, Jordan constructed her knowledge of other trans people’s experiences of care as informing her views of the clinic as a gatekeeping process, stating that throughout the clinic process ‘I was thinking carefully about my words […] just to not slip up and say something that would lock me out’. Her reference to being locked out was indirectly attributed to the gatekeeping within a wider system, which functions to create this as an issue that sits outside service users’ and healthcare professionals’ control.

Constructing the clinic as part of a gatekeeping process contradicts Eli and Monty’s (service users) accounts of the clinic as a space which people can talk openly about their transitions and mental health. Michael (endocrinologist) acknowledged but resisted this gatekeeping construction, describing service users as ‘being a little bit worried that we're acting as a gatekeeping service, and that we're going to come along and say “no you can't do this” and all that sort of stuff, which isn’t the case at all’. Michael’s resistance to the service as gatekeeping further works to mitigate the perceived power imbalance between service users and healthcare professionals, and positions gatekeeping as more of a perception than a reality when accessing gender affirming hormone therapy.

Discussion

This location-specific study provides insight into how trans people and healthcare professionals draw on notions of pathologisation, time, and agency to frame gender affirming hormone therapy as normalised and necessary healthcare. Participants’ constructions of the campus-based clinic supports the view that primary care settings which provide affirming and high-standard care can be emotionally, temporally, and physically accessible for many trans people. Providing gender affirming hormone therapy through primary care can destigmatise gender affirming healthcare as it challenges the idea that trans people make up an ‘exceptional subgroup’ needing specialised care (Snelgrove et al., 2012, p. 10) or hospital services (Guss et al., 2019). Over time, the growing shift towards primary care-based models of care may effect discursive shifts in the ways in which people understand trans health, considering that diagnostic models of care have historically reinforced transnormativity, or a particular way of being trans (Ashley, 2019; Davy, 2010; Johnson, 2019; Vipond, 2015).

Although there is consensus that primary care settings are generally accessible, there is ongoing debate about the requirement for a formal mental health assessment or diagnosis to access gender affirming hormone therapy (e.g. Ashley, 2019; Saad, Blackshaw, & Rodger, 2019). Participants’ dual construction of the clinic process as a flexible space to talk things through which was also at times constrained by external knowledge of assessment requirements, highlights the significant challenge that providing affirmative services within an assessment-driven healthcare context represents, and the need to accommodate for trans people’s varying mental health support wishes. To centre trans people’s agency, healthcare providers could consider how their framing of mental health services involved in gender affirming hormone therapy informs how trans people perceive the service, and thus the information they share with healthcare professionals.

Though participants strongly resisted pathologisation, they used medicalised language to legitimise trans people’s need for gender affirming hormone therapy. Similar tensions between drawing on and resisting medicalised and diagnostic discourses in trans health have been documented elsewhere (e.g. Johnson, 2019), however the nuanced distinctions between medicalisation and pathologisation could be further explored in future sociological research on gender affirming healthcare. Our findings build on Sholl’s (2017) distinction between pathologisation and medicalisation which suggests that medicalised processes can occur in non-stigmatising ways. As Cannoot (2019) notes, ‘fully depathologising medical transition pathways does not necessarily contradict the legitimate wish of some trans* persons to have access to trans*-specific forms of health care’ (p. 4). This distinction demonstrates the potential for gender affirming hormone therapy to be situated within a medical context, yet not require a diagnosis or one-off assessment limiting service users’ agency, similar to other types of healthcare such as fertility preservation. As GPs’ competence in gender affirming healthcare increases, gender affirming hormone therapy will likely become more readily available in primary care-based settings without the need for hospital based care. Crucially, this requires healthcare providers to be knowledgeable about trans people’s health needs and experiences, to provide affirming healthcare and avoid stigmatising trans people.

Our findings reflect a small and relatively homogenous sample of mainly Pākehā (New Zealand European) participants, including service users who were students attending a predominantly Pākehā institution with access to subsidised or free healthcare and who had previously accessed the student health service. Considering that three out of four service users were transfeminine people, the discourses they drew on may have been informed by the compounding discrimination trans women experience such as transmisogyny (Serano, 2016). Different discourses and constructions are likely to arise in other groups, such as Indigenous and people of colour, disabled, older, lower-income, or rurally located trans people, or those who have migrated from other settings, such as in Asia and the Pacific (e.g. Do & Nguyen, 2020). These findings are not intended to be generalisable, but rather indicate the prevalent discourses available to a particular demographic within a tertiary education health setting.

Despite its limitations, this study contributes relevant knowledge to a growing body of literature on gender affirming hormone therapy and its unique positioning in healthcare. Findings highlight the tensions some affirmative healthcare professionals still face due to existing discourses of trans pathologisation. Depathologising gender affirming healthcare therefore benefits from a deeper understanding of how dominant narratives of trans healthcare, such as gatekeeping and one-off assessments as ‘tests’, inform the provision and access to gender affirming healthcare. There is a need for consistent, collaborative approaches to providing gender affirming hormone therapy which also respond to trans people’s diverse healthcare needs. As standards and models of care develop globally, it will be crucial for healthcare providers to acknowledge the ways in which existing and emerging discourses of healthcare inform service users’ agency and access to equitable and affirmative healthcare.

Acknowledgements

The authors thank participants for sharing their experiences, the Sex and Gender Diverse Working Group and Mauri Ora staff who were involved in the pilot clinic, students who gave feedback on the clinic, Jemima Bullock, NGOs who support gender diverse communities in Aotearoa NZ, and the anonymous reviewers for feedback on earlier drafts. We also thank the Faculty of Health at Victoria University of Wellington for funding a research position for this study.

Disclosure statement

No potential conflict of interest was reported by the author(s).