“Ever since I knew I was trans I knew I wanted hormone therapy”: a qualitative exploration into the journey of Australian trans individuals accessing feminizing gender-affirming hormone therapy

Abstract

Background:

For many trans folks, gender-affirming hormone therapy (GAHT) is a desired affirming procedure that has been linked with positive health outcomes, however literature has had little focus on the journeys of trans people as they access GAHT.

Aim:

To understand trans people’s journey of accessing GAHT to delineate supports necessary to better engage trans individuals into gender-affirming care.

Method:

This study conducted semi-structured interviews with a sample of 15 Australian trans adults who participated in a larger study investigating the effects of a cyproterone acetate titration protocol.

Findings:

A four-factor thematic structure was created from the data. Theme one describes early cognizance of being trans and the pivotal moments in their trans realization. The second theme explores the rapid engagement with community to begin accessing information and affirming healthcare, including GAHT. The third theme explores barriers to engaging in GAHT and theme four reflects on advice participants have for other trans people who are considering GAHT.

Conclusion:

Findings from this study emphasize the importance of providing support to young trans people to help reconcile their gender identity and assist them to engage into care as early as possible. It also highlights the key role that community plays in providing links to affirming information and providers of GAHT – but also emphasizes the importance of considering how to engage with community who may be missed. The experience of accessing GAHT is personal and contextual, but signaling of affirming safe spaces and access to salient information may be key strategies to better support trans people choosing to access GAHT.

Keywords:

• Community
• healthcare
• hormone therapy
• qualitative
• transgender

The terms transgender or “trans” (both binary and non-binary), refer to individuals whose gender differs from their sex-presumed or assigned-at-birth (Davidson, 2007; Lindqvist et al., 2021). The terms transfeminine and transmasculine are emerging as more accurate descriptors of identity over binary gender terms traditionally connected with trans folk such as “male-to-female” and “female-to-male” (Quinn et al., 2017; Reisner et al., 2016). This is in recognition of the pivot from cis-normative binary conceptualisations of gender (the belief that all people identify with one of two genders assigned at birth: male or female). As described by Reisner et al. (2016), the terms ‘transfeminine’ and ‘transmasculine’ are intended to represent a spectrum of experiences with masculinity and femininity inclusive of western and non-western conceptualisations of gender—including those who do not identify with binary representations. As part of a larger process of masculinization or feminization, many decide to seek gender-affirmation through gender-affirming hormone therapy (GAHT) (Connelly et al., 2021; D’Hoore & T’Sjoen, 2022). Though other social, cosmetic, legal, and medical changes may also occur in place or in conjunction with GAHT as part of a wider ‘transition’ journey.

In a U.S. national study of over 20,000 trans individuals, approximately 80% indicated ever wanting to pursue GAHT (Turban et al., 2022). Literature generally suggests GAHT is a safe and important process supporting a variety of physical and mental health outcomes (Aldridge et al., 2021; Baker et al., 2021a; Connelly et al., 2021; Weinand & Safer, 2015; White Hughto & Reisner, 2016). The choice to and experiences of undergoing GAHT are highly individual (Fowler et al., 2023), but for those who desire it is often considered essential in improving mental health and quality of life of (Baker et al., 2021b; Chew et al., 2018; Foster Skewis et al., 2021). For example, scholarly work by Riggs et al. (2015) suggests access to gender-affirming care (including GAHT) is a key predictor of the mental health, which is supplemented by qualitative evidence pointing to its impacts on mental health and well-being (Fowler et al., 2023).

Research has often focused on the impact of accessing GAHT (Fowler et al., 2023), or the decision-making process of pursuing GAHT (Clark et al., 2020; Daley et al., 2019), but less is known about the experience of accessing hormones following the decision to seek GAHT. Given the poorer mental health outcomes often identified within trans people wishing to pursue (but who have not yet received) GAHT (Magalhães et al., 2020), this is a key period in the transition journey. During this period many experience a range of challenges, including deterioration of previous social supports due to their “coming out” as trans (Lewis et al., 2021), gender dysphoria (Dhejne et al., 2016) or having to navigate people’s responses to their trans identity (Brumbaugh-Johnson & Hull, 2019; Riggs et al., 2015). It is, therefore, important to consider the experiences of trans people who desire GAHT before they access it to help develop an understanding of the key intersecting factors affecting their journey. Such understanding will help to improve supports offered and facilitate early engagement into safe and affirming long-term care. This emphasis on early and safe access to care is important considering evidence showing that earlier onset of affirming care is associated with better mental health outcomes (Chen et al., 2023; Tordoff et al., 2022).

Evidence shows that the pathway to hormones can be complicated. In one qualitative study with trans youth (aged between 9-17), the process of accessing hormones was described as a “long, winding, complicated path”—highlighting that the journey to GAHT was compounded by a variety of factors, such as having to come out to their parents and relying on their parents to access healthcare (Pullen Sansfaçon et al., 2019). Another study, also focusing on the experiences of trans youth, describes how participants often go through a “discovery” phase of identifying information relevant to GAHT (Clark et al., 2020). This is subsequently followed by interacting with other trans folk and healthcare providers and beginning to address barriers such as geographic access to clinics and financial issues (Clark et al., 2020).

The pathway for adults is less-documented, however it is likely that trans adults experience known barriers to care such as fears of a non-affirming provider, previous discrimination in healthcare settings, and financial barriers (Franks et al., 2022; Safer et al., 2016; White Hughto et al., 2015; 2017). However, the context of adulthood may compound these barriers in a unique way—for example, adults may have additional financial pressures (e.g. health insurance or loss of employment) (Franks et al., 2022; Gonzales & Henning-Smith, 2017). As well, trans adults may have “roles” within the family unit (e.g. as a partner or parent), which can increase pressure to not pursue their desired journey to gender transition (Simpson, 2018). Overall, prior scholarly work makes it clear that the journey to accessing hormones can be complicated but important. Using qualitative approaches that center trans voices (Thompson et al., 2016), the aim of this research was to understand the experiences of trans adults who have accessed hormones to delineate pathways to improve the journey toward achieving this goal for others.

Methods

Participants in this study were recruited from a larger study called ‘GoLoCypro’, which explored the validation of a down-titration protocol of the steroidal anti-androgen cyproterone acetate (CPA). To be eligible for the larger study, participants had to be over the age of 18 and be accessing CPA for hormonal feminization, however they did not need to identify as transfeminine to be eligible for study participation. A major focus of this larger study, conducted by a team of trans, cisgender, and queer identifying researchers and clinicians, was to explore how CPA titration influenced mood, and the participants experiences leading to and during their GAHT journey using semi-structured interviews conducted with a convenience sub-sample of participants enrolled in the titration protocol. This paper reports on findings from these interviews. Ethical approval was sought from The Royal Brisbane and Women’s Hospital (HREC/2019/QRBW/59298).

Participant recruitment and data collection

Interviewees were recruited from the GoLoCypro study participants who had completed the down-titration protocol. Eligible participants were provided information about the interviews by their healthcare provider (who were GoLoCypro site-specific investigators). Participants who expressed interest and provided informed consent to be contacted by researchers were contacted by their preferred communication method (i.e. email or phone) to schedule an interview.

Interviews were conducted by two researchers who have experience working with the LGBTQIA+ community (JF who identifies as a queer cisgender male and JD a cisgender female who also has experience providing clinical care to trans people). Interviews were completed in person, via telephone, or using digital conference software (e.g. Zoom) based on participant preference using a semi-structured interview guide. Interview questions were framed around exploring the experiences of trans people undergoing GAHT and their journey to accessing hormones. Interviews ranged between 30-60 min, and participants were remunerated with an $AU50 gift-card for their participation. Digital recordings were transcribed verbatim using a reputable, confidential, transcription service. As part of the interview, participants were asked to report some brief demographic information including their gender, age, and how many years they have been on CPA.

Data analytical procedures

An inductive thematic analytical approach informed by Braun and Clarke (2013) was used for this study. All fifteen manuscripts were read and re-read to identify initial codes and commonalities by JF. Subsequently, the interviews were categorized into two larger categories—pre-accessing hormones and post-accessing hormones. For this paper, the data coded under pre-accessing hormones were analyzed and re-analyzed to identify relevant codes that would later form themes. The codes and themes were discussed with a trans peer researcher (NF) and disparities were deliberated by all authors. Following this, those that mapped onto a central organizing principle were labeled as themes. A strength of this data analytical procedure is the involvement of diverse gender and sexualities, including trans researchers and clinicians experienced in trans care. This allowed the analytical process to harness the complementary methodological benefits that insider and outsider statuses can have on qualitative analysis (Dwyer & Buckle, 2009; Hayfield & Huxley, 2015). Important to acknowledge however is the risk of inherent bias stemming from lived experience and proximity to community which may have limited creative reflexivity. All authors agreed on the final presentation of themes.

Results

Table 1 presents a summary of the gender identity, age and the range of years the 15 participants had been using CPA.

Table 1. Demographics of participants (N = 15).

Study ID	Name	Gender identity	Location	Age (M = 30years)	Years on CPA
1	Lee	Woman	Regional	29	1 year 11 months
2	Lucinda	Female (but presenting male)	Metropolitan	55	4 years 5 months
3	Morgan	Female	Metropolitan	39	4 years 6 months
4	Demi	Trans fem demi-girl	Metropolitan	29	1 years 11 months
5	Alexia	Transfeminine	Metropolitan	21	2 years 11 months
6	Flora	Female	Metropolitan	39	4 years 6 months
7	Amelia	Non-binary AMAB	Metropolitan	31	5 years
8	Claudia	–		–	–
9	Esme	Female	Metropolitan	27	3 years 2 months
10	Milly	Female	Metropolitan	25	2 years 2 months
11	Paige	Female	Metropolitan	24	4 years
12	Scarlet	–		–	–
13	Tara	Female	Metropolitan	19	1 year 7 months
14	Holly	–		–	–
15	Hazel	Trans woman	Metropolitan	22	2 years 5 months

Notes. All names are pseudonyms randomly generated by computer software. Reported gender identity is self-identified using open-text entry. Three different metropolitan areas were recorded across Australia, however were not described to protect participant’s identities. M: Mean; CPA: cyproterone acetate; AMAB: assigned-male-at-birth.

Our thematic analysis identified four themes that describe the journey of accessing GAHT, from realizing a trans identity to receiving hormones for the first time. Theme 1, “Oh shit there’s a word for this” describes the non-linear and dynamic process of realizing a trans identity and key moments of realization. Theme 2, “From the community I knew where to go” explores the important role that community connection plays in linking trans people to supports and information to be able to access GAHT. Theme 3, “It pushed me back about six months” highlights some of the barriers trans people experienced when pursuing GAHT. Finally, Theme 4, “Don’t panic, you’re not too late” describes advice participants had for other trans people considering accessing GAHT. Overall, whilst the presentation of results may represent a linear journey, participants described a dynamic and fluctuating process of gender realization and access to healthcare.

Theme 1: “Oh shit there’s a word for this”

There are myriad pathways to trans awareness occurring at any moment from infancy to old-age. This theme explores participant narratives for their unique trans awareness experience. Recognizing a lack of correspondence between their felt gender and gender-presumed-at-birth, this incongruence fosters an internalized dialogue around individual gender modality, a degree of body dissatisfaction, and remedy seeking though GAHT (Ashley, 2022; Goetz & Arcomano, 2023). For example, some participants described early childhood senses of being confused and disconnected with their gender. For example, Demi described “confusion” when they transitioned to underwear as a child and the “urine came out of the wrong spot.” Amelia further describes being six or seven years old and “wanting to, you know, get rid of male parts.” Some described more broadly not knowing what being trans was as expressed by Esme, “I didn’t even know it was a thing I guess or like an option. At least not [on] a very conscious level.” However, like Esme and others, Alexia reflected that they knew how being trans felt way before they had the language to describe it and that knowing earlier would have assisted with their coming out:

I didn’t know there was a word for what I was experiencing at all. I feel like if I’d known that there was a word for that and a community for that and things I could do about that I would have come out when I was 15. Alexia.

Some folk described how being trans “never crossed their mind” as they did not have a sense of being “dysphoric or miserable.” This sense of not having sufficient dysphoria, often based on stories of others or misconceptions of trans experiences, meant that some did not actively start their journeys until exposed to other stories they identified with:

The reason it took me so long to get where I was because I didn’t think that I was transgender because anything I’d seen online you had to be depressed, you had to be suicidal, you had to have anxiety, and obviously a lot of people are in that situation but that wasn’t me. Morgan.

When reflecting, some participants spoke to activities and content they had previously engaged with as now being clear signs of them being trans—such as living vicariously through trans and queer authors:

Looking back, I realise it was me trying to find a way to live out this ‘fantasy’ vicariously like I mentioned I was reading a lot of stuff written by trans and queer authors or watching a lot of the anime which is a gender swap story so to speak. Alexia.

Even when they did not know the terminology or feel that they met certain criteria to be trans, many participants described a prevailing internal sense of knowing. As described by Alexia knowing the words or meeting someone earlier with this insight would have guided them onto their journey sooner:

I know without even having to have the language to describe the way that I was behaving. But it was very clear to me that if someone had asked me then [that if you could] press a magic button and be a girl…I would have done it in an instant. Alexia.

It is important to recognize that this journey is not linear or homogeneous, rather it is highly contextual. Nonetheless, many of our participants described similar factors that made them begin to realize that they were trans. For example, some spoke to seeing another trans person sharing their identity and experiences online as a key moment of realization:

I essentially watched a video where this trans woman was talking about her experiences…And I started to relate to that and then she mentioned something about being a man for the rest of her life as she got older. And that just made me have a panic attack for three days. Demi.

For others, a ‘meme’ about questioning gender was the key moment of realization:

I came across a meme of all things that made me go “oh shit there’s a word for this. Okay, that’s me,” and it wasn’t even a question. Alexia.

Others described less specific moments, instead describing a longer process of introspection, deliberation, and questioning before they realized that they were trans. For Milly, moving away from a previously high-stigma environment to a new more affirming city, left a bit more “room to ask those questions.” Others spoke to spending time finding information about what being trans means or gender more broadly (e.g. through feminist philosophy) and then applying this information to their own experiences. This exploration was often also supported by meeting other trans people:

…there was this girl there and I was just like transfixed by her, I thought oh wow this person is really cool. And I ended up talking to her and she was like I’m trans or whatever and I’m like I have no idea what that means… And she like talked to me about the process and I was like ‘oh wow, so there’s actually options for this stuff rather than stuffing things down. Milly.

Social networks expanding to meet other trans people, both physically and online, were important in enabling many participants to find the words, identify as trans, and feel supported to ‘come out’. However, social networks were also barriers to starting their journey as described by participants who had internal dialogue around being trans which was quickly shut-down by non-supportive friends and family:

I had brought it up to a couple of friends and they’d sort of said some shit that really pushed me back down. It wouldn’t be for another two years before I actually found the language to describe what I was experiencing and realised that it wasn’t just me. Alexia.

When reflecting on their journeys to accessing GAHT, the experiences of realization were important because they provided the foundation for subsequent GAHT access. For example, Alexia’s journey into accessing GAHT was stifled by not having the language to operationalize being trans and in-turn accessing supports such as GAHT. For Morgan, the sense of not being sufficiently “dysphoric” to be trans meant decades of not pursuing avenues of affirmation, including GAHT. But it is also important to briefly reflect that these factors are important for more than just GAHT, but often they preceded self-discovery, new friendships, and social transitions. Therefore, this process of learning and its implications for healthcare access are important for all trans people who may or may not access GAHT.

Theme 2: “from the community I knew where to go”

When starting their journey in pursuing hormones, our participants emphasized the importance of community wisdom in finding information about hormone therapy and affirming healthcare providers. Flora felt this community wisdom was essential given the perception that it is “definitely not easy for trans people to find where to go or how to start their journey.” A prominent first port of call for community driven information was online social groups and servers, such as Reddit. Participants emphasized the fact that information was delivered by other trans people, as described by Flora “[Reddit had] lots of other trans people giving that information to their peers.” For Scarlet, other trans people on reddit provided lived experience and expectations surrounding hormone therapy and transitioning which was more valuable than purely scientific information:

I am an avid user of Reddit. And so I jumped onto all of those kind of like transition related subreddits for, you know, support and all that kind of stuff. And started looking at like people’s kind of timelines and changes that they noticed and all that kind of stuff. I guess for me it was getting to read about people’s experiences rather than scientific studies’ experiences and stuff, because I felt like there was a bit of a disconnect between the reality and the like official line of information. Scarlet.

Online communities were also useful in helping trans people identify offline resources, as described by Tara “It was from the online community I knew where to go.” In offline worlds, common places for information came from trans specific organizations and LGBTQIA+ community groups. Akin to online spaces, a shared connection with other trans/queer people made these spaces valuable avenues of support:

But I did go to youth services and LGBT services and that was pretty good… it’s just nice to be around, in person, queers as well. Demi.

A sense of community was also important for some individuals when finding a healthcare provider, as described by Paige “…but I need to find an LGBT doctor because I’m not talking to a cis person, because I just knew how that conversation was going to go.” Others also acknowledged that it was hard to find a trans specific healthcare provider, therefore positive peer referrals were incredibly important:

It was made pretty easy because someone had already found this doctor, because obviously finding trans health care providers is quite hard. But someone had already found this doctor and was just like just go to them, pay the price and go to them. Demi.

Having friends who knew how to access resources and healthcare providers was important for many participants. Particularly, as described by Esme because it reduced the time spent waiting to access care:

[without my social networks] I probably would have been stumbling around for quite a while trying to find doctors. Esme.

Community engagement also assisted in avoiding negative experiences by guiding individuals away from non-affirming providers. Alexia described receiving a list of healthcare providers to avoid from a community organization due to poor community experiences:

[they had a list with] the experiences people [had] with it both positive and negative, this one is considered a ‘do not interact with’, this one’s considered ‘one of the ideal ones’. Alexia.

Whilst the access to community informed information and affirming healthcare providers was predominantly done through the Internet, there was the sense from some participants they felt this was not their preferred method, but there was no alternative available. For example, Claudia was “deeply grateful” for the Internet, but also that the Internet as a primary source was “not preferable…but the only option I had.” As Holly describes “The worst place to look at for scientific information is Reddit…because of how unreliable it is.”

Other participants, such as Milly, described leaving online communities that were initially supportive, but overtime became less beneficial:

I did find, like You Tube was good, sort of initially. But I did find after a while, like in talking to a lot of other trans people, they were like a lot of the stuff on You Tube is kind of glorified … I think a lot of the stuff on there seems to be almost not too healthy in a sort of like dramatizing or like profiting off of being trans. And sort of like they are setting up unrealistic expectations I think was the main thing, a lot of that. Milly.

Theme 3: “it pushed me back about six months”

Through no fault of their own, many described being fully aware of their desire to commence gender-affirming care, but experienced significant barriers that delayed their access. One common experience were non-affirming parents who refused to consent for care to commence:

But ever since I knew that I was Trans I’d always wanted to [be] doing hormone therapy… [my parents said] ‘No we’re not supporting you. If you choose to do that, which we highly don’t recommend, you’re going to have to do that yourself.’ So, when I turned 18 I had the actual ability to sign off and make my own decisions. Tara.

For Demi, their parental resistance amplified their desire to pursue feminizing hormones as well as testosterone blockers as a “fuck you” to their parents. But other complex family relationships can also be a barrier to care. Lee experienced support from their significant other to transition, but a barrier emerged when decisions were made around trying for a baby before commencing hormonal therapies. Lucinda reported a complicated relationship with their significant other, which had left them unable to fully pursue feminization, and having to live a “double life.”

So it’s a no win situation because the more changes that happen to me probably makes my wife feel sad. But it makes me feel happier. So, it causes conflict that way, which is a shame. And if I did go fulltime then - not that in my head I’m not fulltime anyway – then that could be a breakup of the marriage…If I was single, I wouldn’t look like this. Lucinda.

Poor healthcare experiences were common among participants. For example, Amelia was pressured by their school psychologist to disclose their identity to their parents to commence pathways for gender-affirming care. However, when this was explored in-session, their parents reacted negatively to this, and Amelia withdrew from care completely. Concerningly, the psychologist never completed any follow-up care:

As soon as… my mum confronted me [angrily, about my transition]… I shut down and like, you know, I was just like, okay. And then you know, I never actually sought her [the psychologist] out again. So, because obviously I’d had such a severe negative experience and I feel like, yeah, she should have at least followed up. Amelia.

As described previously, another barrier for some trans people was the sense that they were not sufficiently dysphoric to pursue hormonal therapies. This encouraged Scarlet to “blatantly lie” about their feelings to avoid being discredited and pursue therapies:

And then I was really playing up this amount of like social dysphoria distress I was feeling and like how, even though like at the end of the day, like I just wanted to be a girl as far as I was concerned. Like to me it didn’t feel like I was like super dysphoric. Scarlet.

These experiences were sometimes compounded by poor interactions with healthcare providers, which left Paige feeling like “the first steps were difficult” and found that because they did not show enough stereotypical signs of dysphoria, they were then required to go through a “distressing” probationary period of blockers only. Flora also reported that when disclosing to their healthcare provider their intent to pursue hormonal therapies, their provider’s response was “I have no idea what to do,” pivoting the burden back onto Flora to find another healthcare provider.

Another participant described the cost of pursuing care and some of the heavily suggested procedures (e.g. sperm freezing) as being a barrier. Alexia described how all their money was going toward “heavily emphasized” procedures such as sperm freezing and as a “poor broke student,” felt that this was a “poor decision.” The cost it took to complete this set them back “probably about six months.” They also experienced another two-month delay after being required to see a psychiatrist, however Alexia did feel this was a good step in the long-run.

Despite the sometimes-unfair pressures and barriers placed on trans people, overcoming them and accessing hormonal therapies was both terrifying and liberating. Milly described just “staring” at their hormones for several days before having the courage to take them, however once they commenced there was a sense of “this is fine.” Scarlet described how exciting and amazing it was to get a prescription, but also shocked that they were able to access them as they were not “suffering from this massive amount of dysphoria that was running my life.” Tara, who had previously described intense rejection from their family over their decision to pursue hormone therapy, described a moment of bonding between themselves and their father as they accessed hormones for the first time:

It’s obviously also very exciting. Because it’s like “Hey I’m now accessing the thing I wish I had years ago.” And it was very exciting the first time and my dad was there as well. And he saw how excited I was and he’s kind of the only one who’s at least a little bit accepting of my Transness now, because he sees that it makes me happy. And he was there at the time, and he was like “This really makes you happy huh?” And I was “Yep.”. Tara.

Theme 4: “don’t panic, you’re not too late”

Participants reflected on advice they had for other trans people considering GAHT, albeit this was difficult given that “everyone’s journey is so unique.” Some participants emphasized the importance of starting the journey as soon as you feel ready, and whilst there may be reservations, rest-assured that your body will let you know if it isn’t right:

Don’t put it off because you’re nervous. Just try it because you’ll know straight away. Just go for it because like, you know, if that isn’t the right thing for your body will tell you fairly quickly probably before you would get any physical changes even. Tara.

Some participants spoke to the sense of regret and panic that can be common for people who are still contemplating but may feel that it is too late for them to commence the journey:

Probably what I would say is first and foremost don’t panic, you’re not too late… the best time to start is now… don’t sit thinking about the fact that you are like worrying about all the missed time you’ve got…Instead, go right, I’m going to start this now because if you think about the past, we get stuck in the past. You’re not going to bloody move forward. Alexia

Strong social support networks were also emphasized. This was so people could learn about the hormonal process from others who have already been through it to prepare themselves as well as having psychological and physical support to assist them through the journey—for example, to help manage changes in mood, and to provide a safe place to live. Participants felt that the GAHT journey can leave some vulnerable, therefore it was essential to have support networks in place before commencing GAHT, as shared by Milly “…You already have these people who aren’t going to hurt you when you are at your most vulnerable. And they are actually going to support you.”

Advice from Amelia was to keep pursuing both medical and community sides of transitioning and to find people that you feel you can empathize with:

But I’d also say probably seek out more communities where you actually fit in because the world is a pretty huge place, there’s always going to be communities where you find your people, I guess, you know? And if you’re just trying to go through and transitioning and your entire friend group is cishet, [cisgender-heterosexual] you know, you’re not going to have anyone to sort of empathise with, you know? Amelia.

As described previously, online spaces were acknowledged as being a double-edged sword:

I would definitely say connecting with other trans folk online helped me a ton when I was getting started, but then, also disconnected from those spaces, because while those spaces are immensely helpful for gathering information, they’re also places where people vent, and people share their sorrows, and it was very helpful and very supportive at times, but also very draining at times. Paige.

Safely asking questions and learning how to navigate medical systems was also emphasized by several participants. Inherent in a safe and informed journey is social connection to others, potentially those who are trans, to find the relevant information necessary to navigate often complicated models of care:

I’d recommend just going with the safest moves you can, learn as much as you can about the medical system. Go and find people in the community who know if you can’t find out the info, I’ve done that for a lot of people I’ve helped them access medication. Claudia.

Trans people acknowledged the “hate” that comes with being an out trans woman outside, however many urged their peers to not “lock themselves away.” As Alexia shared “Don’t listen to the people around you who are being shitty about it… no one knows you like you know you.”

Discussion

This research aimed to explore the journey trans people took to accessing GAHT. Our findings suggest the journey is often long, with access influenced by a myriad of factors, such as the point where a trans identity is realized, gender dysphoria/euphoria, family and social support, community connection, and personal resources. Our findings offer important insight into the areas of support necessary for trans individuals as they pursue GAHT for the first time. These findings, framed as key recommendations for future healthcare provision, are summarized in Table 2.

Table 2. Recommendations to support trans individuals into the safe access of gender-affirming hormone therapy.

Continue to push for greater knowledge sharing around the diverse experiences of what it may mean to be trans, and have this information available in multiple LGBTQIA+ and non-LGBTQIA+ contexts. Emphasize the role of gender euphoria and decentralize the experience of trans from gender dysphoria. Help connect trans individuals with community and supportive networks. Cultivate resources on affirming and non-affirming healthcare providers. Consider greater integration of informed consent model of care. Train and upskill primary providers on gender-affirming practices to widen the scope of providers trans individuals can engage with Simplify assessment procedures to initiating GAHT. Make available resources to support trans individuals under the age of 18 pursue GAHT without parental consent.

With gender awareness participants described sensing an incongruence with their gender-presumed-at-birth. This contradiction led to reflection on gender modality and adoption of a trans identity to explain their sense of being (Ashley, 2022). A process complicated by participants limited language around being gender diverse, and negative societal narratives. Traditional media has taken a reductionist lens to the trans experience and framed it as a problem requiring “solving,” such as through affirming procedures (Koch-Rein et al., 2020; McLaren et al., 2021; Mocarski et al., 2019). Particular emphasis is placed on gender dysphoria and the “wrong body” narrative (McLaren et al., 2021), which is complimented by the medicalization of trans identities and the emphasis placed on dysphoric experiences (Ashley, 2019; White Hughto et al., 2015). Similarly, these experiences emphasize a binary model of gender—for example, the Diagnostic and Statistical Manual of Mental Disorders Tracked Revisions - (DSM-V-TR) criteria for Gender Dysphoria speaks to a desire to be the “other” gender, placing the emphasis that the individual falls outside the normative binary (American Psychiatric Association, 2022). Consequently, dysphoria and binary gender representations are often tethered with the trans experience, and as described by our participants, can exclude non-dysphoric folk and lead to confusion (Franks et al., 2022). This aligns with our participant’s experiences who did not relate to being trans despite many years of questioning as their experiences did not mirror current media and medical conceptualisations of the trans experience.

Whilst not directly acknowledged by our participants, many within trans communities advocate for ‘gender euphoria’, described as the satisfaction experienced when external gendered features align with internal gender, as being equally important (Beischel et al., 2022). Consideration of euphoria however takes a strengths based approach which rebalances the focus from how being trans detracts from wellbeing, but rather is a driving factor for high wellbeing and flourishing (Tebbe & Budge, 2022). It is therefore essential that concerted efforts are taken to proliferate knowledge around trans identities (especially ‘euphoric’ experiences) from an early age. This may help people connect with an identity and trigger early engagement into long-term affirming supports as well as help reduce discrimination from communities through normalizing the diverse gender identities of individuals.

Our findings showed that connecting with community facilitated the access to information relevant to gender-affirming care, particularly through the access to community-vetted practitioners. This is essential as research consistently shows that a perceived fear or experience with a non-affirming healthcare provider can limit access to healthcare generally, as well as GAHT (Franks et al., 2022; Haire et al., 2021; Kosenko et al., 2013; Safer et al., 2016; Winter et al., 2016). However, as suggested by our findings, community guidance on where to find support may safeguard trans people as they access healthcare, as the risk of poorer healthcare experiences are reduced. This may feed into greater utilization of health services, which can have holistic benefit for trans individuals given research that suggests that trans individuals who delay access to healthcare due to perceived stigma have lower levels of mental and physical health (Seelman et al., 2017). It is imperative that training is provided to promote gender-affirming practices across the healthcare system to not only improve healthcare access but provide trans folk choice in their healthcare provider beyond specialist services (Franks et al., 2022; Lee et al., 2022), and reduce community burden of identifying non-affirming providers.

Whilst the value of connecting to community cannot be understated, our findings highlight that it is important that healthcare does not rely on these as being the primary sources of health information (e.g. advice on where to accessing hormones) and support (e.g. emotional support whilst waiting for access). Community engagement is transient, as described by one of our participants who spoke of a previously valued group as becoming “draining” and unsafe. If communities are the only source of support for an individual, which has sometimes been seen in GAHT when individuals undergo unsupervised hormone use (Fowler et al., 2023)—they may be tethered to specific groups longer than is helpful for wellbeing. As well, some may not be comfortable accessing communities and by extension the information contained within. For example, as seen in sexual minority research, individuals with high levels of internalized transphobia may socially devalue trans identities and wish to not be associated with these communities (Frost & Meyer, 2009). But understandably these individuals still need the healthcare-related information community perspectives can offer, particularly as internalized transphobia significantly predicts genital discomfort and desire for gender-affirming care via surgical procedures (Anzani et al., 2022). Therefore, for more equitable access to health and support services, greater signaling from healthcare systems is essential to establish safe spaces (both within and outside of trans communities) to access information and linkage to health services.

Our findings, like wider literature, suggest accessing care can be a complex and arduous process (Puckett et al., 2018; Pullen Sansfaçon et al., 2019). In some instances, the arduous process of assessment for GAHT can lead to disengagement from care and unsupervised hormone use (Metastasio et al., 2018), potentially resulting in long-term deleterious impacts (Fowler et al., 2023). Therefore, there is a need to consider these assessment procedures to ensure trans people who desire GAHT do not become disconnected from care. One approach to assessing trans individuals for GAHT that removes these demands are ‘Informed Consent’ models of care. This model places emphasis on the trans person’s autonomy and awareness of their gender which is complemented, rather than confirmed, by medical expertise (AusPATH, 2022). Central to these models are that provision of hormones are based on a patient’s understanding of risks and benefits and assessments by medical professionals are conducted where necessary, rather than as essential. One Australian survey compared the experiences of those in informed models of consent comparative to those required to complete psychological assessment to commence GAHT (Spanos et al., 2021). Satisfaction with experience being approved for GAHT was significantly higher in informed consent models (85%) over psychological assessment (40%) and 100% of participants in informed consent models felt they were actively involved in the GAHT decision-making process. Therefore, informed consent approaches are effective and empowering approaches to supporting and engaging trans individuals who may wish to pursue GAHT (Franks et al., 2022).

Another barrier reported by our participants was delayed accessed due to parents refusing access. The prescription of hormones under the age of eighteen has been seen as controversial in popular media, however has been included in professional recommendations since the ‘90s (Giordano & Holm, 2020), and has been found to significantly reduce suicide risk in adulthood (Turban et al., 2022). However, despite its importance, parental barriers to accessing care remain (Puckett et al., 2018). Recently, the World Professional Association for Transgender Health updated guidelines advocate for the provision of hormones to young people without parental consent where parental involvement may be adverse to the young person (Coleman et al., 2022). Given young trans folk already find the process daunting (Pullen Sansfaçon et al., 2019), it is imperative that younger people have clear linkage to affirming support, awareness of the pathways circumventing parental consent, as well as support systems to navigate potential rejection from families.

A key piece of advice that participants wanted other trans people considering hormones to know centralized around it never being too late to start. Some older trans people describe a sense of mourning for lost time when transitioning later in life alongside jubilation from transitioning (Fabbre, 2014). Research suggests that older trans people may find it harder to transition as there is “more to lose” as someone gets older (Benbow & Kingston, 2022), as well as having previous attempts at transitioning. Participants in the study by Benbow and Kingston (2022) also reported having medical practitioners discourage transitioning at “their age” (aged 50 and above) because it would not be “worth the hassle.” Therefore, the points raised within the current study are important to consider across the developmental lifespan and ensure that all trans individuals have equitable access to safe gender-affirming procedures.

Finally, participants implored other trans people to cultivate strong social networks before transitioning. Given the variety of social changes that can occur during GAHT (Fowler et al., 2023), having these social connections in-place beforehand was vital to ensure trusted individuals are available to lean on. Quantitative evidence also suggests that increased levels of perceived social support is significantly connected to improved mental health during GAHT (Aldridge et al., 2021). Therefore, establishing connection pathways for trans people to connect with others ahead of commencing GAHT is an important responsibility for healthcare providers. This may be less formal through referral to common online communities or local LGBTQIA+ organizations. However, there is scope to implement formalized peer-navigation, a concept used commonly within HIV related care (Wells et al., 2022). Its emphasis on guidance through lived experience would be advantageous within trans health contexts and may help illuminate sociocultural factors not otherwise discussed in consultations. More research designing and testing such models are necessary.

Strengths and limitations

A strength of this study was the inclusion of participants across multiple age groups, allowing for inclusion of a variety of experiences with gender identity and accessing hormones. As well, the analysis within this study is heightened by the contributions of insider and outsider perspectives. However, as previously described, there is a potential for bias given the enmeshed status of all authors, as well as the overlapping commonalities in educational background, economic status, and at times societal privilege. All these factors influence the researcher’s personal context and therefore final analysis, and this needs to be considered when interpreting results. A further limitation of the study is that all participants were pursuing hormonal feminization due to the nature of the larger study from which participants were recruited. Inclusion of individuals pursuing masculinization would expand upon the experiences provided. Additionally, the time elapsed between pre-GAHT experiences, and the time of interviews may limit participant’s ability to recall information and in turn, the clarity of their experiences. Most participants reported living in a metropolitan area of Australia, limiting the generalizability of these findings to individuals in regional and rural locations who may experience unique healthcare barriers. Finally, whilst the study team included gender and sexuality diverse researchers and clinicians to consider both insider and outsider perspectives throughout the study process from design to analyses and dissemination, the research team have many commonalities in terms of educational background, economic status, and to some extent societal privilege.

Conclusion

This research expands our current knowledge by describing the experiences of trans adults pursuing GAHT in Australia, a relatively small area of research which prior to this study predominately focused on youth. Experiences accessing hormones are complex and supports are needed across the developmental lifespan to ensure safe and equitable access to gender-affirming health services, including GAHT for all individuals. Overall, clearer, and balanced explanations of what it means to be trans may help trans individuals connect with community. Whilst community are first line supports for trans individuals, it is important to ensure that peers are not solely responsible for providing support and education. Additionally, informed models of consent might reduce logistical and contextual barriers to accessing GAHT. For those who pursue it, GAHT can be a life-changing experience and it is imperative that healthcare systems work collaboratively with the trans community to ensure every trans person has safe access to gender-affirming care.

Acknowledgments

We would like to thank the participants for sharing their journey with the research team. We wish to thank Mattea Lazarou for her contribution to the development and early administration of this study.

Disclosure statement

The authors report that are no competing interests to declare.

Data availability statement

Due to the confidential nature of the data collected, data is not available for access by those external to the research team.

Additional information

Funding

Sexual Health Research Fund Grant (Round 2) 2019. Administered on behalf of Queensland’s Department of Health by Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM).