THe Use of Hormone Therapy in the Male-to-Female Transgender Population: Issues for Consideration in Thailand

ABSTRACT

Objectives: Prejudice against transgender people is evident around the world with discrimination in many aspects of life, including access to health care. Even in Thailand, where male-to-female (MTF) transgender people are particularly visible and society is reputedly accepting, barriers to attaining appropriate health care still exist. The vast majority of MTF transgender people in Thailand are reported to be taking hormone therapy; however, most do not seek medical advice regarding these regimens, with the initiation and tailoring of medication often being guided by sympathetic peers instead. The objectives of this review are to consider hormone therapy in the context of the Thai population and provide recommendations regarding ways to improve practice and reduce health risks. Methods: The data analysis in this article represents a comprehensive literature review regarding hormone therapy for MTF transgender people including the guidelines for initiation, prescribing, and monitoring of hormone therapy, risks for serious adverse events and reported hormone use by the MTF transgender population in Thailand. Results: There is a notable lack of published research regarding hormone therapy in the transgender population. Guidelines, whilst relying considerably on expert opinion, do provide clear recommendations on the initiation, maintenance and monitoring of hormone therapy. Comparison of endocrine guidelines with reported practice in Thailand reveals significant opportunities for improvement in MTF transgender hormone therapy. Conclusions: The incautious use of hormone therapy may represent a considerable health risk behavior undoubtedly contributing to the morbidity and mortality in MTF transgender people. Although there is currently considerable focus on sexually transmitted infections in the MTF transgender population, a more comprehensive approach to health care is required, including education for transgender people and the health professionals who attend to them regarding appropriate hormone therapy.     

Transmen's Health Care Experiences: Ethical Social Work Practice Beyond the Binary

Informed by institutional ethnography approaches, this study includes interviews with 3 young transmen (21–29) about their experiences regarding Canadian health care and the work they perform to access care. Semistructured interviews were used to gather data that were then analyzed to identify key aspects of participants’ experiences and perceptions. Findings describe the extra work transmen perform to compensate for a lack of provider competence in transgender health care. Influences of the dominant gender binary ideology as it shapes the health care experiences of transmen are discussed. This article calls for social workers to challenge the gender binary and use practice frameworks informed by transgender theory.     

A Bioethics Approach to Social Work Practice With Transgender Clients

Increased advocacy for the informed consent model of transgender health care specifies that patients should be in control of access to receiving medical interventions such as hormone therapy or surgery. However, in practice, mental health clinicians, including clinical social workers, are increasingly called upon by medical providers to serve as gatekeepers for these processes. It is frequently the role of social workers to assess transgender clients’ baseline mental health and their understanding of the consequences of treatment, and to forward recommendations to medical providers regarding the readiness of patients to transition. Therefore, social workers assisting transgender clients must be aware of the ethical standards that are particularly pertinent to their work with this marginalized and oppressed population. They must also be prepared to address unique ethical dilemmas that may be especially challenging to resolve. In this article we apply the most commonly utilized bioethical framework known as Principlism to describe the ethical standards and values that are particularly important to consider when working with transgender clients, namely autonomy; beneficence; nonmaleficence; and social justice. Because clinical social workers are frequently in the position of balancing client self-determination with their role as gatekeepers, a framework for resolving resulting ethical dilemmas is described (I CARE) and applied to three case examples.     

Career Decision Self‐Efficacy of Transgender People: Pre‐ and Posttransition

Transgender people often make the decision to change jobs before, during, or after making a social or medical transition. This study explores reported self‐efficacy from an online sample of transgender people. Results indicate that there are differences in self‐efficacy based on one's gender identity, transition status, and education level. This study offers insight into the important and often overlooked vocational experiences of transgender people. Results suggest ways in which the transition process may interact with career decision self‐efficacy.     

Transnormativity: A New Concept and Its Validation through Documentary Film About Transgender Men

While prior research has called attention to how medically based, normative understandings of sex and gender place undue restrictions on transgender people's autonomy, there has yet to be an attempt to consolidate this research into a recognizable concept that is situated within existing theoretical frameworks. This article uses documentary films focused on transgender men as an empirical example to develop the concept of transnormativity. Transnormativity describes the specific framework to which transgender people's presentations and experiences of gender are held accountable. Drawing on research specific to transgender community groups, medicalization, and legal transition, I argue that transnormativity structures transgender experience, identification, and narratives into a hierarchy of legitimacy that is dependent upon medical standards. This ideology, as I show via a content analysis of documentary films, circulates in media depictions of transgender people in ways that eclipse alternative explanations of gender non‐conformity. While medical transition is a central component of many transgender people's gender trajectory, I argue in this article that the privileging of the medical model over others creates a marginalizing effect for gender‐non‐conforming people who cannot or do not wish to medically transition.     

The institution of medicine and transgender identity construction: Between a doc and a hard place

Research shows that when transgender young people are well-supported throughout their gender transition they have similar levels of depression to their cisgender counterparts. For transgender young people who wish to transition medically, these support systems may include parents as advocates and healthcare professionals who specialize in transgender services. Decisions about steps throughout transition are made by transgender children, their parents, and their physicians. An examination of gender structure theory and medicalization literature helps to assess how medicine-on institutional, interactional, and individual levels-contributes to cisnormativity and enables us to reflect on the relationships among sex, gender, and science. This literature review aims to analyze how cultural ideologies influence medical processes that shape the identity construction of transgender children and it sheds light on parental involvement throughout transitions.     

Transgender youth homelessness: Understanding programmatic barriers through the lens of cisgenderism

Service access and acquisition are often complex and sometimes dangerous for transgender and gender expansive young people, who frequently experience stigma and discrimination and face systemic barriers including sex segregated programs and institutional practices that deny their own understanding and articulation of their gender. A common theme in the literature is recognition of the need for affirming services specifically designed to meet the needs of transgender young people experiencing homelessness, as this population may not utilize or have access to much needed services due to systemic barriers and fear of rejection and harassment. The current study investigates the lived experiences of transgender and gender expansive young people with histories of homelessness. This phenomenological qualitative investigation explores aspects of transgender and gender expansive youth's experiences, both at home and on the street. A recurring theme emerged in the participants' narratives — the seemingly insurmountable barriers constructed by systems that were not designed with their unique needs in mind. When understood through the lens of cisgenderism, the findings illuminate the structural barriers that exist for transgender and gender expansive young people and the systemic challenges service providers must address.     

Facilitating Transition Among Transgender Clients: Components of Effective Clinical Practice

Although transgender clients seek services in a number of settings in which social workers practice, there is a dearth of scholarly literature available to guide effective clinical practice with this population. When transgender issues are included in the practice literature, the trend has been to consolidate the needs of transgender clients with those of the larger lesbian, gay, and bisexual community or to simply focus on increasing the comfort level of clinicians working with this population. This is concerning because transgender individuals represent a vulnerable subgroup of clients with unique and specific treatment needs related to the transition experience. Social workers play a critical role; they may serve transgender clients and their families in many ways: as advocate, educator, diagnostician, and individual, couples or family therapist. The purpose of this article is to identify several key components of trans-specific clinical practice and the role of social workers in supporting and facilitating client transition. Specifically, the authors will discuss: (a) relevant definitions and terminology, (b) emerging issues related to depathologizing the needs and experiences of transgender individuals, (c) the critical elements of trans-specific clinical assessment, and (d) clinical advocacy associated with the medical legal and social aspects of the transition process. Specific recommendations for trans-affirmative social work practice will be offered.     

The invisible body of queer youth: identity and health in the margins of lesbian and trans communities

How does complexity in gender and sexual identity construction and partnering practices generate unique vulnerabilities for queer-identified youth? We present two case studies from an ongoing ethnographic study of LGBTQ youth development: "Samantha," a queer-identified woman partnered with a transgender man, and "Reid," a queer-identified transgender man who has declined medical gender transitioning and who partners with lesbians and gay men. We consider the implications of these youths' locations on the margins of both lesbian and transgender communities and the challenges in providing health care and support services for queer-identified youth.     

Exploring the diversity of gender and sexual orientation identities in an online sample of transgender individuals

Although the term transgender is increasingly used to refer to those whose gender identity or expression diverges from culturally defined categories of sex and gender, less is known about the self-identities of those who fall within this category. Historically, recruitment of transgender populations has also been limited to specialized clinics and support groups. This study was conducted online, with the aim of exploring the gender identities, sexual orientation identities, and surgery and hormonal statuses of those who identify with a gender identity other than, or in addition to, that associated with their birth sex (n = 292). Genderqueer was the most commonly endorsed gender identity, and pansexual and queer were the most commonly endorsed sexual orientation identities. Participants indentified with a mean of 2.5 current gender identities, 1.4 past gender identities, and 2 past sexual orientation identities. The majority of participants either did not desire or were unsure of their desire to take hormones or undergo sexual reassignment surgery. However, birth sex and age were significant predictors of “bottom” surgery and hormone status/desire, along with several identities and orientations. This study explores explanations and implications for these patterns of identification, along with the potential distinctiveness of this sample.     

Normative Accountability: How the Medical Model Influences Transgender Identities and Experiences

The medicalization of gender variance is a key force in transgender people's experiences of embodiment, identity, and community. While most directly dictating experiences of diagnosis and medical classification, it is important to acknowledge that the effects of medicalization are widespread across social contexts and institutions. I explore the medical model of transgender identity, with special attention to its current diagnostic classification, in order to highlight how transgender people's interactional experiences of gender are shaped by medical authority. I review literature that highlights the operation of the medical model as a normative accountability structure in its influence across multiple institutions of social life including health and healthcare, transgender community groups, and legal classification.     

Specifying Long-Term Care Provider Responsiveness to LGBT Older Adults

In-depth interviews and focus groups with lesbian, gay, and transgender older adults addressed the question “What does it mean for long-term care providers to be responsive to lesbian, gay, bisexual, and transgender (LGBT) older adults?” Sixteen domains of long-term care provider responsiveness to LGBT older adults were identified, including awareness of centrality of partners, knowledge of importance of preferred gender expression, openness to welcoming LGBT older adults, and ability to create LGBT-safe environments. Future research should include LGBT elders who belong to ethnic minority groups, bisexual elders, and LGBT older adults who do not identify with LGBT labels.     

Clinical and Supervisory Considerations for Transgender Therapists: Implications for Working with Clients

Transgender therapists have unique and valuable perspectives into how gender organizes the therapeutic process. Currently, in the MFT field, there is discussion of the cisgender therapist's experience in the therapy room, but no known articles on the transgender therapist's experience. This article provides insight into the experiences of transgender therapists around issues of self‐disclosure, social locations of both therapist and client, and clinical supervision. Drawing from our clinical experiences as transmen, we highlight special considerations for working with cisgender, queer, and transgender clients. Implications for supervision of transgender therapists are also discussed. As more gender diverse students seek MFT training, there is an urgent need to acknowledge their perspectives. This article is a call for beginning conversations in this direction.     

Do Workplace Gender Transitions Make Gender Trouble?

This article examines what happens when an employee makes the transition from one recognized gender category to another and remains in the same job. Drawing on in‐depth interviews with transmen and transwomen in Texas and California, we illustrate how a new social gender identity is interactionally achieved in these open workplace transitions. While transgender people often are represented as purposefully adopting hyper‐feminine or masculine gender identities post‐transition, we find that our respondents strive to craft alternative femininities and masculinities. However, regardless of their personal gender ideologies, their men and women co‐workers often enlist their transitioning colleague into gender rituals designed to repatriate them into a rigid gender binary. This enlistment limits the political possibilities of making gender trouble in the workplace, as transgender people have little leeway for resistance if they wish to maintain job security and friendly workplace relationships.     

Bathrooms,Boundaries, and Emotional Burdens: Cisgendering Interactions Through the Interpretation of Transgender Experience

Building on findings demonstrating that social institutions may cisgender realities by creating and enforcing binary notions of gender rooted in cisgender experience, this study examines the ways cisgender people reinforce cisnormative gender binaries in their ongoing interactions. Utilizing interviews with 99 cisgender people, I show how respondents react to a vignette about a gender nonconforming person seeking to use a public bathroom by “cisgendering interactions,” which I define as the process whereby people reassert binary understandings of gender to make sense of transgender experience while placing an unequal emotional burden on transgender and gender nonconforming people to mend the interactional disruption of the gender panic. Additionally, my analysis extends transgender scholarship by demonstrating some ways cisgender people make sense of transgender people in public spaces. In conclusion, I draw out insights for understanding (1) the ways people cisgender their realities in the face of conflicting stimuli, (2) the ways in which emotions are a mechanism of inequality reproduction, and (3) the consequences these actions have for the perpetuation of gender inequality.     

Shedding light on thirteen years of darkness: content analysis of articles pertaining to transgender issues in marriage/couple and family therapy journals

What is the extent to which marriage/couple and family therapy (M/CFT) journals address transgender issues and how many of them say they are inclusive of transgender persons when they are not? To answer these queries, a content analysis was conducted on articles published in M/CFT literature from 1997 through 2009. Of the 10,739 articles examined in 17 journals, only nine (0.0008%) focused on transgender issues or used gender variance as a variable. Findings support the assertion that transgender issues are ignored and marginalized by M/CFT scholars and researchers alike.     

The Social Costs of Gender Nonconformity for Transgender Adults: Implications for Discrimination and Health

Research suggests that transgender people face high levels of discrimination in society, which may contribute to their disproportionate risk for poor health. However, little is known about whether gender nonconformity, as a visible marker of one's stigmatized status as a transgender individual, heightens trans people's experiences with discrimination and, in turn, their health. Using data from the largest survey of transgender adults in the United States, the National Transgender Discrimination Survey (N = 4,115), we examine the associations among gender nonconformity, transphobic discrimination, and health‐harming behaviors (i.e., attempted suicide, drug/alcohol abuse, and smoking). The results suggest that gender nonconforming trans people face more discrimination and, in turn, are more likely to engage in health‐harming behaviors than trans people who are gender conforming. Our findings highlight the important role of gender nonconformity in the social experiences and well‐being of transgender people.     

The Lived Experiences of Transgender Persons: A Meta-Synthesis

This article synthesises findings from qualitative studies which have explored the lived experiences of transgender persons, using Noblit and Hare's (1998) meta-ethnography method. Thirty-one qualitative studies related to the lived experiences of transgender individuals, published between 1998 and 2013, met the inclusion criteria. A literature search was conducted between November 2012 and September 2013 using computerized searches from nine databases as well as online manual searches of key journals. Results from these individual studies revealed five major themes: (a) crossing gender and physical problems in life, (b) experiencing psychological distress, (c) encountering discrimination and social exclusion, (d) having relationships does matter, and (e) dealing with difficulties in life. Yet, despite these negative experiences, transgender people have tried to find ways to help them deal with their difficulties. We conclude that there is a need for health care providers, social workers, and health promoters to support transgender individuals, for their health and well-being. This meta-synthesis provides a clear account of what transgender individuals experience in their lives, to support the development of sympathetic health and social care services to assist them with their difficulties, and enhance their health and well-being.     

Transgender and Gender Diverse Children: Considerations for Affirmative Social Work Practice

Given growing public awareness about transgender and gender diverse identities, it is expected that greater numbers of children and families will seek mental health and social services, including transition-related services, from social workers and other mental health professionals. Transgender and gender diverse children have a range of transition-related needs which require the support of informed practitioners with transgender and gender diverse-specific knowledge and skills. Moreover, the needs and experiences of families and caregivers of transgender and gender diverse children will vary greatly. To date, research suggests a paucity of transgender and gender diverse-specific expertise among social workers and other mental health providers; this seems particularly evident with respect to the needs of transgender and gender diverse children. An affirmative practice framework to guide therapeutic work with transgender and gender diverse children and families is presented. In addition, key clinical practice considerations associated with engagement, assessment, psychoeducation, support and referral are provided. Finally, clinical examples illustrating use of the affirmative practice approach with transgender and gender diverse children are provided.     

Gender Labor,Assimilationism, and Transformative Practices: The Relational Negotiations of Cisgender Women and their Transgender Men Partners

Despite the rise in research on the experiences of transgender men (female‐to‐male, FTM) in recent years, little academic attention has been paid to the partners of these individuals. The experiences of a large portion of this population, cisgender women whose partners transition from female to male, provide a unique perspective on how individuals negotiate performances of normative gender ideals and heteronormative practices in transitioning non‐normative relationships. Research has shown that when these cisgender women find themselves in relationships that are socially defined as heterosexual, they often begin questioning their sexual orientation in relation to their partner's gender identity as well as the role and applicability of their beliefs regarding gender equality and anti‐heteronormative practices. This article provides an overview of the current literature that addresses the enactment of gender labor, the practice of reaffirming another person's gender through physical, emotional, and sexual care, by cisgender women whose partners transition from female to male. Specific focus is given to how, in some situations, the performance of gender labor manifests in assimilationist ways that adhere to typically heteronormative frameworks as well as how, in others, the performance of gender labor manifests in potentially transformative and destabilizing ways that serve to challenge normative structures. Gaps in the existing literature as well as directions for future research are also explored.