Table 3.

Perspectives on Health Care

Subtheme 1: An essentialist, binary medical model is inaccurate and oppressive
Subtheme characteristics	Phenomenological interpretations	Participant quotes
Roots of deleterious gatekeeping practices are tied to essentialist, binary assumptions Systemic oppression rooted in essentialist, binary assumptions Pressure to present as “trans enough” by way of essentialist standards to be deemed valid and/or access appropriate health care generates fear, frustration, and anticipated threat Medical intervention assumed to define transitioning process; however, interventions are only one potential facet	Participant 2 demonstrated how the theme of “not trans enough” played out frequently in the context of interactions with health care providers	I'm always kind of concerned that I'll be seen as not trans enough, and they'll be like, “You can't go on testosterone” or something. But that is probably just my brain thinking of worst case scenarios… I don't know. I don't think people have to be hypermasculine. I think everyone should just be themselves. And you shouldn't deny people medical help for that.
	Participant 3 exemplified the idea of “not trans enough,” and binary reification in medical model. Medical interventions are specified as one potential aspect of transition	And if you're a trans man and you never transition medically and stuff… like if you don't even change your name. Maybe you have a gender-neutral name assigned at birth and you never change anything. It's just the same you're still trans.
	Participant 11 reflected on essentialist, binary roots in the medical model and gatekeeping	I know somebody right now who is non-binary and seeking to go on T just for a couple years, but will the doctors even want to treat this person if they express that their end goal is not transitioning? Because the entire process is so focused on, “You want to become cis, don't you?” No, I don't, because that's literally the worst case of anything I could ever be. I don't know, those are some significant things to me, just because everything is deeply rooted in these constructions.
	Participant 7 offered reflections regarding the historical roots of gatekeeping and the invalidation of transmasculine identities	I definitely think that is where [not trans enough] had its roots, because historically if you look at medical transition, trans men were not given access to medical transition because it was only thought of as a trans woman thing. Like, gender dysphoria or being trans was bad. So trans men who said that they were trans and want to transition, it was like, that's not real… that's not a real thing. It was immediately pushed away. People were not allowed to be their full selves if they wanted to be.
Roots of deleterious gatekeeping practices are tied to essentialist, binary assumptions Systemic oppression rooted in essentialist, binary assumptions Pressure to present as “trans enough” by way of essentialist standards to be deemed valid and/or access appropriate health care—generates fear, frustration, and anticipated threat Medical intervention assumed to define transitioning process; however, interventions are only one potential facet	Participant 4 specified medical as one aspect of transition, and demonstrated how “not trans enough” plays out within transgender communities	On Tumblr… I was looking at things, and they were like, ‘Medical transitioning!’ I'm like, “Okay, you got to do that to be this,” because a lot of people wanted it so badly. So, I feel like if they wanted it, it had to be something that was needed for everyone. Until that notion was thrown out the window by co-workers of mine and other trans people I met in person. They were like, “You can still be trans without any medical interventions ever… at all.” I was like, “Oh, cool.”
	Participant 5 pointed to systemic oppression when navigating cisgender frameworks and the necessity of carving out TGD-relevant frameworks	The medical system wasn't set up for trans people. It wasn't set up for queer people. So, trying to etch out a space not made for you is not very easy to do… There's “trans enough” again [laughs]. Am I trans enough for hormones? People pretend they have more dysphoria than they do so they can have access.
	Participant 8 gave practical examples of systemic oppression (e.g., binary only options on medical forms), representing a large misalignment between the current health care system and TGD well-being	But then all the forms that you have to fill out…they did not have anything that was non-binary inclusive. It was all opposite gender, other gender… all that “one or the other.” So, I felt like if I had any inkling of a non-strictly masculine feeling, then [access to appropriate care] would be denied to me.
	Participant 10 specified medical facets as one part of transition, referring to in-group and out-group pressures to conform to binary expectations	I think that was definitely something I thought about more when I first decided to transition, in terms of chest surgery and things like that. But moving along, as I identified more as trans masculine, I realized I was still comfortable with them and I didn't necessarily need to go through a surgery to fully identify with who I am. They weren't keeping me from anything, or inhibiting me from fully identifying with who I am.

TGD, transgender and gender diverse.