Table 4.

Perspectives on Health Care

Subtheme 2: Consequences of medicalizing gender (i.e., gender as a diagnosis)
Subtheme characteristics	Phenomenological interpretations	Participant quotes
DSM=historical stigma Applied consequences of Gatekeeping vs. Informed Consent models of care Essentialist, binary medical model limits ability to self-actualize, hence, limits well-being Essentialist assumptions giving rise to pathology; both have harmful consequences (e.g., internalized oppression, fear, and apprehension/avoidance to seek health care) Forced to accept stigmatizing diagnosis to access appropriate care Diagnosis may not be accurate; seen as “just another hoop to jump through”	Participant 7 reflected on the implications of changes to DSM diagnoses over time, and oppression rooted in the medicalization of TGD identities and embodiment	The whole system is really complicated. I don't think it should be listed as anything honestly. I do think it is an improvement over gender identity disorder being listed as a mental disorder. Now, where it's gender dysphoria, it has less of a connotation of someone being mentally ill. Rather, they have something that exists and it can be treated if they choose… But I am super against the medicalization of trans bodies, and trans identities, which I still think… the idea of gender dysphoria in the medical setting is really limiting, and it also allows doctors to keep resources from trans people… I am also liking how informed consent is a thing now, which I didn't realize until after I had started my [medico-legal] transition. But the gatekeeping model where [they] have to know if you are mentally ill or not before we give you testosterone… where at some places they're like, ‘You are an adult, here is what it does to your body, feel free to take this medication and keep it monitored.’ So, I think that all medical stuff related to transness is bad [laughs]. It's really limiting.
	Participant 5 illustrated how essentialism and pathology contribute to internalized hatred, and how extra work is needed to reclaim identity and live authentically (self-actualize)—both are core to well-being	We want to popularize the term “Gender Euphoria” cuz you know I feel the gender dysphoria in my body, and the internalized trans phobia that society has taught me. Yeah. It's hard because I have gender identity disorder on my diagnoses because it has to be. I mean, I feel gender dysphoria, but not every trans person does. So, I don't think it should be pathologized, I don't think it's an inaccurate way to describe me (laughs) but it's not an inaccurate way to describe all trans people or even trans people who want hormones or medical transition. And I think there is no reason why queer identity should be in the DSM. We should have learned this lesson already. What makes me mentally ill is not that I'm trans! (laughs)
	Participant 6 added a critical aspect of gender as a diagnosis as it pertains to people with multiple marginalized identities	Participant 6: The diagnosis is just pathologizing. It should not even be in the DSM… it is stigmatizing. Informed consent is the way to go. People travel very far distances just to go to a center that has informed consent. They can see therapists that are onsite if they want, but it should not be required to get access to medical transition. Interviewer: Thinking about all the hoops one must jump through to “transition,” or to get legal documents changed. [Interviewer reflected on own bias and privilege when referring to ‘legal documents’]. I can't even imagine what it would be like if English wasn't first language, or if they are undocumented. Participant 6: Yes, and many times it is dangerous for undocumented people to disclose their status to people in health care fields, so they just do not. This is a huge barrier, and very damaging.
DSM=historical stigma Applied consequences of Gatekeeping vs. Informed Consent models of care Essentialist, binary medical model limits ability to self-actualize, hence, limits well-being Essentialist assumptions giving rise to pathology; both have harmful consequences (e.g., internalized oppression, fear, and apprehension/avoidance to seek health care) Forced to accept stigmatizing diagnosis to access appropriate care Diagnosis may not be accurate; seen as “just another hoop to jump through”	Participants 8 offered insight through personal experiences in gatekeeping and incompetent provider care	Oh. My. God. Yes! So, when I talked about hormones with my first “trans expert” therapist, she was… a cis het lady. She had no idea what she was talking about. She had no idea. She just went to some class, and people gave her a certificate that says ‘you're trans friendly’ even though she wasn't… she was like, ‘Oh, your identity has been so fluid lately. You used to identify as non-binary, and I know you had all the same dysphoria and everything, but I would want you to identify as a trans man for six months before I would feel comfortable giving you a letter for hormones.’ That's not okay! I did not schedule another appointment with her after that, but even when I was going in for the psych appointment to get my hormones, luckily the psychiatrist that I had who was evaluating me was really good about it.
	Participant 11 reflected on impact of gatekeeping vs. informed consent models, and the vulnerability of being subjected to inaccurate binary assumptions in DSM diagnostic criteria	I did fib a couple of times. Like, ‘Oh yeah, I feel like the opposite gender. I feel like the body parts of the opposite gender, which is just a really weird and awkward sentence. That could mean so many things. The body parts of the opposite gender… by that, I would assume they mean penises would be more comfortable… I felt like if I answered anything the way they didn't want me to, I wouldn't be able to get what I needed. It takes a long time to get in to even start the process. I hate the process that I had to go through to get on HRT, and throughout that whole process I was being told that I should be thankful it was this easy for me. Like, here at the [college health clinic], they said, ‘You should be glad.’ Whatever. It should be easier. It should be one appointment, like, ‘Do you want this?’ and ‘Yes, give it to me.’
	Participant 10 pointed to how essentialist, binary assumptions are detrimental, and weaken validity of the medical model	I think it can be detrimental to think about it as a mental disorder. I purposely went outside of the state so that I wouldn't have to go through that whole procedure. It just seems wrong to… not medicalize it… but, turn it into a pathology when so much of it is culturally constructed.
	Participant 12 commented on stigma and diagnosis, harmful effects of an essentialist medical model, and stressors associated with accessing appropriate health care	I feel like it's not a disorder, and if it is, then where is my monthly government check? That's what I want to know! I had a friend who lives somewhere horrible, and it is nearly impossible for them to get access to these things. So I told them that you need to tell them… not say that you don't know… or that you feel like “this” one day, and like “that” another day. You have to go in telling people, because it's really hard. I feel like it is important though… and I wish this wasn't a thing, but for ‘transtrenders.’ I couldn't imagine some kid who felt like they were a boy, but really in the long run they are lesbian or non-binary or something like that - to literally physically change themselves just for something they're not too sure about. So, I do think going to therapy is definitely important, but I think that there needs to be more flexibility, and there shouldn't be any Christian therapy.