Motivation and emotion/Book/2021/Transgender medical transitioning motivation

Overview


Transitioning on any level is important to transgender individuals (‘trans-individuals’). Transitioning is the term used to describe a trans-individual's actions to better align themselves with their identified gender identity. This takes on a variety of forms, from taking on a new preferred name to undergoing gender-affirming surgery (Evans et al., 2021). However, undergoing medical-transitioning is a big step because it allows better alignment with someone’s identified gender and increases the quality of life for trans-individuals (Jellestad et al., 2018).

While trans-individuals’ motivations are known to them, misunderstandings of the trans-experience within cisgender circles have created blockades for trans-individuals accessing resources that would allow them to transition (Pearce, 2018). Due to this, making knowledge of trans-issues more accessible to the general populace would improve transgender lives. In addition, a more comprehensive understanding of transgender issues leads to better support systems for vulnerable trans-youth which positively impacts their mental health (Connolly et al., 2016).

This book chapter focuses on medical-based transitioning processes, the motivation behind undertaking them and the psychological underpinnings.

Focus questions:
 * What motivates medical-transitioning?
 * What are the effects of medical-transitioning on the self?
 * Why do people not medically-transition?

What is medical-transitioning?
Medical-transitioning is the term used to describe any form of medical intervention that aids a trans-individual to have their body better match their perceived self and identified gender. Medical-transitioning has a variety of forms. These typically begin with pubertal blockers in preteen trans-individuals and then, when they get older, Hormone Replacement Therapy (HRT) where an individual takes the hormones associated with their identified gender (i.e. testosterone/oestrogen) and undergo a puberty stage similar to their cisgender counterparts (Teller et al., 2020). If a trans-individual was not on pubertal blockers they can still have HRT and undergo puberty with minor complications. After HRT has begun for trans-individuals, medical-transitioning typically follows the path of gender-affirming surgeries to help the trans-individual resemble the cisgender ideals of their identity ("Medical Transition", n.d.).

Some trans-individuals do not follow this method of transitioning. Some may wish to have HRT but no surgery, while others may wish to have some surgeries but not undergo HRT, while others may elect to undergo HRT and some surgeries but not others for a variety of reasons. The trans-experience is unique to the individual and thus there is no ‘correct’ way to undergo medical-transitioning.

Gender dysphoria
Gender dysphoria (‘dysphoria’) is the current term used in the Diagnostic and Statistical Manual of Mental Disorders 5th edition. The term was selected because it was transparent in the averse-nature that categorises the condition (Zucker, 2015). However, true to its naming factor, existing in a state of gender dysphoria is not a pleasant experience. Dysphoria, similar to body dysmorphia (‘dysmorphia’), is obsessing over parts of the body the individual views to be incongruent with their perceived self.

Unlike dysmorphia, dysphoria can be alleviated through medical interventions, such as HRT, breast removal surgery or facial feminisation surgery. While dysmorphia’s obsessions are minor/imaginary, dysphoria’s incongruence between the identified gender and the assigned gender can be rectified, as gender signifiers are more tangible. While medically-transitioning is undertaken to alleviate dysphoria and help align the identified gender with the self, this is not the only motivator for undergoing this process.

A term used to diminish the transgender experience
While dysphoria is the most commonly used diagnostic term, viewing it as the only motivator for transitioning has faced backlash. The main criticism has focused on it not being a term that fully encompasses the trans-experience. Trans-individuals also experience gender euphoria (‘euphoria’), a joyous elation that comes with being perceived or acknowledged as their identified gender. There have been recent pushes to change the diagnostic tool to centre around euphoria. This is seen to change the trans-narrative from one of negativity in the public perception and to pull away from the ‘being transgender is a mental illness’ misconception (Beischel et al., 2021). Gender incongruence, which is the term used in the 11th edition of the International Classification of Diseases, is also seen as a better term than dysphoria, but is not as widely used.

Dysphoria is also criticised because it discredits euphoria as a motivating factor behind wanting to transition. Most people who are friends with someone who has recently come out as transgender will tell you about how their friend will become excited over commonplace things, like others using their correct pronouns or wearing an outfit that makes them feel aligned with their identified gender. This euphoria experienced will often encourage a trans-individual to continue to present themselves in ways that align with their identified gender so that they may continue to experience it (Beischel et al., 2021). So, while dysphoria may be an originating factor for wanting to transition, euphoria can also be a central reason.

Trans-individuals who do not experience dysphoria may still wish to seek medical-transitioning options. This is commonly observed in non-binary individuals, but binary-trans people may also not experience dysphoria, although this is less common. Someone who wishes to present themselves androgynously may seek surgeries or undertake HRT but not go to the full extent as a binary-trans person may wish to. This is because they derive euphoria from looking a certain way but do not experience motivators that would encourage a complete medical transition.

Erikson's stages of psychosocial development - Identity vs. Role Confusion
While most children begin to develop their gender identity while still toddlers, Erikson’s Identity vs. Role Confusion (‘Identity Stage’) takes on another layer for trans-individuals. Erikson defined success of this stage as being able to live by society’s standards (Erikson, 1980), which may not always be possible for trans-youths, some of whom may be only just coming to terms with their gender incongruence. Due to this, trans-individuals may seek to begin medical-transitioning around this time to better fit in with their cisgender peers.

Adapting the identity stage for the modern era
Academics have already interpreted Erikson’s treatment of the first four stages as integral to the identity stage (Levine, 2002). This interpretation makes it easier to adapt the stage from its cis-male-centred focus to one more inclusive of everyone. From here, they have suggested that a model of independence/interdependence would be more flexible for the changing societal platform. Using this definition for the identity stage helps understand trans-individuals medically-transitioning better while keeping the original framework Erikson based his theories upon. For example, a trans-individual with a strong, accepting support system may feel a strong sense of identity and encouragement to begin medically-transitioning, while someone without may feel trapped and anxious and not pursue medically-transitioning, even if both individuals’ dysphoria/euphoria needs are similar.

Devor's 14-stage model of transsexual and transgender identity formation
Devor proposed his 14-stage model of how one explores their transgender identity both intrapersonally and interpersonally (Devor, 2004), but like all things pertaining to people, it may not apply well to everybody. The model includes the stages:

Table 1. Relevant stages from Devor's Model

While this model is useful in identifying a commitment to their gender identity as a motivator for undergoing medical-transitioning, it does not consider that stigma management itself may be its own motivator for medically-transitioning. It acknowledges that acceptance of oneself, and seeing others that reflect our own experiences, are driving factors in deciding to transition, which is a key narrative throughout most modern literature.

Identity theory
Brumbaugh-Johnson and Hull proposed a different identity theory based on stigma management and the social implications of a non-cisgender identity (2018). This identity theory describes the motivation towards coming out as both extrinsic and intrinsic, with a cycle of gender performance and acknowledgement being important in developing the want to transition. As it discusses gender being a socially encouraged construct, this theory implicates the social aspects of gendered performance and community as a motivator behind transitioning. While the cited study only had a small participation group, it mirrors the acknowledged social factors discussed in-depth in Devor’s model.

Maslow's hierarchy of needs
While not typically applied to issues of identity outside of personal growth, Maslow’s Hierarchy of Needs (‘the Hierarchy’) (Maslow, 1943) can be applied for progressing stages of motivation for medically-transitioning. The Hierarchy is viewed as stages that must be met for self-growth to occur. When applying this to trans-individuals’ transitioning journey, it reads similarly to the previous Identity Theory.

The implications of this are that by including certain aspects, such as the need for safety, it encompasses a more realistic view of transitioning-motivation than solely viewing it as a way to alleviate dysphoria. Viewing each additional stage as a driving factor building the motivation describes a process similar to Devor’s proposition but with a more widely applicable understanding.

Safety needs
Safety needs include a multitude of things, such as protection from violence, emotional stability and financial security. Some trans-individuals will not transition unless it is safe for them to do so. When they view themselves as having that safety, it can encourage and allow them to start seeking ways to transition.

Love and social belonging needs
The last of the basic needs, throughout the literature, it is prevalent that medical-transitioning is a taxing task that most people view they can not undergo without a robust social support system. In situations where the biological family is non-supportive, trans-individuals will seek and create their own community. This need for community support is acknowledged within the trans-community. More experienced trans-individuals often take on mentorship or older siblings' roles to youths first coming to terms with their identity. This is shown to have a significant positive effect on trans-individuals, and was incorporated into the Transgender Resilience Intervention Model (Matsuno & Israel, 2018).



Multiple colloquial terms and actions have arisen within queer culture so that trans-youth can easily recognise advice or people that will be safe to be themselves with, particularly in online spaces. These terms can range from things like ‘baby trans’ when referring to someone first coming to terms with their transgender identity, to putting your pronouns in your social media biography or displaying them on your person through things like badges or other accessories (see Figure 2).

Even if the trans-youth does not have a large, personal support network, the support of the wider trans-community can sometimes substitute this.

Esteem needs
Being a part of a strong support network and the wider community can fuel the respect-based esteem need. If a trans-individual is reassured that their identity is valid, they will be more likely to seek medical-transitioning options. Similarly, having this support-need fulfilled can allow for the self-confidence esteem need to flourish. If an individual is confident in their identity, they are also more likely to seek medical-transitioning. Like Maslow’s original intention for the Hierarchy, motivation to begin medical-transitioning builds as each needs category is met.

Self-actualisation needs
Described as the ‘growth’ need, this stage is where individuals begin to embrace themselves and begin self-development. Undergoing medical-transitioning might be considered an essential part of self-actualisation for some people. When that is the case when the other needs are met, this stage is where someone could begin medically-transitioning and achieve their full potential as their identified gender.

Self-determination theory - autonomy
When viewing the motivation to medically-transition through Self-Determination Theory (‘SDT’), the desire to medically-transition would fall under the requirement for autonomy. Undergoing medical-transitioning has visible changes. SDT theorises that the need for growth drives behaviour, and in order to attain psychological growth, 3 needs must be met (Deci & Ryan, 1985). Autonomy is one of those needs and is defined by feeling in control of yourself and your actions. By medical-transitioning, a trans-individual may feel more in control of themselves and their lives, which can be a motivating factor. Fitting into SDT, some trans-individuals feel more confident and capable post-transition.

Quiz {Social support is integral to medical-transitioning motivation across all theories: + True - False
 * type="(+)"}

What are the effects of medically-transitioning on the self?
In addition to social acceptance, safety and dysphoria-management, post-transition effects can also be motivators.

Quality of life improvements
Despite trans-individuals still showing higher signs of low mental health than their cisgender peers post-transition (Jellestad et al., 2018), when comparing pre-transition to post-transition individuals, the post-transition individuals have overall higher mental wellbeing. While this is influenced by a variety of factors, this quality of life improvement can be a motivator to wishing to undergo medical-transitioning.

Body image improvement
Similar to dysmorphia, dysphoria creates an intense, uncomfortable feeling within one’s own body. Due to this post-transition individuals report persistent body dissatisfaction in addition to overall low mental-wellbeing. While this is linked to dysphoria, undergoing any form of medical-transitioning is linked with higher self-image, even in the trans-individuals who solely undertook HRT (van de Grift et al., 2017).

Different gender affirmation routes for different pursuits
Some people who experience gender dysphoria feel they do not need medical-transitioning options to live happily as their gender identity. A study by Nieder et al. evaluated current literature and their own study of people not wishing to pursue medical-transitioning (2019). Their paper discussed how people less likely to pursue medical-transitioning identified as some form of non-binary, which correlated with a lack of motivation to medically-transition. Another cited reason for not wishing to pursue medical-transitioning was perceived potential complications.

Some non-binary people who do not wish to medically-transition sometimes view themselves as not-trans/not-trans enough (Darwin, 2020). As the widely used transgender label and related literature are based upon the binary-transgender, which has caused some hesitation amongst non-binary identified people from accessing transgender resources or the like.

Non-binary people do undertake forms of medical-transitioning. Transitioning may take many forms to affirm a person’s identified gender best. For some people, that involves no motivation to medically-transition.

Case Study:

Banjo is non-binary and they do not experience dysphoria. Despite this they still elected to undergo HRT but no surgeries to better match their identity.

Medical limitations discouraging or preventing medical-transitioning
Some trans-individuals have no motivation to undergo medical-transitioning because of the possibility of complications arising from the procedures. Current literature investigating mainstream forms of medical-transitioning acknowledges the complications associated with the procedures and the uncertainty that accompanies it as a relatively new medical field.

An expanding field within the literature focuses on various genital reconstruction surgeries particularly in how to verify sexual health and wellbeing afterwards (Syed & Honig, 2021). Aside from surgery-related complications, some trans-individuals wish to delay or forfeit medical-transitioning due to the risk of sterility and the barriers that limit accessibility to fertility preservation countermeasures (Mitu, 2016).

Even when a trans-individual wishes to medically-transition, even beginning the process can bring complications. Roberts and Fantz compiled a review of frequent limitations faced by trans-individuals (2014). The review found that complications that arise from societal norms such as stigmatisation and financial barriers such as cost and non-coverage by private health insurance cause complications, particularly for younger, low-income trans-individuals wishing to undergo medical-transitioning. A broader issue discussed is the lack of availability for trans-healthcare, with a lack of knowledge amongst healthcare providers, a lack of certified providers, and the onerous task of consistently travelling to and from providers cited as the widest affecting reason for the delay or prevention of medical-transitioning.

Due to these varied reasons, even if an individual wishes to undergo medical-transitioning, these barriers may stop them.

Case Study:

Elijah is a transman. He experiences dysphoria and has undertaken HRT and breast removal surgery, but he has chosen not to undertake genital reconstruction surgery due to the low likelihood of the penis being functional post-operation.

Conclusion
The motivation behind medically-transitioning can be explained using multiple theories designed to explain the transgender experience and other more broadly applicable ones. No matter which theory you use to explain the motivation, there are overlapping themes. What causes the motivation to medically-transition appears to be a mix of dysphoria/safety and stigmatisation management, which needs a strong support group and committed gender identity to flourish. The initial desire appears to be intrinsically motivated but requires a variety of extrinsic sources to strengthen it enough to pursue.

The effects of medically-transitioning are typically positive, with it being associated with a greater quality of life and mental wellbeing. However, despite this, some people do not pursue medically-transitioning. People tend not to be motivated to medically-transition if they are non-binary, or may undergo different forms of gender affirmation instead. People who initially have the motivation to medically-transition may have this motivation diminished or outweighed by barriers that block them from successfully transitioning. This includes the potential financial burden, stigma around being transgender/transitioning, lack of adequate healthcare providers or the encumbrance of travelling great distances to healthcare providers. There are also the potential health-related risks associated with undergoing medical transitioning.

Despite these obstacles, the literature shows that medically-transitioning tends to be an extremely positive route for trans-individuals. It also shows that the trans-experience is greatly varied but has a consistent thread of companionship and support that cannot be understated when discussing what factors motivate the transition.

Key conclusions
 * Social support systems are integral to medical-transitioning's motivation.
 * The motivation to undergo medical-transitioning is impacted by managing both intrinsic and extrinsic factors.
 * Undergoing medical-transitioning significantly improves trans-individuals' quality of life and mental health.