“It Wasn’t for the Sake of Me and My Mental Health”: Transgender People’s Perspective on the Role of Mental Health Providers in Initiating Gender-Affirming Hormones - a Qualitative Study

Introduction: Hormone therapy can be an essential part of medical transition for some transgender people. Despite ongoing debate on the role of mental health providers in the initiation of gender-affirming hormones, little evidence exists to guide the discussion. We seek to elucidate the patient perspective on the feasibility, utility, risks, and benefits of mandatory mental health evaluation (MHE) prior to hormone initiation. Methods: We conducted semi-structured interviews with individuals who have initiated gender-affirming hormone therapy (n=21). We purposively sampled respondents to include those who indicated that they were required to have mental health evaluation prior to hormone initiation, and those who did not. A transgender advisory board helped develop the semi-structured interview guide. Interviews were transcribed verbatim and coded using emergent and a priori codes. Results: The majority of respondents saw the requirement for MHE prior to hormone initiation as distinct from, and often discordant with, their mental health care. We identified the following roles of mental health care as seen by patients: 1) General psychosocial support; 2) Identity formation: therapy as a safe space to explore gender and self; and 3) Logistics: assistance navigating the healthcare system. Themes that emerged regarding the MHE requirement included 1) Access: for some, the MHE requirement delayed access to gender-affirming care; 2) “pathologizing my existence”: the effects of having one’s identity result in a diagnosis of mental disorder; and 3) “auditioning” for care: fear of being denied care if one does not present with a stereotypical transgender narrative. Many participants drew direct connections between the MHE requirement and negative effects on their mental health and the patient/provider relationship, while concurrently identifying mental health care as essential for wellbeing. Conclusion: While mental health care is appreciated, many transgender people see the universal MHE requirements as having significant negative implications on access, safety, and on even on their mental health. Guidelines should explicitly account for and mitigate the structural barriers preventing transgender individuals from accessing medical and mental health care.