Orla Mahon and Neha Natu explore the multidimensional aspects to gender-affirming care and address the latest breakthroughs in order to align individual’s physical bodies with their gender identities.
Every morning, before the sun even rises, there's a stirring in their chest that pulls them from the depths of sleep. It's a sensation that's become all too familiar, like a heavy weight settling in the pit of their stomach. As they stand before the mirror, they're met with a reflection that feels foreign, a face that doesn't quite match the person they know themselves to be. They trace the lines of their jaw, the curve of their lips, searching for some semblance of recognition, but finding only a stranger staring back at them. Out in the world, they navigate a minefield of misgendering and microaggressions, each one a reminder of their otherness, their inability to fit neatly into the boxes society has assigned them. They plaster on a smile, nodding along to conversations that feel like daggers to the heart, all the while longing for a place where they can simply exist without explanation or justification.
Gender-affirming care is a vital component of healthcare for transgender and gender diverse individuals, providing support and resources to help align their outward appearance with their internal sense of gender identity. By acknowledging and respecting individuals' self-identified gender identity, gender-affirming care affirms their dignity, autonomy, and right to live authentically.
Hormone Therapy
Gender-affirming care includes a variety of services that aim to alleviate gender dysphoria and aid in achieving an individual’s gender-affirming goals. These goals vary from person to person, and many transgender individuals do not decide to pursue hormone replacement therapy, for various reasons. However, for those who do, it has been noted that hormone replacement therapy can improve quality of life for transgender people. In an Irish study, it was reported that 75% of transgender adults expressed an improvement in their mental health and well-being upon beginning the process of medical transition. The two hormones that are generally involved in hormone replacement therapy for trans people are testosterone and oestrogen, which are sometimes referred to as “sex hormones”, as their primary functions involve the development and maintenance of certain sex characteristics - such as facial and bodily hair growth and genital development. Testosterone and oestrogen can also have major impacts on sexual function, such as a person’s sex drive and their ability to have children. Some trans people may also choose to use a blocker, or hormone suppressant, as part of their medical transition.
In an Irish study, it was reported that 75% of transgender adults expressed an improvement in their mental health and well-being upon beginning the process of medical transition.
Many trans people face difficulties in their attempts to begin hormone therapy. Within the Irish context, most trans people seeking hormone therapy must do so via the National Gender Service (NGS), based in St Columcille's Hospital Loughlinstown. This can involve years of being on waiting lists as well as months of assessments that some transgender people find repetitive and humiliating, before the prospect of hormone therapy is considered. Because of this, trans people who wish to begin medical transition may seek out private healthcare (costly, and often involves having to go abroad), or self-medicate with unprescribed hormones bought on the black market - sometimes called DIY trans healthcare. DIY trans healthcare is conducted without the supervision of a medical professional, and as such, may result in complications for those who choose to pursue it. However, with waiting lists for treatment through the NGS reported as being up to seven years long, it’s understandable why trans people may feel that this is the only option available for them to begin their medical transition.
Puberty Blockers
Another area of controversy regarding medical transition has been puberty blockers. Puberty blockers are medications that temporarily halt the body's production of sex hormones, such as testosterone and oestrogen, thereby delaying the onset of puberty and its associated physical changes. These medications work by suppressing the release of gonadotropin-releasing hormone (GnRH), which in turn inhibits the production of sex hormones from the ovaries or testes. Puberty blockers have been prescribed since the 1980s to (cisgender) children in order to treat precocious puberty, or the unusually early onset of puberty. However, their use in the case of youths experiencing gender dysphoria has become a point of contention. This is in part due to the potential unknown risks of prolonged usage of puberty blockers - the impact of prolonged exposure on the development of bone mineral density, the brain, and future fertility is not currently known. According to a statement released by Joe Gannon, Chief Operations Officer of Children’s Health Ireland, the effects of puberty blockers in young people are reversibile: “Once the blockers are stopped, the natural puberty returns quickly and completely and the individual will progress through normal puberty.” Puberty blockers used under correct supervision can be an invaluable resource for young people who are questioning their gender identity - allowing them more time to consider the options available to them, and granting them a smoother transition should they decide to pursue hormone replacement therapy in the future. The use of puberty blockers is also associated with greater mental health outcomes and a lower prevalance of suicidal ideation.
Puberty blockers used under correct supervision can be an invaluable resource for young people who are questioning their gender identity - allowing them more time to consider the options available to them, and granting them a smoother transition should they decide to pursue hormone replacement therapy in the future.
Surgical Interventions
Like hormone replacement therapy, some trans people may choose to pursue gender-affirming surgical procedures, while some may not. Top surgery involves altering the chest to better align with an individual's gender identity. For transmasculine individuals, this might involve mastectomy (removal of breast tissue), while transfeminine individuals may opt for breast augmentation. Bottom surgery involves surgical procedures to alter the genitalia. For trans women (assigned male at birth), this might involve vaginoplasty to create a vagina, labiaplasty, and possibly other procedures such as orchiectomy (removal of testes). For trans men (assigned female at birth), this might involve procedures such as phalloplasty or metoidioplasty to create a penis, scrotoplasty, and possibly hysterectomy (removal of the uterus). There are also facial feminization surgeries or facial masculinization surgeries with alter altering facial features to make them more congruent with an individual's gender identity, including forehead contouring, rhinoplasty, jaw and chin contouring, and other facial procedures. These surgeries are an integral part of gender transition for many transgender and non-binary individuals and can greatly alleviate gender dysphoria, the distress that arises from a discrepancy between one's gender identity and assigned sex at birth.
In Ireland, those that do wish to have gender affirming surgeries usually have to go abroad - the NGS currently has no surgical team. This makes the process of accessing surgery costly, time consuming, and often exhausting. The NGS requires patients to be on hormones for at least six months before being referred for surgical assessment for mastectomy, or top surgery, and at least a year for any other surgery. Like the initial assessment for hormone replacement therapy, many trans people find the process of surgical assessment to be a daunting, emotionally draining, and occasionally invasive process, and often involves a long period of time spent on various waiting lists. Following surgical assessment, the NGS may make a referral for surgery to be carried out - if “it is clear that surgery will help you to affirm your gender and there are no outstanding risks to your health or well-being,” according to the NGSs website.
In Ireland, those that do wish to have gender affirming surgeries usually have to go abroad - the National Gender Service currently has no surgical team.
Access to gender-affirming care may vary depending on factors such as geographic location, financial resources, and availability of knowledgeable healthcare providers. However, efforts are being made to improve access to gender affirming care for transgender individuals, including advocacy for insurance coverage of gender-affirming treatments and increasing cultural competence among healthcare providers.