Trans individuals experience an incongruence between their gender identity and sex assigned at birth, which can lead to gender dysphoria—affective and cognitive discontent with one’s assigned sex [1
]. This incongruence, especially paired with gender dysphoria, often leads to the desire to transition, a process which should enable trans individuals to live as their experienced gender [2
], thereby reducing gender dysphoria. Medical transition involves feminizing or masculinizing the body through hormone therapy and/or surgery to align one’s body to the experienced gender, to the extent possible [1
Trans individuals are likely to experience positive life outcomes when receiving trans-affirmative care, including medical transition [5
]. Individuals further along in transition report better mental health and experience less distress [2
], as measured in decreases of avoidant coping strategies used [6
], rumination [7
], suicidality [8
], and dysphoria [9
], and improvements in quality of life [10
], sexual satisfaction [11
], body image [13
], and depression and/or anxiety symptoms [14
Various experiences of gender and dysphoria mean not all trans individuals require all aspects of transition-related treatment [3
]. For example, many transmasculine (FTM) individuals do not require genital surgery to sufficiently affirm their sense of self [21
]. Non-binary and genderqueer (NBGQ) individuals in particular often experience their genders in such ways which lead to requests for ‘partial’ treatments [25
] to become androgynous [26
] or less interest in passing and medical transition [27
]. It is interesting to note that in the case of NBGQ individuals, context and age appear to play additional roles in the identification with NBGQ identities beyond subjective experiences of gender and dysphoria [29
]; NBGQ individuals are more likely to be assigned female at birth (AFAB) than assigned male at birth (AMAB) [21
], be university-educated, and be younger than binary individuals [21
Recent new diagnoses and understandings of gender (dysphoria) [1
] have resulted in improvements to transition-related care, including value placed on patient satisfaction with the treatment process itself [24
]. Patient satisfaction with treatment process is often used as a measure of healthcare quality; communication with doctors/nurses, timeliness of assistance, easy explanations of treatments, and thorough discharge planning are associated with improved healthcare outcomes, such as decreased hospital re-admission rates [31
], emergency department use [32
], and inpatient mortality [33
Patient satisfaction with the outcomes of medical procedures (i.e., surgery) was previously employed as the sole measure of transition-related treatment success and quality [11
], despite trans individuals focusing on treatment process characteristics when defining positive healthcare experiences [34
]. Nonetheless, several studies show high levels of overall patient satisfaction with trans healthcare services [35
], particularly from nonjudgmental, knowledgeable professionals [34
Updates to manuals and treatment guidelines have placed much emphasis on patient self-determination [24
], which is of current interest for patient satisfaction. This decision is supported by literature; requests for tailored treatments are increasing [21
], and higher satisfaction is reported when treatment approaches are flexible [39
] and offer control over treatment planning [34
]. However, research is lacking on how patients experience their role in decision-making processes.
Requirements of extensive psychotherapy often decrease satisfaction [39
]; however, rates of suicidality [30
] and depression and anxiety [7
] often remain high after transition, indicating trans individuals may benefit from ongoing mental healthcare. In many countries, such as those following the Standards of Care 7 (SoC7) [3
], psychotherapy is no longer a strict prerequisite for medical transition [3
], which can help psychotherapy to remain useful for the transition process [5
]. With these contrasting aspects, it is important to further investigate how trans individuals perceive psychotherapy.
Due to risks, complications, and recovery processes [46
], quality aftercare (wound care, physiotherapy, etc.) influences aesthetic and functional results of gender affirmative surgeries [48
], which trans individuals rate as key factors for satisfaction with surgical outcomes [15
]. As relaxed psychotherapy requirements [3
] and recognition of NBGQ identities [1
] mean more individuals can access surgery [3
], experiences of aftercare are important to investigate.
Parallel to new diagnoses and understandings of gender, research methods in the field of trans healthcare have been updated to better reflect the diversity of trans experiences. The Individual Treatment Progress Score (ITPS) [21
] is a novel new metric score to measure transition progress, which challenges previous notions that all trans individuals move through the same predefined, linear treatment pathway starting with hormones and ending in genital surgery [25
], or that all individuals need the same number of treatments to consider their transition complete. The ITPS allows for comparison of treatment progress of individuals across genders, including NBGQ identities, or transition goals and thus better captures the social and medical transition realities of trans individuals reflected in the findings of current research [3
The ITPS is a continuous value between 0–100% calculated for each participant, based on the number of treatments participants indicated they had completed divided by the number of treatments they still have planned [21
]. It must be acknowledged that the transition end-point is potentially changing in nature when it is individually determined in this way; individuals may desire to undergo another treatment at a later date, thus changing their original ITPS value. The ITPS is also of interest for the investigation of patient satisfaction with transition-related care asresults of other studies have determined that transition progress, when measured by the ITPS, explained a significant amount of variance in quality of life and mental health outcomes in trans individuals [24
Research on patient satisfaction with other treatments may not generalize to trans individuals, and the few studies investigating satisfaction with transition-related care [35
] did not analyze differences in satisfaction throughout the transition process or based on gender identity. As changing treatment approaches cast uncertainty onto patient satisfaction with decision-making, psychotherapy, and aftercare, this study aims to use a more appropriate research tool, namely the ITPS, to close the gap in research on trans patient satisfaction with treatment by answering the following questions:
1.1. How Does Sex Assigned at Birth and Gender Binarity Influence Trans Individuals’Desire to Participate in Decision-Making, Psychotherapy, and Aftercare?
Trans individuals of different genders often undergo different types of transition treatments, due to the types of procedures available based on their sex assigned at birth [3
] or experiences of gender and/or dysphoria [21
], for example. Furthermore, trans individualsface various types of discrimination, which is often gender identity-specific [30
], resulting in various levels of psychological well-being among trans individuals of certain identities [55
]. These aspects may influence the way trans individuals of different gender identities (mentally) approach transitioning as well as their treatment needs, and it is thus assumed that there is a statistically significant difference in desires to participate in decision-making, psychotherapy, and aftercare between trans individuals of different gender identities (i.e., NBGQ vs. binary, AMAB vs. AFAB).
1.2. How Do Trans Individuals Differ in Their Desire to Participate in Decision-Making, Psychotherapy, and Aftercare at Different Stages in Their Transition, as Measured by the ITPS?
Research has shown that trans individuals’ affective and cognitive states change during the transition process. For example, trans individuals face the highest risk for mental health issues before treatment has begun [1
], while improvements in psychopathological symptoms [43
] and quality of life [57
] are found towards the end of transition. Furthermore, trans individuals often have negative experiences accessing (trans) healthcare, leading to expectations of future discrimination by health professionals and forgoing care [22
]. It is thus assumed that trans individuals in the early stages of transition, with potentially poorer mental health and fewer previous healthcare experiences on which to base their desires, statistically significantly differ in their desire to participate in decision-making, psychotherapy, and aftercare compared with trans individuals in later transition stages. Furthermore, it is assumed that trans individuals with no treatment experience, who have may have the poorest mental health and have treatment expectations which may not fully match reality due to lack of healthcare experiences [59
], differ in their desires compared with individuals with treatment experience.
3.1. Descriptive Results
Scores for the variable ‘desire to participate in decision-making’ were negatively skewed in the sample (n = 414), with a mean score of 8.58 (SD = 4.45, 95% CI (8.15, 9.01)) from a range of possible scores from −6 to 15. Scores for the variable ‘desire for aftercare’ were similarly negatively skewed in the sample (n = 407). The mean ‘desire for aftercare’ score was 4.30 (SD = 1.26, 95% CI (4.18, 4.42)) from a range of 1 to 6). Regarding response frequencies (n = 414) for the variable ‘desire for psychotherapy’, 311 participants (75.1%) answered ‘yes’, indicating they would find it helpful to receive psychotherapy during transition, while 58 participants (14.0%) answered ‘no’, and 45 (10.9%) did not want to/could not answer the question. These results indicate participants highly desired participation in decision-making processes, psychotherapy, and aftercare.
3.2. Inferential Results
Results of the Kruskal–Wallis H test determined that there were statistically significant differences in scores for the total sample and the AMAB participants for the variable ‘desire to participate in decision-making’ (see Table 1
). Subsequent post hoc analysis revealed statistically significant differences between the 0% ITPS and 51–100% ITPS groups for both the total sample and AMAB participants (see Table 2
These results indicate that for both the total sample, as well as the AMAB participants, individuals with no treatment experience (ITPS of 0%) desired significantly less involvement in decision-making processes (i.e., approve of healthcare professionals having more say in decisions) during their transition than individuals in the later stages of transition.
Since the 0% ITPS group only differed from the 51–100% ITPS group in this desire, the results only partially confirm the assumption in the second research question, which suggested trans individuals in the three transition stages would significantly differ from each other in their treatment desires. Furthermore, the fact that only the results of the AMAB participants remained statistically significant once the analysis was applied to different gender identities indicates that for all other identities, sex assigned at birth influenced participants’ need for involvement in decision-making processes and not just their stage in transition. Thus, the assumption in the first research question, which stated trans individuals of different gender identities would have different treatment desires, is also supported.
Results of the Kruskal–Wallis H test determined that there were statistically significant differences in scores for the total sample and the binary participants for the variable ‘desire for aftercare’ (See Table 3
). Subsequent post hoc analysis revealed statistically significant differences between the 0% ITPS and 51–100% ITPS groups for the total sample and binary participants (See Table 2
These results indicated that for the total sample and the binary participants, individuals with no treatment experience (ITPS of 0%) had a significantly stronger desire for aftercare than individuals only in the later stages of transition (ITPS between 51–100%).
Since the 0% ITPS group only differed from the 51–100% ITPS group in this desire, these results again only partially confirm the assumption of research question 2, which suggested trans individuals in all three treatment stages would significantly differ from one another in their treatment desires. Furthermore, the fact that only the results of the binary participants remained statistically significant once the analysis was applied to different gender identities indicates that for all other identities, gender binarity and not just stage in transition influenced participants’ desire for aftercare. Thus, the first assumption, which stated that trans individuals of different gender identities would have different treatment desires, is once again supported.
Results of the Fisher’s exact test determined that only the two groups of NBGQ AMAB participants statistically significantly differed in their desire for psychotherapy. Of the NBGQ AMAB participants who responded ‘yes’, indicating they find psychotherapy during transition helpful, 11 (84.6%) had an ITPS under 50%, while only two (15.5%) had an ITPS over 50%. By contrast, of participants who responded ‘no’, indicating psychotherapy is not helpful, only three (30%) has an ITPS under 50%, while seven (70%) had an ITPS over 50% (see Table 4
These results indicated that being in the early stages of transition (i.e., having an ITPS under 50%) is associated with greater desire for psychotherapy, while being in the later stages (i.e., ITPS over 50%) is associated with greater disapproval of psychotherapy, supporting the assumption made in research question 2. Additionally, the fact that only the results of the NBGQ AMAB participants were statistically significant indicates that for all other identities, sex assigned at birth and gender binarity influenced participants’ desire for psychotherapy. This finding supports the first assumption, which stated trans individuals of different gender identities would have different treatment desires.