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cultivating a positive transgender identity promotes mental health. When describing intrapersonal or individual-level factors that promoted mental health, participants referred to experiencing the benefits associated with actions or experiences that contributed to gender identity affirmation such as taking steps to affirm and express gender and

gender was spoken about by all transgender participants as promoting their mental health as well as the mental health of other transgender people that they know of. Alternatively, at the time of interview not all transgender participants had developed a positive and robust view of their transgender identity, yet for those who had and in line with observations from practitioners, it appeared to have a strong influence on self-worth, - esteem, and mental health. In this section, I will first present and explore the health promoting benefits associated with taking actions to affirm and express one’s gender, followed by an exploration of the benefits

associated with developing a positive transgender identity.

5.3.2.1. Taking actions to affirm and express gender identity. As mentioned, transgender participants unanimously described taking steps to socially, psychologically, emotionally, physically, and sexually affirm their gender as important and beneficial to their mental health in various ways. Participants described the desire to “transition” gender as important and prevalent among the transgender people that they know and taking hormone therapy as the most commonly talked about action for physical gender affirmation. Notably, participants varied in their views on surgical affirmation procedures, a trend that was reported anecdotally as “becoming more common in the transgender community”. Taking steps to physically affirm and align one’s body with their internal gender identity provided a variety of benefits including physical,

psychological, emotional, and sexual affirmation of gender identity, as well as positive flow on effects on interpersonal functioning and relationships. Typical comments included:

“Simply going down the track of taking oestrogen, psychologically, has probably been the best thing that [has] ever happened to me. [It has been] Incredibly helpful, I think for me more psychologically than

physically. I like feeling a bit zen’d, I like not being as angsty, I like being able to deal with my buttons being pushed without being all ‘blokey’ and wanting to deal with it physically; [rather], dealing with it in a pretty measured manner and coming around to a resolution or an agreement that we need to agree to disagree.” (Lauren)

“Hormones are hugely helpful and that seems to be a pretty universal experience from the other trans people that I’ve spoken to. I’ve found that because they don’t just affect your body, which obviously happens over time, but they also affect your mood. I’ve felt a great deal more

comfortable in myself almost immediately. It is funny because the trans men that I know have reported exactly the same sort of experience, I mean there are a couple of aspects where trans women and trans men seem to be directly opposed, you know things like level of sex drive and that sort of thing. But, we all seem to be more relaxed and we all seem to be happier and whether that is purely hormonal, or whether it’s because we are doing a thing that gives us agency over ourselves in that respect, I don’t know, but yeah nobody seems to be complaining about hormones.” (Indra)

Reflecting on Lauren’s experience, it was evident that taking oestrogen has had a positive impact on her mood and ability to regulate her emotions, particularly when dealing with challenging interpersonal interactions. This has provided psychological affirmation of her gender (as a woman) and self (as a well- functioning person), allowing her to interact

with people in a manner that is commensurate with her concept of self, and positively impacting her self-image, relationships, and mental health. The emotional and physical benefits associated with taking hormones were confirmed by Indra who attributed a component of the psychological benefits to an action of personal agency. This is an important finding given that the health system in Australia is set up in ways that limit, constrain, and disempower transgender people (see section 5.1.2.1).

When reflecting on the impact of hormone therapy on many

transgender people, nearly all of the practitioners focused primarily on the mental health compromising effects such as increased emotional reactivity and lability. This is likely due to the role of practitioners in supporting people who are distressed, assessing risk, and providing opinions on readiness for medical procedures. However, some transgender

participants described having increased access to emotions and broader range of emotional experiences as providing a valuable source of

emotional gender affirmation and “cathartic relief” for self and others that they know.

“Yes, I had enormous emotional lability and I was crying a lot, an awful lot, and some times that was difficult, and other times it was really good. I suddenly had access to my emotions in a way that I never had before in my life.” (Indra)

For Indra, the action of crying and having access to a broader range of emotional experiences brought her more in line with her female identity and allowed her to overcome the limitations she had long

emotions in a particular way. In instances such as these, the tendency for some practitioners to focus on the potentially mental health compromising effects of emotional lability contrasted with the lived experience of

increased access to emotions and range of emotional experiences felt by some transgender people. It is important to note that the perspective of trans men is notably absent from this finding and anecdotal and literature reports indicate that anger may be a more prevalent, and potentially more difficult to manage, emotion for trans-men. Nevertheless, this finding is worthy of consideration and attention as maintaining a primary clinical focus on risk aversion or avoidance (over careful monitoring and emotional support) may prevent some transgender people from experiencing this broader emotional and affirmative experience.

As previously mentioned, variability existed in relation to desire for surgery. Some male-identified participants expressed desire to “get rid of” their natal female characteristics such as breasts and reproductive organs in order to achieve physical gender affirmation and a sense of

congruence. However, one participant expressed that if he lived in a society where it was acceptable to be male and have breasts then he would “probably not” have surgery. This supports the notion that

preferences or behaviours that appear to be individual or psychological are often influenced by broader systemic factors. Such that, rigid and binary gender rules preclude an individual from living comfortably in their body without surgically removing particular body parts that do not conform with binary notions of sex and gender. Nevertheless, for others who

their genitalia, having surgery provided an important source of physical and sexual affirmation and alleviated distress associated with feeling alienated from own body (see section 5.3.1.2), as highlighted in the following quote:

“[Having my penis removed] was an aspect of physical dissonance that suddenly resolved for me as my physical dysphoria did centre on my genitals, so resolving that made an enormous difference to me.. It is something that you get reminded of several times a day, there is no escaping it. Even now more than two years after surgery, I still regularly have experiences of ‘ohh so I just pull up my underwear, there’s no tucking, getting bits out of the way, I haven’t been reminded of it’, and it’s a little pervasive, it happens, as I say a number of times a day. That has become a positive thing instead of it being a [negative] thing, a several times a day, ‘grrrr and I take this part of my body and grrrr [I tuck it here]’. It is a constant source of affirmation for me and it makes an enormous difference to me sexually as well. It was very much a sudden ‘ohh this is how that’s meant to work and this is amazing, wowwwww, ok I did the right thing.’ [It is] incredibly, incredibly affirming. So yeah for all of the shortcomings of surgery, because obviously it’s not perfect, and there are aspects to the outcomes of surgery for me in particular that I wasn’t happy with. It was a far from ideal outcome, but I still think that I made the right decision.”

5.3.2.2. Cultivating a positive transgender identity. The second intrapersonal factor that promoted mental health related to cultivating a positive identity as a transgender person. As described in the literature (see Chapter Two), this may be an important antidote to the multitude of

negative and stigmatizing views associated with being transgender that are internalized and impact on sense of self and mental health (Riggle et al., 2011). Some participants identified a variety of benefits and positives associated with being transgender including gaining a unique perspective into the experiences and perspectives of both primary genders, increasing personal growth and resilience, promoting self-esteem, improving

interpersonal relationships, and connecting with and being accepted by the LGBT community. A number of these positive identity factors can be viewed in the following quote:

“Being ‘trans’ is a significant part of my identity. I mean ask me in 10 years [whether I still want to identify as ‘trans’ or simply as a ‘woman’] and I may have a different response but at the moment it feels very very much a part of my identity. That’s actually something that I’m good [comfortable] with; before I started [gender] transition, apart from the fact that I was not a man and I thought I really was a woman and transitioning would give me that, I didn’t really see much in the way of a positive of transitioning, it was all scary and negative. I didn’t find out the good stuff and the unique stuff about being trans until after I had done it. So there are positive aspects, such as the fact that I have experienced living in the world as both a man and a woman and that plurality of viewpoints is incredibly revealing and interesting. I see things that nobody else does because both genders have blind spots, because both genders have had conversations that the other gender never gets to participate in. They have blind spots that never get filled in and so [I feel that] it is the cultural equivalent of stereoscopic vision, you actually see so much more having had those two viewpoints. I have learnt so much not just about myself but

about the world around me, and the world around me is an infinitely more interesting place now that I’ve done this. It is an incredibly rich

experience.”(Indra)

These findings are in-line with those reported in another qualitative study on transgender identity affirmation (Riggle et al., 2011), which similarly indicated that being transgender provided a unique perspective on the world and was associated with personal growth for many. These sources of identity affirmation may contribute to a broader and more positive sense of self, as someone who has unique talents and is worthy of acceptance and respect, thereby buffering the impact of stigma and promoting mental health.