Making decisions about hormone replacement therapy for transgender and gender diverse youth in clinical settings in Singapore: a qualitative study

Objective: The objective of this study is to explore how clinical decision-making regarding hormone replacement therapy (HRT) for transgender and gender diverse (TGD) youth takes shape within clinical encounters involving healthcare providers, TGD youth, and their parents.Methods We conducted semi structured in-depth interviews with 13 healthcare providers, 13 TGD youths and four parents and analyzed the data thematically.Results Two themes were developed. The first theme was laying the groundwork. This formed the starting point for decision-making in the clinical encounter. Here, family’s initial request for HRT and the healthcare provider’s identification of appropriate options was bridged. The second theme was shaping the final decision. This reflected the endpoint of the clinical encounter. Here, healthcare providers endorsed or delayed the request for HRT through multiple considerations that are not considered in sequential steps in a decision-making pathway and are revisited repeatedly across multiple encounters.Discussion The decision to endorse or delay HRT is not just shaped by considerations of distress and parental consent. It is contingent on healthcare providers’ interpretations of coping, maturity, parental support and future social functioning. Different healthcare providers weigh these considerations differently. However, it is unclear how precise weights are assigned to these considerations. Findings show that coping may sometimes serve as an implicit rationale to delay treatment reflecting ambiguity in how distress and impairment are interpreted in local practice. In addition, the emphasis placed on the need for parental support beyond consent may reflect sociocultural expectations around family.