3.4. Moderating Factors

Two groups of factors moderating the relationship between stressors, coping strategies and psychosocial outcomes were identified, namely, experienced support and emotional (coping) traits. Emotional traits which were considered to moderate adaptive coping strategies and improve psychosocial outcomes included resilience, optimism, flexibility (the willingness to change or compromise according to the situation), and openness. Most the participants reporting such traits described themselves as happy and content with the physical and mental changes experienced during/after transition. Optimism and flexibility seemed to help some participants to overcome stressors more easily, and also seemed to help to create a more positive outlook on the future. Openness supported participants in seeking help and prevented social isolation. Participants who showed resilience often reported stamina in overcoming stressors and were quicker to recover from setbacks. With regard to resilience, one participant indicated:

“I went all-in with the transition and accepted everything: the ups and the downs. I just know that, even during the darkest times, you will always climb up again to see the light. Hard times will make you stronger.”—Participant 01, male, age 52.

Additionally, multiple negative emotional traits were identified, including anger, pessimism, and fear. These traits were seen alongside maladaptive coping strategies and poorer psychosocial outcomes such as disappointment and lack of acceptance. Participants who reported pessimism and fear also frequently reported depressive feelings, anxiety, and anger. Individuals who showed a tendency to react with anger, regardless of the stressor, were often less satisfied with the results.

In addition, experiences of support seemed to moderate participants’ tendency to use either adaptive or maladaptive coping strategies. On one side, participants who experienced social support often felt accepted and consequently used more adaptive coping strategies such as self-acceptance and seeking help. In contrast, in the absence of social support participants leaned towards maladaptive strategies such as isolation and lower levels of experienced self-acceptance.

3.5. Adaptive Coping StrategiesSix adaptive coping strategies were identified, of which some were subdivided into mini themes. Participants described that using adaptive coping strategies enabled greater well-being and positive emotions during and after transitioning. Two types of coping strategies were identified: cognitive and behavioral strategies. Table 3 shows all adaptive coping strategies, structured by major, minor, and mini themes.

The following three cognitive coping strategies were reported by participants: acceptance; adaptive cognitions concerning gender and transition; and rationalization. The most frequently mentioned adaptive strategy was acceptance (119 quotes). This strategy was used to cope with different stressors, such as accepting one’s (transgender) identity, disappointing results, or one’s appearance. Specifically, participants described acceptance as being helpful in feeling more positive emotions regarding the aforementioned subjects. When participants reported acceptance, for example of one’s appearance, even the parts that were not in line with the individual’s gender identity (ideals), they also reported feelings of satisfaction, perceived control and self-assurance. One participant described the effect of accepting feelings of gender incongruence as:

“Emotionally, I am very stable now. I think that is because I accepted my male sides as well as my female sides.”—Participant 08, female, age 56.

A second, frequently mentioned cognitive strategy included having adaptive cognitions concerning one’s gender and transition. This strategy was used to cope with feelings of incongruence and the individual’s body post- gender-affirming treatment(s). The use of adaptive cognitions meant that participants dismissed stereotypical images of gendered appearance and roles. For many participants this decreased negative emotions that one may have felt if they did not fit perfectly within one of these images.

Rationalization, defined as the effort to explain or justify stressors with logical reasoning [21], was also used to cope with stressors such as a lack of acceptance by friends and family, or social stigmatization. Participants used rationalization as an attempt to understand the environment, as well as themselves (self-knowledge). Rationalization helped to put negative opinions and comments into context and, as a result, helped to relieve emotional distress. One participant describes how rationalizing helps her understand her father’s response to her wish to transition, and thereby helps to accept his point of:

“My dad still asks me why I want to be a girl. But I get it, he is 87 and has called me by my former name my entire life. I get why he still calls me that, it does not bother me. He just doesn’t really get it, that some men want to be women, you know.”—Participant 09, transgender, age 58.

Participants described three types of adaptive coping behavior strategies: seeking help and guidance; taking autonomy during transition; and problem solving. Seeking help and guidance with others was frequently used to cope with feelings of loneliness and isolation and helped to alleviate said feelings. Several participants sought help by actively looking for fellow transgender individuals, seeking out friends or creating an online support system. One participant said, after meeting up with a transgender-support group:

“It was a relief to realize that I am not alone. I’m not insane, I’m not a freak. It is good to know that there are others like me.”—Participant 10, female, age 21.

Additionally, some participants explained that in being autonomous during the transition it enabled the individual to feel more in control and self-assured, especially regarding the transition process. Specifically, individuals described taking non-medical steps to support transition, including physical (e.g., wearing chest binders) or social steps (e.g., dressing in line with the identified gender when going out). While also experimenting with gender and feeling more in control in the process, participants described that it was such behavior that enabled them to start transitioning while waiting for medical care. For example, one participant described that using non-medical interventions made her feel more gender-congruent:

“I made a tight band with a sock so I could bind the penis tightly to the back. When you wear pants, you cannot see a bump. I felt more like myself.”—Participant 11, female, age 28.

Lastly, participants described, generally, that problem-solving skills helped them to cope with stressors throughout the transitioning process. By actively problem solving, stressors could be resolved before they became intolerable, and thus, negative emotions or repercussions could be prevented. Sometimes problem solving was used to prevent undesirable situations from happening (e.g., by actively approaching people). Some participants described taking the initiative to explain their situation or feelings which, as a result, led them to feel more self-assured and understood. One participant discussed how he and his partner talked about the ways in which they could have intercourse in a way they both enjoyed:

“My partner and I discussed it beforehand, so there would be no unpleasant surprises. We talked about what she would like and what I would like and what we could do to make it pleasant for both of us. We talked about it for a long time until we both felt good about it.”—Participant 12, male/transgender male, age 18.

3.6. Maladaptive Coping StrategiesA total of seven maladaptive coping strategies were identified in response to experienced stressors, of which some were subdivided into mini themes. Table 4 shows all maladaptive coping strategies.

In contrast to adaptive coping, maladaptive coping strategies often led to negative emotions, decreased self-worth and less favorable future perspectives. Like the adaptive strategies, cognitive and behavioral coping styles were identified.

The cognitive maladaptive coping styles were subdivided into four main strategies: lack of self-acceptance, maladaptive cognitions concerning gender and transition, external validation of self-esteem, and externalization. It was common for participants to talk about the difficulty they had with accepting themselves, which led to stress, and negative or depressive feelings. Some struggled to accept being transgender, which, at times was due to internalized transphobia or shame. Other participants had difficulty accepting the gender non-conforming parts of their appearance as they wanted to fit into a stereotypical gendered ideal. One participant talked about his lack of self-acceptance:

“I can hardly look at myself in the mirror. When I’m naked, my confidence is almost zero.”—Participant 12, male/transgender male, age 18.

Participants frequently mentioned having maladaptive cognitions concerning gender and transition, which included having stereotypical images of men/women, focusing on gender-incongruent characteristics and experiencing internalized transphobia. When participants were mainly focused on gender-incongruent characteristics they were not easily satisfied with the results of the treatments, leading to increased chances of reporting negative emotions, discomfort and/or requesting re-operations and surgical corrections. This mostly applied to (but was not necessarily limited to) gendered body characteristics such as breasts, curves of the body and facial hair. When participants focused especially on gendered characteristics or had high expectations, extra operations or treatments were often sought. In some, gendered physical ideals were stereotypical and the variation in physical characteristics within cisgender individuals was often dismissed. One participant said:

“I was not very happy with the results, that was difficult. The form and outline of my face was too feminine. I still had boob tissue, and the skin was loose. So, I went back to have another operation to make it look more masculine.”—Participant 07, male/transgender male, age 27.

Thoughts that reflect internalized transphobia were also repeatedly observed. Some participants described internalized negative attitudes towards other transgender individuals in general, and/or towards being transgender themselves. This included internalized disapproval towards transgender individuals, uneasiness with disclosing one’s identity to others and discomfort with being compared to other transgender individuals. Internalized transphobia sometimes led to internal conflicts, lowered levels of self-respect, difficulty accepting being transgender and sometimes depressive feelings. One participant indicated:

“I feel very negatively towards being transgender. I am always afraid that other people notice it and talk about me. If I could make one wish, I would wish that I was not transgender. Then I wouldn’t have all the problems in my life, and I would be able to live normally.”—Participant 11, female, age 28.

External validation of self-esteem was sometimes reported in relation to feeling self-assured, more specifically in the validation of gender-related esteem. In this case, confirmation was sought in friends, family, and strangers to feel assured about gender-typical characteristics, and made participants feel more self-assured. However, when not validated, participants felt more self-conscious and anxious. For example, one participant described her levels of self-esteem and consciousness as being dependent on being correctly or incorrectly gendered:

“I am always aware of other people’s reaction to me. How they look at me and what they think of me. […] The other day, I heard someone ask: is that a man or a woman? That bothered me a lot. Immediately, I wondered what I had done to be viewed masculine. Did I walk too fast or look irritated or behave odd?”—Participant 03, female, age 52.

The last cognitive strategy identified was externalization. Some participants used this strategy to alleviate the emotional pressure of feeling different by attributing negative situations to others. This happened most often when participants still struggled with (gendered) norms and found it difficult to get past these norms:

“Sometimes I think that I’m not the problem, the rest of the world is. They are all confused because I am confused about my gender. But who is really the problem? Not me!”—Participant 13, male, age 40.

Participants indicated the use of several types of maladaptive behaviors to cope with stressors. Three behavioral strategies were identified: isolation, avoidance, and self-destructive behavior. It was common for participants to socially isolate themselves for longer or shorter periods, to avoid confrontation and possible rejection. A variety of isolation methods were described, including social isolation, emotional isolation, and non-communication. Isolation could lead to feelings of rejection and loneliness and increased the risk of depressive feelings. One participant explained:

“Isolation is the real problem when you grow up with gender incongruence. You can never live up to the expectations, so you always feel like you must hide a part of yourself. You feel like you are alone in the world. I still isolate myself when I feel bad.”—Participant 14, male/transgender male, age 62.

In addition, avoidance, in any form, was frequently described. To some, avoidant behavior was an unconscious effort to alleviate feelings of being different and feeling rejected. Frequently, social situations were avoided in order to evade possible negative reactions or stigmatization. In general, avoidance and the unwillingness to seek and accept help when appropriate often led to maintaining negative feelings and behaviors towards both oneself and the other, thereby making participants more vulnerable to a decrease in psychosocial wellbeing. One participant stated:

“Transgender individuals do not often ask for help. We are just used to doing everything alone, that’s a hard habit to break. I always tried to solve everything by myself.”—Participant 14, male/transgender male, age 62.

Finally, self-destructive behavior was used to avoid negative emotions that were linked to the former gender identity. Feelings of low self-esteem or even self-loathing could trigger self-destructive behaviors such as alcohol and/or substance abuse. One participant talks about his substance abuse:

“I was stoned for a very long time, almost 20 years. I tried to dull a lot of pain and suffering by smoking weed.”—Participant 13, male, age 40.