Have we underestimated the possibility of cultural differences affecting prescription of hormone treatment for individuals with gender dysphoria?

To the Editor

Although cross-sex hormone treatment (HT) has been widely used, data on long-term side effects and ideal HT formulations remain limited. In recent years, HT prescription timing has gained more importance. For example, delaying puberty for a girl with gender dysphoria (GD) may help increase height, building positive body image and self-perception. However, some specialists hesitate before prescribing HT, despite growing consensus that HT could be an appropriate intervention for youth with GD (Milrod, 2014). Additionally, cultural differences might have underestimated influences on HT prescriptions. We present a case with HT delay possibly caused by long-standing stigma of seemingly unorthodox HT for individuals with GD and show how cultural differences influenced decision-making on HT.

Mr F, a 20-year-old Asian man with male-to-female (MtF) GD, far taller than average and large-framed, was transferred from another hospital with transgender healthcare program to our hospital for one major reason: a second opinion on HT due to concerns about limited response based on the client’s positive masculinity. According to the World Professional Association for Transgender Health, 7th version (Coleman et al., 2011), there are no contraindications for HT receipt. Therefore, we prescribed HT and continued to help the client with psychosocial problems. One year after prescription, the client was living in a female role and appeared sure of ‘herself’. ‘Why did we not try HT earlier?’ the client asked.

The client greatly benefited from HT to relieve the distress caused by growing masculinity. Therefore, the timing of HT prescription is worth a rethink. The reasons for the client’s immediate need for HT and the postponement of HT may have been the same—the client’s typically masculine body. The client and the first hospital team seemed to have been trapped in a dilemma by cognitive appraisal of body image deeply influenced by the cultural context. Therefore, cultural differences and their influences on body image may explain the first team’s hesitation to prescribe HT. Few reports have explored such impact of cultural differences on decision-making in HT prescription in GD. An epidemiological study in Japan indicated the timing of HT in MtF individuals was earlier than female-to-male (FtM) individuals, which may strengthen our argument in the case report (Nakatsuka, 2011).

In conclusion, the importance of earlier HT use in MtF individuals might be underestimated, especially in Eastern cultures. Therefore, specialists involved in transgender healthcare should be aware of the role of cultural differences in decision-making and timing for HT prescription.