Always Already Geopolitical: Trans Health Care and Global Tactical Technical Communication

Abstract

Transgender persons face many barriers preventing them from accessing and receiving health care. Gender-transition care can be difficult because such care is frequently contingent upon geopolitics, such as location-based health-care policies that exclude transgender community attitudes and values. This article uses rhetorical cluster analysis to explore the combining two conceptual lenses—tactical technical communication and participatory localization—to study the do-it-yourself geopolitical medical literacies of transgender people in one Reddit forum. We found being trans online means to be tactical and geopolitical, encountering and negotiating geopolitical awareness of health-care options, exposing a privilege invisible to cisgender users.

Keywords

culture care health medical international intercultural global

Introduction

Transgender persons face many barriers preventing them from accessing and receiving health care. Gender-transition care can be particularly difficult because such care is frequently contingent upon geopolitics, such as location-based health-care policies that are produced to specifically exclude transgender community attitudes and values. As a result, we argue that theorizing transgender health literacy requires attention to the forms of geopolitical knowledges that enable transgender individuals to negotiate these exclusions.

This article explores the relevance of combining two distinct conceptual lenses—tactical technical communication (TC) and participatory localization—to study the do-it-yourself (DIY) geopolitical medical literacies of transgender people in the Reddit forum Trans Self-Med. We conclude that transgender geopolitical experiences are unique but can also shed light on the need to study health-care communication from a geopolitical and DIY standpoint in any marginalized community. Such an examination helps expand our understanding of health and medical communication in international contexts by demonstrating the geopolitical nature of transgender health care broadly, exposing a privilege invisible to cisgender users and, perhaps, to those who are able to transition within sanctioned, institutional spaces.

Health Care and Global Tactical TC in Online Trans-DIY Forums

“DIY” has been synonymous with the Internet because it enabled individuals to form their own knowledge communities outside of institutional or expert spaces. Of particular ethical relevance is the use of online DIY forums by marginalized communities. As a case in point, in the United States and around the world, transgender (trans) individuals have had and continue to face many barriers preventing them from accessing and receiving health care. Trans¹ people face considerable institutional obstacles such as laws governing insurance coverage, doctors’ ideological discomfort around trans care, psychiatric screening, and, perhaps most prominent, a lack of medical literacy on the part of the health-care provider, even when services are available.

Gender-transition care can be particularly difficult to access because such care is contingent upon geopolitics: location-based health-care policies produced with regard to specific community attitudes and values, some of which are ignorant of or even hostile to trans experiences. As a result, access to gender-transition care necessitates travel, relocation, or otherwise accessing locations where the local politics of health care are more sympathetic or infrastructurally supportive. For example, in the United States, some states have laws protecting trans people from insurance discrimination, but others do not (Health Care Action Center, n.d.) A growing number of trans individuals therefore create and rely upon extrainstitutional or unsanctioned health-care options in DIY online spaces, ranging from general advice about health-care practitioners to instructions on hormone self-administration or self-monitoring.

With the advent of Internet markets and online communities, hormone replacement therapy (HRT) is more available than ever. Many trans individuals now participate in online communities that identify with their health-care challenges, an identification that may not occur in their “physical” location. When trans individuals use networked spaces of sharing medical knowledge across national borders through official and unofficial DIY medical documentation genres, they can do so because of decentralized platforms with little to no barriers to user participation.

These forms of literacy contribute to two research area interests:

TC research interested in social justice and queer theory and

Overlapping TC research in the rhetoric of health and medicine (RHM), which includes patient–doctor literacy negotiation (Bellwoar, 2012) and studies of patient agency through digital media (Freeman & Spyridakis, 2004; Holladay, 2017; Katz & Moyer, 2004).

To contribute to this body of work, this article explores geopolitics and DIY medical literacy formation in Reddit’s Trans Self-Med user forum (anonymized for this article), which is one of the more popular public trans communities on the Internet. We argue what is unique about these forms of geopolitically aware trans DIY literacy is that they are primarily—if not exclusively—a form of what Kimball (2006) called “tactical technical communication” (tactical TC) p. 74. Further, uses of tactical TC in Reddit’s Trans Self-Med community require a specific focus on what Agboka (2013) identified as “participatory localization”: studying social justice through international contexts by engaging local differences in communication knowledges. As a space primarily created to support tactical TC, Reddit’s Trans Self-Med requires attention to the particular geopolitical configurations of a given trans user’s singular health-care needs.

In the following sections, we bring tactical TC and participatory localization together, expanding understanding of international health communication in several ways. First, understanding Trans Self-Med as tactical TC calls for attending more directly to user-generated, informal literacy genres. Second, it reveals a need to explore the geopolitical dimensions of tactical TC. When looking at how geopolitical barriers force trans individuals to create their own DIY networks of care, the lens of tactical TC helps us understand these activities not only as enactments of social justice but also as the primary means of communication for many of these individuals. Importantly, it is not enough merely to study documents produced by trans communities (although it is an excellent first step). Rather, tactical TC and participatory localization are starting places that require recognition of the unique social justice performances of trans DIY online medical literacies. We ground this entry through an analysis of Reddit’s Trans Self-Med community, which features a number of user posts related to tactical TC, specifically in the form of advocating DIY HRT at various stages.

Situating Trans Communities in TC and RHM Research

Access to proper medical care is a critical concern for trans individuals and their families (Bauer et al., 2009; Gehi & Arkles, 2007; Wong, 2012), including accessing preventative care and emergency care (Bradford, Reisner, Honnold, & Xavier, 2013; Wong, 2012). In many situations, the primary barrier to care is at the provider–patient level, where a patient’s trans identity can overdetermine the interaction. For example, because of a provider’s personal bias or ignorance, symptoms (even unrelated ones) may be attributed to the patient’s trans identity (Payton, 2015; see also Drabble, Keatley, & Marcelle, 2003). For example, Payton (2015) described several situations where a person’s “trans status is blamed for a person’s unrelated health problems” (para. 12), including migraines attributed to HRT. Similarly, research has linked difficulties to accessing health care at the intersection of patient–provider interaction and social discrimination (Lombardi, 2001). As Lombardi (2001) explains, provider bias and insensitivity are the primary reason patients who are trans do not have access to care (in this case, HIV-related care):

Insensitivity of health care professionals has been cited as a reason that these and other services are not accessed. Indeed, reports of insensitive behavior among health care providers (e.g., referring to transgender women as “he” and “him” and not acknowledging or respecting their identity) suggest that services are severely lacking in terms of provision of culturally sensitive interventions and, potentially, provision of HIV-related health care. Health care service providers have found that helping transgender individuals obtain the services they need … is difficult because other service providers may not want to work with transgender clients. Furthermore, lack of sensitivity on the part of health care providers who do not respect the expressed gender identity of transgender persons can adversely influence whether these individuals will access and stay in treatment. (p. 870)

In addition to accessing general care, some of the most egregious acts of health-care discrimination can be when patients try to access gender-transition care. According to Lambda Legal (n.d.), patients often face misunderstandings that this type of care is “cosmetic, experimental, or simply unnecessary.” In fact, there is overwhelming medical consensus in support of gender-transition care, as noted by a number of professional associations (see Table 1).

Table 1.

Selected Professional Associations Supporting Gender-Transition Care as Medically Necessary.

Medical organization	Statement
The American Academy of Child and Adolescent Psychiatry (2016)	“Transgender youth in juvenile justice and other correctional systems,” 2016
The American Academy of Family Physicians (2012)	“Resolution No. 1004,” 2012
American Academy of Physician Assistants (2000, 2005)	“Ethical conduct for the physician assistant profession,” adopted 2000 and amended 2004, 2006, 2007, and 2008; “Comprehensive health care reform,” adopted 2005 and amended 2010
The American College of Obstetricians and Gynecologists (2011)	“Obstetricians and gynecologists 1454,” 2011
American Medical Association (2008)	“Resolution H-185.950, “Removing financial barriers to care for transgender patients,” 2008
American Psychiatric Association (2012)	“Position statement on access to care for transgender and gender variant individuals,” 2012
American Psychological Association (2008)	“Policy on transgender, gender identity and gender expression non-discrimination,” 2008
American Public Health Association (1999)	“The need for acknowledging transgender[ed] [sic] individuals within research and clinical practice,” 1999
National Association of Social Workers (2008)	“Transgender and gender identity issues policy statement,” 2008
National Commission on Correctional Health Care (2009)	“Position statement: transgender health care in correctional settings,” 2009
World Professional Association for Transgender Health (2008)	“Clarification on medical necessity of treatment, sex reassignment, and insurance coverage in the U.S.A.,” 2008

Each of these organizations has made statements that transition-related health care is medically necessary, is not a cosmetic procedure, and should be covered by insurance. Yet despite the overwhelming medical consensus, trans patients can still face enormous hardship (Bauer et al., 2009; Gehi & Arkles, 2007; O’Hara, 2015; Wong, 2012).

In addition to health, medicine, and legal fields, clinical researchers and public health scholars have also become increasingly aware of and invested in health literacy among trans populations. According to Drabble et al. (2003), “Health communication is an essential element of disease prevention and health promotion efforts” (p. 3). As already recognized in the field of TC (Grabill, 2000), Drabble et al. (2003) noted that the emphasis on communication around HIV/AIDS prevention is important, but broader “practices and strategies” for reaching lesbian, gay, bisexual, transgender, queer/questioning, and other gender and sexual minorities (LGBTQ +) communities have been historically few if not absent (p. 2). Important to Drabble et al.’s (2003) point, discrimination can be location-based. Lombardi (2001) argued that trans persons “living in isolated areas … may have to find other ways to go about their transition” (p. 870).

In recognition of this link between health communication, location, and access, we identify this research as a particularly acute TC and social justice issue. These developments are also being examined in the field of TC, which has increasingly begun to examine issues of health and medical communication. This article is part of a larger project (Edenfield, Colton, & Holmes, in press) committed to social justice issues for trans people and communities. We are still in the early stages of the project, but our larger goals include making a positive impact on the trans communities we are researching, and we see this work as indicative of action research and part of the recent social justice turn in the field. The relationship between TC and health care is likely more familiar to audiences in the former field than to audiences in the latter. As a result, we include in our literature review a brief statement about the field of TC’s interest in health-care literacy in general and social justice in particular.

As the field of TC gained institutional footholds in academia, a number of scholars raised the need to theorize TC writing practices beyond an instrumental activity (Katz, 1992; Miller, 1979, 1989). By now, critiques of instrumental writing such as those aimed at the “plain language” (Turfler, 2015) movement’s hidden cultural ideologies are well established. Parallel types of ethical and political issues apply to how the field has analyzed TC in science and health fields. To offer an example, Segal (2005) demonstrates how metaphors in biomedicine (see also Derkatch & Segal, 2005), such as “medicine is war,” can make medical care seem like a moral imperative as opposed to a neutral client-based transaction. Within this general interest in connecting everyday language choices to ethical and political concerns, “social justice” represents a more recent and specific area of concern for TC.

While the field of TC has been invested in issues of community, inclusivity, and critiques of unjust power disparities for some time,² a more specific “social justice turn” in TC studies began a little more than 5 years ago (see Agboka, 2013; Haas, 2012; Leydens, 2012; Walton & Jones, 2013) and has recently included an effort to articulate a theory of social justice specifically applicable to TC researchers (Colton & Holmes, 2018). Jones and Walton (2018), two scholars whose work has demonstrated a continual commitment to this turn, define social justice research as “investigat[ing] how communication broadly defined can amplify the agency of oppressed people—those who are materially, socially, politically, and/or economically under-resourced” (quoted in Jones, Moore, & Walton, 2016, p. 219). Although still committed to earlier related work in the field (see, e.g., Scott & Longo’s 2006 special issue of Technical Communication Quarterly and Herndl’s 2004 special issue of Journal of Business and Technical Communication), this new social justice research looks to supplement critical description and analysis with action research committed to also producing change.

This kind of social action research (Rude, 2009) has recently manifested itself in many ways: from service learning with community and nonprofit organizations (e.g., Scott, 2008; Youngblood & Mackiewicz, 2013); nonacademic community-based research (e.g., Faber, 2002; Walton, Zraly, & Mugengana, 2015); action/activist research that looks to benefit nonacademic communities (e.g., Clark, 2004; Grabill, 2000); and civic engagement research to improve public awareness of marginalized groups (e.g., Bowdon, 2004; Moore, 2013). Part of this social justice turn in the field of TC obviously includes elements of advocacy (Jones, 2016), and of course, these different types of social justice/social action research often overlap with one another. In addition, a social justice focus in TC extends to greater global contexts, such as Agboka (2013), Sun (2004, 2006), Walton and Hopton (2018), Walton et al. (2015), and Yu (2012).

Nevertheless, at the time of writing, even with this turn to social justice interests, TC has limited research on LGBTQ+ issues to AIDS/HIV research and communication (Bowdon, 2004; Brouwer, 1998; Grabill, 2000), with some recent exceptions (Cox, 2018; Ouellette, 2014). While this work is critical and must continue, a closer look at the intersection of gender, sexuality, and TC shows that trans-specific medical communication and literacy are important research areas and also means to move beyond instrumental acts of communication and to enact social justice and advocacy in research.

Geopoliticizing Tactical TC

One vital area of inquiry lies in connecting a concern with ethical forms of DIY medical literacy to global or transcultural concerns. Because trans individuals are often legally de jure or de facto excluded from legal forms of medical care, they may seek out medical knowledges and procedures in online spaces and, frequently, in other arenas that consider geopolitics. In this section, we want to briefly foreground how one of our conceptual lenses—tactical TC—syncs with intercultural and global forms of TC.

Considering Tactical TC

Tactical TC (Kimball, 2006) is an area of emergent social justice research that seeks to study DIY forms of TC documents. It is generally defined as the ways in which individuals appropriate formal TC genres or instructionally authorized TC documents for their own noninstitutional purposes. Taken from the space and place theorist de Certeau (1984), “tactics” are everyday forms of resistance—explicitly political or not—to dominant strategies of “control.” Control strategies are neither inherently good nor bad. A pedestrian street crossing sign offers a positive form of social control to protect pedestrians, while many citizens in democratic societies would agree that a prohibition against negative newspaper reporting by an authoritarian political regime is socially negative. De Certeau’s (1984) interest in tactics was to locate especially everyday forms of resistance to dominant capitalist norms, such as a factory worker who takes a piece of equipment from work without permission to fashion a piece of furniture for his or her own personal use.

Following Kimball (2006), TC researchers have used the idea of tactical TC to study texts, such as DIY technical manuals that use informal tones and narratives while nevertheless appropriating and recasting certain forms of formal technical manuals. An easy example lies in Muir’s (1969) How to Keep Your Volkswagen Alive manual (cited in Kimball, 2006). This manual is aimed at “weekend warriors” who wished to use bricolage, or the means at hand, to repair their Volkswagen cars without using factory recommended parts or local car repair dealers. Other examples include the hacktivist collective anonymous’ online circulation of DIY soda bottle gas mask creation kits to aid protests against police tear gas in the 2014 Ferguson Missouri protests (Colton, Holmes, & Walwema, 2017).

As we will note in detail later, a great deal of trans writing in online communities resembles tactical TC in that it combines instructions that merge official medical documentation found in hospitals and clinics alongside unofficial knowledge sources. For example, some trans users have produced DIY HRT medical literacy manuals that draw equally on licensed patient care guides found in actual medical clinics, crowdsourced knowledge located in Wikipedia entries, and narratives of personal DIY medical care experience. By comparison, a patient care manual that a surgeon provides a trans patient would never cite Wikipedia as an authoritative source. These DIY medical manuals are tactical in the sense that they resist a dominant strategy of legal, medical, and social control which forces trans individuals to seek out medical literacy and help outside of institutional channels. As a result, importantly, these documents are, therefore, always already geopolitical or, at the very least, brought into existence by geopolitical constraints.

Geopolitical Factors

In the past, TC researchers have examined geopolitical writing practices, including intercultural technical communication (ITC) across pedagogical innovations (Boiarsky, 1995; Bosley, 2001; Goby, 1999; Thrush, 1993; Tippens, 1993) and enactments of locationalization (Hoft, 1995; Hunsinger, 2011; Major & Yoshida, 2007; McCool, 2006; Sun, 2004, 2006, 2009; Thayer & Kolko, 2004; Warren, 2002). Other topics that researchers have explored were cross-cultural collaboration (Bosley, 1993; Starke-Meyerring et al., 2008) and translation processes (Byrne, 2006; Hann, 2004; Maylath, 1997; Sager, 1993; Somers, 1996; Weiss, 1995). A priority within this body of work lies in exploring how culture, usability, discourse, and communication work in non-American settings (see St.Amant, 2017). However, ITC scholarship and the general interest in global communication practices have not always sought to connect these efforts to social justice. For this reason, Agboka (2013) called on the field of TC to produce “more research and scholarship involving specific case studies, research methodological approaches, and analyses of communication practices that intersect with social justice in international contexts” (p.30). He argued that location was a critical area of neglect, such as how TC impacted unenfranchised “third” or “fourth world” nations (Agboka, 2013, p. 30).

To further this global mode of engagement, Agboka (2013) argues for TC researchers to explore community-based research as well as the politics of “participatory localization.” St.Amant, in turn, has provided a framework for doing this in international medical context through the a process he calls international patience experience design—an approach for working with users in different global regions to identify and localize health and medical materials for their specific local and cultural contexts.

One way to extend these concerns and this work lies principally in studying the intercultural dimensions of DIY activist sites such as Reddit’s Trans Self-Med as part of studying what Walton et al. (2015) called the “messiness” of intercultural community-based research. As a case in point, the study of trans populations requires a different point of emphasis for social justice than Agboka (2013) and others’ calls to prioritize the local community. While many can and do, not all marginalized populations benefit from localization. As the following section will make clear, trans patients craft DIY technical documents about health literacy and post geopolitical information about access to care for international audiences. These activities are performed with a clear exigency that there is no access to local health-care support because access to trans-specific care remains illegal or extremely difficult to obtain in many areas of the world, including parts of United States. In other words, we agree with ITC and social justice researchers that location does indeed matter. However, for certain populations, solutions do not present themselves by only examining the local.

A Study of DIY Genres in Reddit’s Trans Self-Med Community

In this section, we demonstrate the utility of tactical TC and participatory localization through an analysis of tactical TC texts found in Reddit’s Trans Self-Med forum. We selected this particular case study for several reasons. First, Trans Self-Med is the most popular English-language public online trans DIY medical transition forums on the Internet. Not all trans forums devoted to medical knowledge sharing are public for a variety of reasons related to privacy and anonymity. Second, Trans Self-Med is a particularly active trans community with a global base of participants of more than 7,000 subscribers since it first started in 2014, representing a global discussion of ideas around DIY gender transition. Users who post inquiries often receive multiple responses within hours of an initial post and new content is frequently posted. In other words, it remains an active site that a community draws on.

Methods

Most important, our reason for focusing on this site is because it demonstrates the need to study trans medical literacy in greater global contexts through the lenses of participatory localization and tactical TC. As posts in Trans Self-Med overwhelmingly confirm, trans individuals across international contexts face a number of strategies of control that ban or render difficult access to gender-transition care. Even if a trans individual can convince an insurance company to cover DIY HRT surgery, for example, locating a willing and knowledgeable doctor for pre- and postsurgical care can be an equally daunting and costly process. The ability to discuss such issues in greater global contexts is important because a great deal of trans experiences and subsequent turn to tactical TC draws on literacies formed across state and national borders.

The complexities of this online global context are manifold. On one hand, this Reddit forum confirms that the local constraints faced by trans individuals are critically important to consider because their experiences and access to personal or institutional resources can vary from city to city, state to state, and country to country. On the other hand, the difficulty in obtaining resources for surgical transition and medical care highlights the need to seek out means of tactical circumvention often across local and national boundaries. In this way, turning to online communities such as Reddit can help to produce a wide variety of tactical TC both tailored to the challenges of local conditions but also connecting these challenges to global tactical means of overcoming them.

In this entry, we offer an analysis of Reddit posts and replies over a 4-year period. This study was conducted with IRB approval (# 8212) from Utah State University. To select posts, we conducted an initial analysis of the top upvoted posts as of June 2018. Upvotes are voting actions that move a comment up or down in a forum; an upvote generally denotes a useful or liked comment, while a downvote means a comment is unhelpful or unwelcome. We specifically looked for user posts and replies that contained references to geography and obtaining medical supplies. These included references to an online provider or a physical location. We looked for these particular posts because we wanted to identify how, where, and why individuals were locating medical supplies and information.

Analysis

To perform this analysis, we used a version of rhetorical cluster criticism (Foss, 2018) informed by cultural studies (Longo, 1998). Such an approach involves the researcher identifying key terms in regard to frequency or intensity. According to Foss (2018), “The term does not have to appear very often” in the selected artifact, but it must be “critical because it is central to the argument” (p. 64). We selected this method of analysis because it allowed us to identify connections and relationships between posts.

In rhetorical cluster criticism, the researcher then looks to find associations between clustering terms (Foss, 2018). For example, if we were looking at tourist sites, mentions of Thailand would not necessarily be associated with surgery, medical laws, transgender rights, and access to health care, but in this context it was. The frequent or intense linkages can reveal rhetorical significance in context in ways that a term might carry little or a very different meaning in context. When we charted associations, we saw multiple posts referring to their location, over and over again.

The artifacts we collected were in the form of these online Reddit posts. From these posts, we generated a list of the most commonly referenced countries, which included Thailand, United Kingdom, Spain, Australia, and the Czech Republic. We then used the Reddit search function to enter these keywords and to refine our search to identify user posts which demonstrated characteristics of both tactical TC and participatory localization. We did not use a formal coding schema because our primary goal was not, for example, to offer a summary of the total number of posts and user comments over a 4-year period. Nor was it to identify a percentage of total posts that fit into tactical TC. Instead, our initial efforts were simply to find general evidence to help demonstrate the utility of the theoretical lens of tactical TC and participatory localization. We selected this focus because it was the most appropriate tool relative to the global and local DIY features that we were perceiving in the case study.

We found that many users in Reddit Trans Self-Med forum not only address geopolitical barriers and complications to health care that trans individuals experience but also seek to overcome those barriers and complications. Such geopolitical knowledge sharing occurs through tactical TC and participatory localization. Types of geopolitical information sharing include tactical instructions on how (a) to access legitimate medication outside of one’s country or residence, (b) to ship or obtain those medications discreetly, and (c) to locate up-to-date records on locating global medical care facilities.

Perhaps key to this geopolitical knowledge sharing is providing this information in a public forum without drawing too much attention to audiences who are hostile to the trans experience. After describing the unique constraints surrounding the goals of Trans Self-Med, we discuss four themes that emerged in our analysis of the site: networked medical literacies, international access to medicine, the risk of DIYing, and the subversion of geopolitical financial constraints through Bitcoin.

Research Site: Reddit’s Trans Self-Med Community

We were drawn to this community because of how it demonstrated multiple overlapping vectors of identity, TC, location, oppression, and self-advocacy. We specifically wanted to know more about how TC could be used to gain access to life-changing care in global contexts. In many ways, the ability to be technical communicators in this space is empowering: to help themselves and to help other people. We were keen to understand how trans people who sought medical transition help through the Internet used TC tools to do so.

Moderated by a user named “mislabeledhuman,”as of May 2018, Trans Self-Med’s home page indicates that it has been a community for 4 years with a readership of more than 5,000 readers. It would be difficult to know the exact number (short of paying for a marketing web traffic report) of monthly visitors. Searching any combination of keywords in a major browser such as “transgender,” “DIY,” and “online forum,” however, invariably places Reddit’s Trans Self-Med forum at the top of Google’s Page Rank algorithm listings. In other words, though it is by no means the only forum where this communication exchange occurs, it is among the most popularly searched (and accessed) public-facing Internet forums for individuals seeking information about DIY trans medical literacy.

As is the case with any Reddit page, Trans Self-Med offers a short description of its forum goals. It states that it is a site devoted to “Unmoderated trans info/questions/etc… .” At the same time, the site is not entirely unmoderated as mislabeledhuman does curate posts. Banned content includes posts that directly seek to purchase or sell HRT hormones, which are distinct from only seeking information about HRT administration. While we will qualify this claim later, Trans Self-Med also claims to “perma-ban” any users who post content about underage individuals who are engaging in treatment practices that would require an adult caregiver’s legal permission.

Other than these restrictions, Trans Self-Med offers an anonymous forum for any user to post questions, receive answers, and share general and very specific medical information. Viewers can readily locate repurposed institutional medical literature on chemical administration taken from university athletic departments alongside full DIY HRT narratives or manuals, such as Mascara and Hope (2013), which is well known in trans online circles.

DIY Instructions for Medical Care and Supplies Across Borders

One major reason Trans Self-Med is important as an area of study for the alignment of social justice and health literacy in global contexts is because it reveals how the question of health literacy and communication is a geographic one for many of its trans users. Even a cursory glance at the Welcome page reveals a website directed at an international user base if an English-speaking one (with respect to Reddit’s standard interface option for translation into numerous languages).

As a case in point, one extrainstitutional medical literacy function which unites many Trans Self-Med users across the globe is sharing information about how users in locations with considerable barriers to HRT can access a variety of global resources. For example, the site’s “Useful links” includes two resources for users who are subject to the National Health Service in the United Kingdom, yet the top three links (All Day Chemist, in-house Pharmacy, and QHII Pharmacy) are not specific to the United Kingdom. In other words, these links can be used to purchase medical supplies by users who reside outside of the geographical boundaries of the United Kingdom. All Day Chemist, for example, is run by the Indian Company (note: This company does not disclose their geographic location on any of their websites). Their website lists shipping to countries such as Australia, China, France, Hong Kong, Japan, Lithuania, Malaysia, Mauritius, Peru, Philippines, Puerto Rico, Russia, Singapore, Spain, Thailand, Ukraine, United Kingdom, United States, and Vietnam.

Beyond these official website links, individual Reddit users also post information seeking to give or receive knowledge about the processes by which chemicals can be shipped across borders or obtained through an in-person visit by a noncitizen. Consider the following post:

Just wanted to let you know there is a shop for estradiol injections in europe. They ship from czech. No problems with the customs so far to germany. I struggled to give you this information… .I’m afraid they go offline like QHI did once I made this public… .Neofollin ships from Czech and can be paid with SEPA for 7€, Bicalutamide is not available (actually it is, but the price on the website is not correct and they will send you the correct one per email after you ordered - it is extremely overpriced). TretinoinTretinoin was shipped from germany. Some products are only shipped from russia.

This comment offers information on a Czech company, Eu Aibolit (http://eu-aibolit.ru/), which seems to ship difficult-to-obtain chemicals across Europe. Yet, this same post confirms that a different chemical, Tretinoim, comes from Germany. User responses to this post spanned 9 days since its initial post on May 21, 2018, were 14. Demonstrating an investment to the community, The original poster responded to each individual comment, giving tactical instructions and clarifying a number of inquiries. For example, one user posted on March 29,

I am kinda desperate to be on injections again. I am confused by this website. I registered and even with a US address, when I go to check out, it says “Medicines in Europe” for shipping and “VAT incl[uded].” Also the only payment option I see is “Payment by bank transfer” but then USD is not a currency option. Any help??? Thank you! Kinda wish they would take Bitcoin.

The original poster responded on the same day, “I would drop them a mail. I would think they convert the euro amount to usd but idk.”

Challenges With Making Tactical TC Public

Analysis of subsequent posts also confirms that users in Trans Self-Med view their efforts in part as maintaining an accurate record of where and how services and products can be obtained. This ongoing record is particularly important because of the transitory nature and legal status of companies who wish to provide such services and products. In relation to this point, Hesychia123’s post is worth examining in greater detail. Hesychia123 communicates reluctance to share this information in an online public forum because they were afraid of the Czech site being subjected to police scrutiny the way that QHI was. While it is easy to valorize the ability of an anonymous network to share information about how to obtain DIY HRT chemicals across borders, disseminating this information poses complications.

The more public information becomes (even if anonymously posted) in response to the desire to communicate accurate medical literacy information, the more that audiences who are hostile to such content can also access it and attempt to shut down the referenced local sites if it is within their power. Obviously, such problems can be mitigated by making the forum private (and there are private forums such as groups on Facebook). However, a private forum means restricting the circulation of DIY medical literacy in comparison with public-facing forums such as Trans Self-Med.

It is also for this type of reason, as some of our subsequent analysis demonstrates, that users in this forum are very good at updating information from around the world to ensure that other users have access to up-to-date and accurate information. A doctor or an online pharmacist available in 2014 may be shut down by 2015 once publicity reaches unsympathetic audiences. In many places in the Trans Self-Med forum, users from various countries help each other understand the muddled information online and gain access to their medication. That is, they form DIY medical literacy through crowdsourced collaboration and negotiation. There are a number of posts such as this one now, where users are scrambling to find legitimate medication that ships to their country, without a prescription:

I believe they get all of their stock from Portugal, where it is legal So it is legal stuff, as far as I know. Also, not sure why they are selling ethinylestradiol, but I wouldn’t take that personally. Stick with the biomedical stuff, much safer.

Here, the location of the online store plays a role in the perceived legitimacy of the medication and the reliability of the store. Users also frequently communicate to one another the dangers of using unreliable off-marker providers and online distributors. In sum, the unique constraints to trans health care that our analysis describes here affect or are affected by the networked character of medical literacies, international access to medicine, the risks of DIYing, and the subversion of geopolitical financial constraints through Bitcoin. What follows engages with those particular issues.

Findings: Medical Literacies Through the Network

The fact that trans users must constantly negotiate between institutional and extrainstitutional health care through a variety of unique constraints and affordances necessitates tactical TC through the use of networks and geographical sites. This situation is perhaps best encapsulated by this user narrative and inquiry, which we quote at length:

I’m taking my transition (MtF) into my own hands and have decided to seriously plan out my DIY HRT… .One thing I know I need to do is get a baseline blood test to establish not just my hormone levels but also liver function, renal, etc. basic health levels. And I know that I can get a blood test privately via places such as Weblabs here. Here’s the problem: Who/How am I going to have somebody interpret the results?… .I’m currently looking at options such as GenderGP, but it’s not clear to me if they have doctors on hand to actually interpret the results? who do have doctors on hand that can interpret blood test results if needed… .And what about followup blood tests to measure hormones? I imagine it would be straight-forward to interpret the results … but what if I’m concerned about something? How would I get healthcare then?

This post is telling with respect to tactical TC and social justice for multiple reasons. First, it confirms the fact that this individual does have access to medical care. However, the individual is frustrated by the limited resources and timeframe. Second, this user is already aware that part of their medical literacy involves the knowledge of other DIY medical literacy sites such as Weblabs in Sweden. However, one specific and critical element remains unanswered: Where can they find results (i.e., get access to TC documents with hormone level information without having to work within an institutional channel)? The user mentions GenderGP, which is a self-described online trans medical clinic.

The wide range of resources is undeniably globally oriented for this reason. The first user comment actually highlights the fact that the online community within Reddit can help the user interpret results as well.

Hormone results are really easy to interpret, reddit can help you with what you need and how to interpret it. For your general health (liver, etc.) you could just go to your regular doctor for a yearly physical. It will have everything you need. It should probably be covered by public health insurance in most of europe.

In other words, Reddit Trans Self-Med offers an active enough crowdsourced medical literacy base to the point where some users are starting to supplement actual institutional medical consultancy with tactical TC.

International Access to Medicine

Across countless posts, Trans Self-Med functions akin to a real-time index of global health-care accessibility. Individual user posts and replies also confirm that international character of literacy negotiation by location and temporality. This 2017 post by a user is fairly typical: “Hi, everyone. It is possible to get hormones in Portugal, over the counter (without a prescription)? Which brands of estrogen are available?” The first reply contains country-specific information: “shesalady.co.uk operates in Portugal and they sell Dermestril and Estrofem.” However, many Trans Self-Med users have enough investment in the site to make efforts to keep replies and original posts updated. Subsequent responses revised the initial post with updated information about the shesalady.co.uk site being taken down. The original poster replied later with a clarification: “Thanks, everyone. My question, however, was whether it was possible to walk into a local pharmacy and buy the hormones without a prescription. Does anyone know?” Users responded again that Spain was one country that allows noncitizens to purchase HRT chemicals without residency or prescriptions.

It is not just location and time that are documented in Trans Self-Med but also the location of specific surgical or medical services that can be obtained. One user posted, “Does anyone know what part of town sells MtF HRT in Bangkok? I have run out of bioidentical Progesterone and Bicalutamide. Every pharmacist I encounter is not familiar with these meds.” We do not know where they are located, such as whether they are a citizen or expatriate living in Thailand or simply a citizen of a country that poses obstacles to obtaining care to the point where travel to Thailand may be the only available option. In any case, it is clear from this post that they expect the Trans Self-Med base to have international DIY medical literacy information.

One user replied to this post, “South East Pharmacy, Utrogestan 100 mg 30 capsules for 390 baht earlier this year. This place has a very good reputation.” The original post illustrates one important function of Trans Self-Med: to offer users an anonymous and safe community in which to post location-specific questions and to receive location-specific information. Multiple users also shared stories and frequently specific names of doctors, including surgeons. Thus, Trans Self-Med provides a combination of references with specific locations, medical devices, and names of doctors with the anonymity. The site enables users to give very specific information to help others without the risk that other public forums might allow. However, obvious risks and ethical questions still remain.

Risks of DIYing

Users sometimes will comment on the risk of DIYing their medication. For example, in one post, a user comments on a post about creating a “homebrew” of injectable medication. Another user responded, “Don’t DIY injections ever, especially if you’re not a medical professional, there’s so much that can go wrong with injections,” to which the original poster responded,

Look, DIY is risky any way. And where will I get I get my E? I’ve got £300 worth o[f] orders ‘floating’ in the mail… .It’s probably gone now. I can get 1 g of cypionate for £127, that’s like … worth some risk.

Another poster also responded to the cautious poster by pointing out the inherent risk in DIY: “You also shouldn’t skydive or drive a car. There’s so much that can go wrong behind the wheel of a car.” Users warn about the dangers of DIY injections (i.e., making an injectable cocktail).

These comments show their awareness of the riskiness involved in all DIYing hormones but that necessity has driven them to this practice, and another comment downplays the risk. Again, Trans Self-Med is not a space where official medical literacy is passed on as authoritatively as a top-down doctor–patient transaction. Both with positive and negative outcomes, Trans Self-Med is instead a space where medical literacies (in the plural) exist, take shape through various forms related to tactical TC including through collective verification processes such as personal anecdotes, argumentative debates, and countless other rhetorical mechanisms.

As a final note, online comments are a technical genre or a form of interface (Gallagher, 2015). They instruct users how to input content for certain posts. Each template is different. In Reddit, the upvoting and downvoting system helps particular communities to privilege helpful or useful posts over others. Of the most upvoted posts of all time in the 4 years since the site has been running (as of December 2018), despite the site’s efforts to ban content about underage trans individuals, it is telling that two of the top posts are about teenagers who self-medicate in secret in an unsupportive home environment. This, of course, raises ethically challenging questions in relation to social justice issues including consideration of the agency of minors, the age of informed consent, and if/where/how institutions should intervene on familial levels.

Subverting Financial Constraints Through Bitcoin

Even a close examination of the top upvoted post is quite instructive as to the global and tactical character of trans care. To be clear, we in no way, shape, or form wish to condone or condemn these activities by an underage user. We are simply recording and documenting them as part of our analysis, which includes understanding how a new aspect—Bitcoin, as this section makes clear—operates to enable global health-care access.

Hi! I’m Alina, a 17 year-old MtF teenager living in a Korean, Christian, Conservative Republican household– basically the final boss of transphobic families–[sic], and I’ve been transitioning in secret for almost a year now.

“Alina” feels forced to use the Internet to seek out both knowledge and medical supplies through noninstitutional means:

I’m writing this guide because I was told that my experience might be helpful to some people, and I guess by this point I know a fair bit about things such as getting medication without an ID or a prescription, buying bitcoin without a card or bank account, hiding clothes, and concealing changes.

Her practices range from having a sympathetic friend to shipping chemicals to concealing one’s appearance, to ordering medication online in “Incognito” mode so that parents don’t find out, and then knowing how to dispose of boxes and wrappers without attracting family attention.

The reference to Bitcoin highlights another common area in which global concerns define many trans DIY patients’ experience. Bitcoins are a global digital currency (and an anonymous one) that work through a blockchain ledger. Bitcoin users clearly do not need to be 18 (the age to access a credit card) and therefore represent an available option for underage users (again, to be clear, we are just reporting on these posts). As Alina describes,

Well, inhousepharmacy (the place from which you will be buying your medication) allows you to circumvent certain checkpoints if you buy the medication with bitcoin. When I first started, I had to do a bunch of research on what bitcoin was and how to get it because it was the only way that allowed me to bypass their ID check.

inhousepharmcy ships to 38 countries, including the United States, but is located in Vanuatu. In Alina’s case, Trans Self-Med functions as a vital space in which DIY international medical literacies are created, negotiated, stored, disseminated, and most importantly revised and updated. In fact, there are 58 posts in Trans Self-Med that reference Bitcoin, all of which are listed in the last year. While debates exist in the public sphere over whether cryptocurrencies improve on traditional cash economies, it is clear that Bitcoin—like the Trans Self-Med forum—has become an important way for trans individuals to negotiate the always already geopolitical nature of trans DIY health literacy.

Conclusion

To be trans online means to be tactical and geopolitical. It means encountering and, often, actively negotiating geopolitical awareness of health-care options, exposing a privilege invisible to cisgender users and, perhaps, to those who are able to transition within sanctioned, institutional spaces. Cisgender patients may only be vaguely aware of their doctors and insurance networks as most routine care is local and largely forgettable, especially in countries with universal or strongly socialized national health-care plans. For cisgender individuals, facing obstacles of cost or distance, such as having to drive or fly from a rural area to a large urban hospital, is not the same as facing legal prohibitions or an absolute lack of services or willing health-care providers within a given state. The gap in what health experts call “health disparities” (Praderio, 2018) between cisgender and trans patients is large, even in U.S. contexts. For example, one doctor in Northern Indiana had 80 patients who drove individually an average of around 2 to 3 hours for care (Praderio, 2018). Not all trans patients who seek chemical transitioning have the access to financial means and permissive state regulation such as “celebrity trans spokesperson” Caitlyn Jenner, for example.

Furthermore, such comments are particularly critical to consider in an era when trans individuals now face the Trump Administration’s Health and Human Services proposal that allows doctors not to treat patients if it violates personal religious beliefs (National Center for Transgender Equality, n.d.). In other words, to be trans and to seek medical literacy in the United States is likely to become even more geopolitical than it already is. As a result, the theories and methodologies researchers and practitioners use to study trans literacy have to be geopolitical in character to account for the various and multiple locations that chemicals are obtained, knowledge is produced and shared, and practices are observed and reported.

While our analysis in this article is aimed at furthering specific areas of inquiry related to trans individuals, DIY literacies, and RHM scholars, the implications potentially extend to the field’s interests more broadly. First, any researchers studying any aspect of trans health care must consider geopolitical factors and, particularly, localization. For example, Edenfield et al. (in press) argued that queering tactical TC means that it is an ethical imperative to avoid generalizing the experience of any gender, sexual, or cultural minorities.

Researchers must continue to question the idea that a patient’s challenges are over just because a procedure has taken place or medicine has been received. For example, if an individual from Finland, a country that requires sterilization before transition can take place (Glass, 2017), were to travel to the United States for a medical transition surgery, what legal challenges would they face when they return to their home country? Geopolitical and considerations instead must be assessed at each localized stage over the evolution of trans health care. While the trans experience is unique, our study can help extend the contextual frameworks for studying all geopolitics within any population for whom borders, citizenship, identity, culture, and care intersect with forms of legal or de facto marginalization.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

Author Biographies

Avery C. Edenfield is an assistant professor of Technical Communication and Rhetoric at Utah State University. His research agenda works at the intersections of professional communication and community-embedded workspaces with particular attention to how marginalized communities use professional communication for self-advocacy. His research interests include theories of participation, rhetorics of empowerment and democracy, and community engagement in professional communication.

Jarod S. Colton is an Associate Professor of Technical Communication and Rhetoric at Utah State University. He is the co-author of Rhetoric, Technology, and the Virtues with Steve Holmes. He has published research on topics such as ethics, social justice in technical communication, pedagogy, disability, technology, and rhetoric.

Steve Holmes is an Associate Professor of Technical Communication and Rhetoric as Texas Tech University. He is the author of two books: Procedural Habits (2017) and Rhetoric, Technology, and the Virtues with Jared S. Colton (2018). Steve also has multiple publications in the areas of ethics, social justice, digital rhetoric, and rhetorical theory.

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