The Australian Professional Association for Trans Health released standards guidelines earlier this year. WA dermatologist Dr Ahmed Kazmi has been working with trans patients and urges doctors to move beyond the headlines.
Eric Martin reports
Though transgender people have existed down through the ages, the origins of the modern transgender healthcare debate can potentially be traced back to the 18th century Irish philosopher, George Berkley, his theory of ‘subjective idealism,’ and its ideas about how we create reality through the modality of our minds.
Bishop Berkley followed in the footsteps of some of the great philosophical thinkers, yet his theories caused conflict with proponents of Descartes’ ‘natural philosophy’, where matter and form construct the true reality, and the subsequent debate has continued to split the epistemological approach to science, and the trans debate, nearly 300 years later.
Despite the timeless nature of trans identity, the medical need is here and now, and controversial studies such as the one released by Sydney’s Westmead Children’s Hospital in 2021, have involved Australia in the international debate, highlighting the conflict that exists nationally.
Given the necessity for more discussion on the topic, Medical Forum spoke with dermatologist, Dr Ahmed Kazmi, who recently gave the first presentation on transgender medicine to this year’s Australian Dermatology Annual Conference, delivering content that has been subsequently requested for their curriculum. He also spoke to local doctors at the Annual Perth Urology Clinic Masterclass.
“I tend to see people already on gender affirming hormonal therapy who develop subsequent skin problems. But I teach a lot on the subject just because I find it a lovely intersection of a lot of disciplines of medicine,” Dr Kazmi said.
“And I feel like we’re trying to establish health advocacy for a group that’s traditionally had a raw deal – it makes me feel proud to be able to contribute towards trying to improve their health outcomes.”
He said the health authorities should get credit for establishing facilities such as the paediatric service at the Perth Children’s Hospital, and the adult service at Royal Perth Hospital.
Improved services
“For a long time there has been nothing, but now, almost every major city in Australia has some state-backed service of some description for both paediatrics and adults,” he said.
“There’s still a lot of finding feet and trying to see what the best arrangement of services is, but at least there is a home for where this health care is happening.
“As there aren’t many surgical options in Perth yet, many people still end up going abroad. But it’s slowly growing, especially as medical interest increases, and more doctors become aware that there are now options. Lots of GPs that are quite keen to join and prescribe gender-affirming hormones.
“They’re also trying to get allied health professional input too, such as speech and language therapists that specialise in transgender voice and gender affirming voice therapies. Things are really changing, but it’s still like a boat that’s being navigated through uncharted waters.”
Dr Kazmi said that the level of transgender care provided was broadly similar in most countries that he had worked in, though there was always a split in terms of approach due to the impact of people’s different worldviews.
“There are certain areas of medicine where it’s black and white and all of your personal upbringing and political and religious views don’t play a role, no one gets ethical about rhinitis or about atopic dermatitis. And then in some areas, bits start to bleed in, such as when it’s about service allocation, or Aboriginal health, and you can see people’s personal opinions have an influence.
“But areas of medicine like transgender are extremely polarising. The conflict that’s created and the conversation around these issues have been the same anywhere because there are the same varying mixes of political and religious views.
“People speak about it like it’s some kind of fad or fashion, when transgender people have existed since the dawn of humanity. As long as there have been cisgender people and heterosexual people, there have been queer people and trans people.
“I think some doctors are a bit black and white with transgender medicine and they don’t seem to understand the sort of psychosexual, psychosocial nuance and the complexity of it all.
Neurodivergency
“If there’s one thing I could say to communicate, it’s that the aspect of transgender medicine that I find most overlooked by clinicians and the public is the relationship between transgender identity and being neurodivergent or neurodiverse.”
Dr Kazmi said that while official numbers might show that around 35% of children on the spectrum were potentially transitioning, in his anecdotal experience, that number was closer to 100%.
“I would say nearly 100% of my transgender patients have either significant psychological psychiatric morbidity and/or neurodiversity. Almost all of them have ADHD or autistic spectrum disorder or learning difficulties or Tourette’s, something in that spectrum, or epilepsy or dyslexia, or serious anxiety, depression, or OCD – and often the two are different manifestations of the same thing,” he explained.
“We’re only just beginning to understand the overlap with neurodiversity. But that helps explain why people find it difficult to engage with this group and why they often get mislabelled as ‘weird’ or ‘confused’ – those are the type of pejorative words I hear a lot about trans people.
“The other thing that I find interesting is that people always assume that transgender medicine is just about sex changes. Yet if you look at trans men, almost none of them will undergo phalloplasty or some form of gender reassignment surgery. They may well have a mastectomy, or top surgery, but they didn’t just suddenly stitch up their vagina and then ask for a replacement.
“I don’t know the statistics, but although most trans women will want to have full surgery, many end up not, especially in Australia because it’s so difficult to access.”
Dr Kazmi explained that there was a common misconception that transgender meant someone was just ‘trapped’ in the wrong gender, and that they wanted to exactly mirror what societal norms have set for a cis man or a cis woman.
“If this person identifies as a trans woman, we expect they’re going to want breasts, no body hair and to wear a dress. And then, when we find out that actually loads of people are somewhere in the middle, or they want to use she/her pronouns, but they don’t mind having a beard, I don’t know why, but that sets people off,” he said.
“They’re like, ‘Oh, hang on a minute, that’s not the rules of the game. You’re allowed to transition, but only if you exactly match what we think a female should look like’.”
Patient choice
In terms of defining gender as referring to either a biological, physiological trait or as a self-realised or socially constructed concept, Dr Kazmi believed that it depended on the individual.
“People get sex and gender mixed up. For example, you’ll see some discuss gender in terms of genitals and procreation – as we see on television people going, ‘You’ve got a penis, therefore you’re a man, what’s complicated about that?’. Yet there are people born intersex, with ovaries and a penis,” he said.
“Generally, in medical terms, we tend to discuss sex as being a phenotype or a genotype, and it’s attributed to someone. It’s imparted to them at birth based on what they look like, what their genitals are, and therefore what we assume is their karyotype is based solely on their genes. Whereas gender, we’re understanding, is much more socially constructed.”
He noted that even if society comes to some kind of middle ground, where we recognise that the growing mind may be subject to change and that many of these behaviours are on the ‘normal’ spectrum, it was vital to ensure that boundary markers were established for beginning treatment.
“People will recount, ‘Oh, I used to dress up in girls’ clothes when I was six. Doesn’t mean I’m trans.’ Sure you didn’t, but I don’t think you referred to yourself using female pronouns; I don’t think you hated your name; I don’t think you tried removing your own breasts when you went through puberty, and maintained that for six months, one year, three years, or five years,” Dr Kazmi said.
“There’s a definite difference between those people and somebody saying, ‘Mommy, I think I’m a girl’ or ‘I think I’m a boy’ when they’re three. Those aren’t the people rushing to try and be put on hormones, and that is an important distinction to make for the public and for doctors.
Lessons abound
“We must apply the same common sense that we would in other areas. For example, there’s lots of standards that apply for a teenage girl wanting to go on the contraceptive pill without her parents’ knowledge. Even if she’s under the age of legal consent, we’ll say, ‘OK, well, she’s more likely to come to harm from pregnancy and she’s more likely to come to harm from an STI, therefore…’
“So, if we can apply that for the termination of a pregnancy, contraception or accepting a surgical procedure, why is that not relevant here?
“People always seem worried that children or adolescents may undergo the process and then have remorse. But all I’ve seen are adults who were unfairly put through a puberty that they spend the rest of their lives trying to reverse.”
Education was the most important thing that doctors can access to improve their patients’ outcomes, he said.
“No one is ignorant, but this is a growing, evolving area of medicine. There are huge risks associated with hormone therapy, such as the increased risk of malignancy, increased risk of DVT, and increased cardiovascular risk. We don’t have a good enough data set to know how much that risk translates to actual harm – that will only become more evident over time.”
Sex steroids, such as estrogen or testosterone, are commonly prescribed as a part of hormone replacement therapy for transgender patients and these enzymes are known to metabolise several commonly prescribed drugs, including anti-HIV agents like protease inhibitors and other antiretrovirals, the antidepressant bupropion, the opioid analgesic methadone, and even drugs as ordinary as acetaminophen.
Research in cisgender adults already shows that genetic variability in these enzymes can impact an individual’s response to these drugs and continued ignorance may lead to unintended side effects in transgender individuals when prescribing treatments.
“But again, we’ve known these risks for HRT in women. We know these risks for the contraceptive pill. Yet we just say to the patient, ‘These are the pros, these are the cons. It will protect you against this but increase the risk of that. Do you want to proceed?’ And you go for it. I think we need to really toe the exact same line with gender-affirming hormonal therapy.”
Access to gender-affirming interventions in Australia typically follows one of two pathways – either a formal assessment and approval by a mental health professional, or by informed consent, where a decision to commence gender-affirming hormones was shared between a primary care general practitioner and a trans individual – without mandating a formal mental health review.
“No one’s saying that you need to be an expert in this area, but you should know how to take the history for that patient,” Dr Kazmi said.
“You should be able to screen them. You should know where to refer them, if that is something that they want to do.”
In March this year, the Australian Informed Consent Standards of Care for Gender Affirming Hormone Therapy by the Australian Professional Association for Trans Health (AusPATH) was released. It is intended to assist and enable clinicians across Australia to meet the medical gender affirmation needs of their non-binary patients.
The standards state that informed consent models of hormone prescribing “resist the notion that a doctor can determine the validity of a person’s gender, and instead centre the trans person in the decision-making process, whilst ensuring that the patient understands and can consent to the potential impacts that gender affirming hormone therapy may have on their body and life.”
Importantly, they also stipulated that when trans people attend clinical services seeking medical care, it is important to avoid pathologising the trans experience:
“Being trans is not a mental illness, it is an aspect of human variation, and hormones and surgery are not necessarily desired by all trans people.”
Transgender trends WA
Dr Shane LaBianca, from Perth Urological Clinic, said that in WA, transgender patients only had access to aftercare because there was no surgical care as such here.
“We don’t do transgender surgery in terms of gender affirmation, except for orchidectomy: testicular removal for trans females is the only operation we perform,” Dr LaBianca said. “I have probably no more than a dozen patients who’ve had full gender affirming surgery, and maybe another dozen patients in a year who have come to see me to have an orchidectomy, for example.
“Similarly, there’s only a handful of patients in WA who’ve had female-to-male surgery and full reconstruction, they have generally had that done in the US and tend to follow-up with their surgeons there as well.
“But in aftercare, it’s often more complicated.”
Dr LaBianca pointed out that this was often influenced by the enormous variation of what transgender people wanted, a factor that was not limited to the cisgender ideal of what society expected a man or a woman to be.
“People have surgery done in lots of different places, and what they come back with varies considerably depending on their own desires, on how they want to have surgery, what they want to have done, who has performed the surgery, and where it’s been performed,” he said.
“There are many transgender people who don’t want to go to the next step involving surgical procedures.
“So, a lot of the time, it’s a case of re-establishing the doctor-patient relationship with someone who’s newly presented, in terms of determining their medical history and what their ongoing issues are. There’s no single picture in terms of what we see, there’s a lot of variation.
Same principle
“But in terms of urology, a lot of the things we see are similar whether you’re male or female, but they’re just slightly more complicated because of what’s happened in the past.
“Essentially, the principles are all the same. There’s not a lot of difference whether you’re looking at a reconstructed female or a cisgender female, and it’s largely the identical structure in terms of how you approach the problems.”
Dr LaBianca pointed out that one of the issues with developing greater medical expertise in WA was the small number of people who were interested in gender readjustment surgery.
“Many surgeons will not deal with members of the transgender community, they just say, ‘I’m not interested in that, I don’t see those patients here.’ Similarly, they might not work with certain cancers, and that’s reasonable,” he said.
“Because of the low case numbers here in WA, it’s difficult to establish good systems and pathways. Until we see the case numbers, we’re not going to have many specialists interested, therefore we’re not going to have the expertise, and it will remain with generalists like me to be involved.”
Dr LaBianca noted that much like other conditions, where there could be only four cases each year, rather than attracting a specialist, it was more likely to foster a network of medical professionals who had some experience connected to its management and treatment.
“Having a trans health network of interested individuals like myself, GPs, endocrinologists, etc, and having some way of coordinating care through that network, rather than necessarily going to one specific person, is probably the best way to manage transgender healthcare here in WA,” he said.
“Patients will essentially go to see someone who’s a liaison in that network, who can point them in the right direction, and if they’ve got the right people who are receptive, that’s all that really matters.
“A lot of it is just awareness and making sure that GPs understand who the right contact people are and where to go, and we need to get better at getting that information out there, because a lot of the time, patients hit a roadblock when their GP doesn’t know anything about transgender healthcare.
“Yet it’s the same for any area of medicine – you may not know the answer, but you need to know where to find it, and that’s probably more important than knowing all the information.”
Like Dr Ahmed Kazmi, Dr LaBianca also noted he saw a high number of neurodivergent individuals presenting for treatment.
“Disorders such as autism are common among the trans population. There’s also a lot of psychological ill health, depression, and other psychological illnesses, which can be challenging to deal with if they present comorbidly,” he said.
“It’s essential to have staff members and teams that are aware of the distinctions that different individuals present with, and how to deal with those in a clinical environment.
“Yet I think a lot of people just don’t want to take the time to appreciate those things, which can make it quite difficult for patients when they need care – just the same as everyone else.”
Dr LaBianca explained that there were two aspects to providing the necessary follow-up, which required little that was outside a qualified medical practitioner’s clinical expertise, but noted the need for consideration of the patient’s potential physiological changes when prescribing.
“Post-surgical care is often quite significant because the patient may have had their surgery done in Southeast Asia and has been discharged within a short period of time, and therefore perhaps don’t feel they’ve had the support they needed post-operatively,” he said.
“This could be for aspects that such as wound healing, infection, problems with stenosis. And then you’ve got the longer-term complications we sometimes see that tend to approximate CIS gender pathologies.
“So male trans females tend to have issues with bladder infections and urethral complications and may have problems with sexual dysfunction, just as female members of the CIS gender population may as they age.
“The reverse are the trans males who are on anti-oestrogens and female hormones. As they get older, it is possible that with the adjustments in their hormone levels – and depending on how much surgery they’ve had – changes can also potentially occur within their natural organs.
Open approach
“As such, you need to deal with patients according to their chosen gender, but also according to their underlying anatomy, depending on what that is. Just having an open approach and thinking about the problem logically is usually all you need – it’s not rocket science.
“And then you just need to take it back to basic principles and most of the time, it’s solvable.”
Dr LaBianca said that if GPs or specialists were looking to connect with the unofficial trans health network in Perth, the best way to start was by reaching out to a fellow GP, social worker or psychologist already established in the field.
“And they’re well-advertised. There are a couple of GP practices in the city linked to sexual health services, and others like Miranda and Alexander Heights that have developed a strong affiliation with transgender care,” he said.