For many doctors, transgender health was not part of their medical training, so they need resources to come up to speed.
A little knowledge goes a long way
By Dr Irene Dolan, GP and Health Pathways WA GP Clinical Editor, WA Primary Health Alliance.
My interest in trans, gender diverse, and nonbinary health began in 2008 when, as a medical student, I attended the International AIDS Conference in Mexico City. There, I talked with a trans woman who spoke of the stigma that many TGDNB people face when accessing health care and the impacts that misgendering can have.
TGDNB health was not something we were taught as medical students, but her story stuck with me and was the genesis of my most rewarding work to date.
On graduating from medical school, I specialised in general practice and still did not learn about TGDNB health in my studies. So, when I took on a role as a GP at a sexual health clinic and was told I might see TGDNB patients, I asked the clinic manager for some help.
He introduced me to the then chair of TransFolk of WA, a peer support service for TGDNB people and their loved ones, who taught me the basics of respectful and appropriate language, the use of pronouns and chosen name.
These early encounters gave me the confidence to see TGDNB patients at the practice where I was working. I soon discovered that piecing together referral pathways, models of care and the clinical knowledge required was challenging.
At the same time, I was fortunate to be working as a GP Clinical Editor within Health Pathways WA at WA Primary Health Alliance. I took the opportunity to plant the seed about developing a WA-specific transgender health and gender diversity Health Pathway.
Given the organisation’s commitment to diversity and inclusion and the deficit in information for health professionals on TGDNB health, I got the green light to proceed.
I have been fortunate to work with such a knowledgeable and engaged group of subject-matter experts on the pathway’s development. This included representatives of the TGDNB community and clinical specialists from Royal Perth Hospital and Perth Children’s Hospital Gender Diversity Services who work with TGDNB people of all ages. GPs with experience in TGDNB health have also been involved in the pathway development.
Their depth of knowledge and insights into the subject matter helped to create a pathway which addresses the complexities faced by TGDNB individuals when accessing health care and some of the challenges faced by GPs when trying to help their patients access gender affirming care.
The pathway steps GPs through the assessment, management and referral processes to specialised services for TGDNB people of all ages, offers guidance on creating welcoming clinical environments, and provides patient information and information on support organisations for individuals and their families. The pathway also includes links to useful resources and a section on professional support.
The final pathway was informed by consultation undertaken by the WA Department of Health and is a fitting example of collaboration across the depth and breadth of the health system.
The development of the pathway and a forthcoming education series has been shaped by my professional experiences. I share these to show a small amount of knowledge can go a long way and to demonstrate the importance of lived experience.
I cannot recall another 30-minute conversation I had during medical school or GP training which has influenced my work to the same extent as that conversation in Mexico City.
I hope this work will help to bridge a gap as, equipped with knowledge and confidence, GPs can make an enormous difference to the health of TGDNB people.
ED: Health professionals can access the Transgender Health and Gender Diversity HealthPathway and associated Transgender Specialised Assessment request page, or request access.
They can also register for a 2023 education series on trans, gender diverse and non-binary health.
Enlightened consent – going beyond the minimum
By Lena Van Hale, manager of Magenta WA and secretary of Living Proud Inc.
As a long-time trans activist and peer supporter, I’ve watched with delight as informed consent models have surged in popularity within gender affirming care.
When I transitioned, very few of us accessed care at all, and those that did required expert knowledge from our peers. I became informed before I ever saw a clinician. Meeting with a trans friend, I learned how she handled herself, and what preoccupied her. I became an expert through a type of field research, because non-experts were guaranteed to fail the assessments required to access GAC.
It is undoubtedly positive that trans patients no longer need to have an encyclopaedic knowledge of gender to access GAC, however it leaves us with big shoes to fill if we are to replace those older methods of information transfer. Now that our models have improved, we must be flexible enough to both adequately educate patients, while also not delaying urgent care for others.
If we are to go beyond our minimum requirements for good care, for a person just questioning their gender, ‘minimum informed’ might simply be knowing that people with gender incongruence exist. Knowing we exist is one thing, knowing our forms and labels is another, and knowing how to work out if any of these forms fit you is another entirely.
Questioning “does my internal gender feel different to my external?” vs “would I feel more comfortable with a different external gender?” may each return strong feelings for a person. It is important for a trans person to understand that each of these are valid trans experiences, even if their answers contradict. Other valuable questions include “can I picture myself growing old as this gender?”, “can you imagine other people in your life perceiving you as another gender?” and “if you had a button that could change your external and/or internal gender instantly, would you press it?”
When acting on gender incongruence, the ‘minimum informed’ is knowing that hormone replacement therapy exists, understanding its side effects, intended effects and expected time frames, and its reversibility.
For most people this is a tiny piece of their puzzle. Acting on it may mean social transition. It may include dealing with other health issues. Understanding what you can and can’t change about yourself starts before hormones and goes far beyond them.
This includes a long process of picking apart which aspects of the self are a cultural gendered expectation, and which parts may be innate or instinctual. Developing a healthy internal narrative of sex and gender is an important part of living a happy life, even for cisgender people.
A trans person who internalises negative gendered stereotypes may attribute these to themselves (from all genders too), and may even intentionally engage in problematic behaviour, having internalised this as a natural part of living as their chosen gender.
As an educator I often find it important to push back on this. I often joke that just because my gender is valid, doesn’t mean my gender is relevant.
While we may currently lack the perfect informed consent checklist, we need not overcomplicate it. We don’t have to quiz people on gender theory for them to feel safe explaining both what they want and what they think is possible to get from transition.
A questioning person’s needs differ from a confident person who has questioned for years, but each may require urgent care. If someone has an insecurity or stereotype so extreme it may continue to negatively impact them after transition, we should be able to identify that and even challenge it without requiring assessment by a full multidisciplinary team.
All patients should know they can change their mind and should not be judged for it, but they should also know that regret is extremely rare. Not all trans people medically transition, and some choose to take lower doses of hormones or only take them temporarily for some small changes. Clinicians and patients must also understand that some people regret not accessing HRT sooner, not pursuing a stronger regime, or not transitioning faster or slower.
A transparent, collaborative informed consent process is a massive improvement on older models of GAC, positioning patient and clinician as allies rather than adversary and gatekeeper.
Foster a collaborative environment, gather a good understanding of their personalised goals for transition, aim to reach a mutual agreement to where you each think they are well informed, create a shared agreement for you both to sign, and document it.
Caring for trans, gender-diverse and non-binary children
Transgender health care across the life span is a core area of clinical skills for all health professionals, writes child and adolescent psychiatrist Dr Julia Moore.
Trans people have always been around, evident in culture and history worldwide, including Aboriginal and Torres Strait Islander brotherboys and sistergirls, and Maori whakawāhine and tangata ira tāne.
Medical understanding now recognises the spectrum of gender as a normal part of human diversity. Transgender health care is not new: hormonal and surgical treatments were provided in Berlin in 1918, and the treatment of gender-dysphoric adolescents with puberty suppression and hormone treatments commenced in the Netherlands around 1991.
The US Transgender Survey 2015 of 27,715 adults found that 15% first told someone that they were transgender under the age of 15, and 37% between ages 16 and 20 – even before social media, ‘coming out’ in adolescence was frequent. It is important to understand that some people are trans, and this
is OK.
‘Conversion therapy’, or efforts to deliberately change gender identity or sexual orientation, is ineffective, harmful and unethical. Some trans individuals request medical or surgical gender-affirming treatment and experience it as medically essential; some do not want treatment.
These treatment decisions are led by the person’s wishes and needs, and the risks are weighed against the risks of withholding treatment.
It is normal for children to have interests and activities that do not conform to cultural ideas of masculine and feminine. This doesn’t need assessment or diagnosis. Some children are distressed by their sex registered at birth, and make strong statements, wishing to live as their identified gender, at home and school.
Observational evidence indicates that this child-led social transition is associated with positive psychosocial outcomes. This is a family decision, which should be led by the child’s expressed needs.
No medical or surgical treatment is indicated for gender dysphoria before puberty commences. Prepubertal children only need love, support, and listening to. Some become comfortable with their birth-registered sex and gender during late childhood to early puberty, so it is important that children who socially transition are supported to ‘change back’ at any time they wish. Facilitate access to mental health care for common problems including social anxiety, depression, suicidality, autism and ADHD, alongside gender-affirming care.
Puberty suppression with gonadotropin releasing hormone agonists can be indicated when gender dysphoria is exacerbated with distress at the changes of early puberty. Puberty suppression is ideally commenced at Tanner stage 2–3, early enough to provide long-term benefit by preventing breast development or voice deepening and facial masculinisation.
Some young people first experience gender dysphoria peri-pubertally; puberty suppression may still be appropriate to relieve distress and allow time for clarification of identity. Puberty suppression can be ceased if the patient wishes: its effects are largely reversible. Most people who start puberty suppression remain stable in their gender identity and decide to commence testosterone or oestrogen gender-affirming treatment in later adolescence or young adulthood.
Oestrogen/anti-androgen or testosterone treatment can be provided to more mature adolescents with long-term stable gender identity, who have developed capacity to give informed consent, including appreciation of the risk of regret.
This requires repeated consultations, and specific counselling regarding fertility. Masculinising chest reconstruction is not yet provided in the public health system in WA. Genital surgery is not done under age 18 in Australia. Many trans people do not want genital surgery, but for some it is extremely important.
The treating medical practitioner must obtain the active informed consent of all legal guardians before providing gender-affirming puberty suppression, oestrogen, testosterone, or surgical treatment for a person under age 18, regardless of Gillick competence, according to the Family Court of Australia judgement Re: Imogen [2020].
The CAHS Gender Diversity Service is a multidisciplinary team that provides information, support, assessment, and (where requested and appropriate) gender-affirming medical treatment in liaison with the general practitioner.
There is a pressing need to develop more youth trans health care capacity in WA, while maintaining quality and safety of care. Models exist in other states for treatment in primary care with collaboration between GPs and psychologists, with other specialist consultation as appropriate. Peer support through TransFolk of WA, Transcend Australia and PFLAG is very helpful.
ED: Dr Julia Moore is a Consultant Child and Adolescent Psychiatrist with the CAHS Gender Diversity Service. References on request.