Bridging the transgender gap

GPs can take some simple measures to improve the health and wellbeing of trans people

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The complexities of gender diversity can be challenging. But GPs can take some simple measures to improve the health and wellbeing of trans people

Being transgender in Australia isn’t, in itself, harmful to health. The way trans people are regarded, treated and understood, however, can have a devastating – often deadly – effect on the health and wellbeing of the population.

You may never have met a trans person. Precise figures are difficult to come by, but population studies estimate somewhere between 0.5% and 1.3% of Australians identify with a gender other than the one they were assigned at birth. That figure is in the same ballpark as the proportion of Australians who use sign language or own more than five real estate properties. Not huge.

But just because a population is small, it doesn’t mean it’s insignificant. A recent bill passed in North Carolina, which requires people to use only the public bathroom corresponding to the gender on their birth certificate made headlines across the world and prompted protests, petitions and corporate boycotts.

What does it mean to be trans?

The plethora of words used in the lexicon of gender diversity can make it confusing to the newcomer. Transgender, transsexual, genderqueer, non-binary, pansexual, cis – these terms can mean different things to different people. For the purposes of this article, the term “trans person” is used to mean a person who identifies with a different gender to the one they were assigned at birth, whether male, female, both or neither.

Gender incongruence – an inconsistency between the gender a person feels, identifies with and experiences, and the gender assigned to them at birth – underlies the trans experience.

Gender dysphoria is the distress, discomfort and anxiety some people experience as a result of gender incongruence. For some, simply looking at their own body can cause distress as they see in the mirror someone at odds with their own sense of self. A far greater cause of dysphoria is the constant pressure placed on trans people to conform to their assigned gender, and the discrimination and stigma they face daily from a society that often doesn’t accept them as normal.

What makes a person trans?

Our understanding of trans people is nourished by a small, but growing, body of research. Australian and international studies have shown that genetic factors contribute more to gender identity than environmental factors, and that gender identity is more closely related to brain development and hormones than it is to child rearing.

A recent Lancet Series examined the social, legal and healthcare needs of trans people. Associate Professor Sam Winter of Curtin University, a contributor to the series, stressed that trans people do not choose to be the way they are.

“The essential experience of a transgender person, that gender incongruence – that’s not a lifestyle choice. That really isn’t a lifestyle choice. Nor is the gender dysphoria that might attend that incongruence,” he says.

The current classification of gender incongruence and its manifestations as mental disorders in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and the World Health Organisation’s International Statistical Classification of Diseases and Related Health Problems (ICD-10) is unhelpful in understanding gender diversity.

These classifications have been the subject of much discussion, and change is underway as a result. ICD-11, expected in 2018, will likely move the diagnosis out of its chapter on mental and behavioural disorders.

It does trans people no favours to view their gender identity as some kind of illness that needs fixing.

Perhaps in the future, this view will be relegated to the, “Oops, we got it wrong, but we know more about this stuff now” bucket, along with hysteria and demonic possession.

Diversity within the trans population

It’s important to remember that gender incongruence is one of the few things trans people have in common. Trans people don’t necessarily share a single culture, nationality, occupation, income or sexuality. Common stereotypes of trans people belie the diversity within the population. If you try to define trans people by how they look, what they do, where they’re from or who they love, your definition will be inaccurate.

Further, there is diversity in the way trans people express their gender. As Winter says, “Every GP needs to know that, while some trans people are not bothered by their bodies at all, some are quite gender-dysphoric about their bodies.”

Some trans people seek gender-affirming healthcare in the form of hormone therapy and/or surgery; others have no desire for medical transition, or may forgo it because of cost or access issues. Health professionals cannot assume all trans people want to change their bodies, or that their healthcare needs are the same.

Being trans under Australian law

On paper, trans people have the same basic human rights and freedoms as non-trans people. In practice, many laws and systems make it difficult for a trans person to have their documented identity reflect their gender identity.

Discrimination Act 1984, the Privacy Act 1988 and The Australian Government Guidelines on the Recognition of Sex and Gender allow trans people to be protected from gender-based discrimination (including the provision of health services); to have their personal information remain private; and to choose or change the gender that appears in their government records.

State and territory laws are less clear-cut, and in many cases are inconsistent across borders and with federal law. For example, some states require gender-affirming surgery before amendments to a birth certificate can be made, and most state laws don’t permit gender changes on birth certificates if the applicant for the change is married.

By demanding surgery (and sometimes divorce) to enact such an administrative change, state governments discriminate against trans people. Furthermore, because birth certificates are often used as identification for other legal documents such as passports, the state laws complicate the relative simplicity of federal laws.

As far as medical treatment is concerned, The Australian Government Guidelines on the Recognition of Sex and Gender states:

“The necessity of a medical service or associated benefit should be determined by the physical need for that service or benefit, regardless of a person’s recorded sex and/or gender.”

There are, however, age restrictions on some gender-affirming health procedures in Australia. Young people under the age of 16 cannot legally access puberty-blocking medication without permission from a Family Court, regardless of how much support they have from parents, caregivers and healthcare providers. This particular shade of red tape is expensive and unique to Australia.

Living with gender incongruence

Despite the reasonably inclusive position of Australian officialdom, the experience of trans people in Australia is, overall, one of discrimination, marginalisation and in many cases, violence.

In its Lost in Transition report, the United Nations Development Program illustrates the lived experience of trans people in the Asia-Pacific region with the “stigma-sickness slope”. The model describes the role that social stigma plays in the health deterioration of trans people. The report explains:

“They often face stigma, prejudice and discrimination, as well as harassment, abuse and violence. These experiences push many trans people towards the margins of society, where two common consequences are involvement in risky situations and behaviour patterns, and poor physical and emotional well-being. These two consequences can reinforce each other. Many trans people fall sick. Some die.”

A 2013 study by Zoe Hyde et al looked closely at the mental health of trans people across Australia. Titled The First Australian National Trans Mental Health Study, it found alarmingly high rates of depression and anxiety disorders, with self-harm and suicidal ideation common among respondents. The study reported the likelihood of ever being diagnosed with depression is four times higher in the trans population than the general population, and the likelihood of an anxiety disorder diagnosis 1.5 times higher than for non-trans Australians.

What’s behind the discrepancy in rates of depression and anxiety? Matt Tilley, a lecturer in the Department of Sexology in the School of Public Health at Curtin University and one of the study authors, explains:

“It’s terrifyingly simple. The reality is that discrimination and harassment were so common that nearly two thirds of participants reported at least one instance, which was ranging from social exclusion to violence and assault. When a population is experiencing such prolonged and ongoing annihilation of themselves, then we are likely to see a heightened level of distress.”

Though this study restricted the age of respondents to 18 and over, the experiences of trans children and teens cannot be overlooked. Going through puberty can be difficult enough for any young person.

Add to that the stress and confusion of developing unwanted sexual characteristics; enduring the bullying that accompanies so many kinds of adolescent non-conformity; and the inability to legally access gender-affirming health care without a court order, and the potential for mental health issues becomes enormous.

Part of the problem?

Unfortunately, healthcare providers and institutions can contribute to the isolation and suffering of trans individuals. The contribution may be explicit, in the form of express disapproval of a trans person’s appearance, behaviour or healthcare requests; or more implicit, when staff or signage inadvertently use language, systems and processes that are inconsiderate of trans people’s needs.

Dr Tracie O’Keefe, sexologist and psychotherapist specialising in sex, gender and sexuality diversity, has co-edited two anthologies of real-life stories of sex and gender-diverse people entitled Trans People in Love (Routledge, 2008) and Finding the Real Me: True Tales of Sex and Gender Diversity (Wiley, 2003). She says, “It’s a frightening world being a sex and/or gender diverse person faced with clinicians who presume your identity is a psychiatric disorder, rather than listening to you. That frightening world often leads to high levels of suicide when sex and/or gender diverse people feel isolated and dismissed.”

Gender-affirming healthcare saves lives

If there is one clear message that emerges from research into gender-diverse populations, it’s that gender-affirming health care improves the mental health of trans people.

Gender-affirming health care broadly refers to hormone therapy and surgery. Hormone therapy includes androgens and oestrogens for adults, and puberty-blockers for younger trans people who wish to delay puberty.

Puberty blockers, such as leuprorelin (Lucrin) or histrelin, provide pre-pubescent trans people, their families and caregivers with more time to consider their options for gender expression. Generally, puberty blockers are used until the age of 16, after which administration of cross-sex hormones and/or surgery can begin, if desired and accessible.

Histrelin is a gonadotropin releasing hormone (GnRH) agonist that is a potent inhibitor of the production of testosterone in men and oestrogen in women and is used predominantly to treat advanced prostate cancer.

Leuprorelin, given by depot injection, is a synthetic nonapeptide analogue of gonadotropin releasing hormone (GnRH). The analogue possesses greater potency than the natural hormone.

Surgical options include breast augmentation, chest reconstruction, vaginoplasty, phalloplasty and hysterectomy. Not all of these procedures are available in Australia, and many are prohibitively expensive for trans people. But the positive effects of gender-affirming health care are clear.

“It was the best thing I have ever done in my life. I went through puberty wishing there was a pill that would make me a girl so I wouldn’t be a boy and now I have found it. Best ever… life saving,” said one respondent to The First Australian National Trans Mental Health Study.

“I would be dead if not for having transitioned, I experience exquisite joy most days now for being who I am,” said another respondent.

The results of the Hyde study reinforced previous findings that hormone therapy and gender-affirming surgery are associated with improvements in mental health and quality of life for trans people.

“For some of the people going in to the consulting room talking to their GP, that hormonal support that they may be talking about, that can be life-changing,” says Professor Winter. “And for some, it can be life-saving.”

It’s not all about gender 

Obviously, the healthcare needs of trans patients are, for the most part, no different from any other patients. Disease, trauma, ageing and other health issues don’t present any differently in trans people than they do in the rest of the population. However, trans people are frequently regarded by healthcare providers as a peculiarity before they are considered as a person.

This tendency gives rise to a phenomenon known as ‘trans broken arm syndrome’, whereby a person who happens to be trans will visit a health practitioner for a condition unrelated to their gender (such as a broken bone), but the presenting condition is nevertheless treated in relation to, or even as a result of, their gender identity.

Consider this from the perspective of any other patient. If an individual visits a GP because of a persistent earache, how likely is it that their condition is a result of hormones, breast surgery or body image? Not very. Yet some doctors let the gender of a trans patient pervade every aspect of their relationship with that patient.

When a trans patient’s gender is questioned, commented upon or brought up in a situation where it is not relevant, this can contribute to the feelings of discomfort and anxiety they constantly seek to avoid. Gender – no matter how it is defined – is incidental to the vast majority of doctor-patient interactions. If you focus on an individual’s gender and not on their whole person, you do them a great disservice.

Gender and sexuality

Gender and sexuality are so often linked together, it can be difficult to think about these two concepts separately. Of course, we usually define a person’s sexuality with reference to their gender, but even the most common delineation of heterosexual/homosexual is inadequate to describe the range of gender identities and sexualities that exist.

The initialism LGBTQI (Lesbian, Gay, Bisexual, Trans, Queer, Intersex) is used to conveniently group people of different genders and different sexualities together. This can create the impression of a reasonably homogeneous community, but in reality, little common ground is shared by this population except that their gender and sexuality do not fit neatly into the conventional concept of so-called straight males and females.

To have a realistic understanding of human diversity, each individual’s gender and sexuality must be thought of independently. A person’s gender identity has little bearing on who they are attracted to. The range of sexualities among cisgender people (those whose assigned gender matches the gender they feel) is reflected in the trans population. That is, a trans person could be attracted exclusively to a single gender – whether it is the same or different to their own – or they may be attracted to more than one gender. Additionally, some people identify as asexual, having no particular sexual attraction or desire.

When a patient’s sexual health is addressed, it’s important that doctors have an understanding of their physical sexual characteristics and their sexual activity. Making assumptions about sexual characteristics and activity based on gender doesn’t help the patient, but making conversation does.

What can GPs do to support trans patients? 

The complexities of gender diversity, its manifestations and implications can frazzle even the most competent brain.

But the measures GPs can take to improve the health and wellbeing of trans people are quite simple. Indeed, many of these considerations apply to all patients:

• Use the name and pronoun that each patient prefers, and ensure all practice staff do the same. Misuse of pronouns and names is not only disrespectful, it can ‘out’ a trans person against their will, in a situation beyond their control.
• If you need to refer to a patient’s gender, use terms that the patient is comfortable with – “man”, “woman”, “trans man”, “trans woman” or whatever the patient chooses. Avoid situations in which patients are forced to identify as trans.
• If you are unsure of how to refer to a patient, ask them how they would like to be addressed.
• Ask how you can make them comfortable during examinations and procedures.
• Make your record-keeping procedures gender-friendly. When you collect gender information from a patient, provide an option to record a gender other than “male” or “female”.
• Where a patient’s records differ from the patient’s preferred name, pronoun or gender expression, update those records.
• Train practice staff in processes and behaviours that are supportive and inclusive of gender-diverse patients.
• Familiarise yourself with options for providing and referring gender-affirming health care.
• Provide a welcoming and supportive health care environment in your practice. For example, promote your practice as gender-diverse on
  marketing material.

Finally, remember that healthcare providers can significantly change the future for the trans population.

Central to the fulfilment of trans people’s needs is, in the words of researcher Matt Tilley:
“… the idea of ensuring that the GPs and the other practice staff see the person, not the case; as a whole experience rather than a curiosity. And to again ensure that the individual is seen in their choice of identity, rather than seen as some abhorrent apparition of a gender expression”.