Smoothing the rough road of gender transition

For GPs, understanding, not expertise, is the key to treating transgender patients

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It was on a long road trip from Melbourne to Perth that Cassie Workman first made up her mind to transition. She was 25 and had experienced gender dysphoria from a young age, and it was time to do something about it.

That’s not what happened. Instead, a psychologist told her she was not transgender but schizophrenic, and put her on antipsychotics.

“I became totally unable to function because of the medication,” she tells The Medical Republic. “And I became so terrified of the reaction and the fact that not even a professional would believe what I was saying, that I just didn’t say anything again for 10 years and I lost 10 years of my life.”

Workman, a writer and comedian based in Sydney, eventually mustered the courage, or the desperation, to try again. This time, in 2017, she had an understanding GP and a psychologist she trusted. But it still took something terrible to precipitate this second attempt: “Yeah, I tried to kill myself.”

Being transgender or gender diverse (TGD) is now increasingly accepted as part of the spectrum of human diversity, says Dr Ada Cheung, lead author of a position statement on the hormonal management of transgender adults in this month’s Medical Journal of Australia.

Dr Cheung, an endocrinologist at the Austin Hospital and Melbourne University, went into trans medicine about five years ago after a colleague told her that many doctors refused to see transgender patients.

“When I heard that, I thought that just sounds outrageous, and against the Hippocratic oath,” she tells TMR. She began seeing transgender patients, the practice soon grew, and she started the Trans Medical Research Group about two years later.

“I saw every day these stories of discrimination and misunderstanding from my colleagues, and also a real lack of research to guide clinical care,” she says.

A survey of patients found their top priority was better education for doctors, while a doctor survey found that only a few percent had encountered the subject in their training.

“I think health professionals as a whole are a caring profession and wouldn’t knowingly be transphobic, but there’s a lack of understanding and I think it’s natural that humans fear what they don’t know,” Dr Cheung says.

“It wasn’t that doctors didn’t want to treat transgender people, but that they lacked confidence to do so. And an overwhelming majority, 98-99%, desired some Australian guidelines.”

The position statement just published in the MJA is the result of two years’ collaborative work. It sets out to formalise the care of these patients’ specific health needs, mental and physical, before and during transition: from gender-affirming language, to mental health reviews, medical assessments, masculinising and feminising hormone therapy, surgical procedures, and monitoring and support. The latter includes mitigating the increased cardiovascular risk in trans men (still within the normal range for non-trans males) and screening for cancers in accordance with organs, not identity.

Though the long-term effects of hormone therapy are not well known, it appears to be effective in the short term at realigning physical characteristics with experienced gender identity, Dr Cheung says.

“For most people the desire to relieve the mental health distress and the dysphoria is so great that they accept the risks and the uncertainty that comes with gender-affirming hormone therapy,” she says.

Above all, care has to be individualised as trans people have different goals. While some are content to transition socially and some seek only medical interventions, others will opt for surgery.

Gender incongruence affects up to an estimated 2% of the population, Dr Cheung says – “it’s like having red hair”. It is not a chromosomal disorder, nor a psychiatric one. It was recently declassified as such in the 11^th revision of the World Health Organisation International Classification of Diseases.

Nor is it a choice, Dr Cheung says. “We know that in the fetus the brain develops at a different time from the genitals, and so there is a physiological or biological plausibility that there could be a mismatch between the brain and the genitals and sex hormones.”

That’s known as the developmental mismatch hypothesis, and is not the only candidate – a growing number of studies have identified neuroanatomical differences that may form the biologic basis for gender identity.

“It’s very hard for someone who’s not trans to understand what people are going through,” says Dr Cheung, who is not trans herself. “There’s a lot of factors that can contribute to adverse mental health and we need clinicians to assess them, respect them, use their name, use their pronoun and just be willing to listen.

“Some don’t reveal their trans status to doctors for fear of suboptimal care. And it shouldn’t be this way. Anybody, regardless of your gender, your race, your identity, your beliefs should be able to access the same level of care wherever you go.”

Though not itself a mental illness, being TGD brings a lot of distress, depression and anxiety along with it. Dr Cheung says more than 40% attempt suicide and 60% have self-harmed in the past.

“They are a very vulnerable group and really the large majority just want to be validated and affirmed and accepted,” she says.

“I think a lot of people appreciate the fact that the GP or the treating professional might not necessarily know a lot about trans health, but if they’re just respectful and have an open mind and are willing to learn, then I think that goes an awful long way to improving the mental health of the community.”

Workman says that on top of the dysphoria, the fear of social and familial rejection weighs heavily.

“There’s the anxiety of: how am I going to live my life like this? What’s going to happen to me? Will I be alone forever? So it’s no surprise to me at all, given the environment that trans people face, that there are high rates of depression and high rates of suicide and self-harm.

“Honestly, before I came out, I was solely interested in finding somebody to fix me and just make me, you know, ‘normal’ – I wanted to be counselled out of it. And it very quickly became apparent that that’s just not possible. The only treatment that we have for people with trans identities is transition. It’s the only thing that it works.

“I said, I want either to live as a woman or to die. And my psychologist said, well, you know, the second one’s not an option. And that was the day that I decided to transition.”

For some, the journey has been longer. Clare Headland, a patient services assistant at the Austin, began transitioning in her mid-60s after a lifetime of intractable depression and suicidal thoughts.

Now aged 73, she is deeply happy and proud, despite the dangers she says are part of the territory.

“I was born in a time when that kind of thing wasn’t accepted or even countenanced,” she tells TMR. “I was a very girly boy, but because I was in a male body I was always expected to become a man and a husband and a father and grandfather. I married three times and divorced three times and I have seven beautiful children to show for it.

“But for the whole of my life until about seven years ago, I didn’t know anything about transgender stuff.

“I saw a huge number of GPs, psychiatrists, psychologists, primal therapists, rebirthing people, because I was chronically depressed, unhappy, ashamed of myself. I prayed to be run over by a truck or develop cancer or otherwise escape from the horror and the anguish of being a weakling and an inadequate human being.”

It was at the Northside Clinic in Fitzroy that she found the doctor who first raised gender as an issue, and referred her to the Monash gender clinic where she was assessed and diagnosed.

Headland wishes more health professionals dealing with chronic depression would consider gender identity as a possible cause.

“People say, why didn’t you change earlier? I didn’t know what I could change into. There are hundreds of thousands of people like me who have lived their lives with that mental ill health and depression and suicidal thoughts and bad marriages and alcoholism and are still living that life of shame and secrecy because they still have not found somebody that would ask that question.”

If it’s a rough road before the decision to come out, it doesn’t necessarily get easier immediately after. First, Workman had to wait months to see an endocrinologist, just at the time when she felt she couldn’t waste another second.

Then, because surgery is hardly offered in Australia, like most people she went to Thailand. In a country where transgender is conflated with homosexuality, she had to convince a hospital psychologist that she’d been a gay man, which was not the case. And the costs of being stuck in a hotel room for a month, on top of the medical expenses, were enormous.

And yet the change was worth it, despite the risks, difficulties and motives that are still often profoundly misunderstood.

“Germaine Greer once famously remarked that if having a uterus installed was part of the gender reassignment surgery, no man would do it,” Workman says. “First of all, we’re not men. But secondly, if it were possible, I would absolutely do it. What people don’t understand about us is that we don’t just want the good stuff. We want all of the stuff.

“We want the whole experience whether you think it’s good or bad.”

LIFE AFTER TRANSITION

Workman now works in television, including on the ABC’s comedy show Shaun Micallef’s Mad as Hell, but has made her career writing exquisite and melancholy long-form narrative comedy shows. The most recent and her first post-transition was Giantess, a metaphorical tale of a girl taken captive in early adolescence and eventually released. It’s a beautiful piece, suffused with relief and hope.

But Workman didn’t take it to the Edinburgh Fringe Festival, for fear of where she would have to stop on the way: “Dubai, where it’s illegal for me to exist? In Singapore it’s illegal to be gay, so God knows what they’d think of me.”

Unfortunately, she often also fears for her safety here in Australia, where acceptance is still only partial – including among the people whose job is to help.

“Because I travel for my job, I’m always going to new doctors in different places. Quite often I’ll get doctors who have no understanding and will misgender me and deadname me [call her by her former name] and refuse to give treatments. I’ve even been physically ejected from a doctor’s surgery for asking for hormones.” That was in Melbourne.

Since Headland began living and working as a woman in Melbourne, she has experienced fear not only of humiliation but of violence – even though, in her words, she’s built like a brick shithouse.

“It’s part of the territory,” she says. “When you do something this outrageous and so far outside most people’s comfort zones, you have to think that you’re going to be victimised. There’s so many angry people out there looking for something to express their anger at.

“When I was first walking up and down the street, dressed as a female, I used to feel like I had a target painted on my back. I’m very conservative in the way I dress, but still, I travel by public transport every day. I used to go on trains until I got bashed up twice and now I use buses. You feel vulnerable and afraid just going out the front door into the street.

“But, you know, poofter bashing was Australia’s national sport 20, 30 years ago. Time goes on and people get the idea and it becomes acceptable – and then we find something else to beat each other up over.”

For GPs, understanding, not expertise, is the key, Dr Cheung says.

“It’s okay to make a mistake. If you are willing to learn, the more trans people you speak to the more you will realise that they are just ordinary people in need of help and we are in the best position as medical professionals to help them.

“They have often thought long and hard to get up the courage to come and ask for help, so we need to do our best to make people feel comfortable and not add to the distress that they already feel.”

Workman says she can’t imagine going back. “Sometimes I try to remember what it was like before and I just really can’t, it seems surreal that I was ever anybody else. I’m just so happy with how I look and how I feel and my life is just a million times better.”