Introduction to Trans and Gender Diverse Healthcare

Introduction

  • Tessa is a fellow of the Royal Australian College of Dental Practitioners, working at the Pregnancy Advisory Centre at Shine SA.
  • She is a Shaxeville Health Doctor and part of the leadership program as one of the medical leads for education and advocacy.
  • At the Pregnancy Advisory Center, she is a medical consultant passionate about medical education to improve access to inclusive sexual and reproductive health care within the community.
  • The presentation will cover key concepts, language, definitions, gender-affirming care (informed consent model), inclusive practices, mental health, and resources.

Acknowledgements

  • Acknowledgment of learning on Kangaraland and Shine SA's acknowledgment of Aboriginal and Torres Strait Islander people as Australia's First People.
  • Respect is paid to elders past and present, acknowledging the rich history of gender diversity within First Nations communities.
  • The presentation is from a healthcare practitioner's perspective (a cis woman), emphasizing that medical knowledge does not equal lived experience.

Key Concepts

  • Sex, gender, gender expression, and sexuality are distinct.
  • Gender identity differs from gender expression, biological sex, sexual attraction, and romantic attraction.
  • Transgender individuals' experiences within the LGBTQIA+ community are unique due to the gender aspect, requiring specific trans-inclusive considerations.
  • A trans and gender diverse person is someone whose gender is different from what was presumed for them at birth.
  • The umbrella term of trans and gender diverse covers a huge range of experiences.

Language

  • Terms like "cis" and "trans" are borrowed from chemistry, referring to isomers with different arrangements in space.
  • Cis substituents are on the same side, while trans substituents are on opposite sides.
  • People use a variety of terms to describe their gender authentically, such as gender non-conforming, gender fluid, or genderqueer.
  • Use person's terms for their body while accurately describing someone's audits to impact medical care.
  • Assigned female/male at birth is acceptable to be inclusive and accurately describe gender and assigned gender.
  • Important to note the intersex community where nothing is binary, including biological sex.

Intersex Community

  • Intersex people are born with normal differences of chromosomes, gonads, hormones, or genitals.
  • Discovery of being intersex can happen at different life stages or never.
  • It's important to include variances in biological sex when discussing gender identity and expression.

Historical Context and Prevalence

  • Trans and gender diverse individuals have always existed, seen in indigenous associations with more than fifth genders, ceremonies, and rituals.
  • There have been many significant gender diverse and gender non-conforming events throughout history.
  • Estimating prevalence accurately is difficult due to census limitations, but it's thought to be around 2% of Australia's population.
  • Increased visibility and safety contribute to more people identifying as trans and gender diverse.

Gender Affirming Care

  • Gender affirming care includes a range of actions to manifest one's authentic self.
  • Actions should be personally affirming, accessible, affordable, and safe.
  • Cisgender individuals also practice gender affirmation daily.
  • Common types of affirmation: social, medical, surgical, or legal.

Social Affirmation

  • Individuals can start experimenting to determine the social affirmations that best fit their identity.
  • Trying different names and pronouns, wearing affirming clothing, hair modifications, body shape modification (binders, padding), and coming out to family and friends.
  • Speech pathology to assist those who want it, is available between 6−126-12 months, and the goal is to achieve the goals that a person might have regarding their voice.

Legal Affirmation

  • Updating name or gender marker at work, changing birth certificates or passports.
  • In schools, public schools generally have rigorous inclusivity practices regarding chosen names and pronouns.
  • Private schools also have a duty of care to students.

Medical Affirmation

  • May involve hormones or puberty suppression.
  • The informed consent model is used for gender-affirming care in Australia.
Informed Consent Model
  • Primary healthcare providers give proper information and actively listen to the person to make informed decisions. This is the gold standard because the the transgender person is seen as th expert of their own need and experience.
  • No formal psychiatric assessment is required.
  • Individualizes care and reduces barriers. Medical professional follow guidelines to provide sufficient care, such as the Balsbat guidelines.
Steps
  • Initial review: medical history, family history, medications, allergies, and substance use.
  • Open questions to allow the person to tell their story to understand relationship with gender, duration, and support network.
  • Asking whether someone has already started HRT is essential when understanding what's going on with the patient.
  • Examination, taking a trauma-informed approach to explain investigations.
  • Blood tests for baseline measures.
Hormone Education
  • Critical part of the informed consent process.
  • Matching goals, expectations, limitations, and potential irreversible changes.
  • For example, feminizing hormone therapy is not going to change the tone and pitch of someone's voice.
  • Detransition can happen, but data shows it's often due to safety concerns, not changes in gender identity.
  • Close monitoring for the first 12 months, then less frequent check-ups.
Examples
  • Masculinizing hormone therapy (MHT): body shape changes, voice changes, hair growth. One to six months to generally appear and stop.
Informed Consent Form
  • Detailed form covering masculinizing and feminizing hormone therapy (microdosing options for genderfluid/nonbinary individuals).
  • Covers: possible side effects, medical monitoring, fertility, contraception, safe sex, prevention of STIs, and overall health. Have patient read and consider possible side effects.
  • The person is at the center of the process at all times.
Doctor's Role
  • Start low, go slow. Start at low dose for the first one to three months.
  • Individualize medication support based on goals.
  • Connect with allied health and peer community support to have a more comprehensive treatment plan.
Fertility Preservation
  • An essential discussion should be had with someone before beginning the treatment.
  • HRT might impact future fertility, this should be taken into consideration.
  • Fertility preservation processes are mostly in the private sphere, sometimes delaying gender affirmation due to funding.
  • Gender-affirming hormones do not equal contraception.
Contraception
  • People with uteruses need to consider additional contraception since testosterone is teratogenic. (harmful to the fetus)
  • Almost all options are available, except estrogen-containing contraception.
  • Popular methods: Mirena/Kyleena IUDs, Depo injections, or condoms.
Gender Affirming Care for Minors
  • Children's hospital has an excellent multidisciplinary program.
  • Stages: puberty blockers (reversible, no court authorization required) and gender-affirming care.
  • Both parents needed to consent along with the child.
  • Most hormone prescribers will seek a psychiatrist as part of the team before starting stage two.

Surgical Affirmation

  • Essential step for some individuals.
  • Various surgical affirmations: top surgery (chest reduction, breast augmentation), bottom surgery (odoplasty, phalloplasty), middle surgery (fat transfer), and head/neck surgery.
  • Limited providers in South Australia.

Gender Diversity and Mental Health

  • Important to note is the discussion around mental health when working with someone that's transgender.
  • Gender dysphoria (GD) exists within DSM-5, but caution against over-pathologizing or hyper-focusing on it.
  • Mental health comorbidities: disproportionately higher rates of mental health issues in trans folks due to social determinants of health.
  • Higher rates of suicidality (40%), mental disorders, violence, and sexual assault.
  • Problems are not innate, but results of the current societal structures and pressures.
  • Gender-affirming care saves lives. Gender-affirming care includes mental health care because of social determinants of health.
  • It doesn't mean that you need to kind of tick a box before you start HRT, but more kind of actively seeking that mental health history, making clear that it's not a barrier to care.

Specialist Mental Health Care May Be Needed

  • Severe mental health challenges (depression, anxiety, suicide attempt, psychosis).
  • Concerns that gender dysphoria is not the most accurate diagnosis (body dysmorphic disorder, dissociative identity disorder).
  • Concerns about capacity to consent.
  • Complex presentations (neurodivergence).

Preventative Health Screening

  • Treatment of those patients are very much at risk of being under screened for cancer screening.
  • Cervical screening, self-collection is an option.
  • Breast screening, depending on surgery history.
  • Prostate cancer screening.
  • Organ inventory: acknowledging what organs are present or absent to guide the screening questions.
  • Basic health maintenance (smoking, nutrition, alcohol, physical activity).

Five Things You Can Start Doing Now

  • Practice using pronouns.
  • In a challenging setting, wearing programs can signal inclusivity.
  • Prevent trans broken arm syndrome: addressing the presenting issue without inappropriately focusing on gender affirmation.
  • Being properly informed: acknowledging past negative experiences with the healthcare system.
  • Intake forms and electronic medical records are often binary, push against that and show resistance.

Conclusion

  • Allyship is an action, needing to be used daily.
  • Mistakes are okay, apologize and move on.

Resources

  • TransHub (community and clinician resources).
  • AUSPAC standards of care, international guidelines.
  • SA practitioners list (inclusive doctors).
  • TransNurse SA and TransFam SA (community-led groups).