The Lessons of a Decade

The end of a year is always a time of personal reflection, but this one feels like it requires more than previous years. Maybe because it’s the end of another decade (seriously, where did the last ten years go?!), or maybe because so much has happened in a relatively short amount of time.

I turned 40 this year; and I was ok with it. As opposed to the mini breakdown I had months before my 30th. I had set myself all of these arbitrary goals, probably similar goals that you have set yourself: have a partner, be on the way to owning property (i.e. have a mortgage), have a successful career, be happy. Turns out I had none of that at 29, hence that mini breakdown. My 30th came and went, I had an incredible night surrounded by many people near and dear to me, but those aches from unachieved goals lingered. I won’t bore you with a detailed summary of the last ten years, but I feel like a reflection of what I’ve come to know in that time might be useful for some of you. Yes, it’s personal and we should all live our life the way we want to, but some of these things might resonate with you:

You will continue to change and learn more about yourself every year: this is hard to digest as a twenty-something. I felt I knew what I was doing, where I was going, who and what mattered most. The simple fact is priorities change; what you once see as critical to your daily life pales into insignificance when your energy is diverted to new challenges, or new environments. I think there is some humanistic yearning for this ongoing discovery – I do not think we were designed to remain stagnant for all of our lives. This does not necessarily mean a life of constant travel or career changes – change and learning about yourself is as individual a process as you are and there is no blueprint for it. Even if you are convinced that where you are right now is where you will be in ten years, why close the door to any worthwhile opportunity that may present? So, instead of stressing about what next week, or next year is going to bring, try to pay more attention to here and now, and to those in your life who help you be the best you can be right now. And, a real goal of mine is to let people know that I appreciate them, care for them and thank them for any good they do for me. The world sure could use more appreciation and gratitude.

Do not spend too much time regretting decisions made: I think most decisions I have made along the way were the right decision at that time, and with different perspective or understanding, I may have decided differently, but how can you worry about something that you didn’t know at the time? I regularly look back at an opportunity I had nearly 20 years ago for a six-month exchange at McGill University in Montreal, Canada. Of course, things may have taken a different path if I had taken up that opportunity, but life circumstances at the time led me to decide against it. Initially, there was regret, but I have come to realise that this was the right decision for that time. It is probably something I would do differently now, but these decisions are always much easier in hindsight. So, instead of worrying about what could be, or what could have been, try to focus on what is and the possibilities that brings.

You will spend less time trying to be perfect and trying to be liked by everyone: this has been a tough lesson. It was always one of the things my ex partner (who remains a dear friend) would ask me – “why do you need everyone to like you?” I wish I knew the answer to this, but what I can say with some certainty is, you will begin to care less about being liked and care more about those relationships and connections that are genuine and offer each person mutual benefit. We are social creatures – we were not designed for isolation, so perhaps that plays some part in wanting to be liked, but the lack of genuine relationships and interactions is a recipe for loneliness, that I can assure you of. Quality over quantity is ever present.

This leads onto the next point, something I am only recently absorbing: know that actual interactions with actual people will always surpass online interactions. I freely admit that I am guilty of having too great of an online presence – I post numerous stories and updates, mostly photos these days, but nonetheless, most of you would have a fair idea of my habits simply from social media. Yet, I am as lonely today as I was at the start of this decade. That is possibly the reason for the posting – I am yearning for interaction, for connection, which for whatever reason, I have not been getting enough of in the physical world. But is all this online time taking away from the physical time? It is difficult to admit to this, but something I need to acknowledge. The only thing being connected online has brought me is more disconnection. Facebook has been in my life for 12 years and I wonder if it is a coincidence that these 12 years have been my toughest.

Bushrangers Bay selfie
Happy place: a beach, hiking (Bushrangers Bay, near Cape Schanck, VIC, 2019)

Take that chance – generally, the worst that can happen is you learn some things along the way: a question I have been asked more times than I care to remember is “why do you keep changing career path?” Yeah, I’ve worked in retail, accounting, fitness, technology, even dabbled a little with writing and editing, and now I am less than three weeks away from commencing my nursing career. I have never been ashamed to seek something better – one of the greatest traps in life is to settle. This can apply to many situations, not just work life. Don’t settle – you are worth more than that. It might not be clear which path you want to take, but just seeking it is a good start. The alternative is the all-too-real realisation you will get one day of “what if?” and that’s something worth avoiding if you can. I know there are some situations in life where it is not always immediately possible to implement change – the realities of finances and dependants is ever present, but don’t let this lead to a dead end. You might reach a point where you want it bad enough that there is no alternative other than to make it happen. My last three years studying full time, working part time and completing unpaid clinical placements is a decent example – as tough as this was, I saw no other way than to push through it. It involves sacrificing things (such as my desire to travel frequently), but this is short term. Take that chance, at least you can say then that you tried, which is infinitely better than asking “what if?”

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Happy place: a stunning sunset (one of my favourite moments of the decade, near Wreck Beach, Vancouver, Canada, 2017)

This decade has undeniably been the toughest of my life so far and I wouldn’t have it any other way. I have grown so much and learned many things about myself that could not be possible if everything was just swimming along. Adversity is a great teacher – you always have the option to tackle it, or ignore it. While it is difficult to see at the time (sometimes impossible), you will be able to look back and recognise how it helped you along your path and how you are a better person for coming out the other side. Know too that everyone struggles from time to time – this has been one of my most important lessons – and the best way to get through that is remind yourself of your purpose, your hopes and put yourself out there in a genuine sense. And for me, that means less time online and disconnected. Happy new year and I hope some of this helps, or at least resonates, as we all try to push on into a new decade. May it be what you need it to be.

melb rainbow
Happy place: nature, especially when it shows off like this (somewhere along the Yarra River, Melbourne, VIC, 2018)

What’s the T? An exploration into gender dysphoria and why it matters

I am a gay male, yet I feel I am not fully aware of the diversity under the LGBTIQ+ umbrella. The issues gay males face now has some attention of the broader community and while there is still a long way to go, there is even more work to be done to bring transgender, gender diverse and non-binary individuals to the same status.

It is appropriate timing for this Friday (May 17) to be IDAHOBIT Day – the International Day Against Homophobia, Biphobia, Interphobia and Transphobia. Sadly, these types of awareness days are still so vital as LGBTIQ+ individuals continue to be significantly over-represented in poorer mental and physical health outcomes than the general population. It starts with compassion, empathy and education – and I hope the following helps with that.

To clarify terminology, transgender is an umbrella term used to describe a person whose gender differs from that assigned to them at birth and may not fit into the binary categories of male and female (Brady & Molloy, 2018). Gender non-conformity refers to the extent to which a person’s gender identity, role, or expression differs from the cultural norms prescribed for people of a particular sex (Coleman et al., 2012). It follows then that gender dysphoria refers to the distress caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (including the associated gender role and/or primary and secondary sex characteristics) (Coleman et al., 2012). It is important to note that not all gender non-conforming people will experience gender dysphoria, and that gender dysphoria can occur at various stages of life, although symptoms tend to heighten when secondary sexual characteristics develop during puberty (Atkinson & Russell, 2015).

Trans Flag
Above: The Transgender Flag and Symbol. Credit: WeThePeople Clothing. Below: Pride March, Melbourne, 2017.

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When this distress is significant enough to cause an impairment in functioning, and the person meets any two of six diagnostic criteria as set out in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) for at least six months, a diagnosis of gender dysphoria is made (Brady & Molloy, 2018).

Should gender dysphoria be considered a mental illness?

Consider the issue this raises – if a person’s expression of gender characteristics and identity does not match the cultural norm in a society and this causes them distress, should this be judged as a mental illness? Classing it this way attaches a pathological association (meaning that it is caused by a physical or mental disease), and this invariably leads to stigma and discrimination. Consider that homosexuality was treated in the same way and was only removed from the DSM in 1973 and the effect that this removal has had on changing social acceptance (although stigma and discrimination still exists). This stigma can result in prejudice and discrimination leading to minority stress, which is an additional stress minority groups can suffer on top of general stressors all people face, making them more vulnerable of developing mental health concerns like depression and anxiety (World Professional Association of Transgender Health (WPATH), 2010). It is important to recognise that these symptoms are generally the result of social stigma and exclusion and are not inherent to being transgender or gender non-conforming (WPATH, 2010). Please reflect on whether you think gender dysphoria should be classed as a mental illness, as it currently is in the DSM-5, as you read on.

One argument made for gender dysphoria remaining as a diagnosable condition is that it allows for access to health care and various treatment options (Coleman et al., 2012). When the DSM was updated in 2013, the term gender dysphoria replaced gender identity disorder (which was categorised as a sexual disorder), in an attempt to remove the pathological connection from being transgender (Brady & Molloy, 2018). The transgender community and their advocates remain unsatisfied with this assertion, feeling it perpetuates the implication of a mental illness and allows stigma and prejudice to continue. Furthermore, it remains necessary for transgender patients to be given a gender dysphoria diagnosis to access required health care, including hormone therapy and surgical specialists (Brady & Molloy, 2018).

Contrast this with the 2018 update to the World Health Organisation’s ICD-11 (International Statistical Classification of Diseases and Related Health Problems) – the term gender incongruence has been introduced to replace gender dysphoria, and importantly, it has been moved out of the mental disorders category, into a sexual health condition category (WHO, 2018). The WHO stated that their reason for doing so is that “while evidence is now clear that it is not a mental disorder, and indeed classifying it in this way can cause enormous stigma for people who are transgender, there remain significant health care needs that can best be met if the condition is coded under the ICD” (WHO, 2018). This change has delighted transgender advocates as it steps away from the mental illness assumption while still allowing medical and psychiatric treatment for a sexual health condition.

There are two significant factors which make clinical intervention important – the continuing over-representation of the LGBTIQ+ community in poor mental health statistics compared to the general population; as well as the positive results seen through treatment once it is commenced.

One study reported that 71 per cent of people with gender dysphoria will be diagnosed with another mental health condition during their lifetime (Buzwell, 2018). Depression (74.6 per cent) and anxiety (72.2 per cent) are most common, while post-traumatic stress disorder (23.1 per cent), personality disorder (20.1 per cent) and psychosis (16.2 per cent) are significant concerns (Buzwell, 2018). There have also been links found between gender dysphoria and autism and eating disorders, with further research being required to fully understand this (Buzwell, 2018).

Further studies show consistently high rates of mental health diagnoses in those with gender dysphoria: Telfer, Tollit, and Feldman (2015) reported that up to 50 per cent of young people with gender dysphoria have self harmed, and 28 per cent will attempt suicide. Brady and Molloy (2018) suggested even higher rates, where 84 per cent of participants had contemplated suicide and 48 per cent had attempted suicide in their lifetime. These studies showed that these alarmingly high rates of mental health issues are predominately caused by ongoing discrimination, stigma and transphobia, as opposed to being a result of being transgender (Brady & Molloy, 2018).

In relation to treatment outcomes, improvement is evident. Treatment may include a combination of psychotherapy, hormone therapy and surgery – meaning that the prognosis of gender dysphoria is generally positive (Atkinson & Russell, 2015), assuming treatment is sought and effectively managed. Successful treatment is individual – what may assist one person resolve their gender dysphoria could be very different to another person’s treatment, e.g. one person may be satisfied with a change in gender expression, while another person may wish to undergo body modifications (Coleman et al., 2012). Treatments are safe and effective in the long term and very few individuals that have chosen surgical reassignment have regretted their decision later in life (Atkinson & Russell, 2015).

Further evidence shows that the most vulnerable time for people with gender dysphoria is the time between when they decide to seek treatment to when they commence treatment. A study by Erasmus, Bagga and Harte (2015) showed that 28 per cent of gender dysphoria sufferers considering treatment had a past-year suicide attempt, compared to one per cent of those who had undertaken gender-affirmative treatment. This significantly heightened pre-treatment suicide risk was also found in another study by Telfer, Tollit & Feldman (2015), highlighting the critical need for timely access to health care support for this population.

Experiences in health care

Any meaningful therapeutic relationship will be based on openness and trust, yet, evidence shows that it is common for transgender patients to hide their gender identity from health professionals (Brady & Molloy, 2018). There remains a fear of discrimination, stigma and negativity, with various studies reinforcing this reality:

While one study stated some nurses have negative attitudes towards transgender people, another showed nurses are continuing to assume that all patients fit into a gender binary of either male or female, determined by their sex at birth. This results in transgender patients feeling invisible to nurses and less likely to garner a trusting relationship (Brady & Molloy, 2018).

This negativity and isolation extends to mental health services, where one study from Transgender Equality Network Ireland found 52 per cent of participants had a negative experience when they sought help from a mental health service, while other studies showed pronounced discrimination, blatant disgust and noticeable discomfort from mental health professionals when a patient revealed they were transgender (Brady & Molloy, 2018).

Other issues reported in studies (Puckett, Cleary, Rossman, Mustanski, & Newcomb, 2018) highlighted misgendering or being referred to as an inappropriate gender in public health care settings; unnecessary and invasive scrutiny into patient’s personal lives; denial of care; uninformed and/or intolerant medical providers; and being shamed by providers. Some patients reported bias and stigma from mental health providers, where their mental health was inappropriately used as rationale for denying care (Puckett et al., 2018).

There are also systems issues within medical and mental health settings: some patients felt that needing a letter from a therapist before treatment was unreasonable and unnecessary, while requiring a diagnosis also creates a barrier to accessing care (Puckett et al., 2018). Some patients reported feeling unsafe in a medical system that is not designed for them and that the fear of ridicule prevented them from seeking transition-related care. A lack of knowledge on gender-affirming care, including potential side effects, also causes barriers to effective support. Financial issues (cost of hormones, surgery and associated procedures), as well as insurance coverage difficulties provided yet further barriers for gender-affirming care (Puckett et al., 2018).

Stigma and bias can be explicit and implicit, where it is often unconscious and occurs despite the best of intentions. One large study of over 4,000 first-year heterosexual medical students found that almost half of the participants expressed some explicit bias while 81 per cent exhibited at least some implicit bias towards gay and lesbian individuals (Bidell & Stepleman, 2017). The experience of real or perceived stigma and discrimination in health care leads to many LGBTIQ+ individuals deciding to not disclose their true identity, or avoid accessing health care altogether. LGBTIQ+ patients report significantly lower satisfaction with their health care provider than heterosexual patients do (Bidell & Stepleman, 2017). This is one reason that I have attended an LGBTIQ+ friendly clinic for many years – I did not feel comfortable disclosing my identity or discussing my concerns in a standard clinic and I do not see myself changing that in the near future.

A critical factor of any therapeutic nursing relationship is to advocate for the patient in our care, and for that care to be person-centred. It should be a partnership that prioritises on the patient’s unique needs with compassion and dignity. There is a responsibility to care for each patient in a respectful and equitable way, regardless of their status. Mental health nurses in particular need to ensure they are providing an environment that is safe and welcoming to all, so that any person requiring care can feel comfortable to seek it. It is difficult to provide appropriate and individualised care if the patient does not feel comfortable to disclose their true identity and concerns.

The WPATH issued Standards of Care in 2011 for those seeking help with gender dysphoria, and these should be considered when we encounter a patient with this distress. The standards are:

  • Assess for a diagnosis of gender dysphoria
  • Provide information regarding options for gender identity and expression, and the possible medical interventions available
  • Assess and discuss treatment options for any co-existing mental health concerns
  • If applicable, assess eligibility for hormone therapy. Then prepare and refer the patient for treatment
  • If applicable, assess eligibility for surgery. Then prepare and refer the patient
  • If applicable, provide psychotherapy before hormone therapy or surgery (this is not a requirement). Psychotherapy can include counselling and support for changes in gender role, as well as family therapy and support for family members (WPATH, 2011)

Removing the barriers to care

A successful therapeutic relationship with a transgender patient will often mean needing to use gender neutral language. As gender identity is a spectrum, nurses cannot assume that ‘he’ or ‘she’ will be the appropriate pronoun to use. Often, transgender people do not identify as male or female, and may prefer ‘they’ – put simply though, the correct language and pronoun to use is that which is used by the person themselves, so we just need to ask them (Brady & Molloy, 2018). The use of gender inclusive forms is also imperative, especially ones that allow the person to write in their own gender identity, rather than a tick box set up. A lack of awareness of correct terminology can cause the health care experience to be negative, resulting in this population being less likely to seek help, or avoid it completely (Wilson, 2019). In a recent examination of health care organisation intake forms, 74 per cent included questions about gender and/or sex. Of these, 57 per cent were rated as using affirmative language for transgender and gender non-conforming people. Only 6 per cent of intake forms had free space for people to state their preferred pronouns and 18 per cent included an option to designate a chosen name where this differs from their legal name (Holt, Hope, Mocarski, & Woodruff, 2019).

The result of a specialised and inclusive service can be seen in patient findings from the Gender Dysphoria Clinic in Melbourne. 88 per cent of patients were satisfied with the services they received and this significantly reduced their perceived level of distress. They felt understood in a non-judgemental way and importantly, 70 per cent of patients now felt satisfied with their ability to handle their concerns that brought them to the clinic. This survey was conducted for one month and only included those seeking treatment, yet it still highlights the positive impact of person-centred care. A lengthy waiting list for appointments was the most concerning aspect from this survey (Erasmus, Bagga and Harte, 2015).

With the evidence unsurprisingly pointing to benefits of gender-affirming care, barriers to accessing this care must be eliminated. Ways in which this can be achieved include:

  • Being a professional who is culturally competent of all populations;
  • Exploring and challenging any biases towards minority groups;
  • Training for all staff to use patient’s requested names and gender pronouns;
  • Avoiding disrespectful language such as ‘biological’ or ‘real’, instead, using terms like ‘assigned at birth’ and using the patient’s terminology when possible;
  • Providers should explain why some potentially challenging questions are necessary in an assessment; and,
  • Avoid the use of some medical terminology for the body as they may be upsetting for transgender and gender non-conforming individuals, especially in relation to primary and secondary sex characteristics (Puckett et al., 2018).

It is also important to explore the extent of support the person is having with their interpersonal relationships. If they have family, friends or partners trying to stop them pursuing gender-affirmative care, additional support may be required from health care professionals. Post-treatment support should also be established (Puckett et al., 2018).

Education in practice

Numerous studies show a knowledge gap and lack of formal education among health professionals on transgender people. One study found a large majority of nurses had no understanding of the transgender spectrum and were unable to differentiate between sexual orientation and gender identity. Nursing staff also did not consider a person’s gender identity outside of being male or female as relevant to their nursing practice. This lack of awareness leads to unsatisfactory care (Brady & Molloy, 2018).

This study also reported on the lack of transgender education for nurses, where it was found that only 10 per cent of students had a basic level of care knowledge for transgender people; almost 40 per cent of students felt unprepared to work with transgender patients; 85 per cent felt their nursing education institution did not prepare them; alarmingly, 42 per cent believed a person’s gender identity only mattered sometimes while 13 per cent felt it did not matter at all. In further research of 375 health care organisations, most did not provide their staff with appropriate policies and guidelines for nursing care of transgender people and that only 19.8 per cent of nurses had undertaken any formal training on the topic (Brady & Molloy, 2018). Even a current Google search of transgender care information on hospital websites shows a lack of visibility – other than the Royal Children’s Hospital Gender Service, only the Royal Melbourne Hospital and Mercy Health appear to have specific and easily found transgender care information on their public websites. Some educational and government resources are listed at the end of this article if you wish to explore further.

It is imperative to remember that nurses are advocates and educators. The journey of nursing is an ever-evolving process, where continual learning is required to remain current on nursing practice and hospital policy and procedures for anyone under our care. Optimal care is given when compassion and respect for diversity is upheld, improving the health care outcomes for everyone, especially those in minority groups. This does not mean that any particular group requires special treatment above others, it simply means inclusive, respectful and individualised care based on the needs of the person in our care, with their voice always being heard (Wilson, 2019).

Promoting mental health

The Royal Children’s Hospital (RCH) in Melbourne has a multidisciplinary Gender Service, providing transgender children and adolescents care since 2003. Referral numbers have increased to the extent that the service had as many requests for care (more than 200 new referrals) in 2015 than it did combined for the previous 12 years (Telfer, Tollit & Feldman, 2015). The average age when presenting is 12.3 years, but most patients report gender concerns from the age of three or four. In contrast, the Gender Dysphoria Service at the Monash Medical Centre in Melbourne reports an average presentation age of 40 years, although most patients still report gender identity concerns from an early age (Telfer et al., 2015). Increases in awareness and social change will hopefully see the average age of presentation decrease.

The Victorian Government recognised the need to support these services when they announced $6 million in funding to the RCH Gender Service over four years. This will assist the service to fund adolescent physicians, child and adolescent psychiatrists, gynaecologists, an endocrinologist (for hormone therapy), psychologists and a social worker, as well as a speech therapy service for voice training. Services are regularly evaluated to assess treatment outcomes and inform future evidence-based practice (Telfer et al., 2015).

Australia currently has a unique legal barrier to treatment. Precedent from 2004 classified stage one and stage two treatment in adolescents under 18 years of age as ‘special medical procedures’ which necessitates Family Court of Australia approval before treatment can commence (Telfer et al., 2015). Stage one treatment involves puberty-blocking medication (via gonadotrophin-releasing hormone (GnRH) analogues) and this is entirely reversible. It allows the person to develop without experiencing the associated distress that the development of secondary sex characteristics can cause when that person feels it is not their true gender. Stage two treatment generally occurs around the age of 14 to 16 years, where testosterone or oestrogen is offered. This produces partially irreversible physical changes of the affirmed gender.

A legal challenge in 2013 resulted in the Family Court removing the need for legal approval for stage one treatment (as it is reversible) and also agreed that an adolescent who is ‘Gillick’ competent (medical legal test to determine whether a child under 16 years of age can consent to their own medical treatment without the need for parental permission or knowledge) could consent to stage two treatment (Telfer et al., 2015). However, it is the Court that decides whether the young person is competent and the opinion of medical-legal reports tends to determine competency. It is potentially another form of discrimination, where the court’s involvement is an intrusion into a decision which should ultimately be between the patient, their parents (if the patient wishes) and the health care team.

A reduction in anxiety and depression has been noted after the commencement of puberty-blocking medication, followed by hormone treatment. A follow-up Dutch study 15 years post-commencement of treatment (with some also accessing surgery) determined that the young trans-adults’ quality of life, educational and vocational outcomes matched those of the general population in the Netherlands (Telfer et al., 2015).

When a young person presents with gender dysphoria, it is important that the health care provider validates their gender-related distress. Allowing the person to choose their own path without influence or pressure reinforces individualised care. An ideal situation will cater for collaborative decision-making between the young person, their family or other supports and their care providers (Bonifacio, Maser, Stadelman & Palmert, 2019).

Guidance can be found in the WPATH Standards of Care for hormone therapy, with substantially different treatment regimens for adolescents than for adults (due to the different developmental stages at adolescence). The standards also recommend assessing for both gender dysphoria and other concurrent mental health concerns due to the likelihood of co-morbidity, and advises counselling, supportive psychotherapy or appropriate medications (Bonifacio et al., 2019).

Social transitioning

Social transitioning is the process where a person changes their gender expression to better match their gender identity (Buzwell, 2018). It is an important part of the journey and has been shown to reduce depression and anxiety while improving self-worth in transgender children aged 9-14 years (Bonifacio et al., 2019). Social transitioning can include a name change, choosing a preferred pronoun, altering clothing and/or hairstyle, hair removal or growth, use of a bathroom that matches the person’s desired gender, breast-binding or genital-tucking, and adopting new activities and mannerisms. A transition can include one, a few or all of these factors, gradually or altogether – a social transition is highly individual, as is the timing of it (Buzwell, 2018; Bonifacio et al., 2019). Trans children who have socially transitioned demonstrate comparable rates of depression, anxiety and self-worth as their cisgender peers (those whose birth gender matches their assigned gender) (Buzwell, 2018).

So, what’s the T?

Consider the many issues highlighted in the literature: transgender people face stigma and discrimination in society, but also in the health care system. The majority of health care professionals lack formal training on transgender issues and this leads to substandard care for this minority group. Transgender individuals (as well as other LGBTIQ+ individuals) are vulnerable, with consistently higher rates of depression, anxiety and suicidality compared with the general population. Even a basic understanding of conducting a consultation for gender dysphoria is important, as is identifying the level of support the person has around them (Atkinson & Russell, 2015).

Although identifying as transgender is not pathological, the ongoing inclusion of gender dysphoria in the DSM-5 implies this. Other mental health concerns should be assessed, such as body dysmorphic disorder (a preoccupation with an imagined or slight defect in appearance), borderline personality disorder (a disturbance in self-identity) or Asperger’s syndrome (being prone to obsessive preoccupations that could include gender dysphoria) (Atkinson & Russell, 2015).

Individualised treatment and care is as critical here as it is with anyone else. Some transgender people will be happy to live in their desired gender role, but one large Australian study found that 86 per cent of transgender individuals were either using, or intended to use hormone therapy. 39 per cent also had some form of surgery (Atkinson & Russell, 2015). Evidence shows that hormone therapy reduces distress without adverse psychological or physical effects, but with any medication, it is important to be fully informed of reversible and permanent side effects (Atkinson & Russell, 2015). Counselling with a mental health professional proficient in transgender health is recommended, especially in assisting diagnosis of co-morbid mental health conditions.

Changing legal documents is another affirmation of gender, with Federal Government guidelines issued in 2013 stating ‘sex reassignment surgery and/or hormone therapy are not prerequisites for the recognition of a change in gender in Australian Government records’ (Atkinson & Russell, 2015). This means that a letter from a registered medical practitioner or registered psychologist is all that is required to change gender on documents such as Medicare, passport, birth certificate, Centrelink, driver’s licence and Australian Tax Office records, and the forms to change documents are available to download from government websites.

Once patients have been on hormone therapy for at least one year and living in their desired role, surgical interventions are considered. These are often referred to as ‘top’ procedures (chest reconstruction or breast augmentation) and ‘bottom’ procedures (removal and creation of new genitalia). Surgical reassignment tends to occur overseas due to greater expertise and lower cost (Atkinson & Russell, 2015).

Consider that the objective of treatment is not to change how the person feels about their gender. Instead, it is to manage or resolve the distress being caused and support should be given if the individual wishes to make changes to align their external self with their internal gendered self. Remember that there is no correct way to transition and it should be guided by the individual, both in the degree of their wishes to transition, and the timing (Buzwell, 2018).

The following recommendations suggest methods to improve the health care experience for transgender and gender non-conforming people:

  • Health care organisation websites should mention, where applicable, expertise in working with this community;
  • Include links to suitable and professional resources and support groups;
  • Detail all services offered for transgender and gender non-conforming people;
  • List any memberships to professional organisations, such as WPATH;
  • Intake forms should ask for gender or gender identity, not sex;
  • Include free space for people to write in a response for preferred pronoun and/or name;
  • Ask for “I wish to be called…” so that staff are aware of these wishes during consultations (Holt, Hope, Mocarski, & Woodruff, 2019).

In following the WHO’s lead, the American Psychiatric Association should remove gender dysphoria from the next update of the DSM. In doing so, the hope is to reduce or remove the stigma attached to being transgender and the associated distress caused by this stigma, in the same way that removing homosexuality from the DSM was intended to do. The reality is that there is still a long way to go for all LGBTIQ+ individuals to be free of stigma and discrimination, but if the medical field is adding to the stigma (as is the case with gender dysphoria being listed as a pathological issue), the stark over-representation of poor mental health and physical health statistics in the LGBTIQ+ community will not improve.

The WHO’s move to rename gender dysphoria to gender incongruence in the latest ICD-11, and classify it as a condition relating to sexual health is intended to remove stigma and pathological assertions. An international transgender rights organisation, Global Action for Trans*Equality (GATE), is advocating for the complete removal of this category, and instead creating a ‘Z code’ specifically for transgender adults and children. Z codes are used by the WHO to describe non-disease states that can impact health in general and mental health care. Given they are for non-disease states, they are non-pathological in nature, assisting the removal of stigma attached to this issue (Bidell & Stepleman, 2017).

It is important to note that there is currently an even division in professional opinion as to whether gender incongruence should be a diagnosis in the ICD-11 at all (or gender dysphoria in DSM-5 for that matter). Those that believe it should be included mainly cite reasons that a diagnosis enables access to health care, provides a “protected status” to the transgender child and facilitates reimbursement (although the general lack of insurance coverage in this area is yet another barrier for those seeking treatment). Those that believe it should be removed commonly cite removing the pathology, stigma and discrimination associated with a disease assumption as their reasons (Bidell & Stepleman, 2017).

The concept of minority stress is now an important context of the increased prevalence of health and psychosocial problems among the LGBTIQ+ community. This highlights that the increased incidence of poor mental health here is caused by social forces (stress, prejudice, stigma, discrimination), not a pathological (disease) state. This change could not have occurred without the removal of disease classification of homosexuality and transgenderism, so it follows that gender dysphoria or gender incongruence should follow the same path.

 

These helpful resources are available if you need more information or just want some support:

Main healthcare support is the Royal Children’s Hospital Gender Service, which has published the Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents Version 1.1 (2018):

https://www.rch.org.au/uploadedFiles/Main/Content/adolescent-medicine/australian-standards-of-care-and-treatment-guidelines-for-trans-and-gender-diverse-children-and-adolescents.pdf

(endorsed by ANZPATH, the Australian and New Zealand Professional Association for Transgender Health)

 

Gender Dysphoria Clinic – Melbourne

https://www.glhv.org.au/sites/default/files/gender_dysphoria_clinic.pdf

 

Minus18 – youth-driven support organisation, also provides training on supporting trans and gender diverse clients

https://www.minus18.org.au/index.php/workshops/adult-professional-training

 

In terms of hormone therapy medications available, NPS MedicineWise has a resource:

https://www.nps.org.au/australian-prescriber/articles/prescribing-for-transgender-patients

 

Educational resources:

For primary health care staff – ANZPATH (Australia and New Zealand Professional Association of Transgender Health) has a free 60-minute online course to promote more inclusive and responsive services for transgender, gender diverse and non-binary people in primary health care settings

https://www.anzpath.org/education

 

LGBTI National Health Alliance – includes many links to other LGBTIQ+ organisations

https://lgbtihealth.org.au/

https://lgbtihealth.org.au/trainingpackages/

 

Transgender Victoria

https://transgendervictoria.com/information/for-clinicians

 

Shine SA – Gender Wellbeing Service

https://www.shinesa.org.au/community-information/sexual-gender-diversity/gender-wellbeing/

 

Government resources:

 Victorian Government – School policy on gender identity

https://www.education.vic.gov.au/school/principals/spag/health/Pages/genderidentity.aspx

 

South Australian Government, Dept of Education – Supporting students, Gender diversity and transgender (very detailed, includes health-related support info)

https://www.education.sa.gov.au/supporting-students/health-e-safety-and-wellbeing/health-support-planning/managing-health-education-and-care/neurodiversity/gender-diversity-and-transgender

 

Victorian Government, Dept of Health – report on Transgender and gender diverse health and wellbeing (2014)

https://www2.health.vic.gov.au/Api/downloadmedia/%7B3165C620-0649-4EA1-BBA1-4CA4CEF4F58A%7D

 

Services & Support:

National – Headspacehttps://headspace.org.au/

Switchboardhttp://www.switchboard.org.au/

Q-Lifehttps://qlife.org.au/

 

Support services:

A Gender Agendahttps://genderrights.org.au/

The Gender Centrehttps://gendercentre.org.au/

Transhealth Australiahttp://www.transhealthaustralia.org/

 

VIC Services:

The Royal Childrens’ Hospital Gender Servicehttps://www.rch.org.au/adolescent-medicine/gender-service/

Monash Health Gender Clinichttp://monashhealth.org/services/services-f-n/gender-clinic/

Support:

Transgender Victoriahttps://transgendervictoria.com/

Seahorse Victoriahttp://seahorsevic.com.au/main/

ButchFemmeTrans Melbournehttps://www.facebook.com/butchfemmetrans/

Rainbow Network Victoriahttp://www.rainbownetwork.com.au/

PFLAGhttp://pflagaustralia.org.au/about

 

References

Atkinson, S. R., & Russell, D. (2015). Gender dysphoria. Australian Family Physician,      44(11), 792-796. Retrieved from             https://www.racgp.org.au/afp/2015/november/gender-dysphoria/

Bidell, M. P., & Stepleman, L. M. (2017). An Interdisciplinary Approach to Lesbian, Gay, Bisexual, and Transgender Clinical Competence, Professional Training, and Ethical       Care: Introduction to the Special Issue. Journal of Homosexuality, 64(10), 1305-1329.        doi: https://doi-org.ezproxy.lib.rmit.edu.au/10.1080/00918369.2017.1321360

Bonifacio, J. H., Maser, C., Stadelman, K., & Palmert, M. (2019). Management of gender dysphoria in adolescents in primary care. Canadian Medical Association Journal, 191(3), E69-E75. doi: http://dx.doi.org.ezproxy.lib.rmit.edu.au/10.1503/cmaj.180672

Brady, M., & Molloy, L. (2018). Mental health nursing for transgender people: Are we       caring? (2018). Mental Health Practice (2014+), 21(05), 28-33. doi:       http://dx.doi.org.ezproxy.lib.rmit.edu.au/10.7748/mhp.2018.e1223

Buzwell, S. (2018). Gender dysphoria. O&G Magazine: LGBTQIA, 20(4). Retrieved from        https://www.ogmagazine.org.au/20/4-20/gender-dysphoria/

Charter, R., Ussher, J. M., Perz, J., & Robinson, K. (2018). The transgender parent:           Experiences and constructions of pregnancy and parenthood for transgender men in      Australia. International Journal of Transgenderism, 19(1), 64-77. doi:https://doi-org.ezproxy.lib.rmit.edu.au/10.1080/15532739.2017.1399496

Cicero, E.C., & Wesp, L. M. (2017). Supporting the Health and Well-Being of Transgender Students. The Journal of School Nursing, 33(2), 95-108. doi: https://doi-           org.ezproxy.lib.rmit.edu.au/10.1177/1059840516689705

Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., … Zucker, K. (2012). Standards of care for the health of Transsexual, Transgender, and       Gender-Nonconforming People: World Professional Association for Transgender   Health (WPATH). International Journal of Transgenderism, 13(4), 165-232. doi:         10.1080/15532739.2011.700873

Erasmus, J., Bagga, H., & Harte, F. (2015). Assessing patient satisfaction with a     multidisciplinary gender dysphoria clinic in Melbourne. Australasian Psychiatry,         23(2). doi: https://doi.org/10.1177/1039856214566829

Holt, N. R., Hope, D. A., Mocarski, R., & Woodruff, N. (2019). First impressions online: The inclusion of transgender and gender nonconforming identities and services in mental healthcare providers’ online materials in the USA. International Journal of   Transgenderism, 20(1), 49-62. doi: https://doi-  org.ezproxy.lib.rmit.edu.au/10.1080/15532739.2018.1428842

Puckett, J. A., Cleary, P., Rossman, K., Mustanski, B., & Newcomb. M. E. (2018). Barriers to gender-affirming care for transgender and gender nonconforming individuals.     Sexuality Research and Social Policy, 15(1), 48-59. doi: 10.1007/s13178-017-0295-8

Telfer, M., Tollit, M., & Feldman, D. (2015). Transformation of health‐care and legal          systems for the transgender population: The need for change in Australia. Journal of Paediatrics and Child Health, 51(11), 1051-1053. doi: doi.org/10.1111/jpc.12994

Wilson, D. (2019). Inclusive healthcare for members of the sexual and gender diverse         community. Australian Nursing and Midwifery Journal, 26(5), 34. Retrieved from        https://search-proquest-com.ezproxy.lib.rmit.edu.au/docview/2161599276?accountid=13552

World Health Organisation. (2018). ICD-11: Classifying disease to map the way we live and die. Retrieved from https://www.who.int/health-topics/international-classification-of-diseases

Wylie, K., Knudson, G., Khan, S. I., Bonierbale, M., Watanyusakul, S., & Baral, S. (2016). Serving transgender people: Clinical care considerations and service delivery models     in transgender health. The Lancet, 388(10042), 401-411.             doi:http://dx.doi.org.ezproxy.lib.rmit.edu.au/10.1016/S0140-6736(16)00682-6

 

An unequal, still

Those that know me well, know that I wear my heart on my sleeve. I find it difficult to hide my emotions, whether it is a good feeling or otherwise. This can be both a blessing and a curse.

Sleep is evading me tonight. My mind is far too active, even though my eyes are feeling as heavy as my heart. I can rarely pinpoint the cause of this, and trying to resolve that query only serves to extend the sleeplessness. Thoughts of the previous day are at the forefront, but so too are those moments from other days where unresolved matters play out in many different scenarios. It seems wearing your heart on your sleeve also means an over-active mind at the most unpredictable of times.

But, one event from yesterday is clearly troubling me. Yet another opportunity presented itself for Australia to join the many other developed nations of the world in treating a minority with respect and dignity. Once again, a fearful and ignorant few stood in the way of any progress.

Fairness, equality and compassion stand at the very centre of my being, and the continued toxic nature of the marriage equality debacle is taking a toll. I have previously written of the shockingly disproportionate mental health statistics of the LGBTIQ community, yet is it at all surprising when we continue to be told that we are not equal? Why is our love subject to an often hateful discourse, when heterosexual couples can merely go about their daily lives unquestioned, both in marriage and divorce? What impact does our love even have on anyone else’s? The world hasn’t imploded in any of the countries that have moved to protect the rights of all of its citizens, as opposed to just those that meet a religious criteria.

Some of these aforementioned statistics bear repeating:

  • Same-sex attracted Australians have up to 14 times higher rates of suicide attempts than their heterosexual peers
  • Up to 50% of trans people have actually attempted suicide at least once in their lives
  • LGBTIQ people have the highest rates of suicidality of any population in Australia – 20% of trans Australians and 15.7% of lesbian, gay and bisexual Australians report current suicidal ideation (thoughts)
  • Lesbian, gay and bisexual Australians are twice as likely to have a high/very high level of psychological distress as their heterosexual peers (18.2% v. 9.2%). This makes them particularly vulnerable to mental health problems
  • The average age of a first suicide attempt is 16 years – often before ‘coming out’

Source: Rosenstreich, G. (2013) LGBTI People Mental Health and Suicide. Revised 2nd Edition. National LGBTI Health Alliance. Sydney, p 5.

Are we so short-sighted now that we can’t see the impact that this toxic discourse is having on the LGBTIQ community? Particularly those that are younger and still trying to figure out how to make their way through an already difficult time. The last thing any of us need is yet more ill-informed people preaching on a topic they know nothing about. How powerful a statement would it be to those who are currently unequal in the eyes of the government, to finally be treated as equal?

Humans are social creatures. Most of us crave love – some of us spend an awful lot of time thinking about love, both in its positive and not-so-positive forms. Marriage is one way that we express our love for another, and when a segment of the population continually get excluded from this, for no good reason other than tradition or religion, it really is no surprise that mental health issues swing wildly towards the LGBTIQ community. I am sick of having to justify my right to equality and I am sick of having to listen to hate and ignorance as an excuse for it. How dare some people think they have a right to vote on who I can choose to spend the rest of my life with! Did I get a vote on their choice?! The world needs so much more love, and yet, too many people are focussed on anything but love.

As tends to happen with these kind of things, important facts are ignored when they don’t suit the argument. When the Marriage Act was changed in 2004 by the then Prime Minister (to the current day definition of marriage being between a man and a woman only), it was simply done by an act of parliament – no plebiscite, no vicious hate campaigns, no fuss. It just happened. Apparently the same course of action to change it back simply cannot be done the same way, for the opponents are crying foul play, and that only a public vote should decide this – not an act of parliament. Trying to have it both ways without reference to facts that are inconvenient to their flaky argument.

In the meantime, I’ll just prepare myself for another round of bemusing (and probably hateful) commentary around why I’m not worthy of equality. I started wearing the “Live Proud” rainbow band on my wrist many years ago as a reminder to myself that I am equal, and I promised myself that I would wear it every day until I am an equal under the law. It appears we still have a very long way to go…

Live Proud band pic

 

Born This Way

It was just an ordinary day, which meant that one of Australia’s mainstream newspapers was due for some good old-fashioned hysteria, scare-mongering and lies. It’s usually an attempt to demonise a minority or just have some fun at the expense of those that cannot defend themselves. A few days ago, this unashamedly unethical ragtag decided it was time to attack the LGBTI community again. However, this time, they went for the lowest of lows – they went for the youth.

An article at the top of the front page of Wednesday’s edition – an exclusive by the way – was so ineloquently titled “Activists push taxpayer-funded gay manual in schools”. Presumably being in this prominent position meant that it was the most important story of the day, but I’ll leave you to decide whether there were more pressing issues on this Wednesday (I can think of at least one more important issue that involves 267 people about to be sent back to a life of abuse and mental torment, but maybe I just have a different perspective of the world). I’ve actively decided not to link the article here (nor name this shameful excuse of journalism) for two reasons – it’s behind a pay-wall and I really don’t want you to give them any money to read it. It’s also just so farcical from top to bottom, so I don’t want to waste your time. I do however want to draw attention to how damaging this kind of “reporting” is, and will continue to be, if it is left unchecked and unquestioned. Though the “taxpayer-funded” part is quite hilarious – I’m not sure what their point is, but is this a good time to remind them that their beloved church that they so vehemently defend at all times does not pay any tax, while also receiving large sums of funding from the government?

To be clear, there is no “gay manual”. What would a “gay manual” even do, or attempt to do? This strikes at one of the most hurtful aspects of what homophobes believe – that being gay is a choice. Who would choose this? Why would you bring all of this unwanted attention and subsequent disadvantage to yourself if you didn’t have to? I’ll never forget one of the first things my Mum said to me when I finally had the nerve to come out to her (at age 28 by the way) – she was really concerned that I was going to miss out on opportunities, or be treated differently, simply because of my sexuality. And here I was worried about her getting upset at not getting any grandchildren from me. The fact that it took me so long to officially come out to my Mother is a direct statement of the way I felt scared and anxious for the real me to be out there. The prime of my life was spent hiding away for the fear of being found out. I had no boyfriends and I didn’t go out much all those years, simply because I was so scared of being found out. Why did I feel like this? Well, that’s what twelve years of Catholic education will do to you. I’m not upset that my parents felt it necessary for me to go to a religious school, but I do greatly resent the education I received of a narrative of the world in which I was a freak while growing up and discovering myself, while they go through scandal after scandal of sexual abuse of children in their care without any attempts to correct the many wrongs they have committed.

It was during my high school years that I first began to feel attracted to another guy. To say that was a terrifying and utterly confusing experience would be one of the greatest understatements I’ve ever made. I only wish there was something reassuring available to me at the time that explained some of the possibilities of what I was thinking and experiencing. This is no “gay manual”. Labelling it this way implies that you can teach someone to be gay. That would be as effective as gay conversion therapy, which is hopefully and finally about to be made illegal in Victoria. This is a teaching aide that forms part of the Safe Schools Coalition. It is an anti-bullying document designed to help children – all children – understand the differences that make us our own unique individual, and that there’s simply no reason to pick on someone, or exclude someone who might not fit into some main category. I don’t see anything wrong with that, especially as 80 per cent of homophobic bullying involving LGBTI young people occurs at school and has a profound impact on their well-being and education (Australian Research Centre in Sex, Health and Society, La Trobe University, Private Lives 2: The second national survey of the health and wellbeing of GLBT Australians (2012) p 39). I like to be positive though and it gives me hope that LGBTI young people at schools where protective policies are in place are more likely to feel safe compared with those in schools without similar policies (75 per cent compared with 45 per cent). They are almost 50 per cent less likely to be physically abused at school, less likely to suffer other forms of homophobic abuse, less likely to self-harm and less likely to attempt suicide (T Jones and Western Australian Equal Opportunity Commission, A report about discrimination and bullying on the grounds of sexual orientation and gender identity in Western Australian education (2012), p 11). I would think that having this resource available in schools can only have a positive impact, as it appears to be doing, and it certainly isn’t doing what this article is trying to suggest.

With the lack of such a resource in those times, I sought the advice of a teacher (who was also presumably gay, but I’ll never know for sure) who I felt comfortable enough with to share the thoughts I was having. He did help me understand that while I was probably having different thoughts to most of the other boys at school, there was nothing wrong with the thoughts I was having. I am very lucky to have had someone give me this reassurance at a time of need so I didn’t go down the path that sadly too many LGBTI youth go down.

The statistics glaringly show the disparity of mental health, self-harm and suicide in the LGBTI community to that of heterosexuals:

  • Lesbian, gay and bisexual Australians are twice as likely to have a high/very high level of psychological distress as their heterosexual peers (18.2% v. 9.2%). This makes them particularly vulnerable to mental health problems
  • The younger the age group, the starker the differences: 55% of LGBT women aged between 16 and 24 compared with 18% in the nation as a whole and 40% of LGBT men aged 16-24 compared with 7%
  • LGBTI people have the highest rates of suicidality of any population in Australia – 20% of trans Australians and 15.7% of lesbian, gay and bisexual Australians report current suicidal ideation (thoughts)
  • A UK study reported 84% of trans participants having thought about ending their lives at some point
  • Up to 50% of trans people have actually attempted suicide at least once in their lives
  • Same-sex attracted Australians have up to 14 times higher rates of suicide attempts than their heterosexual peers
  • Rates are 6 times higher for same-sex attracted young people (20-42% cf. 7-13%)
  • The average age of a first suicide attempt is 16 years – often before ‘coming out’ Source: Rosenstreich, G. (2013) LGBTI People Mental Health and Suicide. Revised 2nd Edition. National LGBTI Health Alliance. Sydney, p 5.

That all makes for very sobering reading. It also highlights just how critical it is for young people to be supported throughout their journey into adulthood, not to have some elitist set blast false headlines and news stories across their front pages suggesting otherwise. It’s because of continued homophobic examples like this that almost half of all gay, lesbian, bisexual and transgender people hide their sexual orientation or gender identity in public for fear of violence or discrimination (Australian Research Centre in Sex, Health and Society, La Trobe University, note 7, p 46). It’s also why a large number of LGBTI people hide their sexuality or gender identity when accessing services (34 per cent), at social and community events (42 per cent) and at work (39 per cent). Young people aged 16 to 24 years are most likely to hide their sexuality or gender identity (Australian Research Centre in Sex, Health and Society, La Trobe University, Private Lives 2: The second national survey of the health and wellbeing of GLBT Australians (2012) pp 45-46). I wonder why that is.

I am a part of those statistics. Countless times, I have hidden my sexuality from friends, work colleagues, family, Barry next door – you name it. I have encountered discrimination based on my sexuality. A previous boss of mine commented to someone else at this workplace (after I had left that workplace) that he would not have hired me had he known I was gay. I am scared to hold the hand of another man in public for fear of being abused – something I have seen happen in Melbourne before. The number of conversations I have had where I actively used words to avoid questions of why I did not have a girlfriend all those years, or where I faked an interest in “blokey” conversations to keep the charade going. This was all due to the world around me – a world that still tells me I’m not equal. That my love for another man is not the same as the love between a man and a woman. Yes, it’s 2016 and we’re supposedly advancing, but the simple fact is that I am still discriminated against, simply for the love I have for someone of the same sex. So, if there is a teaching aide in our schools reaffirming that we are all the same even though we have our unique identifiers, and that those differences are to be embraced rather than shamed, I am all for that. I am hopeful that the youth of today have more confidence to be themselves and not hide their true identity for as many years as I felt I had to. But as long as mainstream media continues to peddle this hysterical and utterly damaging sensationalism, we still have a long way to go. LGBTI young people report experiencing verbal homophobic abuse (61 per cent), physical homophobic abuse (18 per cent) and other types of homophobia (9 per cent), including cyberbullying, graffiti, social exclusion and humiliation (Australian Research Centre in Sex, Health and Society, La Trobe University, Private Lives 2: The second national survey of the health and wellbeing of GLBT Australians (2012) pp 45-46). These headlines just perpetuate these experiences and the people that write them ought to be held accountable for these actions.

1Rainbow Pic