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).
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 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):
(endorsed by ANZPATH, the Australian and New Zealand Professional Association for Transgender Health)
Gender Dysphoria Clinic – Melbourne
Minus18 – youth-driven support organisation, also provides training on supporting trans and gender diverse clients
In terms of hormone therapy medications available, NPS MedicineWise has a resource:
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
LGBTI National Health Alliance – includes many links to other LGBTIQ+ organisations
Shine SA – Gender Wellbeing Service
Victorian Government – School policy on gender identity
South Australian Government, Dept of Education – Supporting students, Gender diversity and transgender (very detailed, includes health-related support info)
Victorian Government, Dept of Health – report on Transgender and gender diverse health and wellbeing (2014)
Services & Support:
National – Headspace – https://headspace.org.au/
Switchboard – http://www.switchboard.org.au/
Q-Life – https://qlife.org.au/
A Gender Agenda – https://genderrights.org.au/
The Gender Centre – https://gendercentre.org.au/
Transhealth Australia – http://www.transhealthaustralia.org/
The Royal Childrens’ Hospital Gender Service – https://www.rch.org.au/adolescent-medicine/gender-service/
Monash Health Gender Clinic – http://monashhealth.org/services/services-f-n/gender-clinic/
Transgender Victoria – https://transgendervictoria.com/
Seahorse Victoria – http://seahorsevic.com.au/main/
ButchFemmeTrans Melbourne – https://www.facebook.com/butchfemmetrans/
Rainbow Network Victoria – http://www.rainbownetwork.com.au/
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