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.

melb pride

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

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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

 

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An Extra Serve of Chips

Just feeling the need to put this out there. It’s a bit heavy, so feel free to skip it, which is partly what this is about.

Melbourne would not be alone these days in experiencing an ever-increasing and troubling homeless problem. And that is part of the problem – we can all see it, but most of us just keep on walking by. I have been one of those people too, so I’m certainly not trying to make you feel guilty as you read this. I simply want more of us to start thinking about this problem and what can be done about it. Are we ok with the fact that some people find themselves on the fringe of society and then get swept aside as if they don’t exist any longer?

Sometimes it takes a personal experience to make you evaluate your past behaviour. That happened to me tonight, as I was rushing between shifts at work. I only had 20 minutes to get something to eat and the local KFC comes in handy in these situations, so I made my way there to get a quick bite.

It was as busy and messy as it always is but I was still able to see a familiar face among the groups of mostly young and noisy people. A tired-looking man, who has an ever-increasing weathered face each time I see him. He is clearly homeless. He quietly sits in one corner of the KFC and waits for others to leave scraps of food behind. He isn’t picky – he can’t afford to be. He checks each bag left on the tables, lifts each drink cup to see if there’s any left, and yes, he rummages through the rubbish bins on a regular basis when there’s nothing left behind on the tables. But we all go about our lives and he just blends into the scene. Maybe we are so absorbed in our worlds that we don’t notice him, or maybe we just don’t want to notice him so we don’t have to think about it.

I have had a previous opportunity to help this man and for some unknown reason, I got nervous and didn’t do it. I wanted to buy him some food so he wouldn’t have to do what he usually does but I had a thought that he might not like me doing that. Maybe he would be too embarrassed to accept it, or maybe he would get upset? I sat there then for what seemed like a long time over-thinking the entire situation and then just got up and went home. I instantly felt guilty and wished I had acted differently.

So, when I saw him again tonight, I knew I had to act differently. I didn’t buy much for myself tonight but I did get an extra serve of chips. I walked up to him, smiled, and asked if he wanted them. He looked at me, smiled, and accepted the chips. He thanked me, and turned back to his collection of leftovers and mostly empty drink cups. He continues to look as if he is deteriorating, but I suppose that’s the way it is when you are homeless.

I didn’t do much, and it certainly didn’t cost me much, but I had to do something tonight. I was compelled. Anything to help has to be better than what homeless people usually see. It must be so hard to be ignored. We are social creatures and isolation is one of the toughest things to experience, yet this is what we are doing with homeless people.

homeless bunny pic

I have no answers to this complex and troubling problem, but I have to believe that we can at least try to be doing something to help. It’s not realistic to say that you can help every single homeless person, but maybe if more of us started giving them an act of kindness, it could make a small difference. To not ignore them, to offer whatever help you can, it has to be better than what we’re doing right now.

Mahatma Gandhi is quoted as once saying “the true measure of any society can be found in how it treats its most vulnerable members”. We need to think about if we are happy to be that society that ignores its most vulnerable members.

 

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

 

Change The Date

Ignorance in the name of national pride is still ignorance. And it’s ugly. Much in the same way that discrimination in the name of a religion makes no sense, using national pride as an excuse for celebrating Australia Day on January 26 makes no sense. A look into some history (of which every Australian should be aware, but it’s just not spoken of enough) of this issue should show you why:

Interestingly (and something I only recently learned), “the First Fleet, the group of ships which left England to create a penal colony abroad, actually arrived in Botany Bay somewhere between the 18th and 20th of January 1788. However, settlers decided to relocate on the 25th of January in the hopes of finding a more suitable area to construct their colony. They travelled to Sydney Cove and the next morning, on the 26th, Sir Arthur Phillip and a small entourage of marines and officers claimed the land in the name of King George III” (Pearson, L. and Verass, S., 10 Things You Should Know About January 26).

In case you’re thinking this is just another new outrage that the trendy leftists are onto, there have been Indigenous protests of Australia Day dating back to 1938, the 150th anniversary of the British invasion. “We, representing the Aborigines of Australia, assembled in conference at the Australian Hall, Sydney, on the 26th day of January, 1938, this being the 150th Anniversary of the Whiteman’s seizure of our country, hereby make protest against the callous treatment of our people by the whitemen during the past 150 years, and we appeal to the Australian nation of today to make new laws for the education and care of Aborigines, we ask for a new policy which will raise our people to full citizen status and equality within the community”. According to the National Museum of Australia, we even forced some Indigenous men to reenact events of the First Fleet landing at the 150th anniversary in 1938. Yes, at that time, and up until 1967 when a referendum was held to ensure that the First Australians were counted equally as citizens under section 127 of the Constitution, Indigenous communities were not regarded as citizens of the land they had lived on for more than 40,000 years. Incidentally, that referendum was a rare success, with more than 90 per cent of Australians voting ‘yes’ to delete two racially discriminatory references in the Constitution. Further work remains to recognise Indigenous people in the Constitution, with discussions ongoing for the last 20 years.

1988-aboriginal-protests
Aboriginal protests on Sydney Harbour on Australia Day celebrations, 1988 (courtesy: 10 Things You Should Know About Australia Day)

Even if you’re looking for the tradition argument of celebrating Australia Day on January 26, it has only been consistently celebrated as a national holiday (in all states and territories) since 1994. Yes, only 23 years ago. It would hardly be an issue to find another date for a celebration that’s only been known in its current form for 23 years, especially for celebration of an event that dates much earlier than this.

Allow me to point out some further realities – for those that think the Indigenous community gets everything their way and has an advantage over us non-Indigenous – the Indigenous community, while only being about 3 per cent of overall population, make up 27 per cent of the national prison population. There is around a 10-year difference in life expectancy between Indigenous and non-Indigenous people (do I need to point out whose favour this is in?). The non-Indigenous community has a 12 per cent higher cancer survival rate. Indigenous children aged 0-4 years have a 1.9 times higher mortality rate than non-Indigenous.

In 2008, Australian Bureau of Statistics data showed non-Indigenous adults were more likely to have attained at least Year 10 or basic vocational qualifications (92 per cent) than Aboriginal and Torres Strait Islander adults (71 per cent), and were over four times as likely to have attained a Bachelor degree or higher (24 per cent compared with 5 per cent). What can education lead to? While it’s no guarantee of a self-sufficient life, it’s certainly a promising start. In fact, this ABS data shows that “while nationally, Indigenous adults are around half as likely to be in full-time employment as non-Indigenous adults, as educational attainment increases, the difference between the employment outcomes reduces”. Education levels also appear to impact the level of drinking habits with lower rates of acute risky/high risk alcohol consumption (binge drinking) being associated with higher rates of educational attainment (interestingly, the opposite is true for non-Indigenous people). And, education levels are also crucial in relation to housing status – nationally, Indigenous adults were over five times as likely to be living in an over-crowded dwelling as non-Indigenous adults, and less than half as likely to be living in an owned home (with or without a mortgage). At higher levels of educational attainment, these differences reduced. For example, Indigenous and non-Indigenous adults with a Bachelor degree were nearly equally as likely to be living in an owned home.

For those that think the Indigenous people needed our intervention, they seemed to exist successfully for 40,000 years before the British arrived (one of the world’s longest surviving cultures, if not the longest). It was only with our arrival (and the subsequent taking of their land and way of life) did they start to face the undeniable social issues they now face.

So, what are the alternative dates we should use? There’s plenty to choose from and the debate should now focus on these (Sivasubramanian, S., Eight Alternative Days to Celebrate Australia Day That Are Not January 26):

  • January 1: in 1901, the day six British self-governing colonies united to form the Commonwealth of Australia. In my opinion, not ideal as a new date.
  • February 13: in 2008, then-current Prime Minister of Australia, Kevin Rudd formally apologised to the Indigenous people who were forcibly removed as children from their homes and parents’ care and placed in Church missions or adoptive white family.
  • April 11: the day in 1973 that the “White Australia” immigration policy was abolished by the Gough Whitlam government.
  • May 27: the day in 1967 when the referendum asking whether Aboriginal people should be given the right to make laws and be accounted for under the Constitution occurred. The country voted with a resounding 90.77 per cent in favour of the changes. Until then, Aboriginal people were denied several rights, including the right to vote or to be counted within the human census. They were accounted for within the animal population until then.
  • June 3: Mabo Day. This perhaps has the strongest appeal as the alternative date. On 3 June 1992, the High Court of Australia ruled in favour of Eddie Mabo’s case which overturned the legal stance of “terra nullius” (a Latin term meaning “nobody’s land”) and acknowledged native Indigenous land rights. Though the day is already marked as a national holiday, it may fit better as a public holiday.

While the majority will still be celebrating Australia Day on January 26, I hope that we can at least advance the understanding of this issue without ignorance. I was recently told that we’re being over-sensitive about this and that it’s just another thing we all get too easily offended by. Of course, this is easy for us non-Indigenous people to say – we would hardly know or understand what the Indigenous community feels on this day – I’m not even going to suggest that I have the slightest understanding of what they go through when they see a nation celebrate on this day, but I’m prepared to educate myself on why they feel this way and then decide accordingly to join them in the call for change. Not as an offended citizen, but as one who seeks true unity and peace. That’s what this is about – bringing us all together in an all-too-divided world with educated and empathetic minds. I might be asking for too much, but if you don’t ask, you’ll never be answered.

Note: I have intentionally attempted to not use the term “Indigenous Australians” as I am aware that some of the Indigenous community do not use “Australia” to identify with, given that this is the name given to the land that they already lived on.