The end of a year is always a time of personal reflection, but this one feels like it requires more than previous years. Maybe because it’s the end of another decade (seriously, where did the last ten years go?!), or maybe because so much has happened in a relatively short amount of time.
I turned 40 this year; and I was ok with it. As opposed to the mini breakdown I had months before my 30th. I had set myself all of these arbitrary goals, probably similar goals that you have set yourself: have a partner, be on the way to owning property (i.e. have a mortgage), have a successful career, be happy. Turns out I had none of that at 29, hence that mini breakdown. My 30th came and went, I had an incredible night surrounded by many people near and dear to me, but those aches from unachieved goals lingered. I won’t bore you with a detailed summary of the last ten years, but I feel like a reflection of what I’ve come to know in that time might be useful for some of you. Yes, it’s personal and we should all live our life the way we want to, but some of these things might resonate with you:
You will continue to change and learn more about yourself every year: this is hard to digest as a twenty-something. I felt I knew what I was doing, where I was going, who and what mattered most. The simple fact is priorities change; what you once see as critical to your daily life pales into insignificance when your energy is diverted to new challenges, or new environments. I think there is some humanistic yearning for this ongoing discovery – I do not think we were designed to remain stagnant for all of our lives. This does not necessarily mean a life of constant travel or career changes – change and learning about yourself is as individual a process as you are and there is no blueprint for it. Even if you are convinced that where you are right now is where you will be in ten years, why close the door to any worthwhile opportunity that may present? So, instead of stressing about what next week, or next year is going to bring, try to pay more attention to here and now, and to those in your life who help you be the best you can be right now. And, a real goal of mine is to let people know that I appreciate them, care for them and thank them for any good they do for me. The world sure could use more appreciation and gratitude.
Do not spend too much time regretting decisions made: I think most decisions I have made along the way were the right decision at that time, and with different perspective or understanding, I may have decided differently, but how can you worry about something that you didn’t know at the time? I regularly look back at an opportunity I had nearly 20 years ago for a six-month exchange at McGill University in Montreal, Canada. Of course, things may have taken a different path if I had taken up that opportunity, but life circumstances at the time led me to decide against it. Initially, there was regret, but I have come to realise that this was the right decision for that time. It is probably something I would do differently now, but these decisions are always much easier in hindsight. So, instead of worrying about what could be, or what could have been, try to focus on what is and the possibilities that brings.
You will spend less time trying to be perfect and trying to be liked by everyone: this has been a tough lesson. It was always one of the things my ex partner (who remains a dear friend) would ask me – “why do you need everyone to like you?” I wish I knew the answer to this, but what I can say with some certainty is, you will begin to care less about being liked and care more about those relationships and connections that are genuine and offer each person mutual benefit. We are social creatures – we were not designed for isolation, so perhaps that plays some part in wanting to be liked, but the lack of genuine relationships and interactions is a recipe for loneliness, that I can assure you of. Quality over quantity is ever present.
This leads onto the next point, something I am only recently absorbing: know that actual interactions with actual people will always surpass online interactions. I freely admit that I am guilty of having too great of an online presence – I post numerous stories and updates, mostly photos these days, but nonetheless, most of you would have a fair idea of my habits simply from social media. Yet, I am as lonely today as I was at the start of this decade. That is possibly the reason for the posting – I am yearning for interaction, for connection, which for whatever reason, I have not been getting enough of in the physical world. But is all this online time taking away from the physical time? It is difficult to admit to this, but something I need to acknowledge. The only thing being connected online has brought me is more disconnection. Facebook has been in my life for 12 years and I wonder if it is a coincidence that these 12 years have been my toughest.
Happy place: a beach, hiking (Bushrangers Bay, near Cape Schanck, VIC, 2019)
Take that chance – generally, the worst that can happen is you learn some things along the way: a question I have been asked more times than I care to remember is “why do you keep changing career path?” Yeah, I’ve worked in retail, accounting, fitness, technology, even dabbled a little with writing and editing, and now I am less than three weeks away from commencing my nursing career. I have never been ashamed to seek something better – one of the greatest traps in life is to settle. This can apply to many situations, not just work life. Don’t settle – you are worth more than that. It might not be clear which path you want to take, but just seeking it is a good start. The alternative is the all-too-real realisation you will get one day of “what if?” and that’s something worth avoiding if you can. I know there are some situations in life where it is not always immediately possible to implement change – the realities of finances and dependants is ever present, but don’t let this lead to a dead end. You might reach a point where you want it bad enough that there is no alternative other than to make it happen. My last three years studying full time, working part time and completing unpaid clinical placements is a decent example – as tough as this was, I saw no other way than to push through it. It involves sacrificing things (such as my desire to travel frequently), but this is short term. Take that chance, at least you can say then that you tried, which is infinitely better than asking “what if?”
Happy place: a stunning sunset (one of my favourite moments of the decade, near Wreck Beach, Vancouver, Canada, 2017)
This decade has undeniably been the toughest of my life so far and I wouldn’t have it any other way. I have grown so much and learned many things about myself that could not be possible if everything was just swimming along. Adversity is a great teacher – you always have the option to tackle it, or ignore it. While it is difficult to see at the time (sometimes impossible), you will be able to look back and recognise how it helped you along your path and how you are a better person for coming out the other side. Know too that everyone struggles from time to time – this has been one of my most important lessons – and the best way to get through that is remind yourself of your purpose, your hopes and put yourself out there in a genuine sense. And for me, that means less time online and disconnected. Happy new year and I hope some of this helps, or at least resonates, as we all try to push on into a new decade. May it be what you need it to be.
Happy place: nature, especially when it shows off like this (somewhere along the Yarra River, Melbourne, VIC, 2018)
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).
Above: The Transgender Flag and Symbol. Credit: WeThePeople Clothing. Below: Pride March, Melbourne, 2017.
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):
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
South Australian Government, Dept of Education – Supporting students, Gender diversity and transgender (very detailed, includes health-related support info)
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
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
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
You might be thinking this too – that all-too-familiar feeling that each year seems to go that little bit faster than the year before it. I have read a few possible explanations of this – the main idea being that we are simply busier now and this makes time seem faster; or is it that we are too distracted from the present and spend too much effort focussing on the future that today just slips by unnoticed?
I have been guilty of this. Some tough times personally over the last three years inevitably shifted the focus to the future – I needed some hope and some purpose to my life, and this had me envisaging a medium to long term plan, sometimes at the expense of the here and now. While I do not see this as a negative, a continual focus on the future can mean missing the wonderful moments happening right in front of you, or at the very least, appreciating the accomplishments along the way.
I found myself on many occasions this year thinking that down patches were okay because there was a grander plan and that before I knew it, that future time would come. I feel though that it has also led me to wish the last three years away without realising it. Many friends seemed to share the thought at the end of the last few years that it was a relief to farewell the year that had just been, in the hope that the new year would bring a fresh start. Only for the new year to follow along a similar path as the year before it and the cycle continued.
I had these thoughts at the end of the last two years and I could feel myself thinking the same way about this year, until a few weeks ago. 2018 has undoubtedly challenged me in new and sometimes confronting ways – I seriously considered dropping out of uni for various reasons, there were personal and financial issues, as well as unhealthy living circumstances. This is where mindset plays its part – I have been trying to make a conscious effort of seeing unexpected and unwanted events in my life as learnings and opportunities to grow. The alternative is seeing these things as a failure and a waste of time and that thought process invariably becomes destructive. I don’t want this to be my default thought pattern – time is far too precious for wiping it away as a waste. My energy is also too important to spend stressing about things I can’t control, although this is sometimes easier said than done.
Image: Gratisography
The reality is that things can change in an instant, and often. Sometimes these changes are welcome, sometimes they’re not. Which is why being present in the moment and trying to appreciate the little things is becoming more important to me. Try not to focus on things that have not gone to plan, or on things that you did not have control over. It might take time to accept your current circumstances, or to find a way to deal with them – and there is certainly no right or wrong way to do this, but I have learned over the years that a defeatist mindset does not lead to positive outcomes. And if you keep wishing time away, or viewing unfavourable events in your life as a waste of time, you will one day wonder where the years went and why you are still in a place that you do not want to be.
One thing I love about nursing is the perspective it continues to give me and the resultant appreciation of what I have, rather than fretting about the things I don’t. It is important to acknowledge that some days will just be flat and that is okay – you don’t have to feel amazing every day and you certainly don’t have to be down on yourself when you don’t feel the way you want to. The key is to recognise these times and ride that bump – but if it is a feeling you have every day, that is a signal to alter the course and think about your mindset. Find your way to process that feeling and adjust your outlook, whether that is reading a good book, heading outside for a walk in your favourite park, or simply sitting on a beach.
Try not to wish this year, or any year away, even if you are less than satisfied with how it has gone. There are people in tough situations that would love to have some time back, and it is easy to lose sight of this. Your time is precious and it might not seem to be slipping by so quickly if you spend a little more time appreciating the present moment.
Sometimes, expectation and optimism does not match reality. That’s no reason to be pessimistic – just another opportunity to expand your viewpoint on previously held beliefs. This is how I have approached my third clinical placement, which is in a mental health facility in the suburbs of Melbourne. It is an area of nursing that holds great interest for me, hence my optimism. Halfway through this placement, the reality has been somewhat different to my expectation.
I have had to accept that, like with physical illness, not everyone recovers from mental illness. A myriad of factors may explain this – amotivated feelings about their condition (no desire to seek or engage in help), lack of participation in therapy, medication complications (this is its own set of issues, especially in relation to dependence), lack of access to programs or activities that can assist recovery, lack of a support network from family or friends, and medical personnel that are disengaged or victims of the health system, just to name a few.
What has surprised me at this early stage is the number of return patients. The overwhelming majority of patients are known to staff and are on their third, fourth, or even fifth admission. The facility does not accept high-risk patients, so I can only imagine how much worse this scenario is for facilities that do. Some patients only stay for a few weeks; others have been here close to three months. Some patients are being monitored for medication changes, while some patients are admitted for treatment that requires extended monitoring.
One of these treatment options is Transcranial Magnetic Stimulation, or TMS. I was fortunate enough to accompany a patient during one of their TMS sessions, which afforded me a fascinating insight. This patient is currently going through their third round of TMS treatment, and each round has consisted of 30 sessions. The session I attended was their 24th of this third round. The patient does not feel that the TMS is making a difference to their outlook or thought processes, but they do not want to try the alternative treatment (Electroconvulsive Therapy, or ECT, which induces seizures to alter brain activity) because of the sometimes severe side effects of memory loss.
In contrast, TMS reportedly has little to no side effects and is not invasive. It involves using magnetic fields to activate specific areas of the brain – generally the pre-frontal cortex, which is the area of the brain that among other things, is associated with how we see ourselves (self-consciousness) and self-related mental processes. As depression can alter these thoughts and behaviours, TMS has been shown to improve self-perception in depressed patients by progressively altering brain activity in this area with repeated treatments. No anaesthesia is required (in contrast to ECT) and a patient can resume their usual daily routine once treatment has completed for the day, and some patients can even have two treatments in one day (one session takes around 40 minutes, depending on the severity of the patient’s depressive state). TMS is not a first-line course of treatment – it is generally prescribed when a patient continues to show depressive symptoms after at least one anti-depressant medication has been attempted. Interestingly, it is not currently covered by Medicare in Australia as further research on its long-term effectiveness is still ongoing. This results in an access issue, as it requires private health insurance and an inpatient admission or self-funding.
But how effective is this treatment when numerous patients are seemingly coming back for repeated rounds of therapy? Or is it more of a case of these patients not fully understanding their triggers and therefore relapsing? It could also be medication compliance or potentially new triggers. There is no obvious or simple answer, as we are not obvious or simple beings. Our brain exerts more control over us than we may ever give it credit for (side note: I recommend Afflicted, a truly fascinating series currently on Netflix to see some real examples of this). In this case, this patient is having their third round of treatment, reports that they do not see any improvement, yet, this patient is quite engaging, warm and reactive to conversation. They have a supportive family network and cannot specify any possible triggers for their continued admissions other than the feeling of hopelessness and helplessness that engulfs them. Consequently, they continue their treatment in the hope that it may eventually have an effect.
This is another important factor to highlight: it will not necessarily make sense that someone is suffering a mental illness. I was involved in a new patient admission recently – this patient has suffered depression for nine years (from the age of 12), an eating disorder for six years and has attempted suicide twice this year. They have no history of trauma or abuse, no family history of mental illness, no obvious triggers or explanations for why they feel the way they do. There is evidence of alcohol abuse, but not drugs. They have a good social network and a job. Prescribed medications have not had an effect and something just isn’t right, so they want to give ECT a chance to help them. This patient is warm, engaging and not visually distressed. They were studying at university until it became too difficult to manage with their illness. I can only hope that we can help them and not have them become one of the “frequent flyers”.
Naturally, I wonder why patients are returning at the rate that they are. It is clear from speaking with the staff at this facility that the system is letting some patients down. Medications are prescribed and dispensed, mental states are constantly assessed, as are current risk statuses. What might be a confronting question is asked – have you had any suicidal ideation recently, and if so, how do you plan to go through with it? Self-harm is also assessed and is more common than I thought it would be – one patient explained that they self-harm just so they can feel something. Sadly, some patients self-harm so they can be admitted, otherwise they might be turned away for a lack of available beds. There are clear cases of dependence to medications and these are managed as much as possible, but some of the return rate of patients might just sit at the hands of the patients themselves.
Patients need to understand the role they play in their own recovery. As someone who has suffered mental illness, I experienced two critical aspects: I was going nowhere until I acknowledged my illness; the next important step was to seek help and want to work at feeling better about myself and my life, instead of feeling embarrassed and ashamed of my predicament as I initially did. This is by no means an easy or simple step – this is the most difficult thing to do. To acknowledge and accept you are struggling is tough; to seek help and open up to someone that you are struggling and need help is even tougher.
The logical thought would be that the patients in a mental health facility have accepted these two aspects about themselves. Why then are they mostly returning for repeated admissions? Are they returning to past negative behaviours or thoughts? Are they disengaged with their treatment plans (not attending therapy groups or possibly non-compliant with medication)? I believe there is no obvious or logical answer – our complex brain can lead to many variations to mood, behaviour, thought, cognition, desire, as well as many other factors. This is where the nurse must be the patient’s advocate – each patient will bring their unique set of idiosyncrasies and one care plan that has succeeded with one patient might not work with another, just as one type of medication may assist one patient but not another. It is the system that lets patients down when it is assumed one treatment option is a best-fit for all, or indeed, that all patients will fully recover from their illness. It might just mean taking that little bit of extra time to sit down and talk, to listen and to care. Rapport and trust between the patient and the nurse is vital, as is the patient’s want to recover, or at least manage their condition.
This should extend to your network of family and friends – you do not have to wait until you can see an obvious sign of a friend or loved one struggling. Take that little bit of extra time to have a genuine conversation and know that some people are doing it tough, no matter the façade they put up. Try not to judge those who have the courage to admit that they are struggling and instead find ways to understand their struggle and offer ways out of it. There is no telling when or if someone will suffer from a mental illness, but showing that person that they are not alone and that someone cares about them will make the world of difference to them – and you don’t have to be a nurse to do that.
Words Not Numbers 