By Dr. Sally Murray FAChSHM, FAFPHM, MPHTM, MHScPHP, MBBS Sexual Health Physician and Public Health Physician
The new HealthPathways WA Transgender Health and Gender Diversity Pathway is the management site I wish I’d had seven years ago. One place that summed up the pieces in the puzzle and how to put them together, in my context.
Caring for gender diverse patients doesn’t have to be hard. You just have to care, listen, ask, drop your assumptions, and then use skills you already have in general medicine. Same stuff, different context.
If I asked you to start the oral contraceptive pill or perimenopausal oestrogen patches you wouldn’t think twice, you know the contraindications, who you’d ask a second opinion for, which people you might think about doing a clotting profile on. If you had a hypogonadal male you’d look up the andrology guidelines and be happy to start testosterone with a specialist referral in the next 12 months as required by the PBS. Transhealth care is special because of the patients, not because of the medicine.
This pathway helps to map that out. It shows how to help patients as they start their journey, ensuring they have adequate support to explore their gender identity (if needed); and to explore the expected changes (social and physical) of their transition, making sure they can make competent decisions, and understand the risks and benefits of hormone and/or surgical intervention. This can be done using an informed consent process in your rooms as per the AusPath Australian standards, or you (or the patient) might appreciate the support of one of the increasing number of experienced clinical psychologists in Perth. If there is a lot of comorbid psychiatric illness, get help. Just like you usually would.
Once you feel your patient is in a position socially and medically to move on with hormones (assuming they want them!) the pathway outlines the preferred (and familiar) ways of doing this. Want to start oestrogen? In a trans patient I would advise patches to reduce VTE risk, like I would for a post-menopausal woman. Your patient doesn’t like needles but needs testosterone? Use topical. Aim for cisgender ranges of hormones.
The only reason we need a tertiary service for gender management is for the really complicated patients (think psychiatric/medical/social) – these are the same patients you would refer for support in a different context. That, and for approvals for testosterone as the PBS currently require this for Authority scripts. But you can write them! Your patients can be on testosterone for 12 months before we see them and they’ll thank you for those 12 gender-affirmed months, a lot.
I understand that it can be hard to keep up in primary care – but you already have these skills and you have a population that’s crying out for caring, interested, able providers. Please consider stepping into this space and start with your first patient, be honest you’re using the guideline (just like I did seven years ago) and soon you could have a skill and some of the most rewarding clinical work you’ve done.