Trans Healthcare – Transitioning with a patient to better outcome

GP Connect Opinion Piece by Hunter Gurevich, Chair, Transfolk of WA

Current research demonstrates that trans and gender diverse (TGD) people represent about one to two percent of the community, and that number is growing as people become more aware of the distinction between sex and gender. However, the capacity among GPs to provide appropriate care does not meet demand. There is currently a dearth of opportunities for GPs to upskill with regards to providing quality healthcare to TGD people, both in terms of the specifics of gender transition/affirmation, and in terms of the long-term care of an individual.

Resources do exist, but they are not yet made readily available. Further, nothing is currently in the university curricula to ensure graduating doctors are sufficiently educated in this area. Therefore, the onus falls disproportionally on individual GPs and physicians to educate themselves in this area either out of personal interest, or due to the arrival of a patient with these specific needs.

This article provides a brief entry point into care for TGD people, explains the nuances of language, addresses some inaccuracies, and provides some guidance to appropriate care.

Language

  • Sex: Chromosomal, gonadal and anatomical characteristics associated with biological sex.
  • Gender: Part of a person’s personal and social identity. It refers to the way a person feels, presents and is recognised within the community.
  • Cisgender: Adjective describing a person whose biological sex aligns with their gender
  • Transgender: Adjective describing a person whose biological sex does not align with their gender
  • Non-binary: An Umbrella term to describe a person for whom neither ‘man’ nor ‘woman’ sufficiently encompasses their experience. Non-binary may include, but is not limited to, genderfluid, genderqueer, gender-non-conforming, agender.
  • Intersex:  A term used to describe a person who was born with a biological variation in sex. Many intersex variations exist.
  • Pronouns; Article of language denoting the third person. For TGD people, it is preferable that pronouns are volunteered or requested, as not all people will use the pronouns one might presume. Some may prefer they/them pronouns, rather than he or she.
  • Note: Many languages and have their own words for TGD identities that could fill a PhD. Notably in Western Australia, Aboriginal trans people may be called Brotherboys and Sistergirls. It is important to be sensitive to the particular culture of the individual.

Language to avoid

  • Transexual: This is an outdated term with negative connotations. Transgender is the current appropriate term.
  • ‘Used to be a boy/girl’: Many TGD people feel they were never the gender they were assigned at birth. To describe a trans history, we might say, ‘assigned male/female at birth’ or ‘presumed male/female at birth’.

Myth-busting

Transgender and non-binary identities are a pathology – TGD identities are not the norm, but they are as prevalent as blue eyes or red hair. And like blue eyes or red hair, a TGD identity does not inherently create dysfunction. It is simply a natural variation. It is also important to note that a person’s gender identity, like many other aspects of personality, body habitus, disease states and wellness, these may be fixed, but also may vary across time. As with all variation, it is not in itself a pathology, but a natural characteristic of experience for some people.

Trans people are a symptom of modern society – Many cultures have language and long histories of TGD identities. Hawaiian culture describes the ‘Mahu’ people, ‘Hijra’ emanates from the Indian subcontinent, and a huge selection of world religions display gender variant gods and legendary figures. The biblical Adam is described as both male and female before Eve is separated from him. The concept is not new by any means.

Trans people are crazy – TGD people do have higher rates of mental health issues than the general population. This is largely the result of social concerns rather than inherent correlation to a TGD identity. Evidence demonstrates that, when TGD people are not subjected to social exclusion, isolation, stigma, violence and abuse, and when given appropriate medical care, their outcomes match those of the general population.

This is not my problem – Statistically speaking, at least two per one hundred patients will be TGD, and among young people it is more like one in ten. Therefore, it is incumbent upon all health services providers, but especially GPs, to be familiar with providing appropriate care for this community. It is especially important given that many TGD people avoid the GP due to fear of a negative experience, and this contributes to their poorer health over time.

Transitioning to better healthcare for TGD people

The key to better healthcare for TGD people is to communicate and empower.

Flag yourself as a safe provider by providing the opportunity for patients to volunteer their pronouns on intake forms, having staff pronouns on badges, and declaring intolerance for homophobia/transphobia in the waiting room.

Understand that revealing a non-cisgender identity to a GP, even in the context of an existing relationship, may be extremely daunting and make a patient feel vulnerable. Having the context and understanding to receive that information and be able to direct a patient’s care around this revelation is vital to their ongoing health.

Ask a person what they need from you, but do not ask them to educate you. Ask them about their experience, what they feel good about, what they feel bad about, and what they need from you, but do not ask them to explain the language, or what the medical pathways are.

Be aware of how the WA healthcare system operates to provide care around a medical transition/affirmation. WA Primary Health Alliance will soon be releasing a HealthPathway on this.

Be prepared to provide care for a TGD patient across their lifetime. This means committing to continued learning as more research is completed and ensuring your standards of care are up to date and evidence based.

While the HealthPathways WA Transgender Health and Gender Diversity HealthPathway is underdevelopment, see the NSW TransHub website For more information on transgender health.

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