Chantelle: Welcome to the first webinar for 2020 of our Rural Health Webinar Series. This webinar is Supporting Gender Questioning in Rural Adolescents: The Consult Room and Beyond, which will be facilitated by Dr Ashlea Broomfield.
We would like to just start with an Acknowledgement of Country. RACGP would like to acknowledge the traditional owners of the land in which this webinar is being broadcast and we pay our respects to their Elders, past and present.
RACGP would also like to just go through a few housekeeping things before we start. So, firstly, a few tips on using the webinar platform. So you should all be able to see the control panel like the expanded image on the left hand side of your screen. If you can only see a few images like the far left-hand side of the screen, please click on the right arrow to open the control panel. So the control panel provides you with the tools to select your audio options, and it's also the place to ask questions during the webinar. Those of you who have logged in will be using the mic and speakers option as shown in the image on the screen. But if you have any internet issues or a slow connection, please switch to the use telephone option and use the phone number and access codes to listen to the webinar through your phone. Doing this will reduce the bandwidth being used and will provide clearer audio. Now, we do have everyone set on mute to ensure that learning will not be disturbed by background noise. But if you've got any questions, we encourage you to type them into the question log as we go and Ashlea will endeavour to answer those questions for you. Finally, this webinar has been accredited for 2 CPD points. In order to gain these points, you must be present for the duration of the webinar and we also ask that you complete the evaluation activity that will pop up at the conclusion of the webinar. I will now hand over to our presenter, Dr Ashlea Broomfield.
Dr Ashlea Broomfield: Good evening and welcome everybody to the webinar. Thank you for coming along. My name is Ashlea Broomfield and I am a cisgender female and my pronouns are she and her. I would also like to acknowledge the traditional custodians of the land that I'm broadcasting from today, the Gumbaynggirr people, and pay respect to their Elders past, present and emerging.
As you can see from the learning outcomes on the screen, we're going to go over some terms used in the transgender population, look at the issues surrounding mental health, and identify ways that we can actually support our young people who are experiencing gender identity concerns, related dysphoria, or just looking to explore what gender means to them. We'll also cover how we can undergo and get involved in hormonal transition pathways from a rural setting. The webinar will start with a video, then we'll go through some cases demonstrating key points, and then we're going to go through how you can structure your thinking in ways to support adolescents, not just from the consultation room, but the practice and the community Australia-wide and how you can be involved in those different ways.
Okay. So this slide is kind of a nice picture to demonstrate how the patient is at the centre of all of these things, but we can actually help to facilitate some support for the patient at all these different levels.
We're going to start with our video. Is that audio coming through Chantelle? Okay, looks like we’re having some issues with the audio.
I thought this would be a really fun way so you didn't just have to listen to me all night, but we will just try and make sure that we've got the audio coming through that so you can actually hear what these young people are saying. So while Chantelle is getting the audio setup, I'll give you some background for this video. This video is actually part of the Australian Professional Society for Transgender Medicine and this was included in their module of training. This video has actually been completely done by people in the trans community, and in particular young people in the trans community, and they're actually going to talk about different terms that are used in terms of pronouns and different definitions within the trans community as well as what some of the common misconceptions and concerns are. So it's a really useful video and I hope that Chantelle will be able to figure it out for us. Sorry everybody. I’ll just keep going with the webinar while we try to get this sorted.
I'll try and summarize the video in case we can't actually get through to it. Unfortunately, I don't have slides with all the terms on there. But generally, there are certain terms that I wanted to introduce you all to so that when we're talking through the rest of the webinar that you understood what I was referring to. We used to talk about transgender as a whole or someone being trans male or someone being trans female. And, now, generally it's either appropriate to use transgender or trans. However, there's multiple different ways that people may refer to themselves and the young people on the video were going to go through lots of different ones. Sometimes saying that someone is trans male or trans female is not always appropriate for that person. They may just want to be called female or male or a woman or a man. Additionally, they may not identify with any one specific gender at all. They may just identify as what we call, or what the community would call, non-binary and that means that they don't particularly identify with one gender or another and that they're more fluid in terms of their understanding or expression of gender.
When we talk about gender, we're really talking about a social construct. So we're looking at what society sees as gender and I think, you know, 30 years ago it would have been really uncommon for a female doctor to be delivering a webinar on transgender medicine. So we have come even a long way in terms of females within medicine and also educators within medicine and it's quite normal for women to be wearing pants and to be doing traditionally male jobs compared to 50 years ago. And it's quite normal for say men to start growing longer hair and in some cultures wearing skirts or makeup in different circumstances. So gender expression is really a social stereotype that we tend to culturally accept and so a lot of the trans community don't necessarily like to be boxed in by being considered that, you know, you dress or act in a certain way therefore you are male or female and they don't necessarily identify with the gender that they're assigned to at birth based on the sex that they have (or the sex organs that they have).
How we going gentle for the video?
Chantelle: It does not seem to be working, unfortunately.
Dr Ashlea Broomfield: Okay, it would be really useful if we can send everybody the link so that they can watch it afterwards just in case we go over some terms that people don't understand. It's a really useful seven minute video that everybody can watch so that they get a different idea about the different terms.
Chantelle: We can forward that out now (https://www.youtube.com/watch?v=-3ZzpTxjgRw).
Dr Ashlea Broomfield: So when we talk about inclusive language, we're really talking about language that's not boxing people in and the key thing I think with people in the trans community is not assuming anything – not trying to put our own understanding or definitions onto the person in front of us and really being quite open in terms of asking (but also having that background knowledge of what that is). When I introduced myself in the webinar I said that I was cisgender and this is a term that helps to take out this idea of normal and abnormal, in that somebody who identifies with the gender that they were assigned at birth is considered cisgender rather than a ‘normal’ person because we know that generally in a human population it is quite normal for people to experience an incongruence between the gender that they've been born with and the gender that they feel inside. So it's really important to respect people, even if it doesn't look typical of that gender. You know, typically a trans male may identify as male or trans male and it's really important to ask people openly about what the gender is that they identify with. You know, ‘What is your gender identity?’ ‘What pronouns do you like to use?’ and in the recent best practice update they've actually got a section now where you can enter that in in the records, which is really awesome.
Next slide. So this is a photo of a schools based safe schools program for trans people. And as you can see here, just by looking at someone it doesn't necessarily mean that you'll be able to identify what their gender is. It's really important to never assume. Even if you’ve been seeing that patient for a long time it is useful to check and make sure. And the other thing is, their gender doesn't define their sexuality. You know, when I did some transgender training a couple of years ago, I was very carefully told that if someone is at trans male and they like to have sex with other males they would be considered gay or homosexual and that's not necessarily the case – people in the trans community have come out and they're expressing that their gender doesn't necessarily match their sexuality and they may have different ways of defining their own sexuality. And the way that they dress may not necessarily be completely aligned with your ideas of gender. So it's important to be really respectful and avoid using the idea of ‘real’, as in what's your real name or what's your real gender. It can be useful to be a little bit more clinical in terms of ‘what was the name that your parents gave you’ or ‘what was the gender that you were assigned at birth’, asking about what they prefer to call their body parts in gender-neutral normal language and asked in a non-judgmental way. Can you go to the next slide?
So for example, this is from studies that beyondblue did on adolescents and just to demonstrate different approaches – this person is saying that he considers himself a gay male woman (sorry, his or herself - it's really hard sometimes to get used to using different pronouns), but in this statement they’re saying ‘I consider myself a gay male woman. I'm comfortable with my male anatomy and primarily attracted to effeminate men and consider my relationship to be same-sex. However, I expect others to call me she and see me as female and all other areas. Occasionally when I'm attracted to women, I’m attracted to them on the basis of female aspects of myself. So attraction for me is always in some sense same-sex. I'm also attracted to non-binary people or people who push the binary.’ And so you can see for every person it's going to be different and we know that when it comes to sexual orientations, it's not ever black or white and so it's really important to be open and be careful of what gender terms you use in relationships. It's really important to ask, you know, who is this coming with you? Is this your partner? How would you like me to refer to them? Even with children, you know, being careful of father / mother and making sure you're showing that you're generally open. Next slide please.
And the easiest way, as we all know, is to practice on all our patients. And for our young people the easiest way to practice this is when we're doing our HEADS assessment (and there's always more A's and D's and S's in their HEADS assessment than I've got here, but it’s just easier to put one each because I can never remember how many A's and E's and D's there are on this). It's really important to ask in that non-judgmental way, ‘What is your gender identity?’ in that aspect of the HEADS where we're talking about sexuality. You know, it's a really normal time for adolescents to be questioning their sexuality and sometimes issues about gender identity can come up – ‘Are those concerns for you?’ ‘Where are you up to in terms of your sexuality and where you think you're at at this stage in time?’ And that gives people an out to kind of talk about where they think there are now and that doesn't mean that they have to be boxed in about something that they are in now.
I’ve just had a question from Rolf in regards to medical intervention such as the use of formulas – Would you use their sex irrespective of their preference or gender? Yes. It probably would get a little bit more complicated depending on whether they have undertaken a hormonal transition (and therefore the impact of the hormones), but my understanding is that from things like that we could use that particularly. But your medical software will default because, for example, with best practice you can have someone’s sex and then also their gender on the file now in the new update (but don't quote me on that – that's probably something useful to look up).
The other thing to remember is, with the HEADS assessment, it's useful to do that with the young person on their own and without their parents there because their parents may not be outed and that's a really important thing to consider when we go through all of this with our young people – the young person may have outed to you and their close friends, but not their family, not their school, not the receptionist at the front desk, not the entire waiting room. So it can be really important to make sure that when you're talking with a young person really be clear in terms of ‘I know that you're thinking about and you're exploring your gender identity and you know, who knows and who doesn't know? What would you like me to put down in the record? How would you like me to record it? What would you like said in letters? How would you like me to call in the room?’ And we'll go through that a little bit more.
The other thing to remember is that gender doesn't necessarily have to be linked with sex. So you need to be really clear with how we ask people about their sexuality and you would say, framing it in a normalizing way, ‘As part of my role as a GP I do need to consider preventive health aspects and one of the preventative health aspects I think about is sexual health. So can I ask a little bit about your sexual history and preferences’ – and therefore it's not all linked to the fact that they are trans. Sometimes if you find that someone is trans and then the next question you ask is about sexuality that can make it really hard for trans people to feel like their identity is not all about sex.
So let’s start with our first case. We have Evelyn who is a 12 year old female who presents with her parents and her parents actually, you know, bring her in the room (and just as an aside, none of these a real patients – I made all of these up based on an accumulation of young people that I have seen over the years. I was a GP in in a Headspace Centre for quite a while so have experience in this in this population). Her parents come in and they say that Evelyn has cut her hair and she's binding her breasts and asking everyone to call her Evan and by male pronouns and they're really distressed by this. They've called the school, they’ve told the school that they don't want them to use her preferred name or pronouns and they’re expressing to you that she's never wanted to be a boy before now and she has always had boyfriends – does this make her gay and surely this is just a phase to make us upset. So there's a few things that we know from this – Chantelle, next slide.
We know that definitely young people who are experiencing, you know, questioning their gender, exploring their gender, and seeing whether their gender that they feel inside is different from the gender that they were assigned at birth have much, much higher rates of mental health conditions. They have up to four times the rates of depression, up to one and a half times the rates of anxiety, and 20% have suicidal ideation (some have attempts) and there is a higher rate of self-harm in this group. The interesting thing is that we have found that assisting people that are experiencing gender dysphoria, which is the mental health DSM diagnosis related to gender identity questions (and it used to be called gender identity disorder, now it's called gender dysphoria) the rates of distress actually drop when people are assisted to transition in the way that they want to transition and so it is really important to note that, yes, you may have a young person coming to you with depression or anxiety or self-harm or suicidal ideation that does have gender dysphoria or difficulty with coming to terms with the gender that they were assigned at birth and wanting to be slightly different or different completely and presenting with something different and that's why it's important to include that as part of your HEADS. They definitely have a higher rate of abuse and discrimination and you can see in this family there's certain things that the parents are saying in front of this young person that would make it really hard for this person to feel accepted and supported. And then there's reports, specifically in young people, of being bullied at school, in public toilets, in public spaces, and change rooms and they tend to avoid a lot of those places where they feel really uncomfortable and particularly in relation to, you know, if they're changing their hair, uniform or pronouns, when people have previously known them as other pronouns.
We also know that family support is completely protective, sorry not completely protective but family support is really protective for young people. They experience much lower rates of distress when the family is supportive, and also when the school is supportive and they have supportive friends.
So this young person has come out to her parents and is requesting to be now known as Evan and be referred to as he but the family is not supportive and that's a big risk factor for Evan but she's also exploring with them the idea of school being involved in terms of changing the pronouns and changing the name that they're calling her. And so sometimes our role as GPs is helping families to understand that this is a time of change and exploration and, you know, the rates of people experiencing gender dysphoria with other mental health concerns, actually the other mental health concerns go up and the best way we can support our young people at this time is to be supportive, even if it doesn't align with your own ideas of what gender is supposed to be. That actually being pretty supportive of young person actually helps them with their mental health, and as does the school environment.
We do know now that trans identification can start in adolescence. It doesn't always have to start in childhood. In fact, there is some support from the research to suggest that there's actually higher rates of children not going through with the gender that they thought they were as children as time progresses. Whereas most adolescents tend to go ahead with a transition into their adult life. So if an adolescent is coming forward and talking about their gender and their gender expression not matching the gender that they were assigned at birth, for many of those adolescents that actually persists into adulthood. Whereas the children a little bit less likely to, however, reports from The Royal Children's Hospital are starting to show that the rates in children are much higher as well.
Before I go on I'll just answer a couple of questions. So Matt has asked that given that gender identity, like all aspects of adolescent identity, is in flux and fluid in adolescent development, is there a risk that we as professionals can be too quick to progress patients towards medical and/or pharmaceutical interventions? Yes. So I mean not yes in terms of in total but yes, there is a risk and we'll go through that in the next case – so bear with me for a second.
And then Ahmin asks is there any epidemiological data on the prevalence of gender distress amongst gender identity? Yes, there is. I didn't choose to include it in the webinar tonight because I thought it was a little bit dry, but there is some specific training that you can do with AusPATH that I will refer to at the end of the webinar so that you can then go and find out the specific epidemiology, and there's a lot of resources that are attached to that specific module as well.
The other useful thing (and I spoke a little bit about this briefly with gender expression) is that when Beyond blue did some research on some trans young people, they actually found that a lot of them didn't necessarily identify as homosexual or gay or heterosexual. A lot of them, most of them actually, were a bit more fluid with their sexuality as well – about fifty percent of the young people identified as either pansexual (which is attracted to anybody regardless of their gender or sex) or queer (which is, you know, it depends) and many chose to say not sure or questioning to describe their sexual identity, which is about 12%. So it's really useful to make sure that you don't have to pick a sexuality even though sometimes it's on our drop-down menus – you can be a little bit more open. And Matt will get to your question in a second.
So for case two, we have Ollie, who's 10, presenting with his parents for assistance in transitioning. Ollie has identified as female throughout childhood and wants to organise transition before high school and his parents are supportive and engaged, which is really lovely. So onto the next slide…
What we do know, as I said, is that gender affirmation or transitioning is protective and waiting until the age of consent is not a neutral decision. So this is in the W PATH guidelines (the World Guidelines on Trans Health) – they say that just because waiting is an option doesn't mean that it's a neutral decision. So that means that because there's high rates of mental health distress and suicidal ideation (and suicidal attempts) and those rates are much higher than in the general adolescent population (and it often worsens in puberty), waiting for someone to transition through puberty, go through the entire process of puberty, and be physically the gender that they were assigned at birth, has negative impacts on mental health and also physically in terms of that for some genders it can be difficult to reverse those things. For example, for people who are assigned male at birth, going through puberty actually deepens the voice, there's a lot of body hair, and that can be a lot harder to reverse – particularly the voice, even with voice training. So there's certain things it's actually easier for people to transition physically if we can do it at puberty. And that involves processes which will go through.
It doesn't have to be stepwise. So you don't have to start by hormonal transitioning or physical transitioning (and I think hopefully that answers your question Matt). Often the social transitioning can be the hardest part of transitioning – you know, actually coming out and telling people I want to be called by this name, or I want to be known by something else, or presenting in different clothing, going to different toilets, you know exploring what it's like to live as that opposite gender, or, you know, if you're a bit more fluid or non-binary, choosing to present in that way – if you watch the video later, you will see that we don't have to jump into hormones and we don't have to jump into physical changes.
Physical changes we’re not allowed to do until someone is an adult (until they're 18) and hormonal has to be done by a paediatric endocrinologist and have a child and adolescent psychiatrist assessment. So there is a lot of steps that people have to go through in terms of a hormonal transition. So generally we can, as GPs working with adolescents, we can work with them on looking at where they want to be and social transitioning may be the first thing as they're exploring their gender identity. And therefore we can help them keep that door open if they don't choose to go ahead with it. But they do require specialist services to hormonally transition and generally that is part of our role if that is their wish, but they can only access those services if their parents also agree to the process. So the young person has to be able to consent to it. So they have to be the age of, you know, they have to be Gillick competent, in order to make an assessment for themselves and their parent has to consent to it. For children who would like to have puberty blockers before they go on to hormonal transition, their parents have to be on-board with that and it is mostly reversible. The only thing that's not reversible with puberty blockers is bone development – so there's a higher risk of problems with bone develop and they tend to be a little bit higher. But cognitive and emotional development is normal when people are on puberty blockers. So it's only the physical changes that are delayed and then they catch up quickly once the puberty blockers are stopped. So it doesn't mean that if you stop puberty that there's going to be a whole bunch of things go wrong. It can actually just buy you some time to have the right conversations that need to be had.
We'll go through the psychometric measures, Ahmin, and then Rolf had a question about whether in any events that someone had, post transitioning, that the person feels they made a mistake – and actually that's a great question – the research does show that very few people regret at all and, you know, the success and the satisfaction rates are over 90%, which is really comforting as a medical practitioner to know that when somebody is actually transitioning their success rates are much higher. Like you say Rolf, with children it's a much, much more involved process. So before they come into adolescence, if we're looking at puberty blockers, that does involve Child and Adolescent Psychiatric Services and often a tertiary service. So in rural areas, that does mean that we do need to refer them to, you know, generally our major cities for further assessment or Skyping initially and developing a relationship there. But the question is we can't be a hundred percent sure – it really is an ongoing discussion and assessment and there are specific metrics that we can use, but we're working towards, particularly with adults and older adolescents, an informed consent model, whereby a lot of the people in this community are really, really well educated (and they often saying that they're the ones educating us rather than us educating them). So generally a lot of our role as GPs can be more of a supportive, facilitating way in that we can understand and go through options. So on to the next slide Chantelle.
Like I said, transitioning can be all or one of these – and it's not necessarily stepwise. Generally for physical transition, you have to go through hormonal transition first in order to qualify for physical surgery, but people may choose to do a hormonal transition before they do a social transition and a lot of people, particularly adolescents, will choose to do a social transition before hormone. But I think the other thing to really understand is that not everybody wants to transition and not everybody wants to transition in all ways. So I think the really important take-home message from that is it's important to understand that social transition exists, hormonal transition exists, physical transition exists, and be really open with the young person and say, ‘Look, I understand that, you know, when people are considering a gender identity that's different from the one that they're assigned at birth, what comes along with that is working towards being an expression of more of what you feel inside. And what does that look for you right now? What does that look like for you in the future?’ And sometimes explaining the different options can really help people to make decisions. And I think there's more of a trend these days to not go through as much surgical transitions because they can be quite extensive. The trans community often refers to top surgery is top surgery and bottom surgery is bottom surgery. Bottom surgery is a little bit more extensive than top surgery, a lot harder, and can result in changes in sensation and so it's a really big decision. But when we think about a physical, as in surgical, transition it's not just the genitals or the sex organs, it can also be facial reconstructions or, you know, changing of the body shape in a way that's more feminine or masculine or more aligned with the gender that they're aligned with.
Hannah has asked a question about parental consent – Does it have to be from both parents? It basically depends on who has a decision making capacity. If it's dual custody then both parents have to agree. Yes.
And Ahmin has asked – Are there any special centres specialising in gender identity as a referral centre? And the answer to that is yes, but it depends on different states. So what I will refer you to at the end of the webinar is the AusPATH module because it actually goes through these and there's a whole bunch of resources for every different state and we don't have the time to go through them in this webinar (it would just take up most of the time to talk about all of the resources) but there's a whole specific module where you can go in and you don't have to do all the modules, you can click on the referral pathways.
Annette has asked a question about the link between ASD and gender issues. So we do see in the research that there is a little bit of a link between Autism Spectrum Disorder and children who are identifying as a different identity than what they are assigned with at birth, so we see a higher rate of ASD in the children population. I didn't see any research about a link with ASD in the adolescent population in terms of figures, but, in my practice, I have seen that people who have autism spectrum disorder are commonly not as binary as people without ASD, but that's in no way a blanket statement. It's just, I think, that the lines aren’t as black and white and sometimes there is a bit more exploration there and I think it's just useful to keep that in the back of the mind. But there's a really great video that the trans 101 group has done and it's about trans neurotypical and it discusses the link between ASD and trans and they basically, the trans community, want people to know that just because they have a comorbid mental health condition or a neurodevelopmental condition, it doesn't make them any less trans. And I think it's really important to encourage body acceptance. So we'll go to the next slide.
The other thing to think about is this concept of gender dysphoria. So for our mental health plans and for referrals, generally we do need to use this term. In order to access transition through hormonal transition or surgical transition we actually have to diagnose gender dysphoria. It's one of the criteria but it's something that the trans community is exploring because not everybody experiences dysphoria – some people are really comfortable with the gender that they identify with even if it is different from their gender that they've been assigned and they're really comfortable in that and they’re really happy with it and they don't always have dysphoria. So, as part of the process of transition, we do need to diagnose gender dysphoria, and there's a DSM for that you can find just by looking in the DSM or doing the AusPATH training, but it's really important that the way that you bring this up with people in consults is very open as well. And sometimes what I say to people is ‘Look, as part of the process to obtain hormonal transition, we do need to diagnose gender dysphoria. That doesn't always mean that you're really dysphoric but it is one of the requirements that we do need to go with and just because you're not experiencing significant distress at this stage, you know, it is one of those things that we do need to write down.’ And so it's just about kind of normalising and validating why you are using it rather than adding a label that makes them abnormal. We don't want to be saying you're abnormal and this is a DSM diagnosis and therefore that's a problem. The trans community, you know, they seek treatment as becoming more in line with who they are, not as a problem that they need to change back to the gender that they were born with – so just be really careful about the way that you introduce the terms.
We're going to go quickly over it the difference between adults and adolescents for criteria. So for adults, you have to have a persistent well-documented gender dysphoria, they need to have capacity to make decisions, they obviously need to be an adult (so the age of majority), and they need to have stable comorbid conditions (both physical and mental health). In addition, if they want to undergo a surgical transition they need to have taken 12 months of continuous hormonal therapy and have 12 months of real life experience living in that gender (i.e. being socially transitioned). That may change over time, but that helps the surgeons and the people doing a potentially irreversible procedure to know that this person is really happy with it. Most of the hormones can be reversible (as in, once they stop, as long as the gonads haven't been removed, the gonads will then produce either feminising or masculinising hormones that are linked to their birth identity and will go backwards), whereas the surgery isn't. The puberty blockers are considered generally mostly reversible except for the high-end bone changes. There are some things that will not be fully reversible with hormonal therapy, but we won't have the time to go through them tonight (and that's where I would encourage you to do the AUSpath training if you're interested in finding out more about that – the training is amazing).
So for adolescents, it's very similar. We need to have long-lasting and intense gender nonconformity – so they don't actually have to be diagnosed with gender dysphoria, which is a nice change – and it has to have worsened at puberty. So often the change in their bodies tends to create a lot of distress and sometimes that'll change over time. Like adults they need to have coexisting stable conditions and the adolescent and the parents have to have consented and be supportive of the journey.
So case three. Justin is a male presenting for assistance to transition towards female. He comes in and you notice that he has, you know, long brown hair, is wearing a black T-shirt and black skinny jeans and you think oh, I'm not sure exactly where he's going with this or she's going with this. You ask Justin what he identifies as and he says he identifies as female and you ask him what pronouns you’d like to use and what name you would like to be called by and he says that he would like the use of male pronouns and he's not ready to socially transition, but he asks specifically about whether transitioning will affect his future fertility.
So what we do know – again, not everybody wants to transition but there's lots of research to support the positive impact of transition. And like I said earlier, very few people regret it and many people are more happy becoming more aligned with their perceived gender. But some people are really comfortable where they're at and generally my take home from this is the ones that are telling you that they want to transition, support them to do that, the ones that don't and they're happy as they are, then you don't necessarily need to push them into that – you don't need to say ‘well, when are you going to transition’ or ‘if you're not going to transition that means you're not transgender’ because that's not true – no two ways of transitioning are the same.
It’s also really important to talk about fertility. That's where it's important to have our handy endocrinologist relationship developed because, for adults specifically, you can do sperm cryopreservation, women can do egg harvesting and freezing, and there has been reports of people who have stopped their hormones and their gonads have started to produce either sperm or eggs and then they've gone on to successfully have children after that and then go back onto their feminising or masculinising hormones afterwards. So it is important to talk about fertility and not assume that they don't want to have children because, you know, the people in the trans community definitely have expressed that a lots of them would like to have children and may like to use their own bodies to do that. Many patients may be too young to be thinking about children, so it's still an important discussion to have.
For adults these days there's now an informed consent model. So if you do the AusPATH training so you can learn more about what's involved in prescribing, what tests you have to order, how you need to monitor, and how to consent for side effects, and what the process is then GPs can actually start to prescribe hormonal transitions. What I would recommend (and if you go through the module you'll kind of understand this) is that when you’re starting to prescribe it's important to have relationships with specialists so that you can have someone to bounce off, but for adults you actually can help people transition – you don't necessarily need a specialist – we're all experienced in prescribing hormones. It is something that the trans community is hoping that GPs will be able to do more of because it's quite hard to get to specialist gender services. And as I said satisfaction rates are high and regrets are extremely rare.
Before the next case, we've got a question from Sarah who asked what qualifies as long-lasting? I'm not exactly sure what you mean by that Sarah – if you want to ask the question again with a bit more detail then I can perhaps answer that a little bit more fully.
So for case four, we have Bianca or Ben who is a trans male or a female who has transitioned to male (and I've made a mistake on the slide here and said ‘preferred female’ but it's not important for this scenario – so we won't dwell on that too much), and presents concerned about a changing skin lesion. Ah, Ben is the old name – the name that she was assigned with at birth – so she has socially transitioned, is on feminisation hormones, has had top surgery, but not bottom surgery and has never had cervical screening. Her regular GP prescribes and monitors her hormones, but is on extended leave so you can't kind of flick it back to her or him or they when they come back from holidays.
So what do we know about this? So preventative screening is really important. We can't forget about cervical screening but it's important to not necessarily say women’s screening or women's health checks and be very clinical about your questions for this population. So a lot of trans people say they like things to be referred to as the anatomical names but I think the key take-home message is to ask – ‘So how would you like me to refer to your body parts’ and they may be really clear and if they don't know then be anatomical – ‘Do you still have a cervix?’ ‘Do you still have a uterus?’ ‘Do you still have testes?’ ‘It is part of my job to do cancer preventive screening that involves cervical screening. When was your last cervical screening given that we know you still have a cervix?’
And the important part here is just because this person is coming in and is transgender doesn't mean the consultation should be about their trans identity. So if someone who's trans comes to you and you notice that they're trans and they come in for a skin lesion, it's really important to treat it in the same way that you would for any other person. You know, I think something to ask yourself is would I ask this question of a cisgender person? So, you know, if someone comes in for a skin check and you say oh that's great, I need to have a look at that skin lesion and you would normally say well part of my job is I don't just do spot skin checks like I also do a full top to toe skin check, it's really important to be really clear with consent. Because of the higher rates of abuse and violence and discrimination, we need to be really careful that the person doesn't perceive that you're wanting to do a full body skin check just because they are trans. So it's important to say for all of the patients who present to me with skin lesions I offer them a full top to toe skin check and that involves, you know, whatever your consent process is, but for me that involves me having to check under the bra area and also around the underwear area and you know, there are melanomas that can occur in the genital area as well. How would you like me to examine that? Would you prefer to do that when we do your cervical screening or would you like me to do that as part of your skin check?
So I think it's really important to normalise and be really, really clear with consent. If you’re offering them a full skin check that means that you're undressing or if you're offering invasive procedures that involve touching body parts that would be distressing for anybody, it's important to be really clear with the consent and make it clear in your own mind and that you're getting across that this is not about you being transgender, this is what I do for everybody.
Before we go on, I'll just go through a few of the questions. So someone said – Do you think this person needs a very good psychiatrist evaluation before hormonal transition? I think it's a case-by-case basis. It's really important to make sure that, as you’ve seen in the criteria, that their mental health conditions are stable and if you're not confident that their mental health conditions are stable and you feel that a psychiatrist needs to be involved or a psychologist needs to be involved before you go through the transition that's entirely appropriate, because as you can see one of the criteria is that their mental health conditions are stable. They've changed the criteria in the guidelines in that they don't have to be having treatment or mental health treatment in order to transition. They can have a mental health assessment and that mental health assessment can be done by a GP who is experienced in hormonal transition or has done training in it. However, even psychiatrists will do a mental health assessment over multiple sessions. I wouldn't at all ever suggest that you would be able to make a decision on transitioning someone or be able to have all the conversations that you need to have about transition in one consultation – it would occur over time, over multiple consultations and as much as we have the capacity in rural and remote areas to involve specialist services, that would be ideal, but sometimes there's not and so it is okay over time to do some of these conversations if you are comfortable doing the training and having these discussions and create good relationships. We’ll go to the next slide.
A question from Tony – Is it only for specifically over 18 years / adults that GPs can prescribe for? Yes. You can't prescribe for adolescents.
Sarah asked – In terms of long-lasting gender dysphoria as a requirement, how long is ‘long lasting’? Great question. It has to be persistent but they don't really define what persistent is. I think that's on a case-by-case basis. Generally, it wouldn't be a month, you would be looking at years – you're looking at someone who's been questioning their gender for what you would consider a while. We wouldn't be discussing a hormonal or surgical transition for someone who's kind of decided this month that they want to change their gender identity. But I think the more that you open and have these discussions you'll start to kind of understand what is considered persistent. Very few people can't give you a history of what it's been like for them. And if you are in doubt then you can just ask more questions or ask for advice and with the invent of Telehealth these days it's really easy to get a psychiatrist who's interested in transgender medicine for an opinion – and that may take a couple of months and in that time you can get to know this person and generally frame it like ‘I'm here to support you, I'm here to work through the transition with you and so therefore, you know, it will take us a little bit of time to jump through the hoops per se to get you there’ and over time you'll start to see that the gender dysphoria is persistent (or not). And generally if someone has to jump through a lot of hoops and they're at that point where they’re working towards that then they are quite committed and I think that's probably why the success rates are so high.
So if you want to get involved in transitioning, my advice is to do the AusPATH training. Chantelle, do you have the link? I've sent it to you so if you can copy that in to everybody (https://auspath.org/education/). So my advice would be to do the training and really advocate for your trans patients (and we're going to go through this in a second), and network – so network with psychiatrists, child and adolescent psychiatrists who you know have an interest in transgender medicine, find the psychologist locally who has an interest, and find the people within your community or neighbouring communities that have support groups (if there's no support groups maybe find some people in your community that are interested in creating support groups because we know that supportive communities are really useful).
A lot of young people say that when they come to the doctor, they know more about trans medicine than the doctor does (and so do adults) and lots of them say that they don't like being the science project – they don't like being that interesting person that the GP can learn from. So I think even if you're not interested in doing hormonal transition and you want to just be a bit more open and understanding, the training is really useful because it gives you this background that you can seem like you know a lot without having to know everything, and the way that you approach it, nothing is a shock if that makes sense.
So we're going to go through quickly for the end of the webinar different ways that we can support our patients in the community.
So we're looking at the billowing out from the patient to the doctor to the practice. So we’ve spoken a lot about the patient and we’ve spoken a lot about the doctor. So we're going to talk a little bit about some of the things that young people have said made them feel better. So onto the next slide.
So people who are trans find that spending times with their friends, chatting with their friends online, calling their friends, chatting with the health professional, going online, spending time with family – they find that this makes them feel better, which is really similar to other adolescents. On to the next slide.
They often like listening to music, creating art, spending time with pets and friends, and reading books, exercising, eating well, playing video games, watching TV, and some of the things that they do to feel better that aren't so great are harming themselves, seeking out sexual experiences, drinking alcohol, and taking drugs or smoking cigarettes. And, you know, this is just like any other adolescent that I have seen in my practice – just because they're trans doesn't mean the things that make them feel better or the things that they try that may not be so good for their health are any worse. And so I think it's really important to treat a transgender adolescent in the same way that you would with any other adolescent in helping to support them to feel better because reasons for them not seeing doctors are often because they feel like there isn't anything that doctors could do for them, that they wouldn't understand, they couldn't afford it, had past experiences that were negative, or that their parents and carers will find them out or they'd have language that made them feel uncomfortable, won't believe me or distance themselves.
So it's really important to be open, to be using questions about gender openly, and to be using pronouns openly, and be treating them like we would any other adolescent in terms of ways that we can help. In terms of tips for doctors, I think I've gone over this, but in terms of families I think support is really important. As rural GPs, we all have families that we know a lot and we may have to socially transition along with the family – you know, we may have known a young person for a long time before they come out to us and so part of our process is learning to use the same pronouns as the young person is asking us to use, learning to use a new name and showing by example. And I think referring the family for family counselling can be really supportive. If you don't have family counselling in your area and you've got psychological training, which the rural faculty provides as well, then it can be useful to see the families and parents separately without the young person so that they can air their concerns. You can talk about things openly without doing it in front of the young person and sometimes what I say to parents is, you know, if we just allow this young person to explore this and it happens to not be something that they pursue down the track, at least they'll know that they were supported by us. At least they’ll know that they were supported by you and that you love them no matter what gender that they choose – if they decide to change their mind we can also support them in that journey as well.
It can be really, really hard with parents that are unsupportive and sometimes what we will do is in practices (if we can go to the next slide) we will make sure that in our practice software we make it really clear that the young person wants to be called a certain name when they're talking to us themselves, but doesn't actually want their family to be referred to – so sometimes, if we use Evan as an example, so ‘Evan’ for patient and ‘Elaine’ for family or ‘Elaine’ for school or with the pronouns we might say, ‘she’ for the patient and ‘him’ or ‘her’ for the family, because sometimes it can take families a while to come around and sometimes they can be quite angry at a practice for facilitating something that they don't support.
So there is certain ways that we can still support our adolescents and showing that we are a safe space that they can come to and chat on their own, but we can also respect the parents depending on where they go and that's a lot. You know, like I said before you don't have to have psychological treatment for a transition, but it is really important to have psychological treatment to support the social transition because that can be really, really hard and a lot of it is about exploring all the nuances and difficulties that come with that.
Matt has said it's important to note that some mental health conditions can include gender-related delusions or obsessions that can look like gender dysphoria. And, I mean, that's part of the mental health assessment and so it is important to exclude psychotic illnesses or obsessive traits and that's part of the mental health assessment. So if you are worried that they do have a psychotic illness or other disorder that can explain the gender dysphoria it's important to explore that in the process.
For practices it's important to make sure that your new patient forms have places for people to be open with their gender identity, that people when they're answering phones make it really normal to say ‘What is your gender? And what pronouns would you like to use?’ and allow people to say that and ‘How would you like me to record this in the practice software?’ Some trans people have said that they would like doctors to have numbered systems for the waiting room so that they're not called by the wrong name in front of people that they're not comfortable with – and that's something that the practice will need to explore. Having inclusive spaces that allow for gender neutrality – sometimes marking the disabled toilet as a unisex toilet rather than just as a disabled toilet can be really opening and clearly marked spaces that allow for not just binary positions.
In terms of community, as rural GPs, we have a really big role in the community and so we can help to create events, we can help community organisations to create policies, we can create support groups, and we can make young people who are trans in our communities feel really supported. And, if we go on to two slides ahead, when we talk about Australia-wide, actually a lot of young people are involved in advocacy and more young people in the trans population are higher in terms of the advocacy compared to the lesbian or gay community. So there's a big push in the trans community to educate Australia wide and be involved in advocacy in different ways, whether it's on social media, as part of community events, or education.
And there is opportunities for your practice – if you've got young people who are identifying as trans or who have comfortably socially transitioned and they're comfortable being a support person in your practice, to actually involve them in your community, involve them in your policies, and look at supporting events and supporting young people to be advocates and to be involved in events that help to support them because, you know, the number one thing that we know that is protective for them, as I spoke on earlier, is supportive family and supportive communities. And that's one of the biggest roles that we, as rural GPs can play for these young people.
Any more questions? Cool. Well I feel like I just ran right on time and maybe if we didn't have all those video glitches we might have run over time if we had the video. But that video is a really, really cool one to watch to get a bit of an idea about fluidity in the trans community and I would really encourage you to watch the series of videos that are attached to that from the Trans 101 group and to do the AusPATH training. Even if you're not ready to prescribe yourself, being educated and being aware of all of the various ways that these questions and these things that come up over time. It's really a useful resource and there's lots of resources about different states and it's got all the guidelines for diagnosis and the guidelines for assessment and specific research for young people and adults and it's also got people talking about children specifically – so if you're keen and you want to do further training I would highly recommend that even if you're not going to prescribe down the track.
Chantelle: Okay, great. Well, thank you Ashlea and thank you everyone for participating in this evening’s webinar. So sorry about the technical issues, but I think we did forward through the link to the YouTube to everyone but if anyone's got any other issues with that if you go to YouTube and search ‘trans 101 – the basics’ you'll also get access to that video. So thank you again everyone and just a reminder to complete the evaluation form that will pop up in just a minute when the webinar session closes – it will take no more than a minute to complete and certificates of attendance will become available on your CPD statements next week, but for any non-RACGP members who would like a certificate of attendance, please email email@example.com. Thank you everyone and good night.