Journey to care
Author: Amanda Lyons
GPs can be a key part of a transgender patient’s pathway to whole-of-person healthcare.
Clare Headland is a 70-year-old parent of seven who used to work as a chiropractor and remains in the healthcare profession as a patient services assistant at Austin Hospital in Melbourne. She loves her work in the palliative ward at the hospital’s Olivia Newton-John Cancer Wellness and Research Centre, and is soon to start further training as a pastoral care worker.
For most of her 70 years, however, Headland lived with what she described as overwhelming feelings of depression and shame.
‘I had been clinically depressed all my life, with constant suicidal wishes,’ she told Good Practice. ‘I prayed for heart attacks, for cancer, to be run over by a bus.
‘It was confusion and deep, constant pain and fear, from waking up in the morning to going to sleep at night.’
From ‘six years of age until 65’, Headland lived in the shadow of these feelings until she came across something online that made everything fall into place.
‘I was searching information about struggling with depression, anxiety and suicidal tendencies, and I found sites that were about transgender people,’ Headland said. ‘There were clubs, associations, groups and Facebook pages.
‘I thought, “These people are expressing the same things I’ve been feeling. I am not alone.”’
Headland was born male, but had never felt comfortable as a man. Discovering she might be a transgender person started her on a journey that resulted in a state of self-acceptance she had previously found unimaginable.
‘Generally speaking, my [post-gender-transition] life has been so blissful, so joyful, so deeply, deeply happy,’ she said. ‘When people ask, “How are you feeling?” I say, “I feel like a dog with two tails”, because I love myself for the first time in my life.’
The idea that she was a transgender person had never previously occurred to Headland; she had no real concept or even language for such a situation.
‘I saw so many GPs, psychiatrists, psychologists, primal therapists, rebirth people. I went everywhere because I was so unhappy,’ she said. ‘But, because of the time when I was looking, nobody ever said, “Have you considered that you might have a personality that is more feminine than masculine?”’
Dr Vincent Cornelisse, GP and sexual health physician at a clinic with a focus on lesbian, gay, bisexual, transgender, queer and/or intersex (LGBTQI) health, understands that awareness of transgender and gender-diverse identities has traditionally been somewhat limited, but he believes this is changing.
‘I think young people are more aware and, importantly, parents and teachers are also more aware and hence more likely to seek or suggest assistance from a health professional,’ he told Good Practice.
But, according to Assoc Prof Ruth McNair, GP and academic with an interest in LGBTQI health, transgender and gender-diverse people often remain disproportionately burdened relative to others in the LGBTQI community.
‘[Transgender people] are disadvantaged socially, often even more so than lesbian, gay and bi people,’ she told Good Practice. ‘There’s more stigma around transgender identities. It’s particularly hard for transgender people to come out and be accepted by their families, so there’s a lot of family disruption and rejection.’
This social disadvantage and discrimination is manifested in stark statistics, such as transgender people aged 18 and older being nearly 11 times more likely to have attempted suicide than the general population.1 Stigma can also affect a transgender patient’s willingness to seek healthcare.
‘A lot of gender-diverse people are worried that the GP might be surprised or uncomfortable, or have negative attitudes towards gender diversity,’ Dr Cornelisse said.
‘Many of them have had negative experiences in the past. Not necessarily from medical professionals but in general, from people in the community or even family members and friends. So they are vulnerable in that respect.’
Dr Cornelisse believes the therapeutic connection that is fundamental to general practice makes GPs well placed to deliver care to this patient population.
‘The beauty of general practice is that you’ve got the space to have long-term relationships with your patients,’ he said. ‘Treating gender-diverse patients is about looking after their whole health and, as we know, that’s often best done by a GP.’
Assoc Prof McNair observed that, while many GPs may simply be unfamiliar with transgender issues and thus feel uncertain about how to advise patients or where to refer them, most already have skills that are relevant to patients in transition.
‘[GPs offer] accessibility and understanding of the family,’ she said. ‘And we’re already doing hormone therapies with patients such as pre-menopausal women. We’re quite conversant with that, so it’s a small step to understanding transgender hormone therapies.’
Raising the issue
The delicate and deeply personal nature of gender dysphoria – the condition of feeling emotional and psychological identity is gendered opposite to biological sex – means it is often difficult for transgender patients to broach the issue with a GP for the first time.
‘I see that anxiety in a lot of gender-diverse people when they first come to see me, even though they probably know I do a lot of work in this area,’ Dr Cornelisse said.
A practice space that feels safe and accepting can be very helpful for these patients. Dr Cornelisse has some relevant advice about how to create this type of environment, starting with the waiting room.
‘It doesn’t have to be a massive change. For example, placing a rainbow sticker at reception and in the waiting room is a good start,’ he said. ‘Those sorts of signals are picked up quite quickly by same-sex-attracted and gender-diverse patients, and they probably won’t offend any other patients.’
GPs can also take a number of practical steps, from a patient’s first consultation experience through to a practice’s record-keeping processes.
‘It comes down to things like, how do you ask people about gender on their intake form when they join as new patients?’ Dr Cornelisse said. ‘How do you make sure your reception staff address people by their affirmed gender, rather than their Medicare-listed gender? And how do you make sure your software reflects that, so your staff use the correct gender when, for example, someone phones up and their voice might not reflect their gender?’
These types of details can make a significant difference to transgender and gender-diverse patients.
‘It’s such a simple step, to use the name or pronoun the person prefers, even if it’s not yet listed at Medicare,’ Assoc Prof McNair said.
Once a patient has established that they are transgender, they may wish to begin transitioning. This is the process of transforming external gender presentation to accord with internal sense of gender and can involve a range of actions, from dressing in the clothing of your preferred gender to genital reassignment surgery.2
In Australia, the pathway towards physical transitioning follows the standards set by the World Professional Association for Transgender Health (WPATH).
‘[This is] an approach where a person has a psychiatric assessment, usually with a psychiatrist or a clinical psychologist, to do a gender assessment and to confirm that they have gender dysphoria,’ Assoc Prof McNair said. ‘That might take three to six sessions.
‘Then, once they have a letter of confirmation the patient can start hormone therapy. They can access surgery at any time after they’ve had their gender dysphoria confirmed, apart from genital reassignment; they need to have been on hormones for 12 months before they do that.’
Dr Cornelisse is sure to offer important advice for transgender patients regarding the psychiatric assessment.
‘I explain to patients that this is not to determine their gender,’ he said. ‘I think the patient is the best person to judge their gender – no one is questioning that.
‘The purpose of assessment is rather to ensure there are no psychiatric diagnoses that would complicate their gender-affirmation journey. And if there are such diagnoses, to then ensure that these are well managed.’
Dr Cornelisse also cautions patients that transitioning can be a difficult road, even if highly desired.
‘Hormones have direct effects on people’s mental state, and going through surgery can be difficult, as well,’ Dr Cornelisse said. ‘These changes can also come with interpersonal difficulties with family, friends and people at work.
‘So part of the reason for the mental health assessment is to gauge where patients are with their general mental health, and to make sure they have got the support structures that they may need in place.’
It is also important to note that not all transgender patients present as adults. An increasing number of children are presenting with gender dysphoria,3 which poses a more complex treatment approach.
‘Many children exhibit cross-gender behaviours and identities at some point during their childhood,’ Dr Cornelisse explained. ‘For the majority, that doesn’t persist after adolescence. So it’s a matter of trying to tease out which kids are likely to have persistent gender dysphoria and which ones aren’t.
‘On top of that, it’s quite an urgent situation. If a child does have true dysphoria and it is likely to persist, you ideally want start their hormone treatment before they start puberty.’
Assoc Prof McNair recommends referring children who may be transgender to gender specialists.
‘There’s a lot of support to be done around educating families, as well as being sure that a child is not just going through a developmental change,’ she said.
‘[Specialists can] also use puberty blockers for kids, which buys a bit of time until they’re mature enough to make an informed decision about cross-sex hormone therapy.
‘That is quite specialised care and it needs to be done with paediatric endocrinologists and psychiatrists.’
There are various gender-related matters of which GPs can be aware when providing ongoing care to a transgender patient.
‘For example, it is important to keep in mind that a transgender woman, even if they’ve had genital surgery, may still have a prostate. So they would need the same prostate screening a man would need,’ Dr Cornelisse said. ‘If a transgender woman has breast tissue as a result of hormone treatment, they will need the same breast cancer screening as a cis-woman [a woman who is birth-assigned female].’
Dr Cornelisse also suggests caution in regards to drawing too much attention to a patient’s gender identity.
‘What can happen when the transgender person goes to see a GP is that all the attention is focused on their gender identity and the gender treatment they may have had. But the patient may not have come to the GP for that reason,’ he said. ‘It’s important to ensure that consultations aren’t inappropriately focused on gender.’
GPs can also benefit from being aware that genital-reassignment surgery (which is not yet available through Australia’s public healthcare system), may be vital for some, but is not necessarily the ultimate goal for all transgender patients.
‘For many, the main priority is being able to walk around in public and not have strangers look at them, or to be able to sit on the bus without having people stare,’ Dr Cornelisse said. ‘So, for some, facial surgery can be very important. People also have laser treatment to remove facial hair. These things, for a lot of patients, are more important than genital surgery.
‘Genital surgery is very important for some, but a lot of body changes can be achieved with hormone therapy before any surgery.’
The situation of every transgender person is inherently different and each will be assessed individually. For Clare Headland, the core revelation was that she really wanted to, ‘Change from a fake male to a real person – to me’.
‘I’m no longer up on a stage, play-acting as a man,’ she said. ‘I’m down in the audience, being myself.’
Headland wants others to know her story so they might be able to better understand the turmoil many transgender people experience.
‘I know how I felt all those years and any chance I get I will express what it was like compared to what the bliss is now,’ she said. ‘If people can get a sense of what it’s like for those of us who are transgendered, then if they know somebody who’s struggling with it, hopefully they’ll help them.’
- National LGBTI Health Alliance. Snapshot of mental health and suicide prevention statistics for LGBTI people. Sydney, NSW: National LGBTI Health Alliance, 2016.
- Gay and Lesbian Alliance Against Defamation. GLAAD media reference guide – Transgender. NY, USA: GLAAD. Available at www.glaad.org/reference/transgender [Accessed 2 March 2017].
- Government of Victoria. Department of Health. Transgender and gender diverse health and wellbeing. Melbourne, Victoria: Victorian Government, 2014.