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Gender affirming

Welcome everybody for joining tonight's webinar, Gender Affirmation in General Practice. On behalf of myself and my colleague from the RACGP, we would like to warmly welcome you today in joining us. I am now going to hand over and before I do that, hand over to Dr Elizabeth Moore, I just want to let you all know that this webinar has been recorded and we will provide the PDF copy of the record, sorry, PDF copy of this webinar presentation as well as the recording.
Next slide and over to you, Dr Elizabeth Moore.
Thank you Ange and yumalundi, hello and welcome. In the language of the Ngunnawal people on whose lands I now live and work. We would like to formally acknowledge the traditional custodians of the lands and waters on which we are severally meeting. I would like to acknowledge and respect the continuing culture and the contribution they make to the life of the city and region and pay our respects to Elders past, present and emerging. I would also like to acknowledge and welcome other Aboriginal and Torres Strait Islander people who may be attending today's webinar.  We also acknowledge and respect all trans and or gender diverse people with lived experience of mental illness who generously share their experiences to help inform a more inclusive approach to mental healthcare. And thank you all for your attendance today. Over to you, Ange.
I would like to introduce to you all our presenters for this evening. Firstly, Dr Clara. Clara Tuck Meng Soo is a general practitioner in Canberra. She has worked with patients from many populations and groups with complex needs, including the LGBT IQ A+ community, people living with HIV, the culturally and linguistically diverse community as well as people with drug dependency.
We also have Dr Elizabeth Moore who has worked in both public and private hospital and community settings, holding clinical and administrative positions in psychiatry in South Australia, New South Wales, Victoria and Western Australia, and is the inaugural ACT Coordinator General of the Office of Mental Health and Wellbeing.
Also we would like to introduce Dr Betty Ge. Betty is currently a general practice T2 trainee in East Canberra general practice in ACT, and she is also an ordinary board director of the AMA for the ACT area.
So today's our learning outcomes. By the end of this online CPD activity you should be able to discuss how to be supportive to an individual seeking to affirm their gender. Discuss appropriate referral pathways relating to trans and or gender diverse patients, adults and adolescents who require support. Provide examples of patient centred approach within a supportive environment. And lastly, access useful information and resources to enhance their own personal development. Now I would like to hand over to Dr Elizabeth Moore. Thank you.
Thanks, Ange. I think it is important when we talk about this gender affirming guidance that we actually recognise that it was a co-designed process and it was a co-design process with people with lived experience, A Gender Agenda and Meridian, and Clara and many others were part of this. It was officially launched, actually almost a year ago, 17th of November, 2021, and it was in recognition that people from a gender diverse background actually have increased rates of mental distress. And that our GPs and people in mental health care generally, wanted extra guidance to be able to support people to make sure that the best outcomes were obtained. When trans and or gender diverse people receive gender affirming care, they feel supported, respected and heard. They actually have the first step to increasing the number of health professionals and services who have the skills required to serve this population. We have a number of people who have had experiences that are less than optimal from mental healthcare and from general practice, and what we heard from people in general practice is they wanted to learn more and they wanted to have the resources to be able to support this particular part of the population that came to see them. So I am happy that we were able to work with the community and with service providers and general practitioners to provide this guidance. Thank you to Clara and to Betty for being able to go through some of this guidance and I am sure we will get lots of questions following this. So over to you.
Hello everybody. I am Dr Clara Tuck Meng Soo, and myself and my colleague Dr Betty Ge will be actually talking through the slides and will be having a discussion about them. So I thought I will start off first of all by actually talking about why we actually need to provide gender affirming care to the gender diverse population. So this slide lists some of the poor mental health statistics that people of gender incongruence actually experience. So something like 48.1% of transgender and gender diverse people in age 14 to 25 report they have attempted suicide in their lifetime which is 15 times the rate in the Australian population. And an enormous number of people, of trans men, non-binary people, and trans women in a young age group report ever having self-harm, approximately 14 times equivalent of the Australian population. And if you look at rates of depression, anxiety, similarly, they are also much higher than the general population. And these statistics have actually come from that website that I have listed down there. Next thought please, Jen.
So what are the outcomes of treatment? So this is a rapidly moving area and with a lot of research with the transgender population, this is research that actually takes long periods of follow up for us to actually get robust data, so some of this data is actually only just starting to come through now. So the studies now show, you know, that when people actually get good gender affirming care and actually manage to get support from their family environment, their mental health statistics not surprisingly actually improve. So a Dutch study of 55 young transgender adults were followed up before the start of puberty suppression until after their gender affirmation, found that their gender dysphoria was elevated and the psychological and physical wellbeing was actually similar to or better than that the same age young adults from the general population. So, I mean, you know, there has always been a bit of debate about whether, what is the chicken, what is the egg? You know, why do people who are gender diverse have such high rates of mental health issues? And I think these studies are starting to show, you know, that that is not a condition that is innate to being gender incongruent, that, you know, when these higher rates of mental health distress are due to the fact that these adults have trouble actually accessing the care they need and also living in an environment that causes them trauma and fails to support them.
So in another study looking at a cohort of 104 transgender non-binary youths who received gender affirming care including puberty blockers and gender affirming hormones was associated 60% lower odds of depression and lower odds of suicidality, admittedly over a relatively short follow up period. Next slide please, Jen.
And the other reason why it is important for us to be talking to you is because we are actually seeing increasing numbers of people coming forth and identifying as being gender diverse. So studies in adults and you get very similar statistics actually, you know, throughout most of the Western world. So studies in adults show that 0.5 to 4.5, their population identifies as transgender or gender diverse. Whereas in children adolescents, the rate is much higher, 2.5 to 8.4%. And in the Canadian census of 2021, when you look at the whole adult population, 0.33% of population identifies as transgender gender diverse, whereas when you look at the younger cohort Generation Z, it was 0.79%. And then lastly, in the Gallup survey that was released earlier this year, we found that 2.1% of Generation Z identifies as transgender as opposed to 1% from millennials, 0.6% for Generation X and 0.1% for baby boomers. What do I attribute that too? I think I actually attribute it to the fact that social attitudes are changing and therefore we are actually seeing more people feeling, I suppose able, to actually express their gender diversity. And I think it is becoming better known, you know? In my experience, talking to older transgender people, they often report growing up thinking that they were the only person in the world who was feeling like this, you know, and therefore not actually having the words to actually describe how they feel, nor having any ideas about what to actually do about how they might feel. I might include Betty here. I mean, Betty, do you find that as well? We are actually see increasing numbers of young people coming forth asking for assistance?
Yes, certainly that is my clinical experience, Dr Soo. And in Eastern Canberra we certainly see a lot of younger patients. So, the population I see are generally anywhere from 16 up to 50, sometimes even like 50 presentations. And just like you just stated quite clearly before, I think the society is changing, which is towards a positive change. Sometimes conservative cultures are very judgmental and stereotyping of that transgender population. It certainly does not help patients seeking care and putting up extra barriers, which I think is a really depressing, you know, reality in the past. But hopefully by introducing more health professionals into the field we can help break down some of the barriers and make sure that patients are getting safe and appropriate care.
I think, though, I actually went to a conference in Bangkok recently which was the first Asia Pacific transgender master class. And one of the things I did when I was there was I visited a clinic called the Tangerine Clinic in Bangkok that is actually a very large clinic offering multidisciplinary care for transgender people. Most of their clients are actually transgender women. And it is quite interesting the, I suppose, the rhetoric about why we should be providing care for the gender diverse population. So in Australia and in a lot of Western countries, making the point towards the very high rates of mental health issues and also to do what I have done is to present evidence that gender affirming care actually helps alleviate that sort of mental health distress, you know. Whereas in Thailand the conversations around the fact that they still have to work to actually control HIV in the Thai population, and one group that they were having trouble reaching out to were transgender women, and the number one need that transgender women expressed was actually getting access to gender affirming care. So they decided to open a clinic that could actually provide access to gender affirming care and when women then came forth , you know, for medical assessment and treatment, they actually tried to persuade them actually have an HIV test as well. And by doing that and they found that 10% of the transgender population that actually presented to them, were actually found to be HIV positive. So these were people who had not previously been identified with HIV. Obviously we have got a slightly different population there. Among this trans women population in Thailand, a very high proportion of them actually worked as sex workers and in fact around the world, transgender women have the highest HIV positive, even higher than MSM, because around the world so many of them are actually sex workers. But I guess the point I am trying to say is that in different countries we have been using different, I suppose, rationale for actually promoting gender affirming care. But I guess I would like to say, you know, as a trans woman and as somebody who actually does a lot of work with the trans population, we feel that access to gender firming care is a human right. You know, it is what we need to actually be who we actually are, and we feel that we should have a right to be able to access that care, regardless of whether we actually have a mental health problem or not. So I mean, for my gender affirmation, I certainly saw a psychiatrist and I saw a clinical psychologist to get the letters to actually support my gender affirming surgery. But you know, I did not think I had a mental illness. I just needed treatment to be who I was. So next slide please, Jen.
So one of the things, you know, about working with the gender diverse population is words, you know, what terms do you use? So we got this page here from the guidance document with a glossary, some words, you know. So some of the common words that you will come across, there would be things like what cis gender means. Cis gender is basically everybody whose gender identity is the same as that which is assigned to them at birth, which is I guess, you know, most of the population. And what is gender affirmation? Gender affirmation is a process by which, you know, we help somebody to actually live in the gender that they actually see themselves as being, and gender affirmation can mean medical affirmation, or legal affirmation, or social affirmation and that is listed further down in the second page as well. Gender identity I have mentioned already is a person's concept of yourself as whether they are boy or man, or girl or woman or, you know, somebody who is actually non-binary. And I think that we are also seeing more and more people who are non-binary. And further on there is a definition of non-binary, a gender that sits outside the spectrum, the male and female identity, the idea that gender actually exists on a spectrum and that, you know men I suppose are at one end of the gender spectrum and women on the other end, and traditionally, you know when people have actually requested a gender affirmation in the past, nearly everybody who has come to see me says I was born a man, but I want to be a woman, or was born a woman, I want to be a man. But I think we are actually seeing more people who are actually saying that they are actually non-binary. And that often presents complexities of its own as well, doesn’t it, Betty?
Yes, certainly. I remember when I first started working in the field, I certainly benefitted a lot from learning from Dr Soo. I remember the first couple of patients who were non-binary that I saw, surrounding the care I should be providing, and I actually had to, you know, talk to Dr Soo directly about the appropriate pathway to go forward because some non-binary population, they might come to you and they do not want a completely feminising presentation, but they do not want a completely masculine presentation either. And they are just after certain features. And my initial concern when I talked to Dr Soo about this was, you know, if this body dysmorphia instead of a gender issue. And sometimes for I think juniors or people new to the field, it can certainly complicate the matter, because not everybody fits in the traditional guidelines or pathways. Not everyone wants the full shebang of feminising or masculine hormonal treatment.
Yes. Okay. Next slide please.
So I put that up there, you know, because if you lock up the trans hub, they have actually got a couple of pages about language, you know, and so that is quite a useful resource.
Yes. And definitely in terms of the language used, I feel I can really also speak to the topic of language because I must admit that I certainly was not naturally very good at using the correct terminology or glossary, because my native tongue is actually Chinese Mandarin. And in Mandarin, in terms of speaking, we do not distinguish between he or she. And this all pronounced as TA, as ta. So even before I took interest in doing the work in the transgender field, I have issues even with cis population, sometimes I mis-gender the cis population, particularly after a long gruelling night shift in the hospital, sometimes in the morning handover. It can be very confusing for me and also my colleagues. So in terms of addressing the language issue, I feel I got better overtime by practising and simply paying more attention to the details in your consultation and communication. And my general advice for the newbies to the field or for the registrars who are wishing to participate in work in the field, would be just be mindful, be respectful, be curious and be supportive. I think be mindful. I always try to look at the file. We use Best Practise. I usually open up the file before inviting the patient into the room, making sure I have familiarised myself with their preferred name and identified gender, because there is sex that is assigned gender at birth and there is, you know, their preferred gender or identified gender, and also their preferred pronouns. And I usually write it down in my notes and I make sure every consultation I go back and make sure I familiarise myself. And like Dr Soo said, it is a spectrum. Not everyone uses one pronoun or the other. Sometimes it is a fluid issue and sometimes people want me to change them and I will ask them, if things change, let me know. I can change the appropriate pronouns in our software to reflect that. And also I try to rehearse it in my head before I even walk to the waiting room and bring the patient in. And I think be respectful. Dr Soo mentioned that in the previous slide, but no one is perfect, and no trans person would expect their GP to be perfect, so long as we are always respectful. And if we approach it in a very professional and respectful way by asking and clarifying, lots of patients are very, very happy to give you details, give you their preference. And I often say to patients very frankly, even from the very first consultation, if I make a mistake, please correct me and I do apologise, and then if you correct me, I will make sure, yes, I will pay more attention to it and I will not do the same mistake again. And be curious is about, you know, not putting everybody in a set box, because gender is a spectrum and everyone sits at different spots on the spectrum. So we respect that and we asked about that, we do not assume anything. And last point is be supportive. And I think everyone appreciates the genuine care and support you can give them in the GP room and just about supporting their autonomy and creating a very safe, supportive and empowering environment and to let the trans population make decision about their own body and about their own journey. So that is my two cents on the language use.
Next slide please, Jen.
Yes. So I think we might go through this a little bit, you know. So what are the key messages? The first message is, being transgender or gender diverse is not a mental illness.  So there are a couple of medical classifications that are in common use around the world. So there is the DSM classification and ICD classification. So in DSM you still have something called gender dysphoria. But gender dysphoria, which is defined as the distress that somebody feels as a result of this disjunction in gender identity is not an intrinsic part of being gender diverse. So not everybody who is gender diverse will necessarily suffer from gender dysphoria and being gender diverse in itself, you know, is no more a mental illness than, as you know homosexuality is no longer regarded as a mental illness. So in ICD-10 they actually stopped using the term gender dysphoria and actually tend to use gender incongruence as the preferred term. So, Betty has already talked a lot about, you know, using preferred pronouns and the name that somebody wishes to be called, you know, and I think that is actually quite a good way, you know, to actually as Betty was saying, to show respect for that person, you know, and to actually acknowledge, you know, that you accept, you know, who they are, their conception of their own gender. And as Betty also said, in my experience with the vast majority of my trans patients, is that they are generally quite understanding of our human errors. So you know, although Best Practise is better than it used to be, and we can actually indicate preferred identity, and preferred pronouns, and preferred names in Best Practise now, Best Practise, for example, still uses the birth gender to actually indicate gender marker on forms like pathology forms and radiology forms. So, you know, I have to be mindful of that and try to correct that and most patients are very understanding about it. And most patients are also very understanding about the fact that when I explain to them that until they actually change their name and their gender with Medicare, we actually need to keep those details on our file and in official documents, the original name and gender will still be displayed because that is what Medicare actually requires. But I would say for the vast majority of patients, when I explain to them why we do that, they are understanding about it.
And the third point about, treat every person as individual, and the gender affirmation journey is different for every person. I think it is a really important point for me, you know, because everyone is an individual and what they actually want for themselves is an individual thing. There may be some generalities about how we actually know what medical treatments we can provide, but we always need to actually see if that is what works for that person, we have to tailor it to what the person really wants. As Betty was saying, that possibly, you know, the trickier conversations are now with people who are not binary, because it can be difficult to actually tailor say for example, hormone regimens to actually achieve exactly what they want, and sometimes we cannot, you know. But even in my trans patients, I have those conversations about what exactly, you know, what physical feature is it that is important to them, at what stage of their development are they, and therefore what we actually do about their hormone levels and things like that, you know? Do you have something to add to that, Betty?
Yes, absolutely. I think again as a newcomer sometimes you are very regimental about the guidelines and pathways because these are the recommendations. This is the only way I do it. But sometimes patients are actually really educated and they have experience from overseas at different protocols of doing things and they have their individual needs as well, like Dr Soo was mentioning. So I think it is about tailored, like every care we provide, is about patient centred. It is about understanding their demands, their need, and then accommodating our treatment to achieve a realistic and safe goal. So I usually joke about this to my patients. I say, look, if you want orange hair, I cannot provide that with the gender transitioning medicine. But if you want, say you know, bigger muscles and more hair than we can achieve that with testosterone as such. So it is about one, providing safe monitoring in the journey and two, setting realistic goals with the patient and making sure they understand the benefits, which is hormonal treatment bringing on the gendered features that they are after, but also making sure they are not causing harm to them.
And I think Betty made a good point there, which is that quite a lot and by no means all, you know, but quite a lot of my gender diverse patients come in having done a lot of their own research. And even though I have worked in this area for many years, I still get patients coming in saying, have you heard of this latest treatment? Or, you know, what about this particular medication? And you know, I think that is a good way of actually triggering my education because I would say, oh, I actually do not know anything about that, I have to go away and do the research and come back to you about it. So you know, I have actually got all my patients actually doing research on my behalf that is actually helping to actually prompt my education.
Absolutely. Sometimes they do the literature review for you and they bring the evidence to you and say, how about this medication? And then I think again, you can have the open conversation with them and say, look that is not part of the recommendation in the local protocol, but these are the benefits, but these are the potential harms.
And you know, education is in a lifelong thing, you know, so I think that, you know, there are all these guidelines out there and I think at the end of the resources, you know, we would actually point towards some of them. But you know, nothing is set in stone, you know, so I think that, you know, we all need to be continually learning. And if I move further down, you know, I think points 6, 7 and 8 are really talking about how, working again, working with the trans population to actually find out how to actually tailor your services to provide service in a way that actually works for them. And I think the last point there, point 8, is saying again something that we sort of touched upon, which is that not all gender diverse patients coming to see a health professional are necessarily, I think I would rephrase that, yes, if they come to see us they are probably seeking support, you know, but they may not necessarily be seeking for us to actually prescribe medications for them, because not everybody feels they actually need to go on the medication. I might go out to the next slide now, Jen.
So some, you know, research has been done, you know, and focus groups. These are some of the things that would actually help people, you know, to actually access better care. So obviously from our point of view in terms of us being medical practitioners, you know, so practitioners who are trans and gender affirming and knowledgeable, access to available and accessible peer support and services. And again we will talk about those resources at the end. And some information about services that includes safe and affirming integrated wrap around. Now, I think the unfortunate thing is that in Canberra we do not actually have a multidiscipline gender clinic. The ACT government has actually done some scoping around that, but to my knowledge they still actually have not committed to actually providing one yet.
Choice of provider services developed in a timely manner. Well, I think I alluded to the fact in one of the earlier slides that there are increasing numbers of people actually seeking care. So with a lot of these specialists now, they have got very, very long waiting lists. So I think that if we can actually get more GPs coming in and helping to offer care, that will actually take some of the pressure off specialists. And one of the things that is happening now, for example, is that I am actually getting involved in the group that is rewriting the Australian standards of care for children and young people. And we are going to rewrite it in a way that we feel that would actually help GPs to actually step in and provide that care.
Certainly I think we have a real shortage of prescribers in the community. I think Canberra amongst all the states is probably one of the best places to access care. But even with that I think sometimes patients have to wait quite a long time to get an appointment, which can cause a lot of unnecessary stress, which again correlates to the topic we are talking about tonight, about mental health and how to support patients. I think by introducing more prescribers as a subspecialty for general practitioners, it will help reduce that workload in the public clinics and it will shorten the waiting time for patients and certainly improve their mental health immensely.
Next slide, please Jen.
Okay. So this slide talks about something called Informed Consent Protocol. Why do we actually talk about the Informed Consent Protocol? Well, informed consent is taken for granted in virtually every other field of medical practice. I mean, you know, when you are actually referring a patient for surgery. When you are referring a patient for any investigation, it is assumed that you are actually following an informed consent process. You will be telling the patient of the benefits and risks of the treatment or intervention. You would be talking about, say, the side effects of the medication and so, you know, you go through all that. So why is gender affirming care treated different? Well, I would actually put it to you that I do not see it as being different. But the reason we talk about this is because it is still regarded as a controversial area and in fact not that very long ago, you know, I would say probably no more than five or six years ago, the international standards for providing gender affirming hormone care was that every single patient actually had to be assessed by two psychiatrists before they could actually get access to hormones. Now, as I said, you know, that is very different from what we do for every, virtually every other intervention. We do not even, you know, there is no mandate, for example, you know that somebody has to actually see a mental health professional for an assessment, even if they actually request very disfiguring plastic surgery. So I think that we are trying to encourage all general practitioners to say, you know, that there is no, particularly for adults, there is no reason why you cannot actually follow an informed consent protocol for actually providing gender affirming hormones.
I mean, what are the some of the things that may actually impact on the person's ability to actually provide informed consent? Well, if they have a psychosis that affects their mental health, if they have a severe personality disorder. If they have an intellectual disability. But I will put it to the general practitioners in the audience that that is something that general practice actually deals with all the time. We actually work, you know, with mental health all the time. So why is it, you know, that we would feel that we do not actually have the mental health expertise to be able to assess somebody to see whether they have the ability to actually provide informed consent. So I for example, you know, do not routinely require my patients actually be assessed by another mental health professional when they actually come to me to request access to gender affirming hormones. I do actually request assistance from one of my mental health professional colleagues if I have some concerns about the mental health status of the patient, if I have some concerns that they seem to be displaying a borderline personality disorder, or that they could have an intellectual disability that I think may affect their ability to give you that consent.
And on the second page there, right at the bottom, there is a paragraph on conversion therapy. So in the ACT, conversion therapy is now a punishable offence. Unfortunately it has not been classified as such in New South Wales yet. Did you want to say anything at anything that Betty?
I think just to follow on in terms of the mental health assessment, I think for all my trans patients, I always say to them it is great that we are starting this medical journey, but as we discussed in previous slides because it is quite common for transgender patients to have other mental health issues, and by involving a safe and friendly psychologist or counsellor into their care, I think is actually to optimise the holistic care for them. I do not see it as setting up a barrier and I make it very clear to my trans  population. I say look. this is to help us to provide better care because it is a long journey, it is not just overnight I have this magical one, then suddenly everything changes And the medications might, you know, cause sometimes mood change, and to have regular psychologist consultations to support you through the journey is always a good idea.
And on the other side of the coin, when the patient truly has very severe mental health disease, and you are worried about competency, I find that a small percentage of patients actually are very well versed before coming in even to seek that medical care for gender affirming hormonal prescribing, because they usually come with a psychiatrist’s support letter saying look, this particular person, they did suffer you know a psychiatric condition, but it is in full remission and is closely monitored by me and I am happy to support the decision, usually a psychiatrist who oversees the mental health aspect of things are very supportive in my experience and to prove to you that the patient is safe to proceed.
Okay. Next slide please, Jen.
So, some referral pathways. So, the first one is the Community Health Pathway, and they actually have quite a lot of information there about gender affirming care. I do know the GPs who are involved in the transgender pathways and I think they are in the process of being updated. Auspath is the national organisation for health professionals working in the transgender area, and I am the current president of Auspath. And if you go to the Auspath site, they have got sections for providers in all the states and territories. So you can see who are the other health professionals who can actually work with people in this area. The last website is address their, which is the website of A Gender Agenda, and that is the community organisation for the trans and gender diverse community in the ACT. Next slide please, Jen.
Okay. Some further resources here. So the Australian Standards of Care and Treatment Guidelines. So that is the book that was actually written by doctors and other professionals, mainly by the doctors from the Royal Children's Hospital Melbourne, with the help other professionals around Australia, and I alluded to the fact that that is now and of course has been revised and updated. Emerging Minds is a website for mental health, but they have actually got quite a lot of pages and resources for trans and gender diverse children and their families. Meridian is a local organisation in the ACT that actually works in the LGBTQ community and they have actually got quite a lot of resources and they run a clinic called Friday Centre, I think or Friday Clinic, where they have actually got a peer support worker at the top for anyone who is starting on the gender journey. Trans help, which I have mentioned, you know, is a constant digital and resource platform. We have got quite a lot of stuff on there. So, yes, so there is quite a lot of resources that you can actually look through there and update yourself with. Next slide please, Jen.
And you can also look for guidance on the Office of Mental Health and Wellbeing web page. Next slide, please.
Oh, okay. Right. And I think that we then eventually come to a slide where there are contact details for myself and Betty if you want to actually contact us for any advice.
That has been a great conversation, Clara and Betty. And I think certainly what I have taken away from it is, even if people do not want to start on a journey of hormonal changes, what they want is support and they want acceptance. And I think GPs and all mental health professionals can help with that in terms of being aware of pronouns, being aware of people's preferred names, and being accepting of people's gender incongruence. So people’s preferred gender is really important. And have that level of acceptance and then the real conversation can start.
Now there are a few questions that have been posted, so I will actually try and answer them now. So there is a question from Dr Peggy Wen, who says, where can I help my young uni patient to find affordable psychology specialising in gender affirmation in Sydney? Apart from psychology and speech pathologists, what other services or allied health may benefit my patient during her gender affirmation journey as she has found the journey so far very lonely. Are there social support groups? She finds it particularly difficult as her voice remains deep and in her view, does not match her appearance. So I think that yes, there are certainly social support groups, and I think that if you go on to the websites that we have got there, and I think since your young patient is in Sydney, if you go onto the Trans Hub website, you know, they will have links to community organisations there that your patient can actually get in touch with. In terms of someone having a deep voice, you know, the first step is really seeing a speech pathologist and getting training with the speech pathologist. There is a thing about a gender identifying voice. It is partly the pitch of the voice, but partly also about how you use the voice. Because obviously there are women who do have quite deep voices. But you know when you hear them talking on the phone, you can identify the person as a woman. So it is partly about how the person uses their voice as well. Now, as a last resort, you know, there are a few ENT surgeons who can actually do a laryngoplasty, but that is quite an invasive operation. I think the results are still a little bit uncertain, so we would probably regard that as a last resort.
Now Dr Patty Yuan also has a further question saying, my patient also complains a troublesome night sweats since being on oestrogen. This is common? Her endocrinologist has not been able to answer this. Thanks. Not that I have found so far. Have you found people having troublesome night sweats on oestrogen, Betty?
Not based on my limited exposure, but my patients usually can have a little bit of an emotional kind of response to the hormone, feeling quite sensitive, you know? But in terms of night sweats, I have not encountered that issue so far.
Yes, I have not, either.
So there is a question from Dr Aria Hakimi who says, I usually refer patients to an endocrinologist. Is there a team care to refer patients directly to get all supports? Yes. I mean you can write a team care plan for them to access all the other allied health professionals. And then he also goes on to say, you cannot prescribe testosterone on the PBS. No, that is not strictly correct, Dr Hakimi. So some testosterone preparations are actually available as a PBS authority script. And the criteria we use is somebody who is actually born without a congenital, I think congenital, pituitary or testicular disorder or absence, I think that is the wording. And as part of that, you know, that person needs to have seen, or has an appointment to see, an endocrinologist, a paediatric endocrinologists, urologist or sexual health physician. And in Canberra we tend to refer people to the Canberra Sexual Health Centre, but what you can do is that you can actually initiate the person on testosterone preparation on a private script pending their actually seeing a specialist and then when you get approval from the specialist you can then issue the PBS authority script. So I think that was all the questions that we had.
I have got a new one. Should trans men expect some hairline changes like male pattern changes? And if so, is finasteride / minoxidil a good option to manage it or does it often settle?  Well, I think the answer, Melanie, is that testosterone can cause the same androgenetic alopecia enhancement as it does in cis men. So yes, you can treat it exactly the same way and you will probably get exactly the same outcomes, which is that yes, finasteride and minoxidil are quite good, but they probably cannot address it in everybody. I am afraid that is an unavoidable consequence of testosterone.
Okay. I think that was all the questions that we had. So I think they are the contact details for all the presenters tonight, and we are we are happy to field any questions that you might have for us. And I head back to Ange.
Well, thank you Dr Clara, that has just been a fantastic night I believe, and I hope you all have thoroughly gleaned from the information provided tonight. Once again, this is a recorded webinar. We will have this available and we can send this out to you along with the PDF slide presentation. And do not forget you can still continue to send those questions if you find after you have logged off tonight that you have forgotten something, you can certainly do that as well. So on behalf of the team, we would like to thank very much our presenters, they did a fantastic job, and we wish you all a good evening tonight. Thank you very much.

Other RACGP online events

Originally recorded:

17 November 2022

This webinar will equip general practitioners with a gender affirming approach and provide them with resources to support the needs of their trans and/or gender diverse patients.

Learning outcomes

  1. Discuss how to be supportive to an individual seeking to affirm their gender
  2. Discuss appropriate referral pathways relating to trans and / or gender diverse patients, adults and adolescents, who require support
  3. Provide examples of patient centred approach within a supportive environment
  4. Access useful information and resources to enhance their own personal development


Dr Clara Tuck Meng Soo
General Practitioner

Dr Soo is a general practitioner in Canberra. She has worked with patients from many population groups with complex needs including the LGBTIQA+ community, people living with HIV, the culturally and linguistically diverse community as well as people with drug dependencies.

Dr Betty (Xiaoting) Ge
GPT2 Trainee, East Canberra General Practice

Dr Ge, MChD, SCHP and CWH, is currently a GPT2 trainee in East Canberra General Practice in ACT and she is also an ordinary board director of AMA-ACT.

Dr Elizabeth Moore
Coordinator-General, Office for Mental Health and Wellbeing

Dr Moore has worked in both public and private hospital and community settings, holding clinical and administrative positions in psychiatry in SA, NSW, Vic and WA and is the inaugural ACT Coordinator-General of the Office of Mental Health and Wellbeing.


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