Resources
TransHub has a variety of useful resources including a language guide and information for clinicians.
The Australian Professional Association for Trans Health lists healthcare providers who care for transgender, gender-diverse and non-binary people.
Background
Most people are assigned a gender — either male or female — at birth (or even before), based on the appearance of their external genitalia. This classification of gender, although conventional, is inconsistent with the lived reality of some people.
An unknown number of people experience conflict between their assigned gender and their experienced gender. The consequences of this conflict may result in specific healthcare needs of these individuals.
Prevalence
It is difficult to estimate the number of transgender people (whose gender identity or expression is different to the gender they were assigned at birth) in our communities because they likely underreport their gender disparity due to concerns about stigma and privacy, and data collection methods are often inadequate (e.g. sex categorised as either male, female or ‘other’).
Gender dysphoria
Not all people whose gender experience differs from their assigned gender experience gender dysphoria (a diagnostic term used in the DSM-5).
Feelings ranging from discomfort to considerable distress are reasonable responses to the conflict between a person’s assigned gender and their gender identity.
Gender dysphoria itself can be the cause of psychological problems. The discrimination and abuse faced by transgender people may contribute to the higher rates of mental illness in transgender than cisgender people.
Discrimination and abuse of people with gender incongruence
Transgender people experience social marginalisation and health inequities.
Discrimination against transgender people, in many forms, can occur when they access healthcare services, and is a cause of delay or avoidance of them seeking care.
Healthcare providers therefore need to ensure an environment and procedures that are inclusive of transgender people.
The health of transgender people
Transgender people have higher rates of risk-taking behaviours (e.g. substance use, unprotected sex) than cisgender individuals, with attendant higher rates of the negative health consequences.
Transgender people appear to have higher rates of a variety of chronic diseases than cisgender people but the cause for this is unknown.
The healthcare needs of transgender people
Most healthcare required by transgender people, including most gender affirming treatments, does not require specialist medical knowledge.
In some cases, the complex healthcare needs of transgender people require multidisciplinary care from general practitioners, mental health professionals, endocrinologists, sexual health physicians, surgeons, speech pathologists and social services, depending on individual circumstances.
General practitioners are well placed to manage the healthcare needs of transgender people.
Initiation of gender affirming treatment for patients of inexperienced general practitioners is usually performed by, or in close collaboration with, endocrinologists and mental health professionals.
Inclusion of transgender people
Transgender people may seek healthcare for various reasons, ranging from issues that are unrelated to their gender identity, through to a desire to access gender affirming healthcare.
Fear of discrimination is a barrier to transgender people seeking medical care.
Healthcare facilities that are welcoming, inclusive and safe for transgender individuals are essential to facilitate their presentation for care and return for follow-up.
There are various practice design elements and procedures that contribute to establishing a practice that is inclusive of transgender people.
Affirmation of gender identity
Healthcare providers should not make assumptions about someone’s gender identity. Patient information paperwork should include an option for patients to mark their gender as something other than just male or female.
Simply asking a person’s preferred name, pronoun (e.g. he/she/they) and gender identity (on a form or in conversation) is better than guessing.
An important aspect of gender affirmation for some people is consistency with official documents. In Australia, reissue of official federal documents (such as passports) with a person’s affirmed gender is possible with the support of a medical practitioner.
Different Australian states have their own requirements and procedures for changing the gender on birth certificates and other documents issued under their jurisdiction.
During the initial consultation, it is important to take a complete history, assess risks and identify available social support, and perform any necessary examinations.
Gender incongruence and gender dysphoria are not pathological conditions, but they may be accompanied by mental health issues that require attention.
Screening by a psychologist or psychiatrist may be necessary to rule out gender dysphoria as a manifestation of mental health issues (e.g. body dysmorphic disorder) or other conditions (e.g. Asperger syndrome) to ensure appropriate care.
Transgender people have higher rates of suicidal ideation and self-harm than cisgender people, so appropriate screening, surveillance and referral (if necessary) are important elements of their ongoing healthcare.
Not all transgender people will seek gender affirming medical or surgical intervention but may socially affirm their gender by using behavioural changes such as altering their speech and clothing.
Chest binding or genital tucking to hide secondary sexual characteristics can result in bruising, skin irritation and pain, particularly if not performed correctly.
Gender affirmation treatments
Many transgender people seek medical intervention to achieve physical affirmation of their gender identity, the most common form being hormonal treatment.
Box 2.
The timing of masculinizing and feminising effects of hormone therapy
| Physical effect | Onset | Maximum effect | Reversibility |
|---|---|---|---|
| Testosterone therapy | |||
| Skin oiliness; acne | 1-6 months | 1-2 years | Reversible |
| Cessation of menses | 2-6 months | Reversible | |
| Vaginal atrophy | 3-6 months | 1-2 years | Reversible |
| Clitoral enlargement | 3-6 months | 1-2 years | Irreversible |
| Body fat redistribution | 3-6 months | 2 years and onwards | Variable reversibility |
| Facial and bodily hair growth | 3-6 months | 3 years and onwards | Irreversible |
| Deepened voice | 3-12 months | 1-2 years | Irreversible |
| Increased muscle mass | 6-12 months | 2 years and onwards | Reversible |
| Male pattern baldness | Variable | Variable | Irreversible |
| Infertility | Variable | Variable | Variable |
| Estrogen and anti-androgen therapy | |||
| Decreased spontaneous erections | 1-3 months | 3-6 months | Variable |
| Decreased libido | 1-3 months | 1-2 years | Variable |
| Cessation of male pattern baldness | 1-3 months | 1-2 years | Reversible |
| Decreased muscle mass | 3-6 months | 1-2 years | Reversible |
| Skin softness; decreased oiliness | 3-6 months | Reversible | |
| Decreased testicular size | 3-6 months | 2-3 years | Variable |
| Breast growth | 3-6 months | 2-3 years | Irreversible |
| Body fat redistribution | 3-6 months | 2 years and onwards | Variable reversibility |
| Reduced facial and bodily hair growth | 6-12 months | 3 years and onwards | Reversible |
| Decreased sperm production | Variable | Variable | |
| Erectile dysfunction | Variable | Variable |
Box 3.
Alterations to screening guidelines for transgender people
| Screening program | Alteration for transgender men | Alteration for transgender women |
|---|---|---|
| Cardiovascular disease | Initiate screening every 5 years from the beginning of hormone treatment | Initiate screening every 5 years from the beginning of hormone treatment |
| Osteoporosis | Follow guidelines for birth sex | Use fracture risk assessment to identify age to begin screening |
| Breast cancer | Follow guidelines for birth sex | Over 50 years and after 5 years of hormone treatment, screen every 2 years |
| Cervical cancer | Follow guidelines for birth sex | Individualised, based on gender affirming surgical history |
| Prostate cancer | Follow guidelines for birth sex | |
| Bowel cancer | Initiate screening at 50 years of age | Initiate screening at 50 years of age |
| Gonorrhea and chlamydia | Follow guidelines for birth sex | Follow guidelines for females if the person has vaginoplasty |
