Clinical summary guide

Transgender healthcare

13 min

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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 trans and gender-diverse.

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 incongruence 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 trans and gender-diverse 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’).

The Australian Bureau of Statistics estimates that just under 1% of Australians aged 16 and over have a gender that is different than their sex recorded at birth.

Gender dysphoria

Not all people whose gender experience differs from their assigned gender experience gender dysphoria (a diagnostic term used in the DSM-5) or gender incongruence (a diagnostic term used in the ICD-11).

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 trans and gender-diverse people may contribute to the higher rates of mental illness in trans and gender-diverse than cisgender people.

Discrimination and abuse of people with gender incongruence

Trans and gender-diverse people experience social marginalisation and health inequities.

Discrimination against trans and gender-diverse 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 trans and gender-diverse people.

Resources for health practitioners

Inclusive, evidence-based information is available from TransHub and Trans Health Research.

The health of trans and gender-diverse people

Trans and gender-diverse 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.

trans and gender-diverse people appear to have higher rates of a variety of chronic diseases than cisgender people. This may be due to minority stress, which has known negative impacts on physical health, contributes to systemic barriers to healthcare, and delays care seeking due to anticipated discrimination.

The healthcare needs of trans and gender-diverse people

The AusPATH Australian Informed Consent Standards of Care for Gender Affirming Hormone Therapy are intended to assist and enable clinicians across Australia to better meet the medical gender affirmation needs of their trans women, trans men and non-binary patients and are endorsed by RACGP.

Most healthcare required by trans and gender-diverse people, including most gender affirming treatments, does not require specialist medical knowledge.

In some cases, the complex healthcare needs of trans and gender-diverse 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 trans and gender-diverse 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 trans and gender-diverse people

Trans and gender-diverse 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 trans and gender-diverse people seeking medical care.

Healthcare facilities that are welcoming, inclusive and safe for trans and gender-diverse 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 trans and gender-diverse 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 asa manifestation of mental health issues (e.g. body dysmorphic disorder) or other, possibly unrelated, conditions (e.g. post-traumatic stress disorder) to ensure appropriate care.

Trans and gender-diverse 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 trans and gender-diverse 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 are important parts of gender affirmation for some people, helping to relieve their gender dysphoria. Potential risks of binding and tucking include bruising, skin irritation and pain, though these can be avoided or minimised through safe practices.

Gender affirmation treatments

Many trans and gender-diverse people seek medical intervention to achieve physical affirmation of their gender identity, the most common form being hormonal treatment.

Box 1.

The timing of masculinising and feminising effects of hormone therapy

Physical effectOnsetMaximum effectReversibility
Testosterone therapy
Skin oiliness; acne1-6 months1-2 yearsReversible
Cessation of menses2-6 monthsReversible
Vaginal atrophy3-6 months1-2 yearsReversible
Clitoral enlargement3-6 months1-2 yearsIrreversible
Body fat redistribution3-6 months2 years and onwardsVariable reversibility
Facial and bodily hair growth3-6 months3 years and onwardsIrreversible
Deepened voice3-12 months1-2 yearsIrreversible
Increased muscle mass6-12 months2 years and onwardsReversible
Male pattern baldnessVariableVariableIrreversible
InfertilityVariableVariableVariable
Estrogen and anti-androgen therapy
Decreased spontaneous erections1-3 months3-6 monthsVariable
Decreased libido1-3 months1-2 yearsVariable
Cessation of male pattern baldness1-3 months1-2 yearsReversible
Decreased muscle mass3-6 months1-2 yearsReversible
Skin softness; decreased oiliness3-6 monthsReversible
Decreased testicular size3-6 months2-3 yearsVariable
Breast growth3-6 months2-3 yearsIrreversible
Body fat redistribution3-6 months2 years and onwardsVariable reversibility
Reduced facial and bodily hair growth6-12 months3 years and onwardsReversible
Decreased sperm production
VariableVariable
Erectile dysfunctionVariableVariable

Box 2.

Alterations to screening guidelines for trans and gender-diverse people

Screening programAlteration for trans and gender-diverse menAlteration for trans and gender-diverse women
Cardiovascular diseaseInitiate screening every 5 years from the beginning of hormone treatmentInitiate screening every 5 years from the beginning of hormone treatment
OsteoporosisFollow guidelines for birth sexUse fracture risk assessment to identify age to begin screening
Breast cancerFollow guidelines for birth sexOver 50 years and after 5 years of hormone treatment, screen every 2 years
Cervical cancerFollow guidelines for birth sexIndividualised, based on gender affirming surgical history 
Prostate cancerFollow guidelines for birth sex
Bowel cancerInitiate screening at 50 years of ageInitiate screening at 50 years of age
Gonorrhea and chlamydiaFollow guidelines for birth sexFollow guidelines for females if the person has vaginoplasty

Aboriginal and Torres Strait Islander gender diversity

Clinical review

Dr Sav Zwicki MSexol PhD, Trans Health Research Group, Department of Medicine, Austin Health

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Transgender healthcare

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