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Gender-Affirming Healthcare Closer look at topical conditions How to treat You can earn 1 credit by completing the ELearning assessment for this article 1 CR at nzdoctor.co.nz Gender-affirming healthcare This article covers the diverse aspects of providing gender-affirming healthcare for Aotearoa’s transgender and non-binary people, including the use of puberty blockers and hormone therapy, as well as the general principles behind this rapidly evolving area of medicine. It was written by Cathy Stephenson, Alex Ker and Rachel Johnson, and was peer-reviewed by the Professional Association for Transgender Health Aotearoa board A note on language: throughout this article, we use the um- background and access to resources. For some people, tran- Cathy Do you need to read this article? brella term “transgender and non-binary” to describe people Stephenson sitioning is seen as a collective process involving the person’s whose gender is different from the sex they were assigned at (she/her) is a whānau. birth. Gender diversity is recognised, expressed and celebrated GP at Mauri People may face various barriers to transitioning, such Try this quiz in many indigenous cultures, including te ao Māori and across Ora, Victoria as lack of family support or financial resources. Because 1. Transgender and non-binary patients have the the Pacific. These cultures have their own understandings and University of gender-affirming services in Aotearoa are not funded con- same routine health needs as every other patient. Wellington, True/False histories of gender diversity. People may use culturally specif- and a member sistently across DHBs, some people’s ability to transition ic language, such as takatāpui and fa’afafine, to describe their of Capital and are also limited by “postcode lottery”, or their geographic 2. Using a patient’s birth name can trigger gender gender. We recognise that everyone uses different language, Coast DHB’s location. dysphoria. True/False which may be different to the language we use in this article. Sex and Gender A person’s transition goals may (but do not always) in- 3. Mental health issues preclude patients from Diverse Health clude accessing transition-related healthcare, such as accessing gender-affirming hormone therapy. ransgender and non-binary (TNB) people make up a Outcomes hormone therapy or puberty blockers, chest or genital True/False Working Group diverse yet often overlooked part of Aotearoa’s pop- reconstruction surgeries, voice therapy or psychosocial 4. Transdermal oestrogen has a reduced risk of ulation. Despite the growing awareness of gender Alex Ker support. These types of healthcare are commonly referred thromboembolic events compared with oestrogen T (he/him) is a tablets. True/False diversity in Aotearoa, many TNB people still face unique to as gender-affirming healthcare. trans community 5. Yearly genital examinations are required for challenges to their wellbeing due to the compounding ef- advocate and Gender-affirming healthcare is recognised as medically fects of widespread discrimination and stigma against on the board of necessary by national and international health organisa- those on gender-affirming hormone therapy. people whose gender does not align with accepted ideas InsideOUT tions and associations, and can significantly improve TNB True/False about what a “normal” gender is or looks like. These chal- Kōaro people’s quality of life. 1 lenges include high rates of mental distress. Rachel Johnson Counting Ourselves, Aotearoa’s first transgender health Answers on page 43 Most TNB people experience gender dysphoria – the dis- (she/her) is a survey, found that most TNB people in Aotearoa access comfort caused by the misalignment between a person’s paediatrician, gender-affirming healthcare through their primary care gender and their body. Dysphoria can be caused or height- adolescent and providers. Although almost 60 per cent of survey partic- ened by physical, psychological, sociocultural, spiritual or young adult ipants reported that their main healthcare provider knew EARN RNZCGP CME CREDITS medicine relational factors, which contribute to a person’s gender most or everything about gender-affirming healthcare, just This continuing medical education specialist activity has been endorsed by the identity and expression. Some people may alternatively over one-third of participants had not sought general med- at Counties RNZCGP and has been approved for use the term gender euphoria, to describe the positive as- Manukau DHB ical care when they needed it due to being worried about 1 up to 1 CME credit for the General pects of transitioning. Kidz First Centre being mistreated or disrespected. Practice Educational Programme Transitioning refers to the social, legal and/or medical for Youth Health These findings highlight the importance of increasing and continuing professional development purposes steps a TNB person might take throughout their life to af- and an executive medical education on gender-affirming healthcare and en- member of (1 credit/hour). To claim, complete the ELearning assess- firm their gender. Transitioning looks and feels different PATHA suring that healthcare services are visibly affirming and safe ment at nzdoctor.co.nz. Click on the EDUCATION button. to everyone depending on their needs, cultural or religious spaces for TNB people. 21 October 2020 RATA AOTEAROA | NEW ZEALAND DOCTOR 39 HTT Gender-affirming 21 Oct 20.indd 38-39 15/10/20 12:16 How to treat Gender-affirming healthcare How to treat Meeting transgender and non-binary How to support a young person patients’ needs in primary care requesting puberty blockade here are a few overarching principles to consider hough research indicates that the rate of young sec- when working with TNB patients in primary care, as Everyone uses ondary school-aged New Zealanders who identify discussed here. different language to as transgender has remained stable at around 1 per describe their gender T T 3,4 cent over the last decade, the number of adolescents seek- Routine health needs ing gender-affirming healthcare is increasing. This is likely Although many TNB patients will seek assistance from their due to the growing visibility and understanding of gender- primary care provider for specific gender-affirming health- affirming healthcare, and people feeling more able to seek care, it is important not to assume this is the reason for the necessary support in their communities and with whānau. consultation. TNB patients have the same routine health needs as every other patient in your practice, including sex- General information ual health, contraceptive needs, vaccinations and screening All GPs should have basic knowledge on gender-affirming based on their anatomy. healthcare for young people, whānau support, resources, Providing medical care in a way that affirms your patient’s and local care and referral pathways. Given the increase in (THEY/THEM, BARCLAY HE/HIM, IA/TANA/ANA) JAYE gender should be routine, no matter what the patient’s pre- young people seeking care, specialist services should work senting issue is, just as it should be for every other patient collaboratively to transition clients back to primary care and in your practice. provide further support as appropriate. Although no specific medical intervention is required for pre-pubertal children, whānau members may require gen- What is gender? eral peer or formal support and information on affirming their child’s gender (see the resource list at the end of this Gender is the social perception we develop about ourselves, article for links to whānau support networks). and the way we express ourselves, such as through hair - If a child is insistent, consistent and persistent in their styles or clothing. Gender is not the same as sex – they are gender identity or is experiencing gender dysphoria, referral often aligned, but that isn’t always the case – Scott (he/him) to local gender-affirming services is recommended (around age nine/before puberty onset) to ensure timely access to puberty blockers at the onset of puberty, if required. Cultural safety Access Like everyone, TNB patients have unique cultural identi- Don’t be a gate-keeper. As primary care providers, it is not What do you wish your GP knew about Puberty blockers ties, beliefs and values. A person’s cultural background can our role to decide someone’s gender for them but to sup- gender-affirming healthcare? Gonadotropin-releasing hormone agonists (eg, Lucrin influence their gender and transition in many ways, from port them to live in their affirmed gender. or Zoladex) are commonly used among young people the importance of including whānau throughout transi- TNB patients have historically had poor access to servic- Just how to interact with gender diverse patients. It would experiencing gender dysphoria. They are considered to tioning, to cultural understandings of health and gender. es. We can go some way towards redressing this by affirming be nice if they introduced themselves with their pronouns be relatively safe and reversible medications that stop the It is essential to work with patients in a way that aligns our patient’s choices at all times and enabling them to ac- and took the time to check preferred names – Scott production of sex steroids, pausing puberty. with their world views and meets their health needs. cess the care they need, when they need it. Affirming a Puberty blockers have been used for many years to treat which may lead to significant harm and distress. Building trust and relationships are central to Māori and patient’s gender and autonomy can make a service more precocious puberty in younger children. They are ideal- The main potential risk of puberty blockers is the impact CASE STUDY 2 many Pacific cultures. Concepts such as whakawhanaunga- accessible.2 ly used from Tanner stage 2–3 to stop pubertal changes on future bone health, which is not yet clear. This may be tanga (relationship building) and va (“the space in between”) CASE STUDY 1 that would potentially cause intense distress when that increased in later adolescence and with other health risks Teenager wanting puberty blockers are important to practice when working with Māori and Support puberty does not align with the child’s gender identity.
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