27th March 2019 – Jeremy Wiggins – Churchill Report

Best Practice Models of Trans and Gender Diverse Health

The focus of the research was Best Practice Models of Health Care for Trans and Gender Diverse Populations. The research aimed to investigate models of health care for trans and gender diverse populations where people of lived experience were meaningfully engaged, consulted and employed to codesign and deliver depathologising health services.

Jeremy Wiggins

[email protected]

Acknowledgment of Country

This report was written on the lands of the Wurundjeri people and the Djadjawurrung people of Kulin Nations. Respect is paid to elders past and present and is also extended to the trans and gender diverse First Nations People, the Brotherboys and Sistergirls of these lands.

Acknowledgment of Community

Throughout history, many trans and gender diverse people have created pathways to improve our health and wellbeing and in doing so have endured hardship, exclusion and denial of access to essential health care and services. This report honours them and recognises their valuable contribution to this space. Thank you.

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I understand that the Churchill Trust may publish this Report, either in hard copy or on the Internet or both, and consent to such publication.

I indemnify the Churchill Trust against any loss, costs or damages it may suffer arising out of any claim or proceedings made against the Trust in respect of or arising out of the publication of any Report submitted to the Trust and which the Trust places on a website for access over the internet.

I also warrant that my Final Report is original and does not infringe the copyright of any person, or contain anything which is, or the incorporation of which into the Final Report is, actionable for defamation, a breach of any privacy law or obligation, breach of confidence, contempt of court, passing-off or contravention of any other private right or of any law.

Jeremy Wiggins

March 27th, 2019

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It is critical that trans and gender diverse people are in positions of power and have the respect and agency to make leadership decisions about our health care.

Table of Contents:

Acknowledgments 4

Introduction 5

About the Fellow 5

Locations Travelled 6

Visits 6

Reflections 7

Recommendations 8 - 14

Meeting highlights 15 - 22

Conclusions 23

Contact Details for Visits 24 - 26

Glossary of Terms:

TGD – Trans and Gender Diverse

Trans – Transgender, or of trans and gender diverse experience

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Acknowledgments:

I would like to pay special thanks and gratitude to the following people and organisations.

Thank you to the Winston Churchill Memorial Trust for the opportunity to research this area.

My partner Matt who travelled part of the way with me and has provided me with the gentle kindness and support to complete this project.

Razz, the mother of our children Ripley and Ginger who supported me in the very early years of my activism and career and who took care of our girls to enable me to travel for the full 8 weeks. Thank you for your positive enthusiasm and encouragement.

I want to acknowledge the following people who processed this information with me to develop the final recommendations through a community collaborative process: Starlady, Ted Cook and Ryan Phillips. Thank you for your valuable contribution.

I want to acknowledge that although I am the first trans person in Australia to receive a Churchill Fellowship, my contribution is one of many and I want to also acknowledge and thank all people who share a similar experience of living as trans or gender diverse whom are working towards creating a healthier future for us all.

I also want to thank Georgie Ferrari for your encouragement to apply for a fellowship.

I want to thank Thorne Harbour Health (formerly Victorian AIDS Council), where I was employed whilst undertaking this fellowship. Working at this organisation provided me with the resources and scope to create change for Australia that had not been done before. The informed consent model changed the game for TGD health and I was proud to have engineered the delivery of that model in Australia. A special thanks goes to Dr Pauline Cundill for carrying the informed consent torch as the medical professional on this project. Also thanks to Peter Locke, Equinox Program Manager, Kent Burgess, Director of Services and Simon Ruth, Chief Executive Officer. I would like to wish the best of luck to Thorne Harbour Health as it continues with this important work to improve trans and gender diverse health, a project I am grateful to have led whilst there. Thank you.

I want to thank everyone I met with overseas – especially all the trans and gender diverse workers and activists. You are the life blood of this area and it’s our labour, our experiences and our wisdom that informs the progress of our health and we fight hard for it and it does take a personal toll. I have made life long relationships and together we will continue to create important change. Thank you.

I also want to acknowledge Dr Tushara Wickramariyaratne, who was also a Churchill Fellow in the same year as me who travelled overseas to investigate models of psychological care of older trans and gender diverse adults. Thanks for meeting with me and for the ongoing connection.

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Introduction:

This report aims to communicate findings from my Churchill Fellowship and provide a set of recommendations for consideration in the Australian trans and gender diverse health context. These recommendations will also include a range of principles, values and ethical standards which underpin best practice in developing, establishing and delivering health care services to trans and gender diverse communities. It needs to be acknowledged that historically trans and gender diverse health and policy systems have often been designed by people who have no lived trans or gender diverse experience, nor appropriately engaged or consulted with the key affected populations the work seeks to serve. A primary aim of this report is to provide practical and critical guidelines to inform best practice processes for multiple key audiences in an accessible manner. Should any information in this report be difficult to understand, please email the author for further clarification as nobody should be left behind. Contact details can be found at the end of this report.

About the Churchill Fellow:

Jeremy Wiggins is the first transgender Australian to be awarded a Churchill Fellowship. Jeremy is a community advocate and has extensive project management experience working in trans and gender diverse health and , , bisexual, transgender and queer (LGBTQ) community development. Jeremy’s background is in grassroots activism and community building. Jeremy is Co- Chair of the Victorian Government Trans and Gender Diverse Expert Advisory Group, a member of the Victorian Government LGBTI Health and Human Services Working Group, Co-Chair of the Peer Advocacy Network for the Sexual Health of Trans Masculinities and was recently announced as 2018 Victorian LGBTI Person of the Year. Jeremy is also the Founder of LEAP and works with governments, organisations and communities to improve experiences and outcomes for LGBTQ people.

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Locations Travelled:

Bangkok London, Manchester, Brighton, Leicester Edinburgh Thailand England Scotland

Berlin Toronto , Boston, Germany Canada United States of America

Visits:

This is a condensed version of the visits. A full list with names of individuals consulted with can be found at the end of this report. With respect to the full policy cycle that improves health equity and access for our communities, it is important to recognise and value the work of unpaid community members, volunteers, activists, organisers and advocates. A range of individuals not employed by organisations were also interviewed, some of whom requested to not have their names published.

Bangkok, Thailand Brighton United Kingdom New York, USA Asia Pacific Transgender Network Hove Polyclinic / NHS Sussex Partnership Trust Callen-Lorde Community Health Center Tangerine Community Health Centre The Clare Project The Center Thai Red Cross AIDS Research Centre Trans Alliance London, United Kingdom University of Brighton Sylvia Rivera Law Project Dean Street Clinic Edinburgh, Scotland Boston, USA CliniQ Scottish Trans Alliance Fenway Health GALOP Toronto, Canada AIDS Action Committee CATCH Trans Hate Crime Project Rainbow Health Ontario / Sherbourne Health Centre San Francisco USA Transgender Professional Association for Stonewall Housing Transgender Health St. James Infirmary Leicester, United Kingdom AIDS Committee of Toronto Lyon Martin Health Services De Montfort University Gay Men's Sexual Health Alliance Strut University of Leeds Health Initiative for Men (Vancouver) SF AIDS Foundation Manchester, United Kingdom

Macmillan/The Christie NHS Foundation Trust

LGBT Foundation

TransForum Manchester

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Reflections

I am very grateful to have had such a rare and valuable opportunity to explore and investigate trans and gender diverse health globally. I am incredibly passionate about people living healthy and happy lives and having quality and timely access to essential health services. I’m equally as fortunate to be able to know and work with so many other talented, hardworking and committed trans and gender diverse Australians and I want to dedicate this report to you all. I would like to thank the Winston Churchill Memorial Trust for granting me this opportunity. It was one of the greatest achievements and unique experiences of my life. I was able to learn and experience a diverse range of health services, settings and organisations that were either led by us or worked to improve the lives of trans and gender diverse people.

When I set out on this fellowship, I hoped to find new information, innovative models of care or learnings that I could bring back to help advance the Australian context of health care for TGD people. I felt I did achieve that in parts. I certainly found some innovative programs led by TGD people and discovered new work or research projects happening and built valuable relationships with excellent TGD people working in similar field. Overall, I found that comparatively, Australia has some great work in place and can demonstrate leadership and an ongoing commitment to reforming the health status and environment for TGD people. We still have a long way to go, but I need to acknowledge that our position globally is benefited by having a public health care system in the form of Medicare. In addition, Victoria’s current and very supportive Labor State Government is a valuable resource in terms of creating an authorising environment to create action and change. This needs to be nurtured and strengthened for maximum impact. We need to also strengthen collaboration on a national level and create a united national voice.

The biggest revelation I experienced whilst undertaking the fellowship was meeting so many dedicated, knowledgeable and highly competent trans and gender diverse people working in LGBTIQ or mainstream health services who were visibly under-supported, under-recognised and undervalued. These people hold a level of knowledge that cannot be easily replaced. The burden on their shoulders in carrying the responsibility of these portfolios and areas without adequate support was highly evident. It is a risk to their wellbeing, professional practice and ultimately a risk to the sustainability of their work for the communities they serve. Since my return, many of these key people have ceased working in their positions – which is a great loss. Thank you to these people who endured that hardship and whose expertise is often not seen. Many of us hold the threads together to keep our communities going and that labour is often not recognised or valued appropriately.

I also need to acknowledge that whilst this trip was an incredible experience, it was also difficult on a range of levels. I had an incredibly traumatic experience in my 2nd week, where I endured a life- threatening attack. This was directly linked to my work and my experience as a trans person and had an impact on my ability to fully function whist on my fellowship. I want to acknowledge the challenging experience of living as a trans person, working with TGD communities who experience high rates of violence and trauma, and then also personally encountering an act of serious violence. I would like to thank the Churchill Trust for their patience and support during this time.

I hope you find this report useful as an advocacy tool, particularly the recommendations. I hope that the Australian community can utilise them, alongside other forces and work efforts, to advance our human rights and health care status in this country.

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Recommendations

1. Trans and gender diverse people must be affirmed, respected and acknowledged as their gender, regardless of any social, cultural, medical, surgical or legal affirmation process.

2. Nothing About Us, Without Us: Strengthening, supporting and prioritising trans and gender diverse people, organisations, groups and structures

2.1 All strategies, funding streams and programs that focus on addressing trans and gender diverse health disparities must be co-designed, led by and include trans and gender diverse people, community organisations, groups and/or structures.

2.2 TGD, LGBTI and mainstream organisations must commit to appointing and providing appropriate support (including remuneration) to TGD people in governance structures including in management, senior executive positions and on boards.

2.3 Existing programs and services focussing on trans and gender diverse health must be realigned to ensure trans and gender diverse people are engaged and have legitimate and authentic agency in the governance, decision-making and delivery of services and programs.

2.4 Support programs must be established by government, NGOs and philanthropic organisations to build the capacity of trans-led organisations, including in respect of governance, peer support, policy, advocacy and delivering or partnering to deliver services.

2.5 A national alliance of trans-led organisations which represents the diversity of the communities should be developed.

3 Community mobilisation and empowerment

3.1 Trans-led programs focussing on community development, resilience building, education and capacity building for trans and gender diverse people should be developed and funded.

3.2 A national online hub to support self-navigation and information about service systems, rights, gender affirmation steps and pathways for complaints and peer support should be established.

4. Strengthening the trans and gender diverse workforce

4.1 Traineeships, formal training, higher education and scholarships should be established for trans and diverse workers to build their professional skills and access to employment.

4.2 Recruitment processes, employment pathways and skill development should be established for trans and gender diverse people to enable them to access a wide range of roles, including identified positions, leadership roles, and program and service delivery positions.

4.3 Processes should be established to ensure trans and gender diverse staff are rewarded, recognised and retained within LGBTI and mainstream services. This includes:

4.3.1 Paid leave for gender affirming care; 4.3.2 Fostering cultural safety for the trans and diverse workforce; 4.3.3 Training of workforces to better understand and respond to the employment experience of TGD staff;

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4.3.4 Appropriate and culturally competent internal and external supervision that supports TGD workers to overcome and manage the unique stressors of working with trauma affected communities and to maintain good professional practice; and 4.3.5 Recognition, acknowledgement and responses that address transphobia, micro aggressions and lateral violence and trauma experienced by TGD employees; within their workplaces, sectors and stakeholder communities.

5. Legal affirmation: Easily amending legal name and markers on identity documents and in health systems

5.3 Law reform should be implemented to institute a simple, nationally consistent administrative process based on self-determination, which also minimises the need for trans and gender diverse people to submit information to different levels of Government and organisations.

5.4 Support (e.g. peer navigators), information and resources should be established/provided to assist trans and gender diverse people through the process of amending their legal sex classification and/or name on identity documents.

5.5 Any application fee should be waived for changes of legal sex classification and/or name for all trans and gender diverse people seeking legal affirmation.

6. The Right to the Highest Attainable, Standard of Health (Art. 12): Access to healthcare for trans and gender diverse people. (Adopted at the Twenty-second Session of the Committee on Economic, Social and Cultural Rights, 11 August 2000)

6.1 Trans and gender diverse people must be meaningfully included as a priority population in preventive health policy frameworks, strategies, programs, guidelines and health promotion such as cancer screening and sexual health.

6.2 Gender-based services and programs such as women’s health centres, maternity wards, sexual assault and family violence services must be inclusive, acknowledge and respect the gender identity and self-determination of trans and gender diverse people accessing services.

6.3 Inclusive, specialist domestic, family violence and homelessness services that accommodate trans and gender diverse people regardless of their gender identity must be developed. Specialist services should work in collaboration and partnership with existing gender-based services to allow trans and gender diverse people seeking support to have additional, appropriate service choices.

6.4 Trans and gender diverse people must have the right to gender affirming care (including medical and surgical) in a timely manner that is easily accessible, Medicare-funded, depathologised, and respects the trans or gender diverse people as the experts of their own experience.

6.5 Gender affirming surgeries including all post-surgical care, including all care and complications from surgeries performed overseas, should be accessible and Medicare-funded within all public hospitals in Australia.

6.6 Home-based care and practical support programs for TGD people with complex health needs (e.g. recovering from surgeries or acute mental health) should be developed.

6.7 Organisations should create gender affirmation policies, including staff being offered support from Human Resources to update details etc (HR to be trained in how to support trans and

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gender diverse staff regarding transition in the workplace. Refer to the Stonewall and VEOHRC Guidelines in Victoria).

7. Training, support, education and resource development for health and human services

7.1 All training should be co-designed through TGD community consultation and input.

7.2 All training should be delivered and/or co-delivered with paid TGD trainers (lived experience subject matter experts). Where content falls outside of the field of expertise of the TGD person it can be co-delivered with a person holding the relevant medical expertise.

7.3 Training on informed consent for TGD people to be delivered in medical school curriculum and should be rolled out to existing medical professionals through CPD and primary health network health pathways (PHNs).

7.4 Training should be adequately resourced, including setting a minimum safety standard of at least 2 workers to deliver training together.

7.5 Training, guidelines and resources for GPs and allied health professionals around delivering culturally safe healthcare to trans and gender diverse people should be developed and implemented Australia-wide. This includes:

7.5.1 Resource and support for physicians to work more sensitively with trans and gender diverse people about their bodies, sexual practices and healthcare needs 7.5.2 Funded secondary consultation services established nationally to support GPs providing primary health care and the initiation of gender affirming hormones through informed consent models.

8. Navigating the system for better health and wellbeing outcomes

8.1 A paid trans and gender diverse community professional peer workforce providing direct support, navigation and advocacy for trans and gender diverse people should be developed.

8.2 Funded specialist services, resources and peer support should be developed for parents, families, children, friends and partners of trans or gender diverse people

8.3 Multi-disciplinary support programs should be developed that assist trans and gender diverse people to navigate complaints pathways and advocate for their rights including in partnership with community legal centres.

9. Support and engage with a diversity of trans voices (e.g. gender diverse, non-binary, trans, transsexual, trans families, Aboriginal trans people, trans people of colour, trans people with disabilities and other minority voices not always heard or included)

9.1 Measures to ensure Government engages with diverse voices should be established.

9.2 Social support groups and drop in centres should be funded.

10. Cultural change in social service system provision (health care, etc) to ensure TGD appropriate service delivery

10.1 Government to lead and engage closely with community re cultural change process – through funding decisions, mandating rainbow tick accreditation, better coordination to improve

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consistency of service delivery, and the appointments of TGD people to governance structures (senior executive positions & boards). 10.2 There is a need for stronger responses to health care complaints – Government(s) should address the capability / capacity of relevant health care complaints pathways. Note links to navigation support and the potential role of CLCs (see above). 10.3 Establish a national online portal to provide information about TGD rights.

11. Relationships

11.1 Research is required to learn more about trans and gender diverse people’s experiences of emotional, physical, romantic and sexual relationships. 11.2 The capacity of relationship services should be built to respond to TGD needs and the needs of their partner/s.

12. Improved Data Collection

12.1 Appropriate gender identity related indicators in all data collection mechanisms used across all Government and community sector contexts should be strengthened. This includes within the Census, data dictionaries used within research and health systems (MBS and PBS coding), justice, welfare, and education, social and legal settings to ensure population and service level datasets meaningfully include trans and gender diverse people.

13. Research

13.1 Research relating to TGC people should be co-designed and co-developed with TGD community, trans people should be the chief investigators, and trans people should own their own data (it should be considered unethical to conduct research otherwise).

13.2 Ethics requirements – involvement / leadership by TGD people must be a key consideration as part of ethics approval decisions.

13.3 Research projects should benefit the trans and gender diverse community and be aligned with the principles of self-determination, de-pathologisation and empowerment.

14. Human rights, self-determination and autonomy

14.1 The trans experience is not a mental illness and trans and gender diverse people should not have to get a gender dysphoria diagnosis to access gender affirming care, including medical and surgical intervention, unless they choose to. The process should be self-determined.

“TGD people experience a disproportionate burden of poorer mental health outcomes, including anxiety and depression, as a consequence of their experience of stigma and discrimination. It is important that culturally competent mental health services are available and accessible to those who can benefit from their care, but that this is not mandated. Situating the trans experience as a mental illness is not only inaccurate but a harmful barrier to positive health, employment, social, financial and wellbeing outcomes.”

Citation: Oliphant J, Veale J, Macdonald J, Carroll R, Johnson R, Harte M, Stephenson C, Bullock J. Guidelines for gender affirming healthcare for gender diverse and transgender children, young people and adults in Aotearoa, New Zealand. Transgender Health Research Lab, University of Waikato, 2018.

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“Respect the self-determination of each person as being the expert on their experience. This is often referred to as the “informed consent model” of gender affirming healthcare because it counteracts pathologisation and repositions the transgender person as being at the centre of their own life.” (p.22 of NZ Guidelines)

14.2 For those who are currently required or want to seek a gender dysphoria diagnosis to access to gender affirming care, people should be offered peer support (e.g. navigation support) or support by another professional (e.g. mental health or social work) who is not involved in the gender dysphoria diagnosis who works from a de-pathologised lens to provide support / de-briefing in respect of the pathologised process. This ensures that they can access authentic therapeutic care and support mechanisms, if they choose to do so. It also acknowledges that people may have needed to be performative to access care.

‘’I lied and said I was a binary trans man to gain access to the services I needed. The psych was very focused on gender norms and binary identities, and I felt judged and ‘not trans enough’ because some of my hobbies are traditionally ‘feminine’ things.’’ [Agender, 21] (Trans Pathways p.103)

14.3 The process of pathologisation can be harmful and violent.

14.4 De-pathologisation of trans health addresses the impact of this model on TGD health and mental health outcomes. Pathologisation & gender dysphoria diagnoses can also limit access to life & income protection insurance (increasing economic/financial vulnerability of TGD people and their families).

14.5 Discrimination when accessing life, income protection or health insurance on the basis of a gender dysphoria diagnosis should be unlawful.

‘’I felt like I had to prove that I was ‘really trans’ (whatever the heck that means)’’ [Female, 22] (Trans Pathways p. 105)

14.6 Trans Pathways – some TGD people felt they had to be performative – prove they were trans enough, e.g. “The doctor used outdated and offensive terms to describe trans people, including myself, and referred to being trans as pathological.” (Trans Pathways p.103).

14.7 Decision making about gender affirming care should be centred around a trans persons self-determination and based on informed consent.

14.8 Accessing hormones is not specialised medicine – and should occur within primary health care settings.

14.9 Medical practitioners have used the Hippocratic Oath of “First do no harm” to pathologise TGD people and deny them access to care. Withholding gender affirming treatment is not a neutral option as it may harm (from NZ Guidelines on Gender Diverse Affirming Care) – there is an increased risk from denying or delaying care of poorer mental health outcomes, including risk of suicidality and self-harm.

“Withholding gender affirming treatment is not considered a neutral option, as this may cause or exacerbate any gender dysphoria or mental health problems”.

Citation: Oliphant J, Veale J, Macdonald J, Carroll R, Johnson R, Harte M, Stephenson C, Bullock J. Guidelines for gender affirming healthcare for gender diverse and transgender

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children, young people and adults in Aotearoa, New Zealand. Transgender Health Research Lab, University of Waikato, 2018.

14.10 There are very few reasons why access to hormones will be contra-indicated. TGD people with co-occurring mental health conditions should not have their gender affirming health care delayed or denied:

“Avoiding harm is a fundamental ethical consideration for health professionals when considering healthcare. Withholding gender affirming treatment is not considered a neutral option, as this may cause or exacerbate any gender dysphoria or mental health problems. Conversely, access to gender affirming care may reduce the mental health pressures a trans or gender diverse person is experiencing”. (page 26 of NZ Guidelines)

15. Informed consent

15.1 Informed consent to accessing gender affirming care (hormonal and surgical interventions) should be made available across Australia. Doctors already work with patients to enable them to provide informed consent in a range of clinical contexts.

15.2 Drawing upon the NZ Guidelines and Equinox Gender Diverse Health Centre Informed Consent Guidelines, community led and co-designed guidelines around informed consent should be adopted (clinically mandated) across Australia. NZ Guidelines should be localised to an Australian context. They should also be embedded into medical school and as part of health workers continuing professional development (GPs, practice nurses, psychiatrists etc).

15.3 Informed consent breaks down barriers to accessing TGD related health care. For e.g. national Trans Mental Health Study showed difference of rates of experience of depressive symptoms by hormone use and surgical status. In those taking hormone therapy the proportion experiencing depressive symptoms was 39.8% and those who were not taking it but wished to do so the proportion was 58.4%.

16. Access to sexual assault services and resources

16.1 Sexual assault services should develop their trans and gender diverse cultural competency. 16.2 LGBTIQ+ services should develop their sexual assault competency.

16.3 LGBTIQ+ services and sexual assault services should form partnerships to address barriers and service for trans and gender diverse in regard to sexual assault including:

16.3.1 Development of resources and guidelines for workers to provide trans and gender diverse culturally competent care.

16.3.2 Development of sexual assault resources for TGD people who are survivors of sexual assault.

16.3.3 LGBTIQ+ and/or trans and gender diverse sexual assault support groups should be developed and implemented.

16.3.4 Community education session and/or campaigns to increase awareness of the TGD community to enable it to respond to sexual assault should be provided.

17 Reporting crime and accessing support

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17.1 Trans and gender diverse people who have experienced violence need safe, sensitive and culturally competent access to support. Should a person elect to notify authorities about a crime, people may need advocacy support to navigate the system of seeking justice.

17.2 It is critical that trans and gender diverse communities are educated and aware of the services available to them when wanting to report a crime or seek support as a result of a crime. These services should undergo cultural competency training to ensure they can safely support TGD victims of crime.

17.3 Victoria’s Victims Assistance Programs should undergo TGD cultural competency training.

17.4 Ethical and professional practice guidelines and professional development training should be established for the justice system, including courts, court staff, legal teams, judges and police to appropriately support trans and gender diverse people seeking justice for crimes against them.

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MEETING HIGHLIGHTS

Bangkok:

Asia Pacific Transgender Network (APTN)

Cianán Russell

APTN is funded by a range of international global funds, some HIV related, some philanthropic and international development focussed (such as the Recommendation 10.2 Global Fund and UN AIDS). The role of the APTN is to represent the Asia-Pacific region and its transgender There is a need for stronger responses communities, individuals and organisations at the to health care complaints – regional and international level. The APTN feeds into Government(s) should address the the UN processes representing Civil Society, making capability / capacity of relevant submissions and shadow reports to special missions, health care complaints pathways. meetings and engages with Special Rapporteurs. Through APTN’s expertise in this area, they can ensure that the Asia-Pacific region is represented at high level meetings and leverage off jurisprudence to benefit vulnerable transgender communities.

DENIAL OF HEALTH CARE, MEDICAL NEGLIGENCE AND RISK

The APTN is currently supporting a number of cases, some extremely severe. For example, a trans woman in Pakistan was shot and when she arrived at the hospital was refused access to both the men’s and women’s wards. She was therefore refused life saving medical care which resulted in her death. Another example is the case of a trans man in Indonesia who was experiencing vaginal atrophy which resulted in a vaginal wall collapse and led to severe gastrointestinal complications and ongoing health issues. The medical doctor did not properly investigate and reduced it to issues with hormones and indicated that if the patient ceased hormone treatment the issue would rectify. The failure to properly investigate and address the issue resulted in a deterioration of the conditions. Whilst these issues originate in other countries, these stories of poor practice are synonymous with experiences and narratives in Australia. This is particularly the case if someone has had gender affirmation surgery outside of Australia and then has any health issue or condition (either related or unrelated to that procedure) post-surgery.

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Thai Red Cross: Tangerine Clinic

Jemma and Rena

This is trans and gender diverse led and staffed clinic that provides services to Thai trans and gender diverse people. They are funded by the Thai Red Cross with the purpose of reducing the HIV epidemic for trans and gender diverse people and getting people living with HIV into care and onto treatment. It is through this mechanism that they provide excellent wrap around trans specific health care, such as administering hormones and providing sexual health check-ups or sexual assault crisis care. Their client group is 75% trans women and 25% trans men. The clinic identified particular barriers to reaching trans men and are working on strategies to address this.

SEXUAL VIOLENCE

During this meeting, I was informed of the high prevalence of sexual violence being reported at this service where cisgender gay men are using violence against transgender men. It was recognised that there is a lack of support for trans men who have been sexually assaulted. This is also an issue in Australia for all trans and gender diverse people. A new national research piece prepared by the Kirby Institute on trans and gender diverse sexual health will soon publish evidence speaking to the prevalence of sexual assault and the lack of help seeking behaviour in the trans community. More information on that study can be found here (I am one of the Chief Investigators): https://www.tgdsexualhealth.com/

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London: CliniQ - Michelle Ross Turner, Co-Founder

CliniQ is a remarkable service that is completely volunteer run. It is mostly run by TGD people, but also has volunteer assistance from cisgender allies. CliniQ was Co-Founded by Michelle and a clinician from Dean Street. CliniQ is a pop-up clinic that runs 2 hours per week on a Wednesday night. It is a walk in/drop in service that attracts high demand. There is an initial triaging process by a trans and gender diverse peer greeter and this person helps to assess the client’s needs for the evening. CliniQ offers a range of services including counselling, sexual health screening, hormone injections, STI/HIV testing and even acupuncture.

I observed a few sessions – counselling, intake and assessment for counselling or other services at Dean Street clinic (the biggest sexual health clinic in London). The approach provided by this service is sensitive, patient centred, non pathologizing and respectful. There is also other wrap around services, for example a representative from Stonewall Housing was there. People travel long distances to visit, because they feel safe in a space that is run by trans and gender diverse people. There is an intentional set up of space – a big room, free tea and coffee and CliniQ Recommendation 4 volunteers rove around and chat to people – Strengthening the trans and gender checking in with them about what is going on. diverse workforce. CliniQ also provides training and education to other services, develops resources and runs an annual conference on trans health.

(Thank you to Michelle and Serge for your time and generosity)

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London, GALOP

GALOP is a service in London that supports LGBT community members who have experienced hate crime, sexual violence or domestic abuse. Alongside their advocacy and legal service, they also publish reports on LGBT hate crimes, with a range of recommendations including, but not limited to:

 Review training arrangements for professional Recommendation 17.1 working with LGBT victims Trans and gender diverse people who have  Create good practice guidance on anti-hate experienced violence need safe, sensitive crime restorative justice and culturally competent access to support.  Support the professional and capacity building of Should a person elect to notify authorities anti-hate crime support and advocacy work. about a crime, people may need advocacy  Support the creation of a regular survey of LGBT support to navigate the system of seeking perceptions to contextualise changes in recorded justice. hate crime.

GALOP also provide a trans specific advocacy service for people experiencing discrimination or denial of equal service treatment because of being trans.

DEHUMANISING LEGAL PRACTICES DURING CRIMINAL TRIALS I was informed by GALOP that in London there risk for trans and gender diverse people from reporting crime because if the case goes to trial, the process is not safe for them. Legal teams may intentionally undermine the victim by purposeful misgendering, unnecessarily bringing up their past (pre-transition) in ways to undermine their identity, framing and stigmatising their gender identity as a mental health issue and the need to be medicated with hormones. This deters people from reporting crimes to police and from seeking support.

Leicester, UK - De Montford University

Thanks to Professor Julie Fish for inviting me to present at an information day, with other trans and gender diverse researchers such as Ruth Pearce, who is now working on a trans pregnancy project at the University of Leeds. This research project is a collaboration with several universities around the world, including Flinders University in Australia with Dr Damien Riggs. The first poster was recently presented at the 2018 world WPATH conference in Buenos Aires in Argentina. Click here to view the poster and to view commentary on other presentations on trans fertility and reproduction: https://transpregnancy.leeds.ac.uk/2018/11/22/trans-pregnancy-poster-initial- findings-presented-at- wpath/?fbclid=IwAR3W4IyHeEzmtuhS1RC9kvZ4Z2JBYYRmhICFbdaXruzHJ2SLF1rqAqmuLZ0

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Edinburgh, Scotland

Scottish Trans Alliance

Thank you to Oceana Maund and Vic Valentine for meeting with me and detailing your excellent work with developing a body of evidence about alcohol and drug use in trans and gender diverse communities and our experiences of services. The basis of this report which you can download here (https://www.scottishtrans.org/alcohol-and-drug-services/) formed a broader capacity building initiative where services are undergoing training to improve their ability to better meet the needs of trans and gender diverse people. Another piece of important work is the research on Non-Binary people’s experiences in the UK, which can be found here: https://www.scottishtrans.org/wp- content/uploads/2016/11/Non-binary-report.pdf.

Toronto, Canada

Rainbow Health Ontario, A program of Sherbourne Health Centre

Thank you to Devon MacFarlane and Jordan Zaitzow for your time. Rainbow Health Ontario (RHO) is a province-wide program of Sherbourne Health that works to promote the health of Ontario’s LGBT2SQ (Lesbian, gay, bisexual, transgender, two spirit and queer) communities and improve their access to services. RHO creates resources, provides information and consultation services, delivers education and training, and supports research to develop evidence-based practice and informed public policy.

Rainbow Health Ontario also recognise the importance of funding a referral worker who can provide information and support to trans and gender diverse people who are looking for services. It is critical that trans and gender diverse people and their loved ones can access psycho-social and clinical support. Rainbow Health Ontario responds to clinical and general inquiries regarding trans health and access to health care by giving clinical information, coaching, and resources to clinicians and social service providers. They also help Recommendation 7.5.2 providers develop an understanding of treatment Funded secondary consultation services and care pathways across the province. established nationally to support GPs providing primary health care and the initiation of gender affirming hormones , USA through informed consent models.

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Callen-Lorde Community Health

Thank you to Dr Asa Radix and D'hana Perry for hosting me. Callen Lorde Recommendation 14.7 Community Health has provided Decision making about gender affirming care invaluable support, particularly when I should be centred around a trans persons self- was leading trans health at Thorne determination and based on informed consent. Harbour Health, as they provided permission to adapt their hormone protocols to develop the Equinox Gender Diverse Health Centre’s informed consent model.

The informed consent model has revolutionised trans health for Australia and a key learning from this Churchill Fellowship is that many services in North America operate an informed consent model of care, which seeks to depathologise health for trans and gender diverse people. What underpins this framework are principles of self-determination, bodily autonomy and that trans and gender diverse people have the right to make decisions for themselves regarding their health and bodies and are supported in an affirmative way to affirm their goals. The informed consent model supports people to access hormone therapy without placing mandatory requirements to undergo a clinical psychological or psychiatric assessment. Instead, the model places hormone assessment and initiation into primary healthcare, not into specialist transgender health. The process is staged over several visits and patients are provided with clear guidelines about what to expect at each appointment. This process narrows the gap of knowledge between the provider and the patient and instead creates a partnership to support the patients gender affirmation in a way where the patient’s needs are centred and respected.

Callen Lorde has employed multiple trans and gender people, some whom hold senior management positions, which I found to be incredibly rare. But where trans people are supported and promoted into leadership positions, it has positive impacts for the scope and quality of work for our communities.

INFORMED CONSENT MODELS.

Callen Lorde’s Hormone Protocols and Equinox Gender Diverse Health Centre Hormone Protocols.

Equinox: Click HERE.

Callen Lorde: Click HERE.

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Ali Forney Center

The Ali Forney Center is in and provides multiple services to LGBT young people experiencing homelessness and social disadvantage. This organisation also provides additional support and services for trans and gender diverse young people. Through their ongoing partnership with the Institute for Family Health they also offer hormone treatment to young people through their onsite medical clinic. This operates alongside their transgender housing program and it is a vital resource for trans people who are seeking hormone therapy as many of their clients are obtaining hormones through unsafe methods on the streets or are on lengthy waitlists, which can create poor mental health and safety outcomes. Ali Forney Center works to ensure that clients obtain hormones on the safest and least expensive fashion.

During my time at the Ali Forney Center, I noticed a sexual health campaign for NYC that specifically included trans women, with Carmen Carrera - a famous and highly visible trans woman. This is a good example of trans inclusion in health campaigns.

Sylvia Rivera Law Project

SRLP is an organisation that provides legal, policy and advocacy support for trans and gender diverse people. Their goal is continuing to mobilise, educate, and support communities in putting pressure on people and institutions who are impacting trans healthcare and to make sure that the experiences of trans people are listened to and lead to lasting impact and change. This organisation is delivering world class community empowerment and mobilisation work for trans and gender diverse communities, particularly for trans people of colour. I was fortunate to participate in one of their community empowerment and mobilisation workshops with community members. SRLP created a safe space for a high number of highly vulnerable trans and gender diverse people to come together for a meal and be educated on their health care rights. SRLP developed resources to provide to people that outlined what their rights and protections are regarding accessing health care. The community members participating in this workshop were experiencing multiple complex issues around homelessness, surviving trauma and violence, drug and alcohol issues, employment issues and difficulties navigating the health system. These workshops were a highlight of my research trip, as it brought together a combination of grass roots activism, advocacy, policy, community education, community support to empower trans and gender diverse people and build the capacity of the community.

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Boston

Fenway Health

Fenway Health is one of the largest LGBTI health services providers in the United States. Fenway offers primary health care, behavioural health services, women’s health, trans health, dentistry and eye care. Fenway have thousands of trans and gender diverse clients accessing services and have been able to utilise their research and evaluation resources to develop strong evidence around trans health.

In addition to providing services, Fenway Health also provide a strong set of education initiatives for health care providers through the National LGBT Health Education Center at the Fenway Institute. Every year Fenway also organise a national Trans Health Conference https://fenwayhealth.org/the-fenway-institute/education/transgender-health-conference/

In Australia, we do not have a large LGBTI health service provider that also conducts Recommendation 13.3 rigorous research and evaluation of their trans health services or establishes trans Research projects should benefit the trans and health research projects and there is scope gender diverse community and be aligned with and opportunity to build collaboration and the principles of self-determination, de- partnerships across the research and health pathologisation and empowerment. service sectors.

San Francisco

St James Infirmary

This is a service that primarily works with sex workers and their families in the Tenderloin district of San Francisco The organisation provides a range of primary care services, holistic therapies, peer support, psychological support, outreach and delivers a specialised transgender health program called STRIDE. This program supports trans and gender diverse people to access hormones on an informed consent model. It is also a peer-based model of care, where the organisation employs trans and gender diverse people to deliver services to the communities.

Lyon Martin Health Services

Lyon Martin Health Services is a larger primary health service that works with LGBTI communities, but also has a large transgender health program. Lyon Martin established Project Health, a national primary care capacity building project that aims to support primary health care providers across the USA to improve their skills and competencies to better meet the needs of transgender people. http://project-health.org/ There is a need for something similar to be established in Australia.

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CONCLUSIONS

 Key components of a best practice model: o Trans and gender diverse community needs to be empowered to lead in a meaningful way that is enabled by transparent and accountable governance structures. o Non-TGD organisations (including LGBTI orgs and mainstream orgs) who receive government funding to deliver TGD health services need to be accountable to the TGD community and provide evidence that their service design and delivery is TGD led. o Organisations need to provide appropriate support for the skills development of trans and gender diverse staff and develop a professional peer workforce. o The work and skills of trans and gender diverse workers need to be appropriately remunerated, rewarded and recognised. o Organisations need to operate on a human rights based and trauma informed care model that works to reduce the unnecessary barriers to access equitable and quality health care. o Programs and services need ongoing review and evaluation with accessible reporting mechanisms to the communities they serve. o Access to hormone therapy and surgeries should be de-pathologised and unnecessary psychiatric assessments removed, and trans and gender diverse health care reoriented into primary health. o Program design needs to incorporate a whole of life experience, with responses and services that support trans and gender diverse people throughout their lifespan. o Program design needs to involve family of origin, family of choice and wider support and peer networks. o Services need to create intentional trans and gender diverse spaces and campaigns that address safety and inclusions within health settings. o Complaint pathways need to be clear, simple, supported and communicated to trans and gender diverse clients so that their rights are understood and protected. o Peer support and psycho-social support programs and services need to be integrated into the gender affirmation process. o Programs and services need to recognise the diversity within the trans and gender diverse communities, such as people from faith-based backgrounds, Aboriginal and First Nations people, people of colour, people living with HIV, people with a disability and people living with mental illness or drug and alcohol issues. Nobody should be turned away from accessing a gender affirmation process that is based on their desires and relationship to their culture and identity. o Programs and services need to be free or affordably low cost. o Health care pathways need consumer guidelines for clients to have access to in order to understand the care and treatment they should expect o Australia needs the formation of a new national advocacy group for all TGD issues, with TGD people involved/TGD-led. Increasing trans membership of existing groups such as ANZPATH and making it more accessible and adopting a co-design framework to every level of developing policy needs to be a priority.

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Contact Details for Visits

Bangkok, Thailand

Asia Pacific Transgender Network Cianán B. Russell, Ph.D. Human Rights & Advocacy Officer http://www.weareaptn.org

Tangerine Community Health Centre Kritima Samitpol (Jemma) Clinic Supervisor (Thai Red Cross AIDS Research Centre) www.facebook.com/tangerinecenter

London, United Kingdom

Dean Street Clinic David Stuart ChemSex Program Manager

http://dean.st

CliniQ Michelle Ross Turner Co -Founder

https://cliniq.org.uk/ Serge Nicholson Counsellor Graham Reed Co-Founder

GALOP Sanjay Hora Solicitor

www.galop.org.uk

CATCH Trans Hate Crime Project Serge Nicholson Trans Advocacy and Community Development Worker

www.catch-hatecrime.org.uk

Stonewall Housing http://www.stonewallhousing.org Octavian Starr Supported Housing Officer

Leicester, United Kingdom

De Montfort University Prof. Julie Fish Director, Centre for LGBTQ Research, http://www.dmu.ac.uk/research/resear ch-faculties-and-institutes/health-and- life-sciences/centre-for-lgbtq-

research/centre-for-lgbtq-research.aspx Zowie Davey Senior Lecturer, Centre for LGBTQ Research University of Leeds Dr. Ruth Pearce Researcher on ‘Trans Pregnancy’ Project

https://transpregnancy.leeds.ac.uk Sam Hope Non -Binary Affirmative Counsellor

Manchester, United Kingdom

Macmillan/The Christie NHS LGBT Project Worker and LGBT Cancer Network Foundation Trust Lawrence Roberts Coordinator https://community.macmillan.org.uk/c ancer_experiences/lgbt/f/34890/t/126

795 LGBT Foundation Laurence Webb Pride in Practice Manager LGBT Foundation Solvi Goard Trans Programme Assistant LGBT Foundation Sean O'Brien Trans Programme Assistant

https://lgbt.foundation TransForum Manchester Lee Middlehurst Committee Member

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http://www.transforum-

manchester.co.uk

Brighton United Kingdom

Hove Polyclinic / NHS Sussex Partnership Trust Alex Garner People Participation Lead The Clare Project Dr Sam Hall Chairperson Trans Alliance Jacob Bayliss Trans Consultant Director of the Centre for Transforming Sexuality and University of Brighton Prof Katherine Johnson Gender University of Brighton Dr. Kath Browne Researcher on Trans Needs Assessment https://www.bhconnected.org.uk/sites /bhconnected/files/Brighton%20%26% 20Hove%20Trans%20Community%20Re

search%20Project%202015.pdf

Edinburgh, Scotland

Scottish Trans Alliance Vic Valentine Trans Policy Officer

https://www.scottishtrans.org Oceana Maund Community Development Worker

Toronto, Canada

Rainbow Health Ontario / Sherbourne Health Centre Devon MacFarlane Director

https://www.rainbowhealthontario.ca Jordan Zaitzow Trans Health Connection

TPATH Noah Adams Leadership Team (Transgender Professional Association for Transgender Health) http://tpathealth.org

AIDS Committee of Toronto Ryan Lisk Director of Community Health Programs

http://www.actoronto.org Vincent Francoeur Gay Men’s Group Programming Coordinator

Gay Men's Sexual Health Alliance Dane Griffiths Acting Director

http://www.gmsh.ca

Health Initiative for Men (Vancouver) Aaron Purdie Program Manager

New York, USA

Callen-Lorde Community Health Center Dr Asa Radix Senior Director of Research and Education

http://callen-lorde.org D'hana Perry Transgender Health Care Coordinator https://www.youtube.com/watch?v=K

NXSFo8InVs Miyah Tomlinson HOTT Medical Case Manager (Health Outreach to Teens)

The Center Antonio Ruberto Senior Director of Behavioural Health

https://gaycenter.org/home Natasha Jones Director of Youth Leadership & Engagement

Ali Forney Center Joey Lopez Director of Outreach and Health Services

https://www.aliforneycenter.org/ Erika Usui Health Services Coordinator

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Sylvia Rivera Law Project Kimberley McKenzie Director of Outreach and Community Engagement

https://srlp.org Sasha Alexander Director of Membership

Boston, USA

Fenway Health Cei Lambert Pati ent Advocate, Trans Health Program

http://fenwayhealth.org Dana Pardee Director of Epidemiology Projects Danielle Metzger Violence Recovery Program Elliot Marrow Senior Research Assistant

AIDS Action Committee Dwayne Steward Manager of Community Engagement and Prevention

http://www.aac.org

TransCEND Chastity Bowick Transgender Health Coordinator

http://www.aac.org/transcend

San Francisco USA

St. James Infirmary Dee Wollstonecraft Michel Programs Director

http://stjamesinfirmary.org/wordpress

Lyon Martin Health Services JM Jaffe Project Health Lead and Trans Health Manager

http://lyon-martin.org http://project-health.org/contact

Strut Mike Discepola Director of Substance Health Services

https://strutsf.org

SF AIDS Foundation Morty Diamond Manager, CCHAMP Centre of Excellence

http://sfaf.org Rick Andrews PROP Program Manager

I have collected much more information, including resources, brochures and research reports. Should anyone be interested in anything, please get in touch.

Contact Details:

Jeremy Wiggins

[email protected]

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