Re-Thinking Trans Healthcare in the 21st Century Adam Shepherd Overview
✤ What does it mean to be transgender?
✤ Medicalisation of trans identities
✤ Depsychopathologisation movement
✤ Reframing Trans Healthcare
✤ Cultural competency
✤ Structural competency Transgender: denoting or relating to a person whose sense of personal identity and gender does not correspond with their birth sex (Holleb, 2019) Gender in Different Cultures (Nonbinary Wiki, 2020)
✤ Acault (Myanmar) ✤ Muxe (Zapotec of Oaxaca, dating to ✤ Ashtime (Ethiopia) pre-Columbian times)
✤ Burrnesha (Albania, dating to 1400 AD) ✤ Ninauposkitzipxpe (Blackfoot Confederacy) ✤ Fa’afafine (Samoa) ✤ Quariwarmi (Inca) ✤ Femminiello (Italy, dating to 1500 AD) ✤ Sekhet (Ancient Egypt, 2000-1800 BC) ✤ Hijra (South Asia, dating to 400 BC)
✤ ✤ Kathoey (Thailand) Sekrata (Madagascar)
✤ köçek (Ottoman Empire, 1600-1800 AD) ✤ Whakawahine and Wakatane (Maori)
✤ Mahu (Hawaii) ✤ Winkte (Lakota) Medicalisation of Trans Identities (Drescher, 2010; Lev, 2013; Pearce, 2018)
Declassification of homosexuality as a Sexual deviances diagnosis Late 1950s 19th/ early 1930s 20th century: Endocrine Psycho- defining Treatment therapy deviancy Gender deviances Classification of transsexualism/ gender identity disorder as a diagnosis Trans as condition: being trans is fixed and fixable
Trans as movement: subjective social experiences are fluid by nature (Pearce, 2018) The Depsychopathologisation Movement
✤ 1979: World Professional Association for Transgender Health published first International Standards of Care (Drescher, 2010; Lev, 2013)
✤ 1980: Gender Dysphoria included in DSM-III (transsexualism in ICD?)
✤ Since 2002, ‘transsexualism’ has not been considered a mental health diagnosis in England (NHS England, 2017)
✤ 2013: centralisation of funding for Gender Identity Clinic services; increased awareness of non binary genders (RCPsych, 2013)
✤ 2019: GIC service specifications actively promote patient-centred transitions; introducing option for self referrals (NHS England, 2019)
✤ 2019: ICD11 - reframing diagnosis to ‘gender incongruence’, included in sexual health chapter (WHO, 2020)
✤ 2019/20: Pilots in London, Manchester, and Merseyside to integrate Gender Identity services into local primary care and sexual health services (NHS England, u.d.) Trans as transition: the understanding of trans people and their health needs solely in the context of (medically) transitioning (Pearce, 2018)
(Rider et al., 2018) “For transgender people, research evidence on health inequalities was lacking. However, what evidence there was tended to show similar problems to those experienced by LGB people, but experienced by a much higher percentage.” (Hudson-Sharp and Metcalf, 2016) Equality Office’s National LGBT Survey (2018) & Stonewall LGBT in Britain Health Report (2018)
✤ Unequal treatment on basis of sexuality or gender: LGB 19% Trans 27% | LGB 13% Trans 32%
✤ Problems accessing healthcare: LGB 7% Trans 40%
✤ Healthcare refusal: LGB 2% Trans 16%
✤ Lack knowledge of specific health needs: LGBT 25% Trans 62% | LGB 5% Trans 21%
✤ Inappropriate curiosity: LGB 6% Trans 18% | LGB 20% Trans 48%
✤ Concerned about being outed without consent: LGB 23% Trans 39%
✤ Avoided healthcare treatment: LGB 4% Trans 18% | LGBT 14% Trans 37% Cultural Competency
✤ The ability to understand, appreciate, and interact with persons from cultures and/or belief systems other than one’s own (Danso, 2018)
✤ Awareness of own cultural values and beliefs
✤ Awareness of own biases
✤ Knowledge of diverse behaviours and beliefs that may be the norm in other cultures Inappropriate Curiosity
✤ The objectification of patients into an educational experience by healthcare workers asking intrusive questions and conducting examinations that are irrelevant to why the patient has sought medical care, and whose only purpose is to satisfy the curiosity of the healthcare worker (Shepherd et al., 2019)
“I think he just wanted to have a science experiment.” - Vermeir et al. (2018, p238) Being curious (Grossnickle, 2014; Hsee and Ruan, 2016; Kidd and Hayden, 2015; Peterson and Hidi, 2019)
✤ “All men by nature desire to know.”- Aristotle (350 BC)
✤ A virtue vs a vice
A desire for new knowledge, information, or experiences to fill gaps or discover the unknown Curiosity in Healthcare
✤ Paternalism vs Partnership Model (Scambler, 2018)
✤ Biopsychosocial Model (Borrell-Carrio, 2004)
“Medical students have a license to be nosy.” “An obese man who appeared comfortable between bouts of pain” (Stroumsa et al., 2019)
✤ Sam, a 32-year-old man, was brought to the emergency department by his boyfriend. Sam reported an 8-hour history of severe (8 out of 10), intermittent lower abdominal pain.
✤ Sam told the nurse that he was a transgender man. He had taken a home pregnancy test that morning and got a positive result, but he wondered whether it was a false positive. He added that he had “peed himself” that morning.
✤ The triage nurse assessed him to be a man with abdominal pain who had not taken his prescribed blood-pressure medications. Determining that his condition was stable, she triaged him to non- urgent assessment.
✤ Several hours later, an emergency physician came to evaluate him. She noted the positive results of the serum hCG test and took a more detailed history, considering possible early pregnancy complications.
✤ Sam had cord prolapse of uncertain duration. No fetal heartbeat could be detected on ultrasound. Given the fetal death, Sam was transferred to a delivery suite where, moments later, he delivered a stillborn baby. Trans Broken Arm Syndrome
✤ The phenomenon of healthcare professionals disregarding genuine health issues in favour of attributing the patient’s trans identity as the problem (Payton, 2015)
✤ “In the five minutes it takes them to grill me on gender stuff and write it all down, the orthopod has squandered a quarter of the time they’ve got to fix my broken arm, in order to waste another doctor’s time by telling her something she already knows.”
✤ “A woman PinkNews spoke to suffered from migraines, which had a serious negative impact on her life. She said her doctor “just assumed it was some side effect of HRT, [hormone replacement therapy]” and it was several years, and a move to a new city, before a doctor diagnosed and began treating the problem.” Damned if you do, damned if you don’t?
✤ Due diligence: have you considered all possibilities, and how confident are you that you have identified the correct issue?
✤ Trans woman attending A&E with sudden onset chest pain
✤ Trans woman attending A&E with 3/7 history of productive cough and fever Structural Competency
✤ An understanding of how stigma related health inequalities can arise not only from individual encounters, but also from the institutions which shape the context in which these interactions occur (Metzl and Hansen, 2014) Screening Programmes* (Public Health England, 2019)
‘M’ medical ‘F’ medical record record
Will not be Breast Will be invited invited - but - only needed Screening may be needed if breast tissue Will not be Will be invited Cervical invited - only - only needed Screening needed if cervix if cervix Will not be AAA Will be invited - may not be invited - but Screening needed may be needed Bowel Will be Will be Screening invited invited
*antenatal and newborn screening as appropriate for pregnant people The Future?
✤ Increased visibility of trans population
✤ Normalise trans healthcare teaching
✤ Advocate for trans inclusive infrastructure ISBN-13: 978-1785922015 ISBN-13: 978-1447342359 References
✤ Aristotle, Metaphysics, I.1 1a1, tran. Ross
✤ Bachmann, C., Gooch, B., 2018. Stonewall LGBT in Britain - Health. Stonewall.
✤ Borrell-Carrio, F., 2004. The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry. The Annals of Family Medicine 2, 576–582. https://doi.org/10.1370/afm.245
✤ Drescher, J., 2010. Queer Diagnoses: Parallels and Contrasts in the History of Homosexuality, Gender Variance, and the Diagnostic and Statistical Manual. Archives of Sexual Behavior 39, 427–460.
✤ Government Equalities Office, 2018. National LGBT Survey: Research Report. Government Equalities Office, Manchester.
✤ Grossnickle, E., 2014. Disentangling Curiosity: Dimensionality, Definitions, and Distinctions from Interest in Educational Contexts. Educational Psychology Review, 28(1), pp.23-60.
✤ Hsee, C. and Ruan, B., 2016. The Pandora Effect. Psychological Science, 27(5), pp.659-666.
✤ Holleb, M., 2019. The A-Z of gender and sexuality: from Ace to Ze. Jessica Kingsley Publishers, London ; Philadelphia.
✤ Hudson-Sharp, N., Metcalf, H., 2016. Inequality among lesbian, gay bisexual and transgender groups in the UK: a review of evidence 164.[online] Available at:
✤ Kidd, C., Hayden, B.Y., 2015. The Psychology and Neuroscience of Curiosity. Neuron 88, 449–460.
✤ Lev, A.I., 2013. Gender Dysphoria: Two Steps Forward, One Step Back. Clinical Social Work Journal 41, 288–296.
✤ Metzl, J.M., Hansen, H., 2014. Structural competency: Theorizing a new medical engagement with stigma and inequality. Social Science & Medicine 103, 126–133.
✤ NHS England. n.d. Gender Dysphoria Clinical Programme. [online] Available at:
✤ NHS England. 2017. Gender Identity Services For Adults (Non-Surgical Interventions) Draft. [online] Available at:
✤ NHS England. 2019. Gender Identity Services For Adults (Non-Surgical Interventions). [online] Available at:
✤ Nonbinary Wiki. 2020. Gender-Variant Identities Worldwide. [online] Available at:
✤ Payton, N., 2015. Feature: The dangers of trans broken arm syndrome - PinkNews · PinkNews [WWW Document]. URL https:// www.pinknews.co.uk/2015/07/09/ feature-the-dangers-of-trans-broken-arm-syndrome/ (accessed 6.19.19).
✤ Pearce, R., 2018. Understanding Trans Health. Policy Press, Bristol. References
✤ Peterson, E. and Hidi, S., 2019. Curiosity and interest: current perspectives. Educational Psychology Review, 31(4), pp.781-788.
✤ Public Health England. 2019. NHS Population Screening: Information For Transgender People. [online] Available at:
✤ RCPsych. 2013. Good Practice Guidelines For The Assessment And Treatment Of Adults With Gender Dysphoria. [online] Available at:
✤ Rider, G., McMorris, B., Gower, A., Coleman, E. and Eisenberg, M., 2018. Health and Care Utilization of Transgender and Gender Nonconforming Youth: A Population-Based Study. Pediatrics, 141(3), p.e20171683.
✤ Scambler, G. (Ed.), 2018. Sociology as applied to health and medicine, 7th edition. ed. Macmillan Education, Oxford.
✤ Shepherd, A. Hanckel, B., & Guise, A. (2019) ‘Trans health and the risks of inappropriate curiosity’. BMJ Opinion.
✤ Stroumsa, D., Roberts, E.F.S., Kinnear, H., Harris, L.H., 2019. The Power and Limits of Classification — A 32-Year-Old Man with Abdominal Pain. New England Journal of Medicine 380, 1885–1888
✤ Vermeir, E., Jackson, L.A., Marshall, E.G., 2018. Barriers to primary and emergency healthcare for trans adults. Culture, Health & Sexuality 20, 232–246.
✤ WHO, 2020. WHO/Europe Brief - Transgender Health In The Context Of ICD-11. [online] Euro.who.int. Available at: http:// www.euro.who.int/en/health-topics/health- determinants/gender/gender-definitions/whoeurope-brief-transgender-health-in-the- context- of-icd-11 [Accessed 11 June 2020].