When the media talk about transgender people the discussion will often focus on genitals. The question “have you had the surgery” regularly comes up. But it is not that simple. Not all transgender people wish to medically transition; some people only want certain procedures and this does not make them any less trans. Medical transition is a long, nonlinear, and complicated process—a process which is different for every trans person. While awareness is growing about transgender issues, there are still obstacles that limit transgender people’s access to treatments to relieve gender dysphoria and medically transition to the gender they identify with. The current system in New Zealand is full of barriers: the lack of understanding and institutional knowledge, the allowance for doctors to determine whether an individual is trans and whether they are suffering gender dysphoria, as well as a lack of formal policy guidelines. While the awareness of trans issues continues to grow, access to trans healthcare (including hormones and various surgeries) is not getting any easier.
Currently there are 174 transgender patients within the Wellington region and numbers continue to grow. The medical transition process falls into two areas: hormone treatment and surgery. In order for a transgender person to gain access to hormone treatment a GP or mental health professional refers them to the endocrine and diabetes clinics at Wellington hospital. In New Zealand, hormone treatment is covered by individual DHBs such as Wellington’s Capital and Coast District Health Board (CCDHB), and every DHB is different.
Endocrinologists are doctors who specialise in the endocrine system, which is the term for the collection of glands that produce hormones which control metabolism, growth, sexual function, etc., as well as controlling secondary sex characteristics. These hormones are funded in multiple forms in New Zealand by Pharmac. Trans masculine people are prescribed testosterone (T), which can either be taken in pill form or in three injectable forms. T causes body and facial hair growth, the deepening of the voice, higher sex drive, growth of clitoris, fat redistribution, and an increase of muscle mass. It is important to remember that T is not a contraceptive and trans masc people can still get pregnant if they are engaging in “vaginal” sex. Trans feminine people are prescribed oestrogen pills and testosterone blockers. The effects of these hormones are weight redistribution, breast development, decrease in body hair, and softer skin. In Wellington, ultimately, it is the decision of the endocrinologist whether or not to prescribe hormones. They determine, with the help of the patient’s GP and psychologists, whether the person is trans and whether they have enough support to undergo a medical transition. A psychological assessment is mandatory for all those seeking medical transitions to determine if someone is experiencing gender dysphoria or mental illness, regardless of the prior state of the person’s mental health. The psychologist’s assessment, the GP’s assessment, all factor into the ultimate decision made by the endocrinologist.
So that’s the process to access care; a string of consultations and appointments, checking that you fill certain ‘roles’ of the trans experience. However one of the major issues transgender people are faced with is the lack of knowledge and policy within medical institutions. Often GPs and primary care professions have never encountered a trans person before and are unsure about the procedure. This results in transgender people either having to educate their doctors, or being unable to go forward with their transition because they aren’t able to access the information, let alone the treatments.
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Alex, a 20 year old non-binary person, has experienced the effects of a lack of policy while attempting to access trans medical care. Like many trans people they were met with ignorance from medical professionals when discussing medical transition. Initially they felt that they had to lie to their GP in order to gain access to treatment. “I told him that I was trans instead of non-binary because I didn’t want to jeopardise my chances of getting a referral [to the endocrinologist].” Their GP told them “he had never known anyone who wanted to transition from female to male and that it was usually the other way around.” Alex’s GP “made it pretty clear that he had no idea what the transition process was,” but that he would refer Alex to the endocrinologist.
These encounters did not improve with their appointment with an endocrinologist. The endocrinologist misgendered Alex and at one point told them “non-binary people do not exist.” Alex said the experience of attempting to gain access to hormone treatment “was extremely awkward.” Alex felt as though they were “having to prove to him that I was trans enough” through a series of questions about gender identities and being non-binary. “He asked me when I last had my period and I told him I didn’t know / couldn’t remember. He said that was the correct answer and that transgender men are less likely to recall when they last menstruated.”
There is no formalised process, what trans patients are getting is an ad-hoc assemblage of checks-and-balances that the medical profession can scrap together, to ensure they aren’t sending anyone through an unnecessary and unwanted procedure.
The CCDHB were open about their lack of formal policy in regard to transgender patients in a response to an OIA request from Salient. A spokesperson for CCDHB stated that “currently CCDHB does not have formal policies” for transgender patients. They said that: “Patients with Gender Dysphoria are referred to the Endocrinology service by General Practitioners, Clinical Psychologists, and Psychiatrists as for all Endocrine patients. Teenagers or those with possible emotional difficulties are referred for a preliminary psychological or psychiatric opinion. Counselling services are requested from the primary or private sector when appropriate.”
While many primary care centres have limited knowledge of transgender people, this is not reflexive of all GP practices. Evolve, a Wellington youth health and counselling service, is commonly seen as the leader in support for transgender people. Aiden is a 20-year-old transgender student who is a patient of Evolve and they explained their experience with the service. “I changed to a GP at Evolve before I started transition. My GP knew the right people to talk to for me to transition medically, but I’m not sure if he knew the process well himself. He referred me quickly to Mani Bruce Mitchell [an intersex activist and counsellor who specializes in helping gender diverse people] who got me in touch with an endocrinologist.”
Aiden went on to say: “My endocrinologist asked me about why I wanted to transition, if I understood all the implications of starting hormones, and if I had supportive friends and family. I’m not sure that it was necessary, but I also got a letter sent through from a counsellor at Evolve. After this, [the endocrinologist] was happy to start me on testosterone. Because I was young, I started on a very low dose and have built up very gradually. I’ve just been contacted about seeing a psychologist at the hospital retrospectively. This is becoming a required check for trans people starting transition.”
While it is difficult to access hormone treatment, there are further obstacles for transgender people who are looking to undertake gender reassignment surgery. Currently the CCDHB does not fund any surgery to relieve gender dysphoria such as chest reconstructive surgery, facial feminisation surgery, or gender reassignment surgery. The Ministry of Health funds four lower surgeries every two years: one for female to male surgery (ftms) and three male to female surgery (mtfs). However this does not meet demand with 71 mtfs and 17 ftms currently on the waiting list. If the ministry continues to fund only four surgeries every two years, those on the bottom of the waiting list could be waiting many years of their lives before gaining access to funded lower surgery. The inaccessibility of funding for trans people means those who are able to may pay out of pocket for surgery, either within New Zealand or overseas.
While there is limited access to support and medical services for transgender people, there are many who are advocating for change. The Sex and Gender Diverse Health and Outcomes Working Group (SGDHOWG), which is made up of transgender activists and doctors, are working to improve trans people’s access to health care. Cathy Stephenson, a Wellington based GP and member of the SGDHOWG, believes that in order to improve transgender healthcare medical professionals need to be educated about the needs of transgender people. Dr Stephenson described the current state of transgender health care as disgraceful and believes there should be an “upskilling of medical professionals across the board, so if they do not know how to treat a transgender person they know at least where to send them.” Dr Stephenson believes that local DHBs or the Ministry of Health should create funding in order to provide training and support for medical professionals to offer appropriate care for transgender people.
The SGDHOWG aims to produce an informed consent model which would do away with the need for a mandatory psychological assessment. Currently the system requires a person to receive a diagnosis of gender identity disorder and this poses a barrier for trans people who want to access treatment, as they may not fit the exact diagnosis, but also because only one psychologist in Wellington is currently willing to diagnose trans people. “It is wrong to think that transgender people need to be treated by specialists, most of their care can be undertaken within primary care facilities,” Dr Stephenson said. The proposed model for trans health care is based on the notions of informed consent, and would see the patient and health care practitioner engage in a discussion about the proposed medical treatment, consequences, harms, benefits, risks, and alternatives. Informed consent would mean that it is the choice of the transgender person rather than the medical professional to decide whether a person is ready for hormone treatment.
At a recent conference on social movements and social change at Victoria University, members of the SGDHOWG spoke on a panel. They outlined issues with the current system, what a best practice model would look like, and possible improvements for the health care of transgender people. Mani Bruce Mitchell stated: “We have a model and a system that is anchored in the past. It’s a pathologized medicalized model that was developed to respond to a fraction of the numbers of our community that are now coming forward seeking care and support from both our medical system and our broader community.” Mitchell added that “deficiencies are being exposed across the board… access to full care is highly dependent on people’s individual ability to pay privately for services including access to surgery.”
Mitchell went on to say: “The trans, nonbinary, and intersex community deserves access to safe, respectful care from practitioners who have been trained and who understand diversity, minority stress, and intersectionality, and who can support each individual to live a happy and healthy life as the person they know themselves to be. Irrespective of any factors such as disability, their geographic location, financial status, their gender expression, culture, or mental health history, ability to self advocate, fluency with English, etc.”
While the current state of healthcare for transgender people is causing much strife for many in the transgender community, the bright side is that activists and dedicated medical professionals are working to change it—it will get better.
If you are a trans person under 30 looking for information, local support, and resources visit tranzform at tranzform.org.nz.