Challenging Binaries: Transgender and Intersex Health Inequalities

Words by Katie Burkitt (katie.burkitt@amsa.org.au)

“Hi my name is Katie and my preferred pronouns are she/her.”

While many people would consider this an odd means of introduction, for those that do not fit the binary gender norms of ‘man’ or ‘woman’, acknowledging that gender can be experienced in different ways honors their experience and personal approach to their gender identity.

The concept of gender has changed drastically in recent years, with a much greater recognition of the diversity within gender and its role in society. Lesbian, gay, bisexual, transgender, intersex and queer (LGBTIQ) individuals are becoming a more recognised part of society, where they were previously medicalised as having a disorder or brutally punished just for being themselves.

Yet, despite recent advances, gender dysphoria and issues of gender identity are still poorly understood both within mainstream popular culture and medicine. In most Western countries, gender identity is presumed to be based on assigned sex at birth, which is determined principally through visual inspection of external genitalia(1,2). For babies born with intersex characteristics, the medical policy in Australia, North America and many European countries has been to surgically and hormonally assign the infant to either male or female in an effort to construct an identity that conforms to one of these two traditional gender groups(3).

A significant body of evidence shows that LGBTIQ people have disproportionately poorer health outcomes than their non-LGBTIQ peers across a range of parameters, though most notably mental health(4-6), where LGBTIQ individuals have the highest rates of suicidality of any population in the country(4). At least 36.2% of transgender Australians have experienced a major depressive episode compared to 6.8% of the general population(6). Horrifyingly, 20% of transgender Australians have reported suicidal ideations and up to 50% have actually attempted suicide(7,8). This is largely due to discrimination and exclusion both within their families as well as wider society, often expressed as overt physical and verbal abuse, harassment, sexual assault or subtler forms of social marginalisation. Transgender people experience the highest rates of almost all types of violence and discrimination, with approximately 50% reporting some form of abuse(5,7,9). There is very limited data on the experiences of intersex people, though anecdotal evidence suggests they experience similar discrimination and abuse as transgender people(4). Trans people are also at a measurably higher risk of certain cancers(10). In particular, transgender males have disproportionately high mortality rates from cervical, ovarian and uterine cancers due to feelings of stigma and social exclusion that deter them from receiving routine gynaecological exams or screening tests(10).

Transgender and intersex people have unique health care needs, including access to hormonal therapies, surgery and psychological counseling during gender affirmation processes. Understandably then, doctors play a significant role in their health and wellbeing. However, many gender diverse individuals have had negative experiences with their practitioners. These experiences can range from curiosity and surprise, though there are also a disturbing number of reports of open hostility, ridicule, refusal of treatment and even verbal abuse(6,11). Fear of discrimination causes many trans and intersex people to delay health care, which ultimately contributes to poorer health outcomes(12). Overwhelmingly though, reports show that one of the biggest barriers to accessing healthcare for transgender and intersex people is the perceived lack of knowledge of the medical practitioners of gender diverse issues(12). This is reflected in the use of inappropriate terminology, and the need for patients to educate their practitioners on transgender health(6,13). While the media has embraced Caitlyn Jenner’s story, and Catherine McGregor has pioneered for transgender rights as a finalist for Australian of the Year, many health practitioners still remain uneducated in this field. This is in part due to the somewhat limited body of research on gender diversity(14), and the lack of training within medical schools on issues related to transgender and intersex health. Very little specific information regarding effective sexual reassignment treatment is available beyond single case studies and small-scale reports(15). This is in part due to the difficulty in conducting randomised controlled trials of cross-sex treatments, but also the continuing stigma surrounding gender variance and sexual reassignment(15).

Furthermore, physical transition requires numerous meetings with doctors across a variety of specialties, making it an arduous and emotional process, where the individual needs to prove gender dysmorphia to receive treatment. This is an interesting contrast to those seeking breast implants or cosmetic surgery, who are not obliged to undergo months of counseling and psychiatric assessment before altering their appearance. While transitioning is medically and psychologically a very complex process, the model of the doctor as a gatekeeper and the patient needing to conform to very specific stereotypes in order to pass(16), is an outdated one. This is a particularly difficult process for transgender children who face costly legal battles through family court.

I recently facilitated a workshop with SCORA-ANU (ANU’s sexual and reproductive health interest group) on Transgender and Intersex Health. Here, we invited two excellent speakers to share their experiences navigating the health field as transgender and intersex individuals, and how we as future health professionals can effectively support and advocate for our patients. Their personal stories illustrated a great deal of misunderstanding and confusion about trans health within the medical sphere, and were a startling reminder of the inequalities they face on a daily basis.

However, there are still many things we can do to help reduce this inequity in health outcomes and improve the lives of transgender and intersex people. First and foremost, empathy, understanding and compassion for our patients and their journey, creates a safe, non-judgmental space11. Showing respect for patients’ gender identities through use of their chosen names and preferred pronouns, as well as adjusting medical records to align with their gender identity are important aspects of building a strong patient-doctor relationship based on respect, rather than curiosity. It is also critical to recognise that not every transgender or intersex person wants to physically transition, though it is our responsibility as doctors to provide them the information about hormone therapy and surgery options so they can decide what is right for them.

The current inequality in health outcomes for transgender and intersex people is unacceptable. As health professionals, we are in a unique position to support and advocate for these patients, ensuring they receive the same level of health care as anyone else. All individuals deserve respectful, dignified treatment, regardless of gender, sexuality or any other feature. So lets start with something simple. “Hello my name is Katie, my preferred pronouns are she/her.
How about you?”

References
1. Nihoul-Fékété C. Surgical management of the intersex patient: an overview in 2003. J Pediatr Surg 2004;39(2):144-45.
2. Creighton SM, Michala L, Mushtaq I, et al. Childhood surgery for ambiguous genitalia: glimpses of practice changes or more of the same? Psychology & Sexuality 2014;5(1):34-43.
3. Creighton SM. The adult consequences of feminising genital surgery in infancy. A growing skepticism. HORMONES-ATHENS- 2004;3:228-32.
4. Rosenstreich G. LGBTI People Mental Health & Suicide. Revised 2nd Edition ed. Sydney: National LGBTI Health Alliance, 2013.
5. Leonard W, Pitts M, Mitchell A, et al. Private Lives 2: The second national survey of the health and wellbeing of gay, lesbian, bisexual and transgender (GLBT) Australians. 2012.
6. Pitts M, Couch M, Croy S, et al. Health service use and experiences of transgender people: Australian and New Zealand perspectives. Gay and Lesbian Issues and Psychology Review 2009;5(3):167.
7. Couch MA, Pitts MK, Patel S, et al. TranZnation: A report on the health and wellbeing of transgender people in Australia and New Zealand. 2007.
8. Di Ceglie D. Gender identity disorder in young people. Advances in Psychiatric Treatment 2000;6(6):458-66.
9. McNeil J, Bailey L, Ellis S, et al. Trans Mental Health Study 2012. Edinburgh, Scottish Transgender Alliance 2012.
10. Organisation WH. Trandgender People and HIV. Geneva, Switzerland: WHO, 2015.
11. Riggs DW, Coleman K, Due C. Healthcare experiences of gender diverse Australians: a mixed-methods, self-report survey. BMC Public Health 2014;14(1):230.
12. Inc. QAfC. Improving the Health & Well-being of Transgender Queenslanders. Secondary Improving the Health & Well-being of Transgender Queenslanders 2011.
13. Grant JM, Mottet L, Tanis JE, et al. Injustice at every turn: A report of the national transgender discrimination survey: National Center for Transgender Equality, 2011.
14. Academics IoMotN. The Health of Lesbian, Gay, Bisexual, and Transgender People Building a Foundation for Better Understanding. Washington, DC, 2011.
15. Health CoEfT. Primary Care Protocol for Transgender Patient Care Secondary Primary Care Protocol for Transgender Patient Care 2011.
16. Urquhart VV. Gatekeepers vs. Informed Consent: Who Decides When a Trans Person Can Medically Transition? Secondary Gatekeepers vs. Informed Consent: Who Decides When a Trans Person Can Medically Transition? 2016.

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