Recently, there has been increasing visibility, and enhanced social acceptance, of people whose gender identity differs from the sex assigned to them at birth.^{1 2 3} The enhanced recognition extends beyond the general community. Many terms are used to describe these individuals, including transgender (trans), gender non-conforming (GNC) and gender diverse. For readability, this article will utilise the term ‘trans’ as an umbrella term. In 2013 (updated November 2015), the Australian Attorney General’s Department⁴ indicated that the Australian Government recognises that individuals may identify and be recognised within the community as a gender other than their natally assigned sex, or as a gender which is not exclusively male or female. Such a response from the government has led some to nominate Australia as the most accepting nation to the transgender community in the world.⁵

While being trans is now largely viewed as part of the natural spectrum of human diversity,¹ it is frequently accompanied by gender dysphoria (GD), which is characterised by the distress that arises from the incongruence between a person’s gender identity and their sex assigned at birth.⁶ It is important to address the stress, anxiety and depression that often coexists with GD.^{1 7 8 9}

GD is one reason trans individuals may be at risk of negative consequences, however, they are also at risk because of disproportionate levels of discrimination, social exclusion, bullying, physical assault and even homicide.^{9 10} In the face of these difficulties, it is not surprising that almost 80 per cent have engaged in self-harm and nearly half have attempted suicide,^{1 9 10} with trans individuals’ mental wellbeing and physical health being markedly worse than other LGBTI populations and the general population.¹⁰ What may be unexpected is the level of resilience GD individuals display.^{10 11} Importantly, research indicates poorer health is not inherent to being trans, but is caused by stigma, social exclusion, discrimination, bullying and rejection by friends and family.⁹

Along with acknowledgment that not all individuals feel their gender identity fits in the binary category assigned at birth, there has been some recognition of the complexity of issues facing gender diverse people and a greater appreciation of their unique circumstances. An appreciation of the heterogeneity of this group underlines the need to be aware of many intersecting variables that may impact them. Recognising a model of care that has diversity at its starting point has been suggested.¹² Despite this, there exists a substantial lack of understanding in the general community and within health professions about transgender issues.^{1 7 13 14} In order to illustrate the complexities and what might enhance service provision, some issues are explored below.

The trans population in Australia

It is difficult to estimate the size of the transgender population in Australia, as there had been no population-based studies that asked about gender identity until the 2016 census. In the 2016 Australian Census of Population and Housing, 1260 people (5.4 per 100,000) gave an intentional and valid sex and/or gender diverse response. However, this is not considered to be an accurate or representative count, due to limitations associated with collecting sensitive information, limitations of the special procedures required to report sex other than male or female, and the lack of willingness or opportunity to report as sex and/or gender diverse. It should be noted that the 2016 sex and/or gender diverse sample did not form a homogenous group. More than one-third (35 per cent) simply ticked ‘other, not further defined’, while 35 per cent of gender diverse people indicated they were non-binary or another gender. A further 26 per cent reported they were trans male, trans female or transgender. Very few people (3.2 per cent) indicated they were intersex (born with a combination of male and female biological characteristics). A pilot test provided further evidence that the 2016 census underestimated the Australian transgender population, revealing a much higher rate of sex/gender diverse people (257 per 1,000,000). In addition, there were particular challenges in the 2016 census, as it was the first time an online form was utilised. Thus, we currently do not have a clear idea of the size of the Australian transgender population.

Examining other indications of prevalence, The Diagnostic and Statistical Manual of Mental Disorders, Sixth Edition (DSM-6), estimates between one in 7000 and one in 20,000 people assigned male at birth, and between one in 33,000 and one in 50,000 people assigned female at birth seek gender affirmation surgery. This is again likely to be an underestimation, as most do not access surgery. The Gender Dysphoria Clinic in Melbourne reports that only one-third of trans individuals have surgery as part of their transition.¹⁵ While The Royal Children’s Hospital Gender Service reports that one per cent of children and adolescents experience gender identity issues, not all will continue to experience persistent issues into adulthood. In the New Zealand adolescent health survey,¹⁶ it was found that 1.2 per cent of young people reported GD.

Treatment: talking and transitioning

Diagnosis and treatment for GD are crucial, as people with GD have higher rates of mental health conditions than the general community.¹ It is estimated that 71 per cent of people with GD will have some other mental health diagnosis during their lifetime. Importantly, treatment of GD decreases the incidence of other mental health conditions.^{6 17}

The objective of treatment is not to change how the person feels about their gender. Instead, it is important to manage or resolve the distress that may come with GD and support the individual if they feel they wish to make changes to align their external self with their internal gendered self. The first step is to talk to a psychologist or psychiatrist who will be part of any treatment for GD. Beyond therapy with a mental health professional, individuals may wish to transition to their preferred gender. There is no correct way to transition. It must be guided by each individual the degree to which, and the speed at which, they make any changes.

Social transitioning

This is the process by which a person changes their gender expression to better match their gender identity and to make others aware of their desired gender. Social transitioning does not need to be an all-or-nothing approach. Some people will want to transition in all social contexts, while others may do so only in situations where they feel safe. Social transitioning may refer to a number of changes, potentially including:

• Use of a different name and pronouns
• Surface transformations of one’s physical appearance (for example, dressing in the preferred style, adopting a different haircut, hair removal, growing facial and body hair)
• Use of a bathroom that matches the person’s desired gender.

Social transitioning may also involve behaviours such as breast-binding or genital-tucking. Health professionals need to guide patients on safe practices in breast-binding, including using safe equipment and the importance of ‘off’ days.¹⁸ There is no research available regarding the safety of penis-tucking other than anecdotal reports indicating the importance of using easily removable medical tape that does not cause skin irritations. Importantly, evidence suggests that trans children who have socially transitioned demonstrate rates of depression, anxiety and self-worth comparable to their cisgender peers (those whose birth gender matches their assigned gender).¹⁹

Medical transitioning

For many trans people, making social changes will not be sufficient and they will wish to change their physical sex characteristics via hormonal intervention and/or surgery to more closely align their physical characteristics with their gender identity. As with social transitioning, people may vary considerably in this domain.

Medical transitioning is affected by the pubertal stage the individual is at when they decide to transition. If individuals are pre-pubertal or before Tanner Stage 2, they may wish to commence pubertal blockers.

Post-puberty, people may wish to commence hormone treatment and/or surgery. For Australian adults, the pathway towards physical transitioning follows the standards set by the World Professional Association for Transgender Health (WPATH).¹⁴ As indicated by McNair: ‘… a person has a psychiatric assessment, usually with a psychiatrist or a clinical psychologist, to do a gender assessment and to confirm that they have gender dysphoria … once they have a letter of confirmation, the patient can start hormone therapy. They can access surgery at any time after they’ve had their gender dysphoria confirmed, apart from genital reassignment; they need to have been on hormones for 12 months before they do that.’²⁰

A multidisciplinary approach

Trans individuals are likely to present to health services with a wide range of clinical and support needs. Thus, it is not surprising that the optimal model of care for trans patients involves a coordinated multidisciplinary team.^{1 5 21} Depending on the age of the individual, this may include clinicians with expertise in child and adolescent psychiatry, paediatrics, adolescent medicine, paediatric endocrinology, clinical psychology, gynaecology, andrology, fertility services, speech therapy, general practice and nursing. In addition to the complexity of a multidisciplinary team, clinicians have indicated they experience pressure from clients who are certain of their need for treatment and are concerned about the speed of the changes. It is important that clinicians work with patients to manage expectations about progress rates. Clinicians also need to be aware that some trans individuals obtain hormones from non-medical sources, which may affect outcomes. International professionals working in the field have also indicated they feel isolated, as this area of medicine is viewed negatively by medical professionals and society.¹⁶

Co-morbidity

The co-morbidity between GD and a number of psychological conditions, such as depression (74.6 per cent), anxiety (72.2 per cent), post-traumatic stress disorder (23.1 per cent), personality disorder (20.1 per cent) and psychosis (16.2 per cent) are well recognised.¹ What is not as well-known are the high rates of co-morbidity between GD and autism^{22 23 24 25} and eating disorders.^{26 27 28} Clinical guidelines on autism have been published to assist medical professionals.²² For eating disorders and disordered weight management behaviours, addressing GD can assist and should be tackled first.^{26 27 28} Autism and eating disorders are unlikely to be the only conditions that are co-morbid with GD. Health professionals should be aware that individuals with GD may have other conditions, just as with the general population.

General healthcare

Trans people tend to use health services regularly. However, there is a paucity of appropriate services and trans report experiencing both discrimination and exclusion from the health sector. Trans people’s healthcare experiences were explored and it was concluded that the experiences were determined by the effects of cisgenderism, therefore, healthcare staff’s apparent responses to participants’ natally assigned sex, regardless of their current gender identity.²⁹

Overall, people assigned male gender at birth had more positive experiences than those assigned female gender at birth. It was also found that those who had surgery had more positive mental health, as did those who were parents, were older and were in relationships. It should be noted that the study was not longitudinal, thus, directionality cannot be assumed. Sadly, high levels of discrimination were noted. The occurrences were not uniform, but dependent on natally assigned sex.

Not surprisingly, the study found that positive healthcare experiences were marked by caring, knowledgeable and responsive engagements. Negative experiences were marked by having to educate the health professional, feeling pathologised, gate-keeping and the use of inappropriate or misgendering language. The first and last points, in particular, were causes of considerable distress. Overall, negative responses were in relation to interactions with staff rather than treatments, indicating this can be improved by enhancing workforce capacity.

Fortunately, experiences with physical health professionals (including GPs, speech pathologists, sex health clinicians and pharmacists) were positive, with speech pathologists receiving the highest rating. However, all were rated as showing some discrimination. People assigned male at birth had more positive experiences of surgery and post-surgery care than those assigned female at birth, primarily due to less availability and satisfaction with phalloplasty in Australia. In contrast, respondents indicated very positive experiences of surgery in Thailand, while the surgery options within Australia were almost uniformly depicted as negative, onerous, involving gate-keeping and insufficient public health cover.

Other health issues

Other physical factors may impact trans patients. They are twice as likely to have used an illicit substance in the last six months and twice as likely to smoke as the general population.³⁰ Also, international evidence suggests that the incidence of HIV in the trans population is 49 times higher than for the general population.⁹

Other health issues appear specifically linked to GD. For trans women, PSA tests for detecting prostate cancer are often falsely low due to hormonal treatments. Trans women who have had removal of testes should be advised to take steps to prevent osteoporosis. Impacts on cardiac disease should also be considered if taking oestrogen. For trans men, those who have not undergone breast removal have been found to underutilise mammograms, together with pap smears and monitoring for uterine and ovarian cancer. Trans men may need to be reminded to screen for these cancers. They should also be advised to consider bone density screening.

Reproductive issues

Pregnancy among transgender men is increasingly common.^{31 32 33 34} In Australia, 54 people who identified as men gave birth in 2014, according to Medicare, and it has been reported that more than 50 gave birth in 2017.³⁵ In 2018, 25 trans men’s experiences of parenthood and gestational pregnancy were examined.³² It was reported that participants initially described parenthood as alienating and complex, with exclusion, isolation and loneliness as predominant features of the gestational pregnancies. Overall, pregnancy was positioned as a problematic but ‘functional sacrifice’. In addition, dysphoria associated with withdrawing from testosterone and the growing fecund body were significantly troubling. In particular, changes to the chest were of significant concern. The findings reinforce the importance of inclusive and specialised health services to support trans men through pregnancy. In 2018, a law and policy review³⁶ exploring differences between the Australian states in matters of trans pregnancy was published, indicating that there are no laws preventing trans men from reproducing. However, it has also been found that there is a lack of knowledge among medical practitioners at every level and a need for best-practice guidelines.

Conclusion

As GD can affect children, adolescents and adults, a developmentally appropriate approach is required.³⁷ To achieve this, there have been consistent calls from the trans community for services which are non-judgemental, safe and supportive, using staff who have been trained in the relevant issues.38 In response, the following principles for support have been put forth¹ for children and adolescents, but apply equally to those of any age.

Individualised care

Recognise that trans have a unique clinical presentation. Some trans will want to socially transition, others will want to medically transition, both in varying degrees. Interventions need to be tailored for, and driven by, the individual. For any medical transition, consent must be provided.

Language

Use terms (especially pronouns) that the individual suggests and, if in doubt, ask.

Avoid causing harm

This is important when considering options for medical and/or surgical intervention. This includes withholding treatment and using practices that lack efficacy (such as conversion therapies).

Consider sociocultural factors

It is important to consider additional cultural or religious beliefs and values that may be at odds with a gender-affirming approach.

Legal and administration

Be aware of legal and administrative aspects that may act as a barrier. In Australia, some laws vary by state (for example, laws to change birth certificates), while federal laws impact other areas (such as passports and Medicare). Currently, there is no legislation to prevent people with GD transitioning or reproducing.

Finance

There is a high cost of medical treatment attributed to gendered access to some PBS medication. There is also a lack of public-funded surgery and the need for trans adolescents to receive authorisation from the Family Court of Australia before being able to access some hormone treatments and all surgery.

Workforce capacity and integration

Clinicians have been generally found to have poor knowledge about trans and gender diverse healthcare and wellbeing, as well as holding binary assumptions regarding sex and gender identity. Education is required to enhance workforce capacity. Inadequate health service coordination and integration results in poorly identified pathways, which make it difficult for trans people to access the healthcare services they require.

The complexity of working with trans individuals demands a sensitive and flexible approach. Decisions about treatment must be individualised, taking into consideration biological, psychological and social costs, with values and belief systems respectfully considered, and a complete analysis of the complex risk-benefit scenarios undertaken before treatment.

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