health & science

New healthcare guidelines for gender diverse

Practical guidelines have been created to help healthcare professionals navigate how to assist those who don’t feel the body they were born with matches their identity.

The number of people approaching healthcare providers with requests for gender affirming assistance has been growing. Since 2010 the number of people accessing healthcare in Wellington has increased. Auckland has also seen year-on-year increases.

The new guidelines help healthcare providers with the simplest of issues, from knowing terminology, to understanding what treatment options are available, what dosages are appropriate and which treatments are reversible.

"When I meet people clinically and ask how they got to find this service, people have often had quite a journey trying to access health services.”

Jeannie Oliphant, Auckland Regional Sexual Health Service’s sexual health physician, was an author of the guidelines which she said offer a much-needed update.

“The Ministry of Health was hosting the 2011 guidelines, that information was very much in the public arena and had become so outdated really it was sharing misinformation.”

The new guidelines can be viewed via the Ministry of Health's website.

She hopes District Health Boards (DHBs) take up a recommendation in the guidelines suggesting clear information is provided so they know what services are available in their area.

"When I meet people clinically and ask how they got to find this service, people have often had quite a journey trying to access health services.”

Key to the guidelines is the concept of an holistic approach as well as autonomy and informed consent.

“There’s a movement towards recognising the right for self-determination, the right to make an informed consent decision about your care,” said Oliphant.

This includes conversations especially around treatments which have possibly irreversible effects.

Oliphant did not know how many people have started on a course of treatment and then changed their mind but thought the numbers “are very low”.

“We haven’t really had experience of people changing their mind.”

The guidelines offer information around what treatments have irreversible aspects, and include information about the effect of treatments on fertility.

Options for young people

A 2012 survey of 8500 youth estimated around 1.2 percent of adolescents in New Zealand identify as transgender. Around 20 percent of those said they have attempted suicide, and 41 percent had experienced symptoms of depression. In comparison, 4 percent of those who don’t identify as transgender had attempted suicide, and 12 percent experienced depression.

The guidelines stress the importance of support being in place for youth. If family are not supporting young people, then doctors should engage with mental health professionals. Children over the age of 16 are allowed to make their own medical decisions without family approval, however, there is provision for children under this age to make this decision without parental consent if the child is deemed to be able to make a competent choice. In these situations other health professionals may be involved.

"Withholding or delaying gender affirming treatment is not considered a neutral option, as this may cause harm by exacerbating any gender dysphoria or mental health problems."

The main medical help available to adolescents are puberty blockers. These don’t change gender, but they do stop puberty. Originally used to manage early onset puberty they are now a tool to give young people time to explore their identity. These can delay the onset of an Adam’s apple, the deepening of a voice, or menstruation and can be started at around nine to 11 years of age.

The effects of puberty blockers are reversible, however, the guidelines suggest height is monitored. The blockers can suppress a function which stops growing. Bone density for those who take puberty blockers for a prolonged period has also been raised as a concern.

It’s suggested options to preserve fertility are discussed before treatment - like puberty blockers - starts. Mature sperm can be cryopreserved from adolescents approximately 11 years old. Egg or ovarian tissue collection is also an option, however, is not funded if reproductive organs remain. For those who may wish to have gender reassignment surgery at a later stage, consideration needs to be made about how puberty blockers could limit the amount of skin needed for some procedures.

Changing gender assigned at birth

Hormone treatment and surgery are two areas where healthcare professionals can help people affirm their gender. Hormone treatment can start from the age of 16, or earlier if height is a concern due to time spent taking puberty blockers.

Most, but not all, effects of feminising hormone treatment are reversible if the treatment is ceased.

Breast growth which starts three to six months after treatment is started is not reversible by stopping treatment. It’s also not known if decreased testicular volume or sperm is reversible.

For those taking masculinising hormones, there’s less which can be reversed if the treatment is stopped. A deep voice will remain, increased hair growth may remain, as well as hair loss from the scalp. The clitoris will likely remain enlarged and the vagina will remain atrophied. Other practices, such as binding the chest to achieve a flatter appearance can lead to health issues, and the guidelines suggest these are discussed with patients. Ceasing taking testosterone in order to become pregnant is possible, however, the guideline points out it's currently unknown what effect the duration of testosterone treatment could have on ovarian function.

Details in the guidelines are given around the what monitoring should be done and how frequently this should take place.

Numerous surgical procedures are possible, but availability and funding are a significant issue in New Zealand.

In October, 105 people were on the waiting list for gender reassignment surgery. At the current rate of surgeries the list could take 50 years to clear, however, a cap which limited surgeries to three male-to-female surgeries and one female-to-male surgery every two years was recently lifted.

Currently only those over 18 years old can access publicly funded surgeries. A prescribing clinician’s letter is required, as well as letter of support from a mental health professional.

For some surgeries it’s required 12 months of hormone treatment is undertaken prior to treatment, and others there’s a requirement for the recipient to live for 12 months continuously in the gender role which matches the gender they identify with.

There is currently only one surgeon in New Zealand trained in gender reassignment surgery.

In a New Zealand Medical Journal article, Oliphant writes not providing treatment can equate to harm:

“Avoiding harm is a fundamental ethical consideration for health professionals when considering healthcare. Withholding or delaying gender affirming treatment is not considered a neutral option, as this may cause harm by exacerbating any gender dysphoria or mental health problems. This is no different from harm that can be caused by withholding or delaying other medically necessary care.”

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