Transgender health: a call to make the “invisible”, visible

DESPITE recent media attention thrusting transgender celebrities into the spotlight, the transgender population largely remains “invisible”. This is reflected in how researchers have struggled to accurately define the transgender population, and how legal systems have not protected their human rights. The danger of being “invisible” is that you can be ignored or not acknowledged and, at the cruel extreme, not “exist” in the eyes of society, which has led to unacceptable health disparities (and here).

In November 2017, the Australasian HIV and Sexual Health Conference was held in Canberra. This conference is the premier annual gathering of community and sexual health experts to robustly discuss the latest science and how we can improve the sexual health of people living in the Asia–Pacific region and beyond. At this conference, transgender health, particularly in the areas of sexual health and HIV infection, was thrown into the spotlight.

A basic question was asked at the conference: how is it possible to support transgender people if it is unclear whether they are transgender or not? For instance, a transgender woman seeing a doctor with no knowledge of her identity may easily make assumptions about the kinds of services that may or may not be needed. Transgender people seeking health services in rural remote areas are particularly vulnerable to concerns about disclosing their identities. There is an unhelpful assumption that health services that support the gay and lesbian community need only be extended to also include transgender people. It is true that transgender people have many similarities with the lesbian, gay and bisexual  community, with syndemics of mental health problems, substance misuse, and HIV and sexually transmissible infections, but they also face health challenges unique to transgender people. This may include support services that allow them to consider hormonal or surgical options for transitioning and psychological support and health screening in the context of gender recognition and rights protection. In recent years, greater effort has been made to highlight the unique challenges of the transgender community (and here). Further understanding of their shared and unique challenges will help us provide high quality health care.

The health profession prides itself in equitable health care for all, regardless of race, gender, religion, sexuality or any other boxes society imposes on its citizens. So, a fundamental principle is to treat all patients with respect and dignity. But how can we make visible the “invisible”?

While much must be done to tackle the multifactorial inequalities in our health and legal systems, there is one simple thing that health professionals can do. The way we approach how we record the identities of our patients, and the subsequent manner in which we interact with the transgender person may have a profound and long term effect on the wellbeing of that person.

In Dr Ayden Scheim’s presentation to the conference — Trans Right, Sexual Health and HIV — the invited international keynote speaker identified three simple questions that can be asked:

1. What sex were you assigned at birth, meaning on your original birth certificate?
   1. • Male
      • Female
2. Which best describes your current gender identity?
   1. • Male
      • Female
      • Indigenous or other cultural gender minority identity (eg, insert locally appropriate term, such as Sistergirl, Brotherboy, Two Spirit)
      • Something else (eg, gender fluid, non-binary)
3. [If 1 ≠ 2] What gender do you currently live as in your day-to-day life?
   1. • Male
      • Female
      • Sometimes male, sometimes female
      • Something other than male or female

These questions may be asked at the point of patient registration, and more crucially to be included in all future research. Ensuring these questions are asked when collecting gender data will help to have transgender people’s identities recorded and accounted for in a way that legitimises their existence and places them within our societal and health systems. This would address the current fundamental flaw where the majority of health services, health surveillance systems and research do not accurately capture who is transgender. This information will help inform us, as health professionals, so we can deal with specific health needs.

As health professionals, we have a responsibility to improve the health of all people without any discrimination. And if we are to prevent transgender people from being further marginalised, we must help them to have a voice. One of the most basic steps we can take is to help them become visible, because without visibility, how can they be heard?

For clinicians with transgender patients in NSW, the Gender Centre provides specialist health services and emergency accommodation.

Dr Jason Ong is a general practitioner, sexual health physician and post-doctoral research fellow based at the London School of Hygiene and Tropical Medicine, and Monash University. His research focuses on economic evaluations of sexual health programs in marginalised populations living in the African continent, Asia–Pacific region and South America.

 

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