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?
      • Male
      • Female
  2. Which best describes your current gender identity?
      • 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?
      • 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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7 thoughts on “Transgender health: a call to make the “invisible”, visible

  1. Anonymous says:

    Perhaps given we are talking about screening, we should establish beforehand the prevalence of the condition in the community, false negative and false positive rates for the test, and thus the number needed to screen to find one confirmed case.
    Will be important in reallocating general practice resources.

  2. Anonymous says:

    “I say that as a trans woman and a researcher/educator.” Good on you.
    So on what basis do you think such questioning is inappropriate again?

    You have perhaps been privileged to an education and upbringing that allowed you the freedom to express yourself as you have, others, and especially children and adolescents might not have. What is being argued for is screening in order to help such.

  3. Anonymous says:

    Sorry but the questions posed by this “expert” are inappropriate, and I say that as a trans woman and a researcher/educator.

  4. George F. says:

    Anonymous number 2,

    I understand your concerns regarding early intervention in children diagbosed with gender dysphoria, but must confess that I disagree entirely with your conclusions.
    Childhood and adolescence is certainly a time of experimentation sexually, but it has been proven that suicide rates are very high amongst children with gender dysphoria. This undoubtedly proves that we must intervent as early as we can to prevent thus occuring.

    Your comment that “most of the world is either male or female” proves nothing. All the world is essentially male or female in sex, not gender. What we are referring to and arguing for is treatmebt for those whose felt gender is not correctly aligned. I hope you are open to treating such children fairly and correctly. I refuse to be guilty for refusing treatment that would prevent many suicides amongst such children.

    Claire M. Peterson, Abigail Matthews, Emily Copps-Smith and Lee Ann Conard. Suicidality, Self-Harm, and Body Dissatisfaction in Transgender Adolescents and Emerging Adults with Gender Dysphoria. Suicide and Life-Threatening Behavior, 19 AUG 2016 DOI: 10.1111/sltb.12289

  5. Anonymous says:

    George F, with great respect, I find your comments frightening.
    The teenage years are recognised as a time of discovery, uncertainty and experimentation regarding sexuality. Transient orientations in teenage years most often pass: the notion that medical practitioners would actively screen for gender dysphoria and could intercept a teenager in this transit period and then institute life-altering treatment and perhaps mutilating surgery needs serious pause (unless the unspoken purpose is one of an activist recruitment agenda).
    BTW, if we are able to label exam stress as a mental illness, then I suspect having a mind imprisoned in a genetically opposite body might also pass muster, and thus need not have attached to it the stigma that you seem to perceive. To deny the illness label is then to deny the need for treatment, support, therapy, counselling: trans-life is not all cruisy.
    I fear in years to come your proposed medical practices regarding gender dysphoria will rebound in much the same way as Repressed Memory has, with similar negligence and even criminal repercussions.
    Do be careful not to get swept up in the rhetoric of those whose aim it is to break down all biological concepts of gender. The fact is that most of the world is either male or female, and they like it that way.

  6. George F. says:

    Anonymous, I applaud your courage in standing up for such a tortuous and difficult issue. Rates of those identifying as transgender are rising in Australia and internationally, and no doubt because of the increasing tolerance of our society. What was once considered a mental illness is now recognised for what it really is, an identification with another gender. Many people have such thoughts but are afraid to voice them. We use questionaries such as the K10 to identify mental illness, and it would be appropriate I think to use similar screening questionarres (perhaps during general check ups or health assessments) to screen for gender dysphoria or gender identity disorder, especially in children and adolescents, where they may be treated as early as possible, and avoid the serious untoward mental effects of living in a body not identified with their own gender for life.

  7. Anonymous says:

    I wholeheartedly agree, and it is true that we do not screen enough for ‘transfenerism.’ I have begun performing a screening questionarre with my patients, to screen for possible transgenderism. I ask each patient ‘have you had any doubts about your gender at any stage?’ I am surprised by the number of patients that reply in the affirmative, and this has already resulted in several patients who were unaware up to that point that they were transgender being referred for surgical and hormonal therapy. We need to burst the taboo of this topic, and allow quality of care for all our patients.

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