Joint Symposium - Getting it Right: Trans-Inclusion in Clinical Care

Day 2: Afternoon Session Joint Symposium

Chaired by Teddy Cook and Ange Davidson.

So I'm going to be jotting ideas and themes as I go, paraphrasing.

Trans populations are and are becoming more so a at risk population in multiple areas, including violence, socioeconomic disadvantage, but also within HIV and sexual Health.

Teddy goes to say that despite your personal thoughts towards trans and gender diverse people, today is about your clinical practice, and this is what counts. "Lets consider this a call to action" "Because we need you. We have been erased over the last 30 years. We are not considered as a priority population in any state and except for the most recent statement".

The capture of data using sex, gender or identity is has been holding back ability to identify and treat. This has become so that people consider rates of trans and gender diverse people within risk populations to be low. This is false and unless people identify or area identified within data, we cannot make decisions on providing services to this population.

Furthermore, within the grouping MSM, trans men or trans masculine have been forgotten and erased.

Trans and gender diverse (GD) people area a VERY diverse group. Some define themselves within a multitude of different ways, a handful of examples being Trans, non--binary, brother-boys and sister-girls, queer... I could go on.

Trans men are men, and trans women are women. I would qualify this statement however trans and GD people do have some particular needs met (such as identifying that trans men may still need pap tests or trans women will need to consider prostate checks as they age).

Teddy asks, Will you stand with us to stand with us to move toward meaningful steps towards trans inclusion and recognition in this area of clinical care?

Panel Members (apologies if I don't go into everyone's CV's, believe me they've an interest and investment in this area).

Ange Davidson is a Sexual Health Nurse at Gateway in Wodonga, Victoria

Mish Pony, Gender Diverse and Trans sex worker representative for Scarlett Alliance, Australian Sex Worker Association

Dr Ayden Scheim, Global Public Health at University of California

Lisa O'Brien, Sistergirls and Brotherboys Australia, NSW

Jeremy Wiggins, Victorian Aids Council, EQUINOX Clinic, Vistoria

Dr Stuart Aitken, Sexual Health Physician, Gold Coast, Qld.

Dr Vincent Cornelisse Sexual Health Physician, HIV, PrEP and Transgender medicine, Melbourne SH Centre

Q: What does trans and GD inclusive clinical care look like to you?

The underlying theme here is that currently, in Australia, trans and GD people have fragmented care. Multiple panelists recognised this and that integration within primary care is needed to provide holistic care to this population.

Specific healthcare needs such as ARV treatments may be attended by GP's with experience and knowledge in this area, much in the same way as hormone therapy for trans people. The specific need to see an endocrinologist is not always necessary and some panelists make reference to "gatekeeping" within the medical profession, where patients require clinicians approval and guidance in this area, which may not always be the case.

Another theme that arose was the lack of experienced clinicians in rural or remote areas, even in cities outside the East Coast, meaning that people seeking medical transition (ie. hormone therapy) will need to travel for these healthcare needs, often away from their families and communities. In particular this is raised as a potential issue with Aboriginal or Torres Straight Islander people away from their mob, moving to larger centres or cities and the increased risk of socioeconomic disadvantage when moving to areas of higher cost, less support and increased isolation.

Another point made by the panelists is that there is significant difference from state to state (or territory) in regards to models of care, legality, requirements in particular to gender marker recognition. Informed consent is a healthcare model that removes particular onus from clinicians and allows trans and GD people to engage in their own healthcare and needs. It is not always necessary that someone be deemed "Trans" by a psychiatrist or psychologist before being allowed to commence on hormone therapy.

One great quote was "We don't send gay people off for sexuality assessments anymore, why should we do so for trans people?".

Q: Trans-specific healthcare is not specific healthcare, it is general, simple healthcare. How does this play out in your practice?

One panelist referred to their own practice and the normalisation of providing care to trans and GD people is paramount, that many of the clients they see have grown up in a society and culture hostile towards them and historically a medical model pathologising them. From a social justice point of view, one panelist made the statement that workings with trans and GD people was "very clinically satisfying" for these reasons, helping people through providing comprehensive general practice care.

One idea that was brought forward, that the concept of Evidence based practice is particularly binding to us as clinicians. Not all areas are so bound to the requirement that we must have hard available evidence in studies before we change practice. This in my opinion is an interesting concept, as on one hand I agree that we must be guided by scientific methodology that has been proven to be what makes "best practice" however the thought from the panelist(s) that we should strive to be more open to other forms of practice whilst evidence and studies are conducted in this area.

Q: In regards to HIV and Sexual Health care, where does this place trans and GD people?

Not all panelists agree that TGD people should be a priority population for HIV! Controversy!

One panel member refers to data showing that approximately half tans women in the last 12 months were not sexually active. Although limited accurate data exists, there is evidence that trans and GD people are both at higher risk and not at higher risk of HIV.

The panel then discussed how appropriate training for care of trans or GD people can and should be implemented. A general concensus that training should commence early in the career, preferably at university, to explain the basics of transgender and GD persons and their healthcare needs. There is experience within the trans and GD community that when meeting a practitioner who has a gap in experience or knowledge that they then need to themselves educate the practitioner in "trans 101" type information and this is not seen as ideal, particularly when a client themselves is not in a position to do so.

Final Thoughts, in no particular order.

- Training to include trans and GD issues, particularly for specialists

- Changes to data collection to include trans and GD persons

- Trans healthcare is simply healthcare. It should not be only for Psychiatrists or Sexual Health practitioners.\

- Increase in culturally appropriate healthcare for trans and GD persons

- Opportunity for trans and GD inclusive programs for Sexual Health and HIV medicine.

- That systems can and should change to adapt to new models of care (for screening, SH and HIV care and general healthcare for trans and GD persons).