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Understanding Transgender Healthcare @Lwnurses #LWN #LearnWithNurses Claire Carmichael (she/her) – Registered Nurse / assistant lecturer Experience in: GPN, sexual health, LGBTQ+, transgender healthcare, education and elderly care Socials: @ccarmichael_83 www.youtube.com/clairecarmichael George Blake (he/him) – Support worker • Proud transgender man • Wolverhampton LGBT volunteer • Previous experience includes working with youths and prison service Who are transgender people? Transgender people are people whose gender identity is different from the gender they were thought to be at birth. “rans” is often used as shorthand for transgender (T rans equality org, 2016) • 500,000 people in the UK are Trans / Non-binary The first transgender people 3. Michael Dillon (1915-1962) was the first 2. Christine Jorgensen (May 30, 1926 – May 3, 1989) One of the first trans woman (USA) to undergo reassignment person in the world to transition from female-to- surgery, which started in 1951. male through hormones and surgery in 1940’s Eleanor Rykener: A transgender sex worker in 1394 who had sex with both men and women. 3 2 1 1. Roberta Elizabeth Marshall Cowell (8 April 1918 – 11 October 2011) First British Transgender woman to undergo gender reassignment surgery in 1951. Google images (2022) The first transgender people Marsha P. Johnson (August 24, 1945 – July 6, 1992) • An American gay drag queen and activist. • One of the most significant people in history - She created Street Transgender Action Revolutionaries (S..A.R.) in 1970 which provided housing and support to homeless LGBT youth and sex workers. • Diagnosed with AIDS and mental health Google image (2022) problems but always went out of her way to help everyone she could. • June 28, 1969 – Stonewall uprising and a year later in 1970 was when she was part of the first march / protest. History of LGBTQ+ - culture The Igbo and Yoruba tribes, found mostly in present day Nigeria, did not have a binary of genders and typically did not assign gender to babies at birth, and instead waited until later life. Similarly, the Dagaaba people (present day Ghana) assigned gender not based on one’s anatomy, but rather the energy one presents. In the royal palaces of Northern Sudan, daughters were sometimes given slave girls for sex. Stonewall (2020) Transgender history – its not new • Sometime from 200 to 300 B.C., in ancient Greece, some gods were worshiped by galli priests who wore feminine attire, identified as women and have therefore been identified by scholars as early transgender figures. • In the fourth century, Anastasia the Patrician fled life in Constantinople, the capital of the Roman Empire, to spend the remainder of life dressed masculinely as a monk and has become viewed by some scholars as transgender. • In South Asia, at least eight-known gender-expansive identities have historically been present in the subcontinent, the most well-known being hijra - third gender people of historical, spiritual, and cultural significance in South Asian society. Hijra and individuals of diverse gender identities have been well-documented in religious and cultural texts and legends. These individuals often form intentional communities for community as well as survival. • Around the 18th century, the Itelmens of Siberia recognized a “third gender” called “koekchuch” to describe individuals who were assigned male at birth but expressed themselves as women. (Human Rights Campaign, nd) Terminology Transgender / Trans Gender a person was born with doesn’t match the gender that they are assigned at birth Transgender man (Trans man or FTM – Female to male is used) Assigned female at birth but is now a man (or lives as a man) Transgender Female (Trans female or MTF – male to female is Assigned male at birth but is now a female (or lives as a female) used) Transitioning Steps a person is taking to transition to become male / female / non-binary. Which may involve hormone therapy / surgical interventions but not all trans people will do this. Everyone has their own journey. Cisgender / CIS Someone who’s gender is the same as they were assigned at birth Non-binary People who don’t feel like a man or a woman Gender Dysphoria A clinical term for a person who is officially diagnosed with discomfort / distress because there is a mismatch from the gender they were assigned to at birth Pronoun (He / she / they / them / their name etc) Words to use to refer to people’s gender in conversation which varies depending on which gender or not they are. There are many pronouns out there. Dead Name A name assigned to someone at birth which is no longer their name Gender neutral language Gender neutral language and use of pronouns such as ‘them / they / their’ has been around for centuries and has been used by famous writers. Yet, in society today, people have an issue with it or get confused. In The Canterbury Tales, from around 1395, Chaucer wrote ‘and whoever finds him out of such blame, they will come up.’ Shakespeare used the singular ‘they’, too. In The Comedy of Errors, in 1594, he wrote ‘There’s not a man I meet but doth salute as if I were their well-acquainted friend’.What do Trans people go through? • 41% of trans people have experienced hate crime or incidents as a result of being transgender in the last 12 months • 25% of trans people experienced homelessness at some point • 67% of tarns people avoid being open about their identity due to fear of reactions • 48% of trans people have attempted suicide and around 84% have thought about it • 54% of trans people have reported their GP didn’t know enough information to provide the right care for them • At LEAST 375 people have died over the last year through killings / discrimination. Stats from GOV (2018) and Stonewall (2017) One study by Wiepjes et al, (2020) conducted in Amsterdam, discovered that suicide rates were higher in the transgender community than the general population.What do Trans people go through? In 2020/2021: • 2,630 Hate Crimes against transgender people were recorded by the Police, an increase of 16% from the previous year (Home Office, 2021). • This number is still severely underreported because out of 108,100 responses to the National LGBT Survey, 88% of transgender people did not report the most serious type of incident. • 48% of transgender people were not satisfied with the Police response after reporting the most serious types of incidents. (Stop the hate, 2021) The Equality Act 2010 Who is protected by the Equality Act? Under the Equality Act you are protected from discrimination: Everyone in Britain is protected. This is because the • when you are in the workplace Equality Act protects people against discrimination because of the protected characteristics that we all • when you use public services like healthcare have. Under the Equality Act, there are nine (for example, visiting your doctor or local hospital) or education (for example, at your protected characteristics: school or college) • age • disability • when you use businesses and other • gender reassignment organisations that provide services and goods • marriage and civil partnership (like shops, restaurants, and cinemas) • pregnancy and maternity • when you use transport • race • when you join a club or association (for • religion or belief example, your local tennis club) • sex • sexual orientation • when you have contact with public bodies like your local council or government departments The Transition process • GP appointment • Referral to Gender Identity Clinic (GIC) • Initial diagnosis with GIC • Counselling / psychological assessment • Health checks • Prescription for hormone therapy (depending on ages) • Referral for surgery (depending on ages) • Waiting times are 4 years currently for NHS GIC (as of July 2022) • Child can be even longer … Not everyone takes surgical / hormonal routes Transition process – private care • Due to extreme waiting times with NHS, a lot of people go private to get started • Same process applies as NHS • Faster service and run by healthcare professionals • Once initial prescription is done – shared care between GP should happen • However , funding this is an issue: surgery, prescriptions declined by GP’s due to lack of understanding Let’s talk transitioning Female to Male transition: Diagnosis – hormone treatments (testosterone) – surgery – vocal exercises Male to Female transition: Diagnosis – hormone treatments (HRT) – surgery – vocal exercises and sometimes vocal surgery Transition can take years and years…. It’s not an over night fix.Let’s talk transitioning - Children “Gender identity development service (GIDS) is for children and young people, and their families, who experience difficulties in the development of their gender identity. It's a national specialised service, based in London and Leeds, and is the only one of its kind in Great Britain.” – (Tavistock NHS) Growing and developing as a child can be a confusing time for anyone. Children will often dress how they want to express themselves, say different things that they might not mean. It can be difficult to assess whether a child is transgender or just growing and developing naturally. Guidelines are stricter for children as a result of this within the NHS. De-transitioning A very small number of people will detransition. “A research analysisshowed that of the 3,398 trans patients who had appointments at an NHS Gender Identity Service between 2016 and 2017, less than one per cent said in those appointments that they had experienced transitioned-related regret or had detransitioned. However, just because people have detransitioned it doesn’t make the experiences and existence of trans people any less valid or real” (Stonewall, 2019) In a recent study it showed 94% of transgender youths were still in the gender they transitioned into 5 years later (Olson et al, 2022). One study conducted in America found that out of 17,151 trans people, 2242 of them had detransitione. 82.5% of these people had at least one external factor which made them do this. Including: Pressure from family and society. The other 15.9% of respondents reported uncertainty or fluctuations in their gender (Turban et al, 2021) Intimiate screening • Concerns around testing when gender is changed on the system • Be respectful and reassure the person • Avoid using the person’s sex or gendering people as ‘women / girls’ etc • Ask if they would like a partner / friend / family to attend with them • Take your time, avoid rushing and explain everything you're doing as you go • You don’t know what this person has been through (trauma / abuse) • Being mindful of language – avoids words such as ‘relax’ • Be mindful of body dysphoria with assessments of chest / genital areas • Be mindful of someone's under garments such as binders / bras etcEvidence Based Practice Why do men have nipples? Scientific facts tells us we were all born as gender neutral or ‘female’ depending what way you look at it Evidence Based Practice • Research by Boucher and Chinnah (2020) - The brain vs the body – showed a trans male brain was identical to a cis-gender male and vice versa. • Effects of HRT on female athletes will reduce muscle mass, Haemoglobin levels are reduced, which allows less oxygen to get into the muscles. (O’donnell et all, 2021) - its not an advantage! Trans females have to work over double harder to be able to maintain any strength. • What about trans men athletes? Gudelines to follow / resources • Royal College of physicians - Good practice guidelines for the assessment and treatment of adults with gender dysphoria • World Professional Association of Transgender Health (WPATH) - Standards of Care for the health of Transsexual, Transgender, and Gender Nonconforming People • Endocrine Society - Endocrine Treatment of Gender-Dysphoric/Gender- Incongruent Persons: An Endocrine Society Clinical Practice Guideline • NHS GIC - Guidelines for shared care and prescribing protocols • NHS GIC links on transgender healthcare and resources • CQC Transgender care pathway • Gender GP resource pages • Charities; stonewall, mermaids, transactual etc Best Practice Do’s Don'ts • Be respectful • Ask someone what genitals they have • Maintain dignity • Ask someone to see what they • Keep a non-judgmental approach looked like before • Use peoples preferred pronouns • Ask someone what their birth name • Listen to people was (dead name) • Don’t put anyone down • Don’t act shocked • If you make a mistake – apologies • Don’t make comments such as ‘oh • Do some research wow you’d never tell!’ • If you don’t know ask References 1. Boucher and Chinnah (2020) Gender Dysphoria: A Review Investigating the Relationship Between Genetic Influences and Brain Development. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7415463/ 2. Department of Health (2009) Guidance on NHS patients who wish to pay for additional private care. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/404423/patients-add-priv-care.pdf 3. Endocrine Society (20210) Available at: https://academic.oup.com/jcem/article/102/11/3869/4157558 4. Gov (2018) Trans People in the UK. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/721642/GEO- LGBT-factsheet.pdf 5. Equality Act (2010) Your rights under the equality act. Available at: https://www.equalityhumanrights.com/en/advice-and-guidance/your-rights-under-equality-act- 2010#h3 6. Harper, J., O’donnell, E., Khorashad, BS., McDermott., and Witcomb, GL. (2021) How does hormone transition in transgender women change body composition, muscle strength and haemoglobin? Systematic review with a focus on the implications for sport participation . Available at: https://bjsm.bmj.com/content/55/15/865 7. Human Rights Campaign (nd) Availabe at: https://www.hrc.org/resources/seven-things-about-transgender-people-that-you-didnt-know 8. NHS GIC (2021) Shared Care Protocol. Available at: https://gic.nhs.uk/gp-support/shared-care-protocols/ 9. NHS GIC resources. Available at: https://www.nhft.nhs.uk/gic?reload=4#venue-the-team-tab 10. NHS Sunderland. GUIDELINES FOR THE USE OF FEMINISING HORMONE THERAPY IN GENDER DYSPHORIA (2015). Available at: https://sunderlandccg.nhs.uk/wp- content/uploads/2016/03/SCCG-Gender-Dysphoria-Feminising-Hormones-Dec-2015.pdf?UNLID=186170263201831532222 11. Olson, KR., Durwood, L., Horton, R., Gallagher, NM., and Devor, A., (2022) Gender Identity 5 Years After Social Transition. Journal of Paediatrics. Available at: https://doi.org/10.1542/peds.2021-056082 12. Royal College of Physicians. Good practice guidelines for the assessment and treatment of adults with gender dysphoria. Available at: http://www.tgmeds.org.uk/downloads/CR181_Nov15.pdf 13. Stonewall (2019) Dispelling myths around detransition. Available at: https://www.stonewall.org.uk/about-us/news/dispelling-myths-around-detransition 14. Stop The Hate (2021) Transgender hate. Available at: https://634d4f8793.nxcli.net/about-hate-crime/transgender-hate/ 15. Tavistock NHS (n.d) Gender identity development service (GIDS) Available at: https://tavistockandportman.nhs.uk/care-and-treatment/our-clinical-services/gender- identity-development-service-gids/ 16. Trans equality org (2016) FAQ about transgender people. Available at: https://transequality.org/issues/resources/frequently-asked-questions-about-transgender- people 17. Turban et all (2021) Factors Leading to “Detransition” Among Transgender and Gender Diverse People in the United States: A Mixed-Methods Analysis. Available at: https://dx.doi.org/10.1089%2Flgbt.2020.0437 18. Wiepjes et all (2020) Trends in suicide death risk in transgender people. Available at: https://doi.org/10.1111/acps.13164 19. World Professional association of transgender health (2021). Available at: https://www.wpath.org
