A third opinion: transgender healthcare tips for clinicians

This pamphlet was made in 2015, and was the result of asking our communities what they wanted their healthcare providers to know.

A quick guide to respectful and effective care of transgender, transsexual, takataapui, intersex, and other gender minority patients, who will be referred to as ‘trans patients’, in the context of a sexual health or general practice clinic.

We touch on barriers to care, getting through the door, language, opinions, clarity and professional conduct, ethical issues and medical models, informed consent, and info about this document.

Barriers to Care

Trans people experience high levels of discrimination in many areas, including employment, housing, access to medical care, and education; for example, sex education which affirms their existence.

Many trans people have limited income, access to transport, and other material means to arrange and keep appointments – such as a computer and a phone with credit.

Many trans people have high anxiety about accessing health care, and may be suspicious of providers or expect to be discriminated against due to negative past experiences.

Many health care providers do no know about trans people, their needs, who to refer them to, or how to prescribe, for example, Hormone Replacement Therapy (HRT).

Some providers refer to trans patients using stigmatising language; such as ‘biologocally male’, ‘genetically male’, or ‘transgenderism’.

Solutions – Getting Through the Door

1. Affordable or free clinics near public transport.
2. Routine reminder text or call on the day of the appointment.
3. Registration and all other forms can have ‘transgender’ and ‘intersex’ options (except lab forms at present – patients can be asked what to put on lab forms).
4. Not ‘telling people off’ for previous missed appointments.
5. Professional development around areas of trans treatment such as prescribing HRT.
6. Staff are sensitive to trans needs – sensitivity training.
7. Have a clear policy that includes trans patients explicitly and market towards trans patients.

Sensitive Language

1. Takataapui – Maori who are not heterosexual and/or not cisgender, similar to ‘Rainbow Community’. A takataapui person may fit any of the below descriptions, but may or may not identify with English words or western concepts of gender. The only Maori language pronoun is the genderless ia, but takataapui patients may use any of the following pronouns.
2. Trans woman – woman. Pronouns she/her/hers.
3. Trans man – man. Pronouns: he/him/his.
4. Non-binary genders – not a man or a woman. Pronouns: ia/they/them/their/ask for pronouns.
5. Where possible, use ‘genitals’ rather than ‘penis’ or ‘vagina’.
6. Don’t use terms like ‘sex change’. Medical transition may involve a range of treatments such as HRT, and a range of surgeries. Use ‘genital reconstruction surgery’ (GRS) instead of ‘sex change operation’.
7. Don’t say trans women are ‘biologically male’, ‘genetically male’, or ‘born a man’. Instead, if one must refer to the sex they were assigned at birth, use ‘assigned male at birth’. The same principle applies to trans men, and non-binary people.
8. Intersex people have sometimes been assigned a gender and re-assigned another gender multiple times; do not make assumptions regarding their histories.

Personal Opinions

1. Don’t tell a trans woman that she has ‘a male brain’, or ‘male socialisation’, or is ‘male bodied’ (or ‘female bodied’ etc for trans men).
2. Don’t say things like ‘taking hormones will make you look more like a woman’, which implies that she doesn’t already look like the woman she is, or that there aren’t many ways which women look.
3. Don’t tell a trans man ‘but you look so pretty as a girl’, or ‘but you’ll lose all your lovely hair’.
4. Don’t tell a non-binary person that they’re just confused, in a phase, uncertain, or that they need to go away and decide which gender they want to be.
5. Don’t tell young trans people ‘it’s just a phase’ or ‘you’re too young to decide’ Young trans people decide to take their lives into their own hands every day.
6. Don’t define people’s changes by your own standards; for example what is satisfactory or unsatisfactory breast growth or facial hair growth.
7. Don’t assume that anxiety conditions are a result of being trans, a result of the way they are read by others, or because of their anatomy.
8. Don’t share personal opinions such as ‘men’s brains are like this and women’s brains are like that’.
9. Don’t try to talk trans people out of treatment.

Clarity and Professional Conduct

1. Be clear about the pathway forward, what information you need, and why.
2. Acknowledge your area of expertise and what you don’t know; for example if you are an endocrinologist then psychology is not your department.
3. There are very few circumstances under which an internal examination is medically required. If another option such as self-swabbing exists, offer the patient this option. If it is absolutely necessary to carry out an internal examination, explain the exact reason and the consequence of declining the examination, obtain consent – ensuring the patient knows they can decline. Record that the examination took place and the result.
4. Don’t try to look at, measure, or touch a patients breasts or genitals without explaining the exact reason for the examination, obtaining patient consent, and recording that the examination took place.
5. If the patient is visiting your clinic for a reason that doesn’t relate to being trans, don’t bring it up.
6. If you have a letter asking you to prescribe HRT from a patients psychologist, psychiatrist, therapist etc, you do not need to interrogate or ‘confirm’ the patients gender. You can simply take the specialists professional opinion and prescribe HRT.
7. Keep it professional – please don’t indulge your curiosity, either in your lines of questioning or in your medical practise.

Ethical Issues and Medical Models

Do not tell a trans person to ‘live as their preferred gender for a year’ – their ‘preferred gender’ is their gender. They have likely tried very hard to not be trans and waited years to get through the door. They are here now begging for assistance.

‘Living as’ often means putting themselves into danger – without testosterone blockers, laser hair removal, oestrogen, and other treatments, wearing a dress and makeup is highly dangerous for many trans women and directly results in harassment, assaults, sexual violence, or worse.

Attempted suicide amongst trans populations sits at 40%. If healthcare providers refuse assistance, this increases to 61%. It is unethical to withhold treatment.

Informed Consent

In the USA, many health care providers are using an ‘informed consent’ model. This is consistent with the World Health Organisation, the World Professional Association for Transgender Healthcare, The Ottawa Charter, Te Pae Mahutonga, Te Whare Tapa Wha, Fonofale, and other Public Health approaches.

Gender Minorities Aotearoa supports moving toward Informed Consent.

For more information on this and other trans health care issues, please visit our website.