The Pae Ora (Healthy Futures) Bill submissions close tonight at 11.59pm, 9 December 2021.
There is still time to make a submission, even if it’s as simple as saying “Please name transgender people as a priority group. We don’t want to be lumped into ‘rainbow’, we want our unique disparities addressed and our unique needs taken care of”.
Our submission
We agree with and support the intent of this Bill. However, we feel that amendments are needed and that transgender people, as a population facing severe health inequities and unique health needs, should be named as a priority population in order to fully achieve the purpose of the Bill. These inequities particularly affect irawhiti Māori, who are marginalised within the healthcare system as Māori and as transgender people.
Transgender healthcare
The Ministry of Health and World Health Organisation recognise social determinants of health as the most significant factor contributing to the health outcomes faced by particular populations. Māori, Pacific peoples, and disabled people are all groups who face discrimination across all areas of life, which is why they are priority populations in the new health system. In addition to this, disabled people have unique healthcare needs. Transgender people also experience extensive discrimination: the median income for transgender people is half that of the general population; they are more than twice as likely to experience discrimination than the general population; one in five transgender people experience homelessness; transgender people experience high or very high psychological distress at nine times the rate of the general population. For Māori, Pacific peoples, and disabled transgender people, the disparities with the general population are notably higher. For example, one in four non-Pākehā transgender people have been homeless, and 60% of disabled transgender people have experienced discrimination in the past year.
Transgender people also have a unique relationship with the healthcare system, resulting in a considerable number of unmet specific needs. The World Professional Association for Transgender Health is clear that gender affirming healthcare is a medical necessity. Despite this, national data shows that the healthcare system has been unable to meet the needs of the transgender population. The 2019 Counting Ourselves survey asked transgender people throughout Aotearoa about their access to various gender affirming healthcare treatments, including: hormone replacement therapy, mastectomies/chest reconstruction, breast augmentation, permanent hair removal, mental health support, facial feminisation, voice therapy or surgery, orchiectomies, hysterectomies/oopherectomies and genital reconstruction surgeries. In all cases, there were high rates of unmet need (19-48%), and the recurring reasons for the unmet needs were cost, and a lack of clarity about the healthcare pathways available for accessing treatment.
Tan et al. in their study on the mental health of transgender New Zealanders conclude that:
“Transgender people have greater healthcare needs due to gender minority stress experiences and their need for gender-affirming medical interventions, and yet our findings suggest that they experience inequities and gaps in accessing both gender-affirming and mental health services. It is very concerning that healthcare services, which should be supporting transgender people during some of the most difficult times of their lives, may present obstacles to accessing medically necessary healthcare, may exacerbate mental health symptoms through gender minority stress and pathologisation models, or may be avoided for fear of unhelpful and non-inclusive treatments.”
Other research highlights harmful trends in the provision of gender affirming healthcare, demonstrating a consistent tendency for healthcare practitioners to employ an outdated pathologising model, where patients were expected to prove that they are ‘trans enough’ to access treatment, and transgender patients feel pressured to fit into a binary idea of gender to receive healthcare. These trends are at odds with the Health and Disability Act, which requires a healthcare code of rights that guarantees healthcare services to provide treatment of an adequate standard, and “in a manner which respects the dignity and independence of the individual.” Further, it is more specifically a violation of the current Code of Health and Disability Rights, which specifies assumed competence as a foundational part of informed consent in healthcare. This reveals a systemic inconsistency between transgender people’s rights within healthcare, and the standard of care provided in Aotearoa. The Human Rights Commission’s Prism Report highlights unmet healthcare needs as a critical human rights issue faced by Rainbow New Zealanders, and commented at length about the high rates of unmet need for gender affirming healthcare.
The recent bill to ban conversion practices makes exceptions for healthcare practitioners, despite the many transgender people and organisations (including Gender Minorities Aotearoa and the Professional Association for Transgender Healthcare Aotearoa) who submitted that transgender people often experience conversion practices in healthcare settings so that legal exceptions for healthcare providers leaves them vulnerable to those practices. Research from New Zealand has connected these experiences of conversion practices in healthcare settings with higher levels of psychological distress and discrimination. The disparities faced by transgender people in the healthcare system are clear and well-documented, yet still transgender people are overlooked in the Government’s Health and Disability System Review.
At the highest level, transgender healthcare is invisible in the government’s health system review, and neglected in legislation. At an intermediate level, transgender people face barriers around accessing healthcare due to unclear or non-existent pathways, and a lack of funding for necessary treatments. At the ground level, transgender people regularly encounter healthcare providers who do not understand their needs, and who subject them to pathologising frameworks which violate their rights. Leadership is urgently needed to address these barriers and the adverse health outcomes they cause.
Recommendation
Transgender people should be named as a priority population for Health NZ. This should be reflected by the inclusion of a transgender healthcare strategy as part of the Minister’s responsibilities in Section 10.1(a) and 29.1(b), and by adding a new Section after Section 40 which outlines the contents and process of a transgender health strategy in a similar manner as the Hauora Māori, Pacific peoples and disability health strategies.
This bill should include explicit reference to the Health and Disability Commissioner Act 1994. The Code of Rights within healthcare settings set out by the Health and Disability Commissioner should be added to the objectives in Sections 12 and 18, as well as the role of the Minister of Health in creating Government Policy Statements for all priority populations.
