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Healthcare and acceptance for transgender patients

Endocrinologist Dr Ada Cheung is campaigning for increased acceptance, understanding and healthcare for transgender members of society.

Dr Ada Cheung is a practising endocrinologist and medical researcher. With a clinical interest in treating conditions that affect testosterone and oestrogen, a lot of her patients are transgender individuals. Her work in the field has led her to run a transgender research program through the University of Melbourne at Austin Health.
Cheung began her work with transgender patients two years ago when a colleague let her know that he couldn’t find doctors to treat transgender patients. There was a lot of prejudice and discrimination, even among doctors. Outraged, Cheung said, “Well, I’ll treat them.”
While her work is taking off – with more and more patients every month – the lack of doctors, health service and information are ongoing barriers that only serve to motivate her further.

The Manual: What motivated you to start the research program?
Dr Ada Cheung: We’ve seen a rising number of individuals identifying as transgender over the last three years, and an increasing demand for transgender healthcare. The problem is that there’s not a lot of research to guide clinical guidelines and quality evidence-based care. In response to that, we’ve identified many questions that are unanswered.
We’ve started the research program to try and answer some of these questions that revolve around the best ways to give cross-sex hormone therapy, long-term side effects, and how can we improve mental health and break down barriers to healthcare for trans individuals.
We do know that there is an increased need for training health professionals in treating trans and gender-diverse individuals.

Have you witnessed any improvement since you started your work?
The reason that we’re seeing a lot more individuals seeking healthcare is that there is an improvement in social acceptance and community awareness. This is especially so after celebrities have come out [as transgender], like Caitlyn Jenner and Laverne Cox.
I don’t think that that the prevalence is changing. Gender dysphoria is something that is biological. People are born with it. Often, it’s suppressed. Allowing someone to live as their affirmed gender improves the quality of life, decreases depression, decreases suicides and allows someone to live to their true potential.
Now that there’s more awareness about what identifying as transgender, or gender diverse, is people are realising ‘Oh, this is something that I can do something about’ and that’s led to the increased demand for healthcare.
By the time they’ve come to see me, they’ve usually been assessed by a psychologist or a psychiatrist, who has confirmed the diagnosis of gender dysphoria and continues to give them mental health support.
They come to me wanting to medically transition. They want hormone therapy to help. Basically, [they want] their physical appearance to be more aligned with their inner gender identity. They come to me for cross-sex hormone therapy, essentially.

And what does that entail?
For someone who’s born a male, and their gender identity is female, that involves feminising hormones and giving someone oestrogen, and to get their hormone levels into a normal female range so that they feminise. They develop breasts and have a feminine body shape. It doesn’t change their genitalia, but it can often change their external appearance.
For someone born a female and identifying as a male, we give masculinising hormone therapy, which is testosterone. It changes their facial shape, voice, body hair. They can present, on the outset, more like their affirmed gender.

What’s your advice for general practitioners treating transgender patients?
You don’t have to know everything. In fact, you don’t have to know anything; all it requires is open-mindedness, acceptance and a willingness to listen. The medical aspect you can always look up or refer to someone else.
What patients complain about most is that they can’t find doctors who accept that gender dysphoria is a real issue, something that needs treatment.

Is this a common complaint?
Definitely. Statistics show that one in four gender diverse individuals have been refused medical care. About 28 percent have experienced harassment or discrimination in a medical setting. It’s alarming and goes against the Hippocratic oath. That’s what motivates me to work in this space.
The biggest issue for trans individuals is the barriers to healthcare. We’re trying to improve acceptance and access to healthcare and improve mental health for these individuals.
The suicide rate, and attempted suicide rate, is alarmingly high – at about 40 percent. That’s the biggest thing we need to work on.

What are some key considerations general practitioners should have when encountering transgender patients?
Often the first step towards respect and acceptance is just asking an individual what their gender identity is, what their preferred name is and what their preferred pronoun is. They may be born a male, but feel that their gender identity is female, and [wish to] be referred to as ‘she’ rather than ‘he’. Or ‘he’ rather than ‘she’.
Sometimes, when they feel that they don’t identify as any particular gender, they may prefer to be referred to as ‘they’ as the pronoun rather than ‘he’ or ‘she’.
It’s a matter of communication, and asking an individual how they feel and how they prefer to be referred to.
Then, referring them on for the necessary psychology or mental health assessments. A list of providers is available on the Australia and New Zealand Professional Association for Transgender Health website (anzpath.org).
Not a lot is known about the medical aspects of care and more research is needed in this area.
In the last 20 years, we’ve really seen the acceptance of lesbian and gay communities, and homosexuality, dramatically change. We’re at a place today where we’re looking at marriage equality. I’m hoping that in another 20 years that the same acceptance will occur for transgender individuals.

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