This paper was written by Julie Peters for Transgender Victoria, while she was one of its convenors.

The Ministerial Advisory Committe on Gay and Lesbian Health (MACGLH) was asked by the Government of Victoria, Australia, to include transgender health issues within its portfolio. TGV suggested a committee be set up to specifically look at transgendered issues but the Government insisted transgendered be included as a sub-set of Gay and Lesbian.

TransGender Victoria (TGV) is very pleased with the way the papers discuss the secondary health issues which are only indirectly caused by having gender identity issues: physical health, drug and alcohol abuse, life stage issues and sexual health. But TransGender Victoria is appalled that the papers do not address the primary health care issues involved with being transsexual such as transition counselling, hormone therapy, surgical interventions, passing skills, work place education and stopping puberty. We find this especially disapointing when the Minister of Health, Hon John Twaites MP, wrote to a member of TGV: ``It is appropriate that the funding of the Monash Medical Centre's Gender Dysphoria Clinic be part of the work of the Ministerial Advisory Committee on Gay and Lesbian Health.''

Our submission will be in 3 parts plus appendices. Part 1 will address the issues of the MACGLH papers, Part 2 will address transsexual health issues not addressed by the MACGLH papers, Part 3 will summarise TGV's position and we have appendiced two letters from the Ministry of Health.

Part 1: Secondary Health Issues

TransGender Victoria (TGV) acknowledges the very high quality of work done by the MACGLH in bringing to the attention of the Ministry of Health the importance of gender identity as a key social determinant of health.

TGV certainly agrees with MACGLH that the socially dominant views of gender and gender identity lead to marginalisation and discrimination against transsexual, transgenderist and cross dressing peoples. And one of the major effects of this shared discrimination with GLBI groups is a set of health problems common to GLBTI people as well as specific patterns of illness.

TGV would like a number of the definitions to be defined more rigorously.

TGV is unhappy with the definition of cross-dresser. Cross-dressers are offended by the references to erotic pleasure and personal expression. TGV proposes the following definition:

Cross-dresser - Someone who has an inescapable bona fide emotional need to identify as a member of the opposite gender on a tempory or permant basis.

The term "transgender" is hard to define rigorously because it is used so differently by different groups and geographically. For example many transsexual women and men are very uncomfortable being called transgendered. Section 2.1 of the TGV Rules of Incorporation allows self-definition. This rule states: "Transgender" means any person who considers they have gender identity issues.

Whilst TGV is happy with this definition in achieving it's objectives TGV believes the term has to used very carefully by the MACGLH and proposes the following definition of transgender:

Transgender - The term transgender not well defined by common usage. It's use as an umbrella term will offend many transsexual people who believe their behaviour falls well within gender norms but they were incorrectly categorised at birth. Other groups do use transgender as an umbrella term to include groups as diverse as cross-dressers, transgenderists, gender-fuck and transsexuals. In the issues papers it refers to individuals who do not identify with the gender assigned to them at birth. The terms male-to-female and female-to-male transgender persons are used to refer to individuals who are undergoing or have undergone a process of gender affirmation (see Transsexual).}

TGV proposes the definition of "Transsexual" be broadened to express the range of theories that exist for transsexualism rather than simply put the psychological theory:

Transsexual - Refers to individuals who seem to be born as anatomically normal male or female but have a profound and bona fide identification with the gender opposite to that assigned to them at birth. There are genetic, brain sex, familial, social and psychological theories for the causation of transsexuality. None of these theories has the full endorsement of all medical professionals. Although it is worth noting that the most recent research emphasises the brain-sex causation. In these issues papers `transsexual' refers to people who are making, intending to make or who have made the transition to the gender with which they identify. It also includes people who wish to transition but are prevented from doing so. Transition refers to a number of different though related processes including changes to a person's outward appearance such as hormonal treatment and surgical gender reassignment which are best mediated by specifically trained medical professionals. (see Affirming Gender)

On page 12 of the Introductory paper in the section on estimates of population, TGV proposes the headings which currently read "Transgender" be changed to read "Gender Identity Issues". The discussion then needs to clearly discriminate between those who have secondary health issues that overlap with the GLBI groupings and transsexual people who need very the specific medical treatments discussed in Part 2 below.

1.2 Physical Health Issues for GLBTI Victorians

The MACGLH paper on physical health issues addresses the key issues for people with gender issues.

Prioritising the physical health issues for people with gender issues: limited knowledge of health professionals, non-presentation for medical examinations, bone density screening, cancer detection, body image issues. We have separately listed those physical health issues that affect transsexual people affirming gender in Part 2 of this reaction paper.

Specialist services are definitely needed for transsexual people affirming gender. These issues are listed separately in Part 2.

Non-specialist services can be made more transgender friendly by normalising it. For example having brochures on gender issues in medical foyers and better educating medical professionals.

Transsexual people are a group that have not been adequately covered by this paper. We have dealt with some issues here and others in part 2 of our paper.

1.3 Drugs and Alcohol Use within GLBTI Communities

TGV agrees that gender identity based discrimination and internalised transphobia result in significant drug and alcohol misuse. The pattern of misuse are very similar to that in GLB groups.

All the major issues have been raised by the paper.

Prioritising the drug and alcohol use issues for people with gender identity issues: alcohol, tobacco, party drugs and steroids.

There is no need for specialist treatment for drug issues as long as the patients with gender identity issues are treated with respect.

1.4 Life Stage Issues within GLBTI Communities

The Life Stage issues raised in this paper are certainly relavant for people with gender issues.

But there are two very important life stages issues that have not been raised by this paper. They are puberty and gender affirmation. Puberty is a very traumatic time for transsexual peoples. Puberty is when their previously androgynous bodies take very decisive moves in the totally wrong direction. And so it is a life stage that most often results in severe psychological stress. On the other hand gender affirmation is a time that transsexual people expect to be joyous but is often very difficult because of the discrimination and vilification they receive.

Prioritising the live stage issues for people with gender issues: dealing with the hated hormonal puberty, gender affirmation, relationship formation. The other issues listed by the MACGLH paper are also important but very little research has been done.

Specialist counselling is required for dealing with puberty issues and gender affirmation. We look at this in more detail in Part 2.

The majority of other age related counselling needs are very similar to GLBI groups and so services can be shared. The key to success in shared services is in making sure people with gender identity issues are welcome and will be genuinely cared for.

The specific needs of transsexual people are not dealt with adequately by this paper. These issues are developed more fully in Part 2.

1.5 Mental health issues for GLBTI Victorians

Overall the major issues around mental health raised by this paper match the understanding of TGV.

The key to mental health of people with gender identity issues is early non-intimidatory diagnosis so that they can be professionally guided through the psychological minefield of puberty. This will certainly help all areas of mental health especially youth suicide. The hormonal delaying of puberty is a tool that can be used to great effect here.

Prioritising the mental health issues for people with gender identity issues: early non-intimidatory non-outing diagnosis, delaying puberty, self-esteem issues, dealing with internalised transphobia.

There is certainly some need for specialist mental health counselling and diagnosis for people with gender identity issues in the initial stages of treatment. But as they progress there is a great benefit to be obtained from normalising the patients care. This is possible as the emphasis of treatment shifts from gender identity specific issues to self-esteem issues.

Transsexual people are a group that have not been adequately covered by this paper. We have dealt with some issues here and others in Part 2.

1.6 Sexual Health Issues for GLBTI Victorians

Overall the major issues around sexual health raised by this paper match the understanding of TGV. But we emphasise the need for more research

An area that needs to be raised that was not mentioned is the particular dangers for post operative transsexual women having unprotected vaginal sex. This is because the internal vaginal wall is an easily damaged tissue type and does not self lubricate.

Prioritising the sexual health for people with gender identity issues: safe sex education, dealing with self-esteem issues, post operative sexual counselling, research in the long term effects of hormone therapy and ongoing need for gynecological support for transsexual men and urological support for transsexual women.

Many transgendered people would not use a service specifically for them because they don't want to labeled and ghettoised. It would be preferable to have the general services better educated. But strategies would need to be developed to prevent under utilisation of services where patients would have to out themselves to use the service. Transsexual people in particular will not present for services unless they can be treated as their affirmed gender.

One possible advertising strategy which would make transsexual women feel more comfortable would be "Sexual Health for all women, no matter what your history is".

Transsexual people are a group that have not been adequately covered by this paper. We have dealt with some issues here and others in Part 2.

Part 2: Specific Health Needs of Transsexual Men and Women

There are many causation theories for transsexualism but that is of little concern compared to the need for effective medical treatment. So TransGender Victoria is dismayed that the MACGLH didn't address the very specific medical interventions available for people with transsexual health issues.

From the mid-1960's we saw the emphasis within the medical professions shift from the prevention of cross-gendered behaviours to that of helping the patient with the acceptance and management of their gender role transition. TGV urges the MACGLH to request urgent funding of the Ministry of Health for the following physical and social health needs of transsexual people in Victoria.

We have listed these primary physical and social health care needs following an average chronology.

2.1 Personal Assessment and Transition Counselling

It is important to ensure that people with psychological health issues are not presenting as transsexual. A mis-diagnosis can lead to tragedy. And as mentioned in the papers of the MACGLH, transsexual people are under enormous stress and this often leads to a broad range of health issues. These secondary health issues we discussed in Part 1 of our reaction paper certainly apply to transsexual people.

Specialist counselling on puberty and gender affirmation are essential. Puberty is a time when transsexual people become very stressed because their bodies seem to be denying their affirmed gender. Many transsexual people expect gender affirmation to bring them joy but often find the opposite because of the discrimination and vilification they receive. Well funded transition counselling is essential in helping transsexuals lead socially integrated lives.

TGV notes that many people with transsexual issues set up informal support networks, which carry out the vast majority of personal counselling. The widespread nature of these groups suggests their necessity and TGV believes there would be great benefits in self-esteem growth in also having formal groups mediated by psychological health specialists. This would also catch those who do not find an informal network. These counselling services need to be funded and covered by medical insurance.

2.2 Work Place Transition Counselling and Education

One of the greatest sources of discrimination, vilification and consequently stress leading to potential psychological health issues for transsexual people is the work place when transition is announced. This needs to be dealt with sensitively by work colleagues, human resources and management. Funding is needed for mediation in these areas. And in the event of umemployment caused by transitioning the medical professionals need to mediate to fast track social security.

2.3 Passing-skills and Self-esteem Therapy.

One of the least spoken about areas between transsexual people and the helping professionals is `passing'. But please note: passing in the affirmed gender is probably the most thought about issue amongst transsexual people. Not passing is considered to be the prime source of discrimination and vilification. It is important to be able to mix in society without being noticed. Add to this internalised transphobia and it is easy to understand why some transsexual people have poor social skills, adopt inappropriately stereotypical sex-role models and in severe cases are house bound with agrophobia.

Transsexuals can be helped lead fulfilling lives with a skillful combination of passing skills and self-esteem counselling. The areas that need to be addressed vary with the individual and may include voice therapy, achieving gender appropriate hair distribution, dress sense and cosmetic surgery. These passing-skills and self-esteem therapies need to be recognised as medical treatments and funded under Medicare and medical insurance schemes.

2.4 Hormone Therapies

Endocronological advise and hormone therapies are essential in enabling transsexual people to live healthy well integrated lives. These would normally be hormones that help align secondary sexual characteristics with the affirmed gender but may include treatments that delay the onset of puberty for patients yet to reach the age of legal consent. TGV wants the costs of medications to covered by the pharmacological subsidy schemes.

2.5 Gender Reassignment Surgeries

Gender reassignment surgery has often been seen as the "holy grail" of transsexual people. It has even been used as a measure of success as a transsexual person. TGV would advocate the availability of a range of surgical procedures, which would be made available after the appropriate counselling and needs assessment. These procedures need to be recognised as essential surgeries by medical benefit schemes.

2.6 Cost of Treatment

The decision of a transsexual person to publically affirm their gender most often comes with very very high familial, social and psychological costs. It is therefore not at all surprising that there is very high unemployment amongst transsexual people during this transition period when medical treatment is most costly. TGV urges the Department of Health to ensure all these treatments are adequately funded either by direct funding or ensuring coverage under medical and pharmacological subsidies and by medical insurance tables.

2.7 Post Surgery Care

Transsexual people need to be made aware of the specific health issues which will remain with them for life because of the medical interventions they've had. These issues include genital cleansing, infection control, safe sex, dilation, the use of prothetics and bone density reduction.

2.8 Definition of Standards of Care

There is a great deal of confusion and disagreement amongst medical professionals as to what constitutes appropriate care for transsexual men and women. Only a multi-disciplined approach can give us practical realistic patient care. The definition of Standards of Care at least need to include medical, familial, social and the psychological disciplines. It is essential that the Department of Health fund appropriate research, define minimum standards of care and provide training for medical professionals.

2.9 Funding of the Monash Medical Centre's Gender Dysphoria Clinic

This is Australia's only Gender Dysphoria Clinic and has been helping transsexual people through transition since the mid-seventies as well as helping other people with gender identity issues live more fullfilling lives. Their multidisciplined team are mostly known for their role in assessing facilitating candidates for gender re-assignment surgery. This clinic has not had a funding increase since it's inception. This clinic needs to be adequetely funded for assessment, counselling and research.

2.10 Funding of Gender Centre/s

Transsexual patients need multidisciplined medical care and need a single point of reference where they can be refered to specialists. In the past the Monash Medical Centre and to a lesser extent the Carlton and Prahan Clinics have done most of this work. Research is needed to determine the best model, taking particular care to look after the needs of rural patients.

2.11 Emergency Ward Treatment

One of the most traumatic events for people with gender identity issues is being presented in a helpless condition into an emergency ward. Such people have traditionally suffered very high levels of discrimination, vilefication and humiliation in situations where they need care. Emergency ward staff need to respect the affirmed gender of clients and be trained to be able to psychologically deal with men who don't have penis and may have bound breasts and women with penises.

Conclusion

TransGender Victoria is very pleased with the MACGLH analysis of the health issues for people with gender identity issues which are basically caused by the stressful lives they lead because the discrimination and abuse they receive. But TGV cannot emphasise enough how appalled and dismayed it is that the MACGLH choose to ignore the very demanding and specific health needs of transsexual people.