Reaction to MACGLH discussion papers
by Transgender Victoria
date: 15 March 2002
This is TGV's reaction to the five discussion papers commissioned by
the Ministerial Advisory Committee on Gay and Lesbian Health that
address areas of major health concerns of gay, lesbian, transgender
and intersex Victorians. The discussion papers address the areas of
physical health, sexual health, mental health, life stage issues and
drug and alcohol issues and can be accessed via The ALSO Foundation..
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
1.1 The Introductory Paper - Glossary of Key Terms
TGV would like a number of the definitions to be defined more
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
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
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
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
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
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
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
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
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.
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.