This study, led by Dr. Katie McMenamin, provided a sector analysis of the current state of transgender health and gender-affirming care within primary care in the Whanganui region. Using an asset, or strengths-based, approach, interviews with primary care agencies involved in the health and care of TGD people and the voice of TGD adults, youth, and their whānau provided information around what is working well and areas that require further support.

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Background:

Transgender and gender diverse (TGD) adults and youth are a minority group that currently experience inequitable access and numerous barriers to healthcare, both nationally and internationally, with indigenous TGD adults and youth experiencing additional inequity (Boyd, Hackett, & Bewley, 2022; Professional Association for Transgender Health Aotearoa (PATHA), 2020; Strauss, Winter, Cook, & Lin, 2020; Temple Newhook et al., 2018; Ziegler, Valaitis, Carter, Risdon, & Yost, 2020). This includes both general healthcare and gender-affirming healthcare, due to ‘discrimination, personal reluctance to access care, and structural barriers to healthcare’ (p. 2) (Ziegler et al., 2020). As a result, TGD people have higher levels of mental health and distress than their cisgender (those whose gender identity matches their sex at birth) counterparts, with increased risk of self-harm and one of the highest rates of suicidality among any other group (Clark et al., 2014; Spivey & Edwards-Leeper, 2019; Strauss et al., 2020; Tan, Ellis, Schmidt, Byrne, & Veale, 2020; Temple Newhook et al., 2018; Veale et al., 2019; Ziegler et al., 2020). For example, the New Zealand Counting Ourselves study found that 56% of TGD people had seriously contemplated suicide during the last year, with 37% having attempted suicide at some stage over their lifetime (Veale et al., 2019). Similarly, an Australian study found 48.1% of TGD youth had attempted suicide over the span of their lifetime (Strauss et al., 2017). In addition, TGD adults, youth and their whānau find it difficult to navigate the health system for gender-related healthcare, due to a dearth of designated gender health services and an overall lack of health providers with proficient knowledge about gender diversity among this population (Strauss et al., 2017; Temple Newhook et al., 2018; Veale et al., 2019). Access to appropriate gender-related healthcare is lower for TGD adults and youth living in rural areas (Temple Newhook et al., 2018).

Until recently, identifying as transgender or gender diverse has been pathologised, placing the ‘problem’ on the person identifying as TGD (Temple Newhook et al., 2018). In recent years, however, worldwide standards have identified being transgender as “a matter of diversity, not pathology” (p. 4) (The World Professional Association for Transgender Health, 2012). When TGD adults and youth are well supported by whānau, they demonstrate equivalent rates of mental health as their cisgender counterparts; for example, in a recent New Zealand study, TGD people who reported being well supported by whānau were nearly half as likely to have attempted suicide in the past year than those who were not well supported (Veale et al., 2019). However, in a recent Canadian study of TGD youth, it was found that only 13% of youth identified their parents as supportive (Temple Newhook et al., 2018). It has also been noted that there are high rates of extra- and intra-familial physical and sexual abuse among TGD youth (Strauss et al., 2020), which, within the Gender Minority Stress Model is believed to be the result of hostile reactions toward the person’s gender minority status (Hendricks & Testa, 2012).

General practitioners (GPs) are usually the first point of healthcare and access to gender-affirming care for both TGD adults and youth (Cundill, 2020; Strauss et al., 2020). Numerous issues within primary care have been reported, however, including expectations that TGD patients will educate their provider on gender-related issues, feeling misunderstood, stigmatised, or unsupported by practitioners or reception staff, or facing long wait-list times to be seen by TGD-friendly GPs (Boyd et al., 2022; Strauss et al., 2020). In addition, this group report difficult experiences with secondary psychiatric care, describing psychiatrists as the ‘gate-keepers’ to whether or not they received care (i.e., having to convince psychiatrists that they are ‘trans’ enough), and highlighting long wait times to be seen, unless they chose the high-cost private route (Strauss et al., 2020).  

Taken together, these issues highlight the important role of those working within primary care in supporting this vulnerable population. Many TGD adults and youth are not well supported by family and, therefore, may be navigating their healthcare by themselves. Moreover, they are at increased risk of mental health issues, suicidality, and physical and sexual abuse. Despite the important role of GPs, many TGD adults, youth, and parents of transgender children report a lack of education and understanding around gender-related issues within the health system, including primary care. White the Whanganui region has recently created an official transgender clinical pathway, there has been no research looking specifically at the needs of Whanganui TGD people, parents of transgender children, or primary care clinicians working with this population. For this reason, this study investigated current experiences and needs of TGD adults, youth, and parents of TGD children from primary healthcare services.

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Ethical Approval

Ethical approval was obtained through the Health and Disability Ethical Committee (HDEC).

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Project Outcomes:

Using an asset-based approach, the study investigated healthcare needs of TGD people in Whanganui and examined how best to support primary care practitioners to provide optimal gender-affirming care (GAC). Interviews with 14 TGD individuals and parents, alongside five practitioners, revealed the need for a transparent clinical pathway, ongoing clinical oversight, and strong collaboration between medical and community-based organisation. From these outcomes, a collaborative transgender-focused model of care for the Whanganui region is proposed, acknowledging benefits of Kaupapa Māori service provision. This model of care has the potential to be applied nationally, as a way to address both TGD and other areas of health inequity.

Access to the findings can be obtained by downloading the documents below.