Journal Article Review: Gender Identity and Gender Affirming Care
- Clinical Services Team
- Nov 11
- 7 min read
Updated: 8 hours ago
WCF Clinical Team
Terms
Sex is understood in relation to sex characteristics. Sex recorded at birth refers to what was determined by sex characteristics observed at birth or infancy.
Gender is about social and cultural differences in identity, expression, and experience.
Non-binary is an umbrella term describing gender identities that are not exclusively male or female.
Gender identity is about who a person feels themself to be
Gender expression is the way a person expresses their gender. A person's gender expression may also vary depending on the context, for instance expressing different genders at work and home
Gender experience describes a person’s alignment with the sex recorded for them at birth i.e. a cis experience or a trans experience.
Gender affirmation is the process an individual goes through when they to begin to live as their authentic gender, rather than that presumed at birth. This process can include all or any combination of social, medical and legal affirmation.
Social affirmation may include coming out, clothing, voice and names and pronouns.
Medical affirmation may include, but is not limited to, surgery and/or hormone therapy.
Legal affirmation may include, but is not limited to, name and gender change on documents.
The Stats
Recent estimates suggest that the prevalence of young people identifying as gender diverse is about 1 in 100 in the western world.
About 45,000 school aged children in Australia (1.2%) are thought to identify as trans.
Gender Affirming Care
Note: studies are concluding that gender identity and gender affirming care is a very under researched area in Australia (including the prevalence of people identifying as gender diverse, e.g. non inclusive 2021 census).
For trans people under 18 whose parents, carers or guardians will not consent to starting hormones, the Family Court must be involved.
Experiences of transgender and non-binary youth accessing gender-affirming care: A systematic review and meta-ethnography (2021)
The demographics of adolescents presenting for intervention are changing over time, with more people who were assigned female at birth presenting to services than people who were assigned male at birth
Non-binary individuals are often underrepresented as most population health surveys only collect binary gender data, which makes it difficult to gain reliable estimates of gender affirming health care
Literature strongly highlights that systems frequently fail transgender individuals, even in countries with progressive civil liberties. Multiple studies describe the arduous experiences of trans adults seeking healthcare. Notably, most will report experiences of stigma and discrimination when accessing healthcare, from encounters with administrative staff to encounters with healthcare providers.
Primary barriers found to accessing gender-affirming care: stigma- overt refusal of care as well as subtle stigmatisation (refusal to use affirming language), lack of policies to reflect the need for structural changes, reluctance to disclose identity, financial barriers, insurance coverage denials, age (parental consent required), concerns over quality of care, and, being refused general healthcare due to gender identity.
The United States National Transgender Discrimination Survey reported that 19% of trans individuals were refused care. Due to discriminatory actions of health providers, many trans individuals avoid interaction with them, and have sourced medication and care from unregistered sources.
For most young people, parental/guardian consent is a prerequisite to accessing care, and thus “coming out” is an imperative step.
Postponing disclosure of gender identity: This is evidenced by studies which detailed that young people postponed this step due to fear of not being accepted, fear of being bothersome or a lack of comfort talking about gender questioning. Even at the point where participants were receiving care, (after coming out) they worried that health care providers would document their gender identity status and this may negatively affect their insurance coverage
Pursuit of care: structural barriers to care include finding a competent/appropriate provider, geographical accessibility, onerous waiting times/waiting lists
Cost of care: young people’s guilt or worry about how much services will cost and what will be covered, worry about burden on parents. Disparity in what insurance policies cover (and getting insurance in the first place). Often caregivers need to battle to have hormones or surgeries covered.
Complex family/caregiver dynamics: family/caregiver willingness to listen and learn with regard to gender affirming care and being a united front, parents inhibiting gender affirming care (reluctant to support or averse to medical intervention), impact of stress on other family members (siblings etc).
Patient/provider relationships: barriers include healthcare providers being ill-equipped on gender related care (or not utilising multidisciplinary support), referring between healthcare providers due to provider not comfortable or not feeling it is their expertise. Another barrier found was related to dread, fear and avoidance of presenting to a health facility due to staff’s lack of training or judgement. Young people also felt obligated to prove their gender identity (being demanded of them) which is very distressing. Some explained that they felt they had to perform gender expression to align with their gender identity due to expectations. Others described lack of etiquette with pronouns and names, as well as blatant refusal of care by individual healthcare providers.
Among some members of the transgender community, there is a perceived health belief that medical or surgical intervention is a requirement to legitimise the trans experience. This has the potential to minimise the role of healthcare professionals in providing care for trans individuals who do not seek medical or surgical intervention but may seek social transition support or psychosocial supports. This focus on medical aspects of transition can also inadvertently devalue the affirming power of personal and social transition. It is striking, but unsurprising, that the focus for young people is hormones, and that barriers are perceived as barriers to hormones rather than barriers to care. Specialist gender services may provide supports such as speech and language therapy, assistance with legal document change and paperwork, peer-support groups, family counselling or support, family planning services and any of these services have the potential to be gender-affirming.
To enable positive outcomes, youth require access to unbiased and accurate medical information, sufficient insurance and income, support from family and caregivers, and support from healthcare professionals well-trained on gender-related issues.
School experiences of transgender and gender diverse students in Australia (2015)
Data collected through a survey of 189 young people and interviews with 16.
25% of the survey participants reported that they avoided their schools because they cannot conform to the gender stereotypes dominant within these contexts
Barriers & considerations:
Basic record keeping – wanting/ability to change name/gender on school records
Sexuality and puberty education classes - two-thirds of the survey participants rated their schools’ provision as mostly inappropriate and less than 10% as mostly appropriate. Some reported that trans/ intersex were not mentioned in sex ed.
Counselling - Younger survey participants (14–17-year olds) were more likely to have been provided with trans-inclusive counselling at school (67%; compared to 37% of 18–21-year olds and 22% of 22–25-year olds). Those in Christian schools sometimes reported having a chaplain available rather than counsellor, so felt uncomfortable.
Segregation of facility use - Over 40% of the survey participants felt that gender segregation (such as lining up in rows of boys and girls, or segregation for learning, etc.) was too often applied at their school
Uniform - For some young people, the uniform code at their school was strongly gendered.
Staff - Survey participants who reported receiving no teacher support were over four times more likely to leave school. Students whose teachers’ use of pronouns, name or identity, was perceived as ‘mostly inappropriate’, experienced increased abuse from peers and suffered poorer educational outcomes compared to those whose teachers used appropriate language. They were more likely to report being unable to concentrate in class, that their marks had dropped or that they dropped out of school entirely.
What are the health outcomes of trans and gender diverse young people in Australia? Study protocol for the Trans20 longitudinal cohort study
Being transgender is frequently accompanied by gender dysphoria, which often coexists with mental health concerns. Serious psychiatric disorders are very common, with rates of self-reported depression and anxiety diagnoses in transgender and gender diverse (TGD) young people in Australia as high as 75% and 72%, respectively, and 80% reporting ever self-harming and 48% ever attempting suicide.
Ongoing longitudinal study looking at aspects of gender identity, mental health, education/school, drug use and sexual health, experiences of care, physiology. “It will be paramount to fill existing knowledge gaps and determine empirically how best to manage the care of TGD young people so that future best practice guidelines can be based on as much robust evidence as possible.”
Equality Australia article 18 oct 2023
A bill has been introduced by Senators Alex Antic (Liberal Party), Malcolm Roberts (One Nation), Ralph Babet (UAP) and Matt Canavan (National) to Federal Parliament – Childhood Gender Transition Prohibition Bill 2023 - The bill: prohibits health practitioners from performing gender clinical interventions intended to transition a minor’s biological sex, subject to limited exemptions; and prohibits the Commonwealth from entering into arrangements involving the expenditure or payment of money that provides or facilitates the provision of such a procedure or treatment.
LGBTIQ+ Health Australia (LHA) CEO Nicky Bath: “Gender-affirming care is crucial for the wellbeing of trans and gender-diverse youth, providing them with the opportunity to access life-saving and life-affirming support. "Studies consistently show that denying access to gender affirming care, and subjecting trans and gender diverse young people to hostility, negatively impacts their mental health. Depression, anxiety, self-harm, and suicidality rates are a result of barriers to care, discrimination, and stigma.”
Why have nearly half of Transgender Australians attempted suicide?
Gender affirming care can be lifesaving. This study found that desiring but not having had gender-affirming surgery is associated with a 71 per cent higher chance of reporting a lifetime suicide attempt.
This research shows that the situation will only improve if we reduce societal discrimination and ensure safe, low-cost and accessible mental health support services as well as gender-affirming medical and surgical interventions for those who need them.
References
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