'The gender thing': Barriers to health for trans New Zealandersby Jenny Nicholls
Two new studies promise to throw a lifeline to trans New Zealanders.
Dove was born female, but “passed” as a male firefighter in Colorado for 11 months before becoming a model. She has quite the backstory, and dazzling looks – but it is, perhaps, her insights and intelligence transfixing the press.
Although her Wikipedia entry uses the gender-neutral pronoun “they”, Dove told The Guardian to “use she, he, it, one, they. You could call me mow mow and I honestly don’t care. A pronoun is just a sound. All I’m listening for in that sound is positivity.”
Her tranquil wit – “I went to whatever bathroom was the shortest line" – sets journalists to furious scribbling and suggests it’s all been a doddle. In fact, as she admitted to one writer, she has been pepper sprayed by someone who thought she was in the wrong bathroom.
Dove’s modelling debut was certainly a memorable one for her booker: “They handed me some underwear and said, ‘Go put on your outfit.’ I said, ‘Okay, but where do I get the outfit?’ and they were, like, ‘That’s it.’ Just the underwear. It was a men’s underwear show!”
The newbie had been booked by an agent who hadn’t realised the 1.9m (6ft 2in) Dove came with breasts attached. “I could [have said], ‘Hey, there are some things in my body that don’t align with the particular marketing scheme you have in mind for this garment.’”
But she didn’t.
“I walked out topless. The casting director looked like he was going to shit himself.”
Brave, but not career-ending. Dove now appears in women’s and men’s fashion shows – she says she wears an “angry face” when modelling menswear – has shot ads for the likes of Chanel, models for Vogue, and is dating #MeToo activist Rose McGowan. She is one of a number of gender-fluid pop-culture stars whose success might lull us into thinking their life is easy, or all about clothing.
But this is not remotely true.
“Public health researchers are becoming aware that trans persons represent one of the most marginalised and under-served populations in medicine,” warned US researchers Tiffany Roberts and Corinne Fantz in 2014 in the Clinical Biochemistry Journal. They felt the need to explain the difference between sex and gender on their paper’s second page.
“It is important to understand that the terms ‘sex’ and ‘gender’, while often used interchangeably, have specific medical and psychological meanings. ‘Sex’ commonly refers to physical characteristics whereas ‘gender’ represents identity and self-image.” As Dr Jaimie Veale, a lecturer in psychology at the University of Waikato, explains, “Gender is what’s in your brain and sex is what’s between your legs.”
Biology 101 tells us human men and women have different chromosomes: XY for men and XX for women. But biology 101 oversimplifies. Sex can be assigned by a blizzard of bodily forces – anatomy, hormones, chimeric cells and chromosomes – and these can clash.
“Nature loves diversity,” says Veale, “but society doesn't, always.”
Biologists versed in human gender now see human sex as a spectrum. As an article in Nature proclaimed in 2015, “The idea of two [human] sexes is simplistic.” A fun Twitter account to follow is “gender of the day”. Sample tweet: “Today’s gender is the sound of thunder in the distance” (73 retweets, 166 likes).
A 2013 Canadian study, Reported Emergency Department Avoidance, Use, and Experiences of Transgender Persons in Ontario, Canada, revealed that dealing with medics leaves many trans people with a dislike of hospitals so intense they avoid emergency departments.
Surely this wouldn’t happen here? North & South can testify that it does. A trans person we know was involved in a serious accident. The thought of going to hospital was so scary she lay at home for days without seeking care. When admitted to hospital, she was initially too zonked to realise that while painkillers were being generously supplied, the hormones prescribed by her GP a year earlier were not. When she was able to raise this with the nursing staff, she told them an earlier attempt to go off them had resulted in her having suicidal feelings. However, no hormones were supplied and she was unable to continue her treatment until she went home after being discharged.
A 2015 paper by Dr Veale and Dr Frank Pega from the University of Otago notes that in overseas surveys of trans people, up to a third reported attempting suicide. A US survey of 6450 trans people in 2011 revealed that 41% reported attempting suicide, compared to 1.6% of the general population.
Despite disturbing international data like this, published research into trans welfare in New Zealand is almost non-existent. Our best data comes from a single survey of teenagers. In the Youth’12 health and wellbeing survey of 8500 secondary school students, 1.2% described themselves as transgender. These young people were five times more likely to report attempting suicide than other students.
What happens to these kids when they grow up? A 10-year-old series of interviews by the Human Rights Commission gives us some clues. One trans man who returned from the US called it a “utopia” compared to New Zealand.
The commission’s report concluded that, in this country, most trans people cannot access the services necessary for them to live “in their gender identity and appropriate sex”.
Since then, little has improved. We know this because Gloria Fraser, a PhD student at Victoria University, is studying trans health care in New Zealand. She hasn’t finished her analysis yet, but her work points to wide variations in the care offered by different DHBs.
“There are huge structural barriers to accessing gender-affirming care,” she says. “My participants shared with me how difficult it is to find providers, including GPs, who are knowledgeable about transgender health. Those that are, tend to be overwhelmed with demand. Many services are dependent on age, so gender-diverse people age out. ‘Evolve’, for example, is a queer- and transgender-friendly service in Wellington, but they are only funded to support people until the age of 24. So for lots of patients, coming up to that age is scary. There are fewer transgender-friendly services once people get to their late 20s and older.”
Some DHBs, she says, report they have no dedicated funding for services like hormones or surgery, at all. The ones that do often demand a mental health assessment before a trans person can even chat with an endocrinologist (a specialist in hormone-related conditions). While many DHBs provide funding for this mental health assessment, some DHBs require patients to access it privately, often at a cost of $500-$1000.
Veale’s project, Counting Ourselves, an anonymous survey for trans and non-binary people, has just closed. More than 1000 people responded.
The survey results, out next year, are likely to show, she says, that trans people are still being treated poorly by the health system, still being refused care, and still fear being mistreated. And many are saying – as they did a decade ago to the Human Rights Commission – that they have to educate every medic they interact with about the basics of their care.
A new era may be dawning, though, with a pilot Gender-affirmative Hormone Clinic in Wellington set up to side-step ponderous DHB systems – and promising trans-led initiatives in Auckland, too. Because it just shouldn't be that hard.
GP Cathy Stephenson is a member of the working group behind the Wellington clinic. She says the vast majority of patients need either support and advice, or to talk about gender-affirming hormone therapy. “Most won’t be thinking of surgery – possibly because it has been too hard – but also because they may not want that.”
For a treatment that is so transformative (and possibly life-saving too), hormone therapy is cheap. The highest dose of oestrogen (a feminising hormone) costs $40 for a three-month supply. Testosterone blockers (often part of the same treatment) cost less than $20. With testosterone injections, says Stephenson,“it depends on what you have, but the three-monthly option is around $90”.
She believes it isn’t cost that’s the problem in getting health funding, “but awareness of the importance of this type of treatment for these patients”.She calls her work with the clinic “one of the most rewarding things I have ever done. It isn’t complex from a medical point of view, but is life-changing for patients.”
Trans experience has, surely, much to teach us, including insights into sexual bias. Take the female-to-male Stanford neuroscientist who, having recently transitioned, heard a fellow academic say, “Ben Barres gave a great seminar today, but then his work is much better than his sister’s.”
Dove has a brave manifesto. “The gender thing doesn’t exist,” she told BuzzFeed News. “It’s a social construct you don’t have to fit into.” Her implication – that gender is a choice, freely made – is one few of us, trans or not, might honestly agree with.
Family Doctor has a guide for trans patients, GPs, friends and family here.
This article was first published in the November 2018 issue of North & South.
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