Characteristics and gender affirming healthcare needs of transgender and non-binary students starting hormone therapy in a student health service in Aotearoa New Zealand
Rona Carroll
1 2 * , Bianca Sepulveda 2 , Lane McLeod 3 , Cathy Stephenson 4 , Richard W. Carroll 5
1 Department of Primary Health Care and General Practice, University of Otago, Wellington, New Zealand.
2 Mauri Ora Student Health and Counselling Service, Victoria University of Wellington, New Zealand.
3 University of Otago Medical School, Wellington, New Zealand.
4 The 502 Rangatahi Ora, Wellington, New Zealand.
5 Endocrine, Diabetes and Research Centre, Te Whatu Ora Capital, Coast and Hutt Valley, New Zealand.
Journal of Primary Health Care 15(2) 106-111 https://doi.org/10.1071/HC23040
Published: 23 June 2023
© 2023 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of The Royal New Zealand College of General Practitioners. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)
Abstract
Introduction: Traditionally, gender-affirming hormonal therapy (GAHT) is initiated in secondary care, but a primary care based approach has been developed to reduce access barriers.
Aim: We aim to describe the demographics, hormone choices, and additional referrals made for young people initiating GAHT in a primary care setting in Aotearoa New Zealand.
Methods: Clinical notes were reviewed for all patients who commenced GAHT between 1 July 2020 to the end of 2022 at a tertiary education health service. Data were collected on age, ethnicity, gender, type of hormones prescribed, and any additional referrals.
Results: Eighty five patients commenced GAHT during the review period (64% assigned male at birth and starting oestrogen-based GAHT, 36% assigned female at birth and commencing testosterone-based GAHT). Fourty seven percent of patients identified as transgender female, 38% as non-binary, and 15% as transgender male. Spironolactone was the most common choice of testosterone blocker (81%). The choice of oestrogen formulation was fairly equal between patches (54%) and tablets (46%). Eighty percent of those assigned male at birth chose to preserve fertility, 54% requested voice therapy, and 87% of those assigned female at birth requested top surgery.
Discussion: There is a need for improved understanding of non-binary gender-affirmation needs, in particular those of Māori and Pasifika youth. An informed consent approach in primary care can reduce barriers and distress for transgender youth seeking GAHT. The high unmet need for top surgery for transgender people assigned female at birth requires attention.
Keywords: endocrinology, healthcare access, hormone, primary health care, sexual health, transgender, youth health.
References
[1] Chen D, Berona J, Chan YM, et al. Psychosocial functioning in transgender youth after 2 years of hormones. N Engl J Med 2023; 388 240–50.| Psychosocial functioning in transgender youth after 2 years of hormones.Crossref | GoogleScholarGoogle Scholar |
[2] Veale J, Byrne J, Tan KK, et al. Counting ourselves: the health and wellbeing of trans and non-binary people in Aotearoa New Zealand. Transgender Health Research Lab; 2019.
[3] Cundill P, Brownhill A, Locke P. Protocols for the Initiation of Hormone Therapy for Trans and Gender Diverse Patients. Equinox Gender Diverse Health Centre; 2020.
[4] AusPATH. Australian Informed Consent Standards of Care for Gender Affirming Hormone Therapy. AusPATH; 2022. Available at https://auspath.org.au/wp-content/uploads/2022/05/AusPATH_Informed-Consent-Guidelines_DIGITAL.pdf
[5] Cosio I, Goldman L, MacKenzie M, Townsend M. Gender‐affirming primary care. B C Med J 2022; 61
[6] Labour rainbow policy. 2023. Available at https://www.labour.org.nz/rainbow
[7] Government NZ. Rainbow health gets funding boost. 2022. Available at https://www.beehive.govt.nz/release/rainbow-health-gets-funding-boost
[8] McGonigle L, Nicholls R. A community-based initiative to improve transgender mental health in Canterbury, New Zealand. J Prim Health Care 2022; 14 43–7.
| A community-based initiative to improve transgender mental health in Canterbury, New Zealand.Crossref | GoogleScholarGoogle Scholar |
[9] Carroll R NR, Carroll RW, Bullock J, et al. Primary Care Gender Affirming Hormone Therapy Initiation Guidelines. 2023. Available at https://blogs.otago.ac.nz/rainbow/
[10] Veale JF, Bullock JJ, Byrne J, et al. PATHA’s vision for transgender healthcare under the current health reforms. N Z Med J 2023; 136 24–31.
[11] Ker A, Fraser G, Lyons A, et al. Providing gender-affirming hormone therapy through primary care: service users’ and health professionals’ experiences of a pilot clinic. J Prim Health Care 2020; 12 72–8.
| Providing gender-affirming hormone therapy through primary care: service users’ and health professionals’ experiences of a pilot clinic.Crossref | GoogleScholarGoogle Scholar |
[12] Delahunt JW, Denison HJ, Sim DA, et al. Increasing rates of people identifying as transgender presenting to Endocrine Services in the Wellington region. N Z Med J 2018; 131 33–42.
[13] Spanos C, Grace JA, Leemaqz SY, et al. The informed consent model of care for accessing gender-affirming hormone therapy Is associated with high patient satisfaction. J Sex Med 2021; 18 201–8.
| The informed consent model of care for accessing gender-affirming hormone therapy Is associated with high patient satisfaction.Crossref | GoogleScholarGoogle Scholar |
[14] Cheung AS, Ooi O, Leemaqz S, et al. Sociodemographic and clinical characteristics of transgender adults in Australia. Transgend Health 2018; 3 229–38.
| Sociodemographic and clinical characteristics of transgender adults in Australia.Crossref | GoogleScholarGoogle Scholar |
[15] Bauer GR, Pacaud D, Couch R, et al. Transgender youth referred to clinics for gender-affirming medical care in Canada. Pediatrics 2021; 148 e2020047266
| Transgender youth referred to clinics for gender-affirming medical care in Canada.Crossref | GoogleScholarGoogle Scholar |
[16] Cocchetti C, Ristori J, Romani A, et al. Hormonal treatment strategies tailored to non-binary transgender individuals. J Clin Med 2020; 9 1609
| Hormonal treatment strategies tailored to non-binary transgender individuals.Crossref | GoogleScholarGoogle Scholar |
[17] Xu JY, O’Connell MA, Notini L, et al. Selective estrogen receptor modulators: a potential option for non-binary gender-affirming hormonal care? Front Endocrinol 2021; 12 701364
| Selective estrogen receptor modulators: a potential option for non-binary gender-affirming hormonal care?Crossref | GoogleScholarGoogle Scholar |
[18] Tan KKH, Byrne JL, Treharne GJ, et al. Unmet need for gender-affirming care as a social determinant of mental health inequities for transgender youth in Aotearoa/New Zealand. J Public Health 2022; 44 fdac131
| Unmet need for gender-affirming care as a social determinant of mental health inequities for transgender youth in Aotearoa/New Zealand.Crossref | GoogleScholarGoogle Scholar |
[19] Dragoman MV, Tepper NK, Fu R, et al. A systematic review and meta‐analysis of venous thrombosis risk among users of combined oral contraception. Int J Gynaecol Obstet 2018; 141 287–94.
| A systematic review and meta‐analysis of venous thrombosis risk among users of combined oral contraception.Crossref | GoogleScholarGoogle Scholar |
[20] Millward CP, Keshwara SM, Islim AI, et al. Development and growth of intracranial meningiomas in transgender women taking cyproterone acetate as gender-affirming progestogen therapy: a systematic review. Transgend Health 2022; 7 473–83.
| Development and growth of intracranial meningiomas in transgender women taking cyproterone acetate as gender-affirming progestogen therapy: a systematic review.Crossref | GoogleScholarGoogle Scholar |
[21] Gil M, Oliva B, Timoner J, et al. Risk of meningioma among users of high doses of cyproterone acetate as compared with the general population: evidence from a population‐based cohort study. Br J Clin Pharmacol 2011; 72 965–8.
| Risk of meningioma among users of high doses of cyproterone acetate as compared with the general population: evidence from a population‐based cohort study.Crossref | GoogleScholarGoogle Scholar |
[22] Nota NM, Wiepjes CM, de Blok CJM, et al. The occurrence of benign brain tumours in transgender individuals during cross-sex hormone treatment. Brain 2018; 141 2047–54.
| The occurrence of benign brain tumours in transgender individuals during cross-sex hormone treatment.Crossref | GoogleScholarGoogle Scholar |
[23] MacKinnon KR, Grace D, Ng SL, et al. “I don’t think they thought I was ready”: how pre-transition assessments create care inequities for trans people with complex mental health in Canada. Int J Ment Health 2020; 49 56–80.
| “I don’t think they thought I was ready”: how pre-transition assessments create care inequities for trans people with complex mental health in Canada.Crossref | GoogleScholarGoogle Scholar |
[24] Fraser G, Brady A, Wilson MS. “What if I’m not trans enough? What if I’m not man enough?”: transgender young adults’ experiences of gender-affirming healthcare readiness assessments in Aotearoa New Zealand. Int J Transgend Health 2021; 22 454–67.
| “What if I’m not trans enough? What if I’m not man enough?”: transgender young adults’ experiences of gender-affirming healthcare readiness assessments in Aotearoa New Zealand.Crossref | GoogleScholarGoogle Scholar |
[25] Gridley SJ, Crouch JM, Evans Y, et al. Youth and caregiver perspectives on barriers to gender-affirming health care for transgender youth. J Adolesc Health 2016; 59 254–61.
| Youth and caregiver perspectives on barriers to gender-affirming health care for transgender youth.Crossref | GoogleScholarGoogle Scholar |
[26] Ho F, Mussap AJ. Transgender mental health in Australia: satisfaction with practitioners and the standards of care. Aust Psychol 2017; 52 209–18.
| Transgender mental health in Australia: satisfaction with practitioners and the standards of care.Crossref | GoogleScholarGoogle Scholar |
[27] Dhejne C, Van Vlerken R, Heylens G, et al. Mental health and gender dysphoria: a review of the literature. Int Rev Psychiatry 2016; 28 44–57.
| Mental health and gender dysphoria: a review of the literature.Crossref | GoogleScholarGoogle Scholar |
[28] Bauer GR, Scheim AI, Pyne J, et al. Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada. BMC Public Health 2015; 15 525
| Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada.Crossref | GoogleScholarGoogle Scholar |
[29] Ker A, Fraser G, Fleming T, et al. ‘A little bubble of utopia’: constructions of a primary care-based pilot clinic providing gender affirming hormone therapy. Health Sociol Rev 2021; 30 25–40.
| ‘A little bubble of utopia’: constructions of a primary care-based pilot clinic providing gender affirming hormone therapy.Crossref | GoogleScholarGoogle Scholar |
[30] Oliphant J. An update for the provision of gender affirming healthcare across the district health boards of Aotearoa New Zealand. 2021. Available at https://patha.nz/gender-affirming-care-2021
[31] Poudrier G, Nolan IT, Cook TE, et al. Assessing quality of life and patient-reported satisfaction with masculinizing top surgery: a mixed-methods descriptive survey study. Plast Reconstr Surg 2019; 143 272–9.
| Assessing quality of life and patient-reported satisfaction with masculinizing top surgery: a mixed-methods descriptive survey study.Crossref | GoogleScholarGoogle Scholar |
