A collaborative model aligning adult sexual health and endocrine gender health services

Keywords: community health, contraception, endocrinology, estradiol, gender-affirming care, gender-affirming hormone treatment, health services, HIV, implants, sexual health, STIs, testosterone, transgender.

The past decade has seen a rapid increase in demand for transgender health services, both in Australia and internationally.^1–4 The benefit of gender-affirming care in improving mental health and wellbeing has been established;^5–7 however, barriers to accessing gender-affirming treatments have been identified by the trans and gender diverse (TGD) community in Australia, particularly in regional and remote areas.^8–10 The recent New South Wales (NSW) LGTBIQ+ health strategy prioritises access to gender-affirming care.¹⁰

The 11th edition of the International Classification of Diseases (ICD-11) removes diagnoses related to gender identity from the chapter on mental health and included a diagnostic code of gender incongruence in the sexual health chapter.¹¹ This progress, with the identification of TGD people as a priority population in Australia’s National HIV strategy, paves the way for transgender health service provision within sexual health settings.¹²

A TGD community survey in Hunter New England (HNE) health district previously identified barriers to care, including access to publicly funded specialists.⁸ In 2018, the HNE sexual health service commenced a dedicated referral-based gender clinic to increase access to gender-affirming hormone treatment (GAHT) for TGD adults. The HNE endocrinology service has offered GAHT since 2013 and these services established monthly gender clinics, which are operationally independent but co-located in a community health setting, with two endocrinologists and one sexual health physician prescribing GAHT using an informed consent model. The sexual health gender clinic also provides cervical screening, assessment of genital symptoms, contraception, and estradiol implants to TGD adults.

A referral is required for either gender service and consultations are Medicare bulk-billed. The HNE HealthPathways, an online portal providing health and referral information for general practitioners, direct referrals to either the endocrine or the sexual health service for GAHT. Although the two clinics are not a single service, it was envisioned that co-located, contemporaneously occurring clinics would enable collaboration, cross-referral, and case discussion. The publicly funded sexual health general STI clinic delivered services in the same location allowing patients to attend without a referral for STI testing, treatment, and prevention. It was hypothesised that this may increase access to sexual health care for those attending the gender clinics.

The aims of this descriptive study were to:

1. Describe the sociodemographics, clinical characteristics and STI screening of TGD adults attending endocrine and sexual health gender clinics for GAHT.

2. Identify patients with attendance at both specialty services (endocrine, sexual health gender and/or sexual health general STI clinic) and describe reasons for dual attendance.

A retrospective audit of electronic medical records of all patients with initial consultations for GAHT at the endocrine and sexual health gender clinics between 1 January 2018 and 31 December 2019 was undertaken, and demographic and clinical data were extracted. Variables of interest were operationally defined with specific parameters prior to data collection. Self-reported gender identity was categorised as: (a) transmasculine (birth-assigned females who identified as male/transmale); (b) transfeminine (birth-assigned males who identified as female/transfemale); (c) non-binary; and (d) other (gender identity not adequately described by the previous terms). Remoteness was classified by postcode using the 2016 Australian Statistical Geography Standard Remoteness Areas (ASGS-RA) framework. Physical and mental health morbidities were self-reported and extracted from clinical notes. The Charlson Comorbidity Index was calculated as a quantitative measure of medical morbidity. Clinical characteristics are reported as number and proportion or median and interquartile range. A Chi-squared test was used to compare proportions, except where cells had a frequency of less than five, when the Fischer’s exact test was used. A Mann–Whitney U test was used to compare medians, as these data were not normally distributed.

A second data set was established including any adult TGD patient who had any attendance (initial or subsequent) at either service from 1 January 2018 to 31 December 2019. Patients with dual attendance at the endocrine gender clinic and sexual health service (gender clinic or general STI clinic) were explored and reasons for attendance recorded. The study was approved by the HNE Research Ethics and Governance Committee as being low or negligible risk.

During 2018 and 2019, there was a total of 150 initial consultations for GAHT: 110 at the endocrinology gender clinic and 40 at the sexual health gender clinic. Baseline demographic and clinical characteristics were similar regardless of the service attended (Table 1). The median age was 23 years, physical morbidity was minimal (median Charlson comorbidity index 0). Unemployment (44%) and self-reported mental health diagnoses (69%) were common. A higher proportion of non-binary patients attended the sexual health clinic compared to the endocrine clinic (22.5% vs 6.3%, P = 0.0045). Types of hormones prescribed are listed in Table 2. Endocrinologists were more likely to use spironolactone for androgen blockade than the sexual health physician (77.8% vs 43.8%, P = 0.0096), but prescribing patterns were otherwise similar. STI screening was more frequently performed in patients accessing GAHT through the sexual health gender clinic than the endocrine gender clinic. Thirty-five per cent of patients who attended the sexual health gender clinic for GAHT had an STI screen within the first 12 months of attendance versus 0.9% in the endocrine clinic. One diagnosis of Neisseria gonorrhoea and three diagnoses of Chlamydia trachomatis (two of which occurred in the same person) were treated in patients attending the sexual health gender clinic for GAHT within the first 12 months of follow up. Three patients (7.5%) attending the sexual health gender clinic for GAHT were initiated on HIV pre-exposure prophylaxis (PrEP) within the first 12 months of attendance. The endocrine gender clinic did not commence any patient on HIV PrEP, although one patient commenced HIV PrEP with their general practitioner.

Table 1.  Baseline sociodemographic and clinical characteristics.

Table 2.  Hormone treatments prescribed.

During 2018 and 2019, a total of 250 transgender adults had at least one visit (initial or subsequent) at the endocrine gender clinic or sexual health service (gender clinic or general STI clinic). There were 12 patients (4.8%) with an attendance at both endocrine and sexual health gender clinics in 2018–19 (Fig. 1). These 12 patients all attended the endocrine clinic for GAHT and attended the sexual health gender clinic for services including assessment of genital symptoms, cervical screening tests, contraception and estradiol implant insertions. There were eight patients (3.2%) who attended both the endocrine and sexual health general STI clinic. These patients attended the endocrine clinic for GAHT and the sexual health general STI clinic for either STI screening, HIV pre- or post-exposure prophylaxis.

Fig. 1.  Number of TGD adult patients with any attendance (initial or subsequent) at the HNE endocrinology clinic, the HNE sexual health gender clinic or the HNE sexual health general STI clinic; or a combination of these between 1 January 2018 and 31 December 2019.

Our clinic model enhanced delivery of GAHT by virtue of an additional provider. The co-located clinics facilitated STI screening and other sexual health services, with 8% of patients attending both services. Integrating sexual health and endocrine clinics increases capacity for GAHT, with the aim of lowering psychological distress and improving mental health and wellbeing.^5–7,13 Access to gender-affirming care is associated with improved sexual and romantic satisfaction,¹³ and may limit HIV/STI vulnerabilities.^14–16

Globally TGD populations, particularly transfeminine individuals, are disproportionately burdened by HIV.¹⁷ The prevalence of HIV and STIs in TGD populations in Australia is not well described; however, a recent Australian study showed HIV was more common in transgender men and women compared with their cisgender peers.¹⁸ There were no participants with a prevalent or incident HIV infection in our primary cohort attending for an initial clinic visit. One TGD patient living with HIV attended a subsequent appointment during the study, but their initial visit was outside the timeframe of inclusion. TGD people are a priority in Australia’s National HIV strategy and a key area of action is to improve access to HIV testing and prevention.¹² TGD adults have specific sexual health needs and unique barriers to prevention, treatment and care that must be considered in the HIV/STI response. Cultural insensitivity in sexual healthcare encounters limits future HIV/STI testing;¹⁹ therefore, provision of GAHT by culturally safe sexual health clinics may overcome barriers for STI/HIV testing for this priority population.

Although evidence on the optimal model of care for delivery of GAHT is lacking, multidisciplinary services are recommended by expert consensus.^10,17,20,21 Our parallel model allows access to a broader skill mix, but may be more difficult for referrers and patients to navigate. A social worker was available in the sexual health gender clinic, but mental health clinicians, nurses and peer-workers were not employed or accessible. Sexual health physicians could access expert endocrine advice, although any benefits of case discussion were not captured in this study. A publicly funded service, Maple Leaf House, has since opened in HNE during 2021 to provide gender-affirming care for TGD people aged <25 years, utilising a multidisciplinary team including endocrinology and sexual health.

Study limitations include the retrospective study design; current and previous medical conditions were not discriminated, potentially influencing the prevalence of mental health conditions; and referral bias may have influenced sexual health care, as those with expressed needs would likely have been referred to the sexual health clinic. The smaller group attending the sexual health gender clinic precluded subgroup analyses. Future service reviews could incorporate consumer feedback.

Co-located gender clinics staffed by endocrinology and sexual health physicians provide care for a similar patient population and facilitate access to GAHT and sexual health care for the TGD population.

The data that support the findings of this study are protected by confidentiality and cannot be transferred outside Hunter New England Health.

The authors do not have any conflicts of interest to declare.

The authors received no financial support for the research, authorship, and/or publication of this article.