Family doctor

Making the transition - an article about transgender people and how their families and friends can support them

Introduction:

Most of us take it for granted that we feel comfortable in the body we are born in to. For transgender people, it isn’t quite so straightforward. Trans men and women identify with a gender that is different to that which was assigned at birth.

Society’s awareness of transgender people is increasing as people are feeling more and more comfortable to come out to their friends and family and live their life as the gender they really are. Despite increasing acceptance, transgender people still face significant hardship and discrimination in society. A New Zealand survey in 2012 found that around 40% of all transgender youth had significant depressive symptoms, had harmed themselves and had felt they had been unable to access health care when needed. It also reported that trans people have a 5 times greater rate of suicide than the non-trans population. On the bright side, three-quarters of trans youth reported having at least one supportive parent and felt comfortable in their school environment.

Greater awareness of the struggles faced by trans people, the correct use of terminology and language used to describe the trans narrative and support from friends and family can all help to relieve the stigma and discrimination trans people often feel.

How common is it?

Studies probably underestimate the true prevalence of trans people in society because a lot of people still don’t feel comfortable coming out to their friends and family.

The most reliable statistics we have, come from the Youth’12 study - a survey of 8,500 high school students around New Zealand undertaken by the University of Auckland. The survey found that 1.2% of high school students reported that they were transgender. 2.5% reported that they were not sure of their gender identity. The incidence of 1.2% is similar to figures in North America and other overall estimates.

Gender dysphoria

All transgender people experience gender dysphoria - the painful conviction that the body you are born into does not match your true gender identity. Very little is known about why it occurs. What we do know, is that it can be relieved when people begin their transition and are accepted in society as the gender they really are.

Current scientific theory hypothesises there may be a genetic aspect to gender dysphoria, with identical twins being more likely to both be transgender than fraternal twins. Some studies that have imaged the brains of transgender people have noticed that in certain cases, trans people have brains structured more like the gender they associate with than their biological sex. However, there is still a huge amount of variability between each individual’s brain and the studies in this field are still in their early days.

Occasionally, the feeling of gender dysphoria can be so unpleasant it leads to depression and thoughts of suicide. This is made worse in an environment where people are unaccepting of change. Bullying and discrimination, both personal and institutional add to this dysphoria and increase an individual’s risk of suicide.  

The experience of gender dysphoria is not the same as a rejection of gendered norms although this rejection may be a manifestation of the dysphoria. For example, because a girl refuses to wear a dress and prefers to wear pants and sneakers does not mean she has gender dysphoria.

How is it recognised?

Each individual’s experience is different but puberty is a common time for trans people to start to realise that they feel uncomfortable in their body.

Some people may experience this discomfort without recognising what it is. This can be a very distressing time for adolescents. On the other hand, there are children as young as 5 who know exactly that they are ‘in the wrong body’.

For the majority of trans people it is very clear to them that they are transgender and the relief they experience when they are able to open up and share their gender identity is a testament to this.

Occasionally, it can be a bit trickier in younger, pre-pubertal children who are questioning their gender identity. It is not uncommon for kids to experiment with cross dressing and to explore their gender identity in various ways. Many kids who do this, do not go on to identify as transgender. It can be hard for parents and children to decide what to do in these circumstances but the most important thing for these kids is to create a welcoming, accepting environment for them to explore their gender in, regardless of their decision later in life.

These children can also be referred to specialist paediatric mental health teams to explore this further and facilitate hormonal treatment if needed.

Terminology:

The terminology used to describe transgender people may seem confusing to people at first but it is very important to get right because being misgendered is a very unpleasant experience for a trans person.

One of the first principles is: when in doubt, ask. It may feel uncomfortable initially but simply asking ‘what pronouns would you like me to use?’ if someone’s gender seems unclear can mean the world to a trans person.

People who are assigned male at birth (i.e their biological sex appears male) and transition to being female are referred to as transgender women and use the pronoun ‘she’. They are also often referred to as MtF trans women in the literature.

Referring to these women by male pronouns, even if referring to them in the past prior to their transition is considered offensive by most people in the trans community. Of course, this may differ for each individual and it is important to be mindful of this.

A person who was assigned female at birth and then transitions to become a male, is referred to as a transgender male. In the literature, female to male trans people are often shortened to FtM trans men.

More on terminology and language:

Many people in the transgender community are uncomfortable with a concept that is commonly presented in the media as ‘the sex change’. It is natural for people to be curious about a trans person’s experience, but questions about whether people have had surgery or not can be considered offensive and inappropriate. For example, asking a trans person about their genitals or what they were like ‘before the change’ is not a pleasant experience for a trans person.

Gender identity exists on a spectrum and not all people will identify as either strictly male or female. Other gender and sexual identities which will not be explored in depth in this article exist and include intersex people, gender queer and agender. Agender people do not identify with one particular gender at all and use the pronoun ‘they’.

The term transsexual is mostly outdated and many transgender people consider the term derogatory, particularly the term ‘tranny’.

What can be done for people who have newly come out as transgender?

There are many different social, medical and surgical interventions that can help people transition. The following list is by no means exhaustive but gives a general idea of the path many trans people embark on. It is important to appreciate that there is no one set way of transitioning and every person should be treated as an individual on a case-by-case basis.

Social, medical and surgical transition:

Social transition:

This is often the first step in transition. It requires a lot of courage and support from close friends and family.

Most commonly it means coming out to friends and family as transgender, asking people to refer to them by different pronouns, changing their name and gender on legal records, changing their hairstyle, wearing different clothing and underwear.

It is common for FtM to bind their chest with tight elastic binders (widely available online) and MtF may wear prosthetic breasts, these women may also wear make up and remove their facial hair.

Hormonal treatment:

There are four general types of hormonal treatment available and funded in New Zealand.

For those who have realised their gender identity before the onset of puberty,

puberty blockers can be administered during Tanner pubertal stage 2 (at an early but defined point within puberty) to prevent pubertal progression. Puberty blockers work at the level of pituitary gland in the brain and stop the signals that tell the body to start puberty. This medication is also used for the treatment of early puberty in non-trans people and is an entirely reversible treatment, ie puberty will restart once the blockers are stopped. There is a very low risk of fertility problems associated with puberty blockers but for the most part they are very safe.

Puberty blockers can be really helpful for trans people who haven’t yet developed the body that puberty brings with it. It makes sense that preventing the development of body hair in trans women or breasts/hips in trans men in the first place saves a lot of distress and energy in the long run.

Puberty blockers can also be used in trans people who have gone through puberty to help block their natural hormone production, particularly in MtF trans woman, where their own testosterone levels can interfere with the oestrogen that they will receive as hormonal treatment. Puberty blockers are not generally used in the long-term.

The other hormonal treatments are oestrogen for trans women and testosterone for trans men. This is usually a life-long treatment for trans people.

Oestrogen therapy:

Oestrogen is usually taken in an oral form. Oestrogen treatment in MtF trans women results in redistribution of fat to a female shape, breast development (which is irreversible), reduced muscle bulk and reversal of a male balding pattern.

Oestrogen treatment causes irreversible infertility and some MtF may freeze their sperm before commencing treatment.

Progesterone is rarely used as hormonal treatment for MtF women because it provides no obvious added benefit and may increase facial hair and the risk of breast cancer and heart disease.

Androgen (testosterone) blockers, such as those used in the treatment of acne and polycystic ovary syndrome can also be prescribed, initially by a hormone specialist (an endocrinologist) and then managed by the GP. These block the effects of the body’s natural testosterone and help with feminisation.

Testosterone Therapy:

FtM trans men can commence testosterone therapy which promotes beard and body hair growth, redistribution of body fat, increased muscle mass, and deepening of the voice.

Testosterone also stops menstruation and increases libido as well as irreversibly causing infertility.

Testosterone is most effectively given via intramuscular injection on a week-monthly basis.

Surgery:

Many trans people also undergo surgery as part of their transition, but some choose not to and it is entirely up to the individual.

Some surgical procedures that trans people may wish to undergo include:

• Chest reconstruction (breast removal also called “top surgery”) for FtM trans men

• Facial surgery

• Laryngeal surgery (reducing the bulk of the laryngeal bulge ‘adam’s apple’ in MtF trans people)

• “Bottom surgery” to align trans people’s genitalia with their lived gender

Transitioning in the New Zealand health system:

Unfortunately, the pathway through the healthcare system for trans people is not always as straightforward as it should be, with lots of inter-DHB and clinician variation.

Some health professionals may be unsure about how to go about referring patients on to get the treatment they need because they may only see a limited number of trans people every year. There are organisations in New Zealand which are dedicated to improving the experience of trans people in the healthcare system but often these services only operate in main centres such as Auckland and Wellington.

Usually, the first contact with the health system to begin medical transition is through a GP who can refer trans people on to psychologists and endocrinologists. Most GPs who specialise in youth and sexual health services are particularly clued-up about how to support trans people and may be the desired initial point of contact for trans adolescents.

Prior to commencing hormonal treatment in the NZ healthcare system, trans people need to have been assessed by a mental health professional - usually a psychologist, to ensure that they have the capacity to understand the implications of their treatment and to ensure that they are safe in their environment. Following assessment, an endocrinologist (a doctor who specialises in hormones) can commence patients on hormonal treatment.

Are there age limits?

For patients under 16, and usually up until age 18, consent for starting hormonal therapy is recommended from both the patient and their parents/caregivers. Under exceptional circumstances however, people under 16 may be allowed to start treatment without the consent of their parents as long as they are deemed competent.

Surgical treatment:

Unlike hormone therapy which is funded in New Zealand, only a few trans-related operations are funded in NZ each year. They are typically very difficult to access due to huge waiting lists and a lack of surgeons specialising in trans-surgery in New Zealand. Private surgery is costly but is probably the most common route for patients to take to get their surgery.

What can you do to help?

As a parent, sibling or friend, one of the most important things you can do if a person you know opens up to you as transgender is to show your support and acceptance.

It may initially come as a shock and it is natural for people in support networks to feel a sense of loss of the person as they transition from brother to sister or daughter to son.

It is important to remember that once someone transitions, they often become more themselves, feeling more comfortable in their bodies and are often far happier and have a better quality of life.

Voicing your support, being there for them, asking them what they need, helping them come out to other people if needed, helping them get in touch with services, asking them which pronouns and name they would like to be called, letting others know that the person has transitioned and would now like to be referred to by different pronouns are all supportive measures which can help protect trans people from the high rates of distress and suicide that the community experiences.

Resources (sourced from the Youth’12 fact sheet in New Zealand)

• Rainbow YOUTH http://www.rainbowyouth.org.nz/ for information about the ‘Star*’ group (and other helpful resources).

• OUTLineNZ 0800 OUTLINE (6885463) offers toll-free phone counselling and support for lesbian, gay, bisexual and transgender people http://www.outline.org.nz/.

• Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7 http://www.wpath.org/uploaded_files/140/files/IJT%20SOC,%20V7.pdf

• Refuge Restroom (which seeks to provide safe restroom access for transgender, intersex, and gender nonconforming individuals) http://www.refugerestrooms.org/

• Trans people: facts & information from the Human Rights Commission http://www.hrc.co.nz/human-rights-environment/action-on-the-transgender-inquiry/resources/trans-peoplefacts-information/

• Gender is not a uniform http://safeschoolscoalitionvictoria.org.au/wp-content/uploads/2014/06/Resource-Booklet.pdf a resource from the Safe Schools Coalition Victoria

References:

1. Clark, Terryann C. et al. "The Health And Well-Being Of Transgender High School Students: Results From The New Zealand Adolescent Health Survey (Youth'12)". Journal of Adolescent Health 55.1 (2014): 93-99. Web. 22 Mar. 2016.