Aotearoa’s healthcare system was created with cisgender people’s interests in mind, who are the majority of the population. Transgender (trans) people experience enormous barriers to healthcare, including constant challenge and denial of their identity, of who they are and what they need. (Human Rights Commission., 2012).
Aotearoa’s healthcare system was developed by cisgender people, and does not recognise or address the health needs of trans people.
We have seen, researched, and understood this dynamic in other contexts: we know that a health system developed by pākehā fails to recognise and address the health needs of Māori, resulting in major health disparities.
In the case of Māori, this recognition has led to the theory and practise of Cultural Safety (Williams, R.,1999), (Nursing Council of New Zealand., 2002).
Similarly, disparities in transgender healthcare must be viewed as resulting from a cisgender focussed health system, and thus need to be addressed at a national systems and policy level.
Trans people are discriminated against in their access to essential medical treatments including chest and genital reconstruction surgeries, facial hair removal, vocal surgeries, breast augmentation, and other treatments which would make life livable and reduce the staggeringly poor health outcomes many face. (Human Rights Commission, 2007).
These treatments are often viewed as elective, despite enormous bodies of evidence which reveal astounding risk factors for untreated transgender people, incuding shockingly high attempted suicide rates, mental illness, and a raft of other issues. (Haas, A. P., Rodgers, P. L., and Herman, J. L., 2014).
“In over 80 qualitatively different case studies and reviews from 12 countries, it has been demonstrated during the last 30 years that the treatment that includes the whole process of gender reassignment is effective.” – (Pfäfflin F, Junge A., 1998)
While treatments for transgender people are simple, safe, effective, and inexpensive, the small percentage of the population requiring these treatments are nonetheless required to self fund the majority of these treatments. Sex reassignment surgeries, hormone replacement therapy, laser hair removal for facial and other hair, breast removal surgery, and vocal cord surgeries to raise the pitch of the voice – these are just a few of the essential healthcare needs of trans people.
These medical treatments are often cited as the most important priority for transgender people, superseding even the need for safe housing or food (Human Rights Commission, 2007).
The cost of non-treatment on the lives of transgender people
Suicide review
In Aotearoa, there is very little research evidence about transgender people; however we see common international disparities for transgender people the world over.
The Youth ’12 survey study of 8,166 secondary school students from throughout Aotearoa showed that Transgender students in Aotearoa experience compromised mental health and personal safety, and had difficulty accessing health care, and that 20% had attempted suicide in the previous year.
(Clark, T. C., et al., 2014).
In the USA, 4.6 % of the overall population has self-reported a suicide attempt, with that number climbing to between 10 and 20 percent for lesbian, gay or bisexual respondents.
For transgender people the figure is 41%. This does not include those whose suicide attempts resulted in their death (Haas, Rodgers, et al. 2014)
The Williams institute study of 6,456 transgender adults identifies the key characteristics and experiences associated with suicide attempts, noting their most significant finding as the exceptionally high prevalence of suicide attempts across all demographics of transgender people.
Suicide attempts among trans men (46%) and trans women (42%) were slightly higher than the full sample (41%), while cross-dressers assigned male at birth had the lowest reported prevalence of suicide attempts among gender identity groups (21%).
The Williams institute study also found that suicide attempts were more common amongst multiracial people and people who report that others read them as transgender all of the time (42%), or most of the time (45%), without being told. (Haas, Rodgers, et al. 2014)
65 % of respondents who experienced a substantial mental health condition reported attempting suicide.
There was also an elevated prevalence of suicide attempts, at 60%, amongst those whose doctor or health care provider refused to treat them. (Haas, Rodgers, et al. 2014)
These figures are consistent across many countries and studies, thus we might draw the conclusion that those in Aotearoa with a diagnosis of Gender Identity Disorder/Gender Dysphoira (transgender, gender non-conforming, and other gender minorities), are facing an epidemic crisis – that if left untreated, 41% to 60% of transgender people are at risk of premature death from suicide alone.
Increased HIV risks created by healthcare disparities
Despite low HIV prevalence in Aotearoa, transgender women are at increased risk when compared with the general population. (AIDS New Zealand, 2014).
It is noted by the Centres for Disease Control and Prevention (USA) that transgender people are among the highest risk populations for HIV infection. Findings from a meta-analysis of 29 published studies showed that 27.7% of transgender women tested positive for HIV infection (4 studies), but when testing was not part of the study, only 11.8% of transgender women self-reported having HIV (18 studies). In one study, 73% of the transgender women who tested HIV-positive were unaware of their status. (Centers for Disease Control and Prevention. Undated)
L. Merbruja, transgender activist and writer, notes that due to inaccessible costs and the trauma caused by being misgendered by healthcare professionals, many trans women avoid going to visit doctors. She also notes that this healthcare barrier is one of the key reasons why trans women face increased risks of contracting HIV.
‘Imagine not being able to access healthcare. I don’t mean exclusively hormone replacement therapy. I’m talking about any healthcare.’(Merbruja,2015)
‘Transgender people [in Argentina] have an average life expectancy of about 30 to 32 years. They don’t live any longer; I think that statistic alone says so much.’ (Murphy, A, 2012)
Exceptional 35+ year waiting list for essential medical care
No patient should be on a waiting list in Aotearoa longer than five months, according to the national health target on ‘elective surgeries’. (Duff, M., 2014)
Even a wait of 224 days is considered to be excessive. (McKracen, H., 2013)
However, for those who manage to access The High Cost Treatment Pool waiting list for trans surgeries, the time spent waiting is approximately 35 years. (Roy, E., 2016).
The Health Minister considers this an unimportant issue. (Logie, J., 2015).
Between 2004 and 2014, there were just 18 publicly funded Genital Reconstruction Surgeries (GRS), with trans men being sent overseas and trans women seeing the sole GRS surgeon in New Zealand, who retired in 2014.
Over 70 patients are currently on the list, but now that Aotearoa’s only surgeon to perform GRS has retired, the 61 transgender women left waiting are doubtful as to whether they will ever access this essential, often life saving surgery.
Some trans people travel abroad for personally funded GRS, which at it’s least expensive costs around $20,000 for trans women and starts at around $30,000 for trans men.
However, the vast majority of transgender people cannot afford to access this. (Logie, J., 2015).
There are also other essential costs for most, including top surgery (removal of breats) for trans men and Laser hair removal for trans women.
‘[previously] Every two years the state pays for three male-to-female operations (at around $50,000) and one female-to-male (performed abroad for around $100,000).’
(Dudding, 2014)
However with the 2014 retirement of Dr Walker, Aotearoa’s only GRS surgeon, this list is now completely on hold. (Murphy, S., 2013)
No top surgery most places in Aotearoa
Trans men in need of essential top surgery in Aotearoa are often unable to go on any waiting list, as there is no publicly funded top surgery available in most parts of Aotearoa.
The World Professional Association for Transgender Health (WPATH) states that chest reconstruction surgery – also known as ‘top surgery’ – is “Not optional in any meaningful sense, but understood to be a medically necessary treatment for a diagnosed condition.” (Murphy, A, 2013)
Laser hair removal not funded
Even laser hair removaltransgender women
Hirsuitism, or excessive facial hair in cisgender women, is considered a medical condition worthy of attention, yet in transgender women this is considered elective, or cosmetic.The average transgender woman must self fund $2000 or more for the removal of facial hair.
While this is an inexpensive treatment relative to most medical treatments, for many transgender women who face routine employment discrimination, this is an enormous cost.
Creating equity
Prejudice and discrimination against non-cisgender people is built into the system. The result is widespeard transgender suffering and early death. This must be recognised, and changes must be implemented at a systems level – structural and systemic change is needed to ensure the human right to appropriate health care is upheld. We must implement both an informed consent model for access to hormone therapy, as well as creating pathways to access fully funded surgeries and other treatments for all trans patients. (ICATH, undated) (Indiana Transgender Network, 2015).
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References:
- Human Rights Commission. (2012)., A fair go for all? Rite tahi tätou katoa? Addressing Structural Discrimination in Public Services (p26)
- Williams, R. (1999). Cultural safety – what does it mean for our work practice? Australian and New Zealand Journal of Public Health, 23(2), 213-214.
- Nursing Council of New Zealand. (2002). Guidelines for cultural safety, the treaty of Waitangi, and Maori health in nursing and midwifery education and practice. Wellington: Nursing Council of New Zealand.
- Human rights commission. (2007). The Transgender inquiry summary of submissions https://www.hrc.co.nz/your-rights/social-equality/our-work/inquiry-discrimination-experienced-transgender-people/
- Haas, A. P., Rodgers, P. L., and Herman, J. L., Williams Institute (2014). Suicide Attempts among Transgender and Gender Non-Conforming Adults: Findings of the National Transgender Discrimination Survey http://williamsinstitute.law.ucla.edu/research/suicide-attempts-among-transgender-and-gender-non-conforming-adults/#sthash.hBpZk0AY.dpuf
- Pfäfflin F, Junge A. (1998). Sex Reassignment. Thirty Years of International Follow-up Studies After Sex Reassignment Surgery: A Comprehensive Review, 1961-1991. (Translated from German into English by Roberta B. Jacobson and Alf B. Meier).
- Clark, T. C., Lucassen, M. F. G., Bullen, P., Denny, S. J., Fleming, T. M., Robinson, E. M., & Rossen, F. V. (2014). 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, 93-99.
- Haas, A. P., Rodgers, P. L., and Herman, J. L., Williams Institute (2014). Suicide Attempts among Transgender and Gender Non-Conforming Adults: Findings of the National Transgender Discrimination Survey http://williamsinstitute.law.ucla.edu/research/suicide-attempts-among-transgender-and-gender-non-conforming-adults/#sthash.hBpZk0AY.dpuf
- AIDS New Zealand. (2014)., issue 73.
http://dnmeds.otago.ac.nz/departments/psm/research/aids/newsletters.html - Centers for Disease Control and Prevention (undated). HIV among transgender people. Retrieved from http://www.cdc.gov/hiv/risk/transgender/
- Merbruja, L. (2015). 3 common feminist phrases that (unintentionally) marginalize trans women. everydayfeminism.com/2015/05/feminist-phrases-marginalize-trans–women/
- Murphy, A. (2012). No more ‘lying’: law bolsters transgender Argenitnes. http://www.npr.org/2012/10/01/162100680/
- Duff, M., (2014). No room on surgery wait list
http://www.stuff.co.nz/national/health/9837997/No-room-on-surgery-wait-list - McKracen, H., (2013). Kiwis face massive ‘hidden’ surgery wait list http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11169539
- Cairns, L., (2014). Gender surgery cost too high for many
http://www.stuff.co.nz/the-press/news/9598471/Gender-surgery-cost-too-high-for-many - Roy, E., (2016). Transgender New Zealanders face 30-year wait for surgery after only specialist retires, http://www.theguardian.com/world/2016/apr/22/new-zealand-transgender-waitlist-surgery-30-years?CMP=twt_a-world_b-gdnworld
- Logan, J., (2015). Access to gender reassignment surgery essential
https://blog.greens.org.nz/2015/05/20/access-to-gender-reassignment-surgery-essential/ - Dudding, A. (2014)., NZ’s only sex change surgeon retires. Retrieved from http://www.stuff.co.nz/the-press/news/10664572/NZs-only-sex-change-surgeon-retires
- Murphy, S. (2013). Top Surgery No longer Offered by Auckland Surgeon.
- DermNet NZ. (undated). Hirsutism
http://www.dermnetnz.org/hair-nails-sweat/hirsutism.html - ICATH. (undated). Informed consent for access to trans health.
http://www.icath.org/ - Indiana Transgender Network. (2015). Informed consent in trans health care.
http://indianatransgendernetwork.com/resources/medical-info/informed-consent-in-trans-health-care/
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