Health Report number: 20180198
Security classification: In-Confidence
File number: AD-62-14-2018
Action required by: As soon as practicable
Potential priorities for Rainbow policy
To:
Hon Dr David Clark, Minister of Health;
Hon Julie-Anne Genter, Associate Minister of Health
Purpose
This memo provides information on health and wellbeing issues for Rainbow people. Rainbow issues are
best seen through a social model of health, which looks beyond issues of healthcare at the way factors
in the environment, like stigma, affect health.
Key points
The Ministry and other agencies already have work underway that will impact positively on Rainbow
people.
Issues that are currently topical, and are receiving media coverage, include the availability of gender
reassignment surgery (which is patchy across the country); HIV and the drug PrEP; and the collection
of data on gender identity by government, particularly through Census 2018.
The Ministry has established quarterly meetings with a group of academics, researchers, clinical
leaders and advocates from the transgender community, to strengthen the Ministry’s knowledge and
relationships with the community.
While gender reassignment surgery is topical, it should be looked at in the context of a broader
spectrum of transition-related healthcare to transgender people. A review of the model of care is
required.
Looking at this spectrum of transition-related care, and at the accessibility and suitability of wider
healthcare for Rainbow people, could be potential priorities for the Ministry.
We would welcome the opportunity to discuss with you what areas of Rainbow policy the Ministry
should focus on.
Recommendations
It is recommended that you:
a)
note that the Ministry and other agencies already have work underway that will
Noted
have a positive impact on Rainbow people
b)
note that increasing access to gender reassignment surgery, ending HIV, and
Noted
collecting data on Rainbow populations are currently topical issues
c)
note that the Ministry is meeting regularly with a group of transgender academics,
Noted
researchers, clinical leaders and advocates, who have approached the Ministry
seeking funding for a range of activities
Contacts:
Hannah Cameron, Deputy Chief Policy Officer, Strategy and Policy.
Dr Anna McMartin, Manager, Community Wellbeing, Strategy and
Policy.
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d)
note that the following two areas could be potential priorities for the Ministry:
Noted
improving the whole spectrum of gender transition-related services (not just
surgery) by developing a model of care; and improving the accessibility and
suitability of healthcare for Rainbow people
e)
agree to discuss with officials where the Ministry of Health should focus our work
Yes/No
in the Rainbow policy area.
Hannah Cameron
Minister’s signature
Minister’s signature
Deputy Chief Policy Officer
Strategy & Policy
Date:
Date:
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Current work relevant to Rainbow people
1. The Ministry and other agencies are already doing work that will have a positive impact on
Rainbow people. There is potential to build on existing or emerging work programmes to improve
the health and wellbeing of Rainbow people.
2. The Intersex Clinical Network is already working to ensure that children born with intersex
conditions are getting the right support.
3. The Ministry has developed a proposal for a ten-year Sexual and Reproductive Health Action
Plan (SRHAP), which you will receive advice on. The draft SRHAP has a strong emphasis on
health equity for different groups, including people on low incomes, youth, Māori, Pacific and the
Rainbow community.
4. The draft SRHAP proposes actions in five key areas:
reproductive health
sexually transmitted infections (STIs) and HIV
sexuality and gender
sexual violence
information.
5. While all five areas of the SRHAP are relevant to Rainbow people, the ‘sexuality and gender’
area is particularly relevant. It focuses on inclusive schools, communities and health care. The
issue of HIV prevention, discussed in the section below, is also strongly relevant.
6. The Government’s youth-focused policies, both within and outside health, are expected to have a
positive impact on the health and wellbeing of Rainbow young people. These policies include
expanding School Based Health Services to all public secondary schools, and developing a
sustainable funding model for Youth One Stop Shops (which anecdotally are preferred by
Rainbow youth).
7. There is also scope to increase the focus on Rainbow people through other health policy
commitments, such as the primary care review.
Current Issues
Gender reassignment surgery
8. Gender reassignment surgery is currently topical, although it is important to note that surgery is
part of a broader spectrum of care for those seeking to transition their gender. Surgery is not
sought by most transgender people.
9. However, the demand for health services to support people undergoing or considering gender
transition is growing significantly, but public health service provision has not kept up with
demand.
10. General practitioners are key providers of services to transgender people, with secondary
services providing counselling and psychological services, hormone therapy and some gender
affirming surgeries (eg, mastectomy, hysterectomy, orchidectomy, and facial appearance
surgery). Gender reassignment surgery1 is provided overseas and is funded through the Ministry
of Health’s High Cost Treatment Pool, which is set up to fund surgery that is only available
privately or overseas.
11. Under current policy settings, which have not changed since 2004, up to four people every two
years can receive publicly funded gender reassignment surgery. To improve the availability and
quality of surgery options for transgender people, a model of care would have to be developed,
with a number of issues needing to be worked through:
1 The term is used here to refer to genital surgery, not other kinds of gender-affirming surgery to other parts of the body.
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what minimum level of care DHBs should be required to offer to transgender people seeking
to transition
how services to support transition could be arranged, at DHB and/or regional and national
level, so the limited expertise New Zealand has is made available across the country, and is
consistent
potentially adopting an ‘informed consent’ model, where transgender people can take the
decision to transition themselves, without needing the agreement of a mental health
professional
how gender reassignment surgery can be better provided nationally, given the recent
appointment to Counties Manukau DHB of a plastic and reconstructive surgeon with training
in this surgery, which has raised the Rainbow community’s expectations around the
availability of surgery.
Ending HIV Big Gay Out
12. Ending HIV is the theme of this year’s Big Gay Out, on 11 February in Auckland. Minister Genter
has been invited to speak, and the Ministry is supporting her with speech notes. We understand
the Prime Minister may also attend this event.
13. In 2017, Medsafe registered a new indication for the antiretroviral Truvada, registering it for pre-
exposure prophylaxis (PrEP). PrEP keeps the ‘viral load’ low in people with HIV, preventing
transmission to others. Men who have sex with men, transgender women who have sex with
men, and people with partners with HIV infection are most at risk of HIV infection. Yesterday (7
February 2018), PHARMAC announced that it will be widening funded access to Truvada for use
as PrEP in eligible people from 1 March 2018. This follows consultation on the proposal late last
year. Up to 4,000 people could benefit from this treatment in New Zealand. There is likely to be
high national stakeholder interest, and potentially international interest given New Zealand is one
of the first countries in the wold to publicly fund PrEP for the prevention of HIV.
Collecting data on gender identity
14. There has recently been public discussion around collecting data on diversity, in part because of
the upcoming Census, and the decision not to include questions on sexuality and gender
diversity.
15. Statistics New Zealand has developed a standard for the collection of data on gender diversity.
The Ministry and other agencies have been involved in this work. Some parts of the health sector
have adopted the standard, but others have not.
16. The challenge agencies now face is how to implement the standard. The Ministry is reaching out
to other agencies to scope up the kinds of implementation questions we will need to answer.
17. Issues to work through include supporting health professionals to have confident, comfortable
conversations about patients’ gender identity, the IT costs associated with changing data
collection, and timeframes needed to implement changes to data collection processes. It will be
important for agencies to work through these issues together, to make sure consistent
terminology is being used, and that agencies are identifying the same people consistently
through their different data collections. This enhanced information will enable us to better
understand and meet the needs of the Rainbow client group.
Sector engagement
18. The Ministry has a set up a quarterly meeting with a group of academics, researchers, clinical
leaders and advocates who work together on transgender issues (see Appendix One for their
details). This group has raised the followed suggestions with the Ministry, and may also raise
them with you:
the group is setting up a New Zealand Professional Association for Transgender Health
(NZPATH), and is seeking $15,000 from the Ministry to support a national hui this year
the group wants a New Zealand guideline on standards of care for transgender people to be
developed, and would like a financial contribution from the Ministry
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the group would like to work with the Ministry to improve our web content in relation to gender
reassignment surgery.
The Ministry is willing to support all three areas, but does not have funding available to offer financial
support.
Next Steps
19. In the Ministry’s view, the following issues are potential priorities for the health of Rainbow
people.
Gender transition-related health services that are publicly provided for transgender people are
provided by DHBs, with some GPs also providing hormone therapy, but service availability is
patchy. More consistent access to gender-transition healthcare is needed across the country.
Work is needed on a proposed model of care that includes a new national approach to
gender reassignment surgery.
Rainbow people (including transgender people) need access to healthcare that is accessible,
appropriate, and affirms their gender and sexual identity. A key element of primary care
accessibility is making sure health workforces have the capability to deliver Rainbow-inclusive
services.
20. We would welcome a discussion with you, on where the Ministry should focus its efforts in
relation to Rainbow policy.
END.
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Appendix One: Network of transgender academics, researchers, clinical leaders and advocates,
who the Ministry has an ongoing relationship with.
The following network of people has approached the Ministry for discussion. We have agreed to meet
with them quarterly.
Jeannie Oliphant – Clinical lead for Northern Region Transgender Health Services
Duncan Matthews – Waitemata DHB, Transgender Health Project Manager
Jack Byrne – Human rights consultant, TransAction
Jaimie Veale – Waikato University Transgender Health and Wellbeing specialist, Australia and New
Zealand Professional Association for Transgender Health Executive Board Member
Tom Hamilton – Community advocate, works for Outline, Body Positive and Unitec
Joey McDonald – Kāhui Tū Kaha, LGBTTI Liaison & Training programme lead.
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