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Trans People’s Access to Gender Reassignment Services
Health Sector Round Table Discussion
Introduction
This paper has been prepared by the Human Rights Commission, as
background information about the discussions we are facilitating between
trans people, health professionals and the Ministry of Health on access to
gender reassignment services. It outlines the objectives of the 27 February
2008 health sector round table discussion, and its specific focus on treatment
pathways and standards of care.
Background
On 18 January 2008, the Human Rights Commission published the report of
its Inquiry into discrimination experienced by transgender people,
To Be Who
I Am: Kia noho au ki tōku anō ao (www.hrc.co.nz/transgenderinquiry).
One of the three key areas identified in the Inquiry’s Terms of Reference
was:
• the accessibility of public health services to transgender people
(incorporating the minimum core obligations of both the primary
and secondary health services, including, but not limited to, gender
reassignment services)
The report’s Executive Summary sets out the following conclusions about
trans people’s access to health services:
The Inquiry found significant gaps and inconsistencies in the provision
of health services. The services that are available are ad hoc and
provided by a few dedicated health professionals. Most trans people
cannot access the gender reassignment services necessary for them to
live in their gender identity and appropriate sex.
The vast majority of services are not available within the public health
system, resulting in many trans people bearing the cost of private
assessments and medical treatments, either in New Zealand or
overseas. The cost of gender reassignment services is a significant
barrier to many trans people.
Trans people and health professionals are consistent in how to address
these problems. The first priority is to build on the Inquiry by having the
Human Rights Commission facilitate discussions between trans
people, health professionals and the Ministry of Health to map out clear
treatment pathways and standards of care.
Page 101 of the Inquiry report lists four recommendations and suggested
actions to improve the health of trans people:
Action
Who
With
Improve the health of trans people
Providing clear information about gender Ministry of Health
District health boards,
reassignment services available within
trans people
each district health board
Publishing a case study on treatment Ministry of Health
Trans people, health
pathways for trans people
professionals
Developing treatment pathways and Ministry of Health Trans people, health
agreed standards of care
professionals, Human
Rights Commission
Considering health insurance coverage for Insurance industry
Human
Rights
trans people
Commission,
trans
people
The focus of the 27 February health sector round table is on the highlighted
recommendation listed above. Health professionals, trans people and the
Ministry of Health have each indicated that the Human Rights Commission is
well placed to facilitate such discussions.
As the Inquiry report notes, the Ministry of Health has stated its support for the
development of an appropriate treatment pathway that addresses the whole
continuum of care from primary care through to secondary services:
The Ministry would be keen to support sector leaders, in partnership
with trans people, to develop an appropriate treatment pathway. This
process may also help to explore what kinds of supports would be of
greatest benefit to trans people in the public health system.
Further information about the Inquiry’s health findings can be found in Chapter
5 of the Inquiry report, and Chapter 9 which sets out the Inquiry’s findings and
recommendations. That material is an important foundation for the round table
discussions and includes the four components of the United Nations
framework for assessing whether the right to health is promoted and
protected. Specifically this framework requires that health services are
available, accessible, acceptable and of good quality.
Objectives
The objectives of the day are focused on a small number of concrete tasks
around the Inquiry’s recommendation that treatment pathways and standards
of care /best practice guidelines are developed for gender reassignment
services. The three objectives are:
Bringing trans people, health professionals and Ministry of Health officials
together to identify:
• the work required to develop treatment pathways and standards of care
/best practice guidelines
• the options for how this work could be done and
• the next steps for progressing this Inquiry recommendation
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Gender Reassignment Services
Trans people and health professionals raised significant concerns about the
barriers faced by those attempting to access gender reassignment services.
The Inquiry report used the term ‘gender reassignment services’ to describe
the wide range of health services that can assist a trans person to transition
medically. These include, for example, counselling, psychotherapy, hormone
treatment, electrolysis, initial surgeries such as a mastectomy / chest
reconstruction, hysterectomy or orchidectomy1, and a range of genital
reconstruction surgeries2.
Treatment Pathways
A treatment pathway is a specific plan outlining the various steps that a
patient will take from their first contact with a health professional, and what is
likely to happen at each stage. It includes any referrals until the completion of
the person’s treatment. The Inquiry used the concept of treatment pathways
to describe the need for clear steps that trans people can follow to obtain the
combination of available gender reassignment services that best met their
health needs. The steps taken, and in what order, will depend on the health
needs of an individual.
Standards of Care
During the Inquiry, both trans people and health professionals stressed the
need for standards that set out best practice guidelines for health
professionals who support trans people to transition. Most submitters cited the
Harry Benjamin Standards of Care (which have recently been renamed the
World Professional Association for Transgender Health’s Standards of Care
for Gender Identity Disorders). They can be downloaded from
http://wpath.org/Documents2/socv6.pdf
While these are titled standards of care, the document itself explicitly states
they are clinical guidelines intended to provide flexible directions for the
treatment of trans people. In many ways they reflect a consensus of best
practice, developed initially by members of the Harry Benjamin International
Gender Dysphoria Association. Trans people increasingly play a pivotal role
in the now renamed World Professional Association for Transgender Health
(WPATH), including its ongoing work revising these standards.
The WPATH standards of care focus on five aspects of clinicians’ work:
diagnostic assessment, psychotherapy, real-life experience, hormone therapy,
and surgical therapy. Submitters to the Inquiry identified the importance of
standards or guidelines that reflect international best practice and are also
modified to be relevant to this country.
The WPATH standards summarise the historical development of terminology
describing the diagnostic process whereby a trans person is deemed eligible
for medical interventions that will enable them to transition. That material
includes information about the diagnosis of Gender Identity Disorder in both
1 Surgical removal of the testes
2 Vaginoplasty for MtFs, metatoidoplasty or phal oplasty for FtMs
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the DSM-IV and the ICD-10. It concludes “the designation of gender identity
disorders as mental disorders is not a license for stigmatization, or for the
deprivation of gender patients' civil rights”.
Submitters to the Inquiry raised significant concerns about gender identity
being classified as a mental disorder. While amending this classification is
outside the scope and powers of this health sector round table discussion,
those concerns highlight the importance placed by trans people and health
professionals alike on developing gender reassignment services that accord
trans people dignity, equality and respect.
Process for Round Table Discussion
The agenda on the following page outlines the process for the 27 February
round table meeting. The meeting will be chaired by Commissioner Joy
Liddicoat and the facilitator is former Commissioner Warren Lindberg.
Appendix 1 lists the names of all those attending.
The agenda has been developed to draw on the expertise of those present, in
order to identify the necessary next steps for developing treatment pathways
and standards of care for gender reassignment services. While it includes
some short presentations, it focuses primarily on large and small group
discussions, to enable as much dialogue between participants as possible.
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Trans People’s Access to Gender Reassignment Services
Health Sector Round Table Discussion 27 February 2008
St John’s in the City Conference Centre
Corner Willis and Dixon Streets, Wellington
Agenda
Coffee and tea available from 8am onwards
9.00
Mihi / Introductions
Housekeeping
Ground rules / Meeting procedure
9.30
Objectives for the day (Warren Lindberg)
9.45
Inquiry overview and questions (Commissioner Joy Liddicoat)
10.10
Morning tea
10.30
Treatment pathways overview
(Deborah Woodley, Ministry of Health)
10.50
Group brainstorm of key issues
11.15
Small group discussion to discuss process for developing
treatment pathways
11.45
Report back from small groups and discussion
12.15
Lunch
1.00
Standards of care / best practice guidelines overview
(Judi Strid, Office of the Health and Disability Commissioner)
1.15
Group brainstorm of key issues
1.45
Small group discussion of options
2.15
Report back from small groups and discussion
2.45
Afternoon tea
3.00
Next Steps
3.45
Reflecting on progress against the day’s objectives
4.15
Decisions about material to be reported back
4.30
Closing
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Appendix 1: Health Sector Round Table Participants
The selection criteria for health professionals were that, between them, they:
• cover a range of medical disciplines
• have knowledge about the issues trans people face trying to access
gender reassignment services
• have worked with a range of trans people (e.g: MtFs, FtMs, trans
youth)
• come from a range of geographical regions
The selection criteria for trans individuals was people who:
• have been involved in the Inquiry
• have particular knowledge about the issues trans people face trying to
access gender reassignment services
• reflect the diversity of trans communities accessing gender
reassignment services including MtF, FtM, whakawāhine and fa’afafine
• come from a range of geographical regions and
• some of these participants also work in the health sector.
The following people participated in the round table discussion:
[ s 9(2)(a) ]
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Apologies were received from additional health professionals who were
unavailable on this specific day but are interested in this work. In addition, the
following officials participated from the Ministry of Health, or the Office of the
Health & Disability Commissioner
Judi Strid
Director of Advocacy
Office of the Health & Disability Commissioner
Alison Barber
Sector Accountability & Funding Directorate
Ministry of Health
Deborah Woodley (
morning only)
Sector Capability and Innovation Directorate
Ministry of Health
The Human Rights Commission organised and funded the round table
discussion, with participation from the following Commissioners and staff:
Commissioner Joy Liddicoat (Chair)
Former Commissioner Warren Lindberg (Facilitator)
Jack Byrne (Project Manager)
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