Is the provision of gender affirming health care equitable across the District Health Boards in Aotearoa, New Zealand?

21 Sep 2019 4:16 PM | Anonymous member (Administrator)

The inaugural Aotearoa Trans Health Symposium was held in Hamilton in May 2019. The symposium attracted almost 200 delegates, including health professionals and community members. As part of the event, a panel discussion was held to outline what gender affirming health care was being provided by District Health Boards (DHBs) around the country. Panelists involved in the provision of trans health from 13 DHBs spoke about the services available in their DHB.

Prior to the symposium, Dr Jeannie Oliphant conducted a survey of clinicians from around New Zealand. Information was sought from clinicians providing gender affirming healthcare in all of the 20 DHBs in New Zealand with the exception of West Coast DHB for which no appropriate clinician could be identified. No response, unfortunately, could be elicited from the clinicians approached in the Southern DHB but survey responses were received from clinicians representing the 18 remaining DHBs. In some regions, multiple DHBs share services and resources, such as the Auckland region which is made up of three DHBs; Waitemata, Auckland and Counties Manukau and the Wellington region which also has three DHBs; Capital and Coast, Hutt and Wairarapa.

The 2018 Guidelines for Gender Affirming Healthcare for Gender Diverse Children, Young People and Adults in Aotearoa, New Zealand has made a series of recommendations for the provision of gender affirming healthcare in this country.1 One of the key recommendations in the guidelines is that DHBs provide clear information on pathways to access gender affirming healthcare services and that DHBs have clear and timely referral pathways for young people and their whānau to access information and trans health care.

There is good evidence that provision of puberty blockers and gender affirming healthcare for trans young people significantly improves mental health and wellbeing outcomes.2,3 It is well recognised that young people who are trans and gender diverse report high rates of distress, with a national survey of secondary students showing that significant depressive symptoms and suicide attempts in the past 12 months were reported by 41% and 20% of trans students, respectively, compared to 12% and 4% of their non-trans peers.4

Of the 18 DHBs, 9 (50%) have some information available to clinicians regarding referral pathways for gender affirming healthcare in their region but only the three Auckland region DHBs (17%) provide information to the public on the healthcare available and how to access this. The simple act of providing publically-available information would relieve a huge amount of distress and frustration for those people trying to access support for themselves or their whānau.

Another key recommendation in the guidelines is that DHBs provide equitable and accessible gender affirming healthcare services that align with international standards, evidence-based literature and community feedback. While detailed information about the health services were not obtained, it was reassuring that puberty blockers and hormonal therapies could be accessed through all 18 of the DHBs, although some smaller DHBs reported difficulty in providing this care.

The guidelines recommend that health services enable the involvement of trans and gender diverse people, including Māori trans and gender diverse people, in decisions that affect them with regard to the development and provision of services.1 The importance of involving consumers in the development and oversight of clinical services is well understood in the health sector. However only nine DHBs (Auckland region x 3, Waikato, Wellington region x 3 and Canterbury region x 2) have some form of clinical and consumer advisory group providing input into service development. The guidelines also recommend that DHBs provide clear pathways for timely access to gender affirming healthcare, including puberty blockers, hormonal therapies, fertility preservation, voice therapy, counselling and mental health support, and gender affirming surgeries. Not all trans and gender diverse people will want to access all of these interventions, but for some this is immensely important.

Counselling support was available in seven of the DHBs, with nine DHBs only having limited access and two DHBs not providing any counseling support. The table below highlights the postcode lottery nature of obtaining gender affirming healthcare in New Zealand at present.

District Health Board

Fertility (sperm freezing)

Voice therapy

Chest surgery

Hysterectomy

Orchiectomy

Northland

Yes

Yes

No

Yes

Yes

Waitematā

Auckland

Counties Manukau

Yes

Yes

Yes

No

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Waikato

Yes

Yes

No

Limited access

Limited access

Lakes

No

No

No

Unclear

Unclear

Bay of Plenty

Yes

Yes

Some access

No

No

Tairāwhiti

No

No

Yes

Yes

Yes

Hawkes Bay

No

No

No

No

No

Taranaki

Yes

Yes

No

No

No

Whanganui

Yes

No

No

Unclear

Unclear

MidCentral

Yes

No

No

Yes

Unclear

Capital & Coast

Hutt

Wairarapa

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

Nelson/Marlborough

No

Yes

No

Limited access

No

West Coast

Not contacted

Canterbury/Sth Canterbury

Yes

Yes

In progress

In progress

In progress

Southern

No response

It is clear from the above table that there is a need for a conversation between the Ministry of Health and DHBs regarding the minimum standard of gender affirming healthcare that should be provided. This would be beneficial for trans and gender diverse people in all regions of New Zealand. In addition, there are some very simple and low-cost initiatives that would make a huge difference for trans and gender diverse people and their whānau around New Zealand, such as DHBs providing publicly-available information on the pathways to access services.

References:

1.      Oliphant J, Veale J, Macdonald J, Carroll R, Johnson R, Harte M, Stephenson C, Bullock J. Guidelines for gender affirming healthcare for gender diverse and transgender children, young people and adults in Aotearoa, New Zealand. Transgender Health Research Lab, University of Waikato, 2018.

2.      de Vries AL, McGuire JK, Steensma TD, Wagenaar EC, Doreleijers TA, Cohen-Kettenis PT. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics. 2014;134:696- 704.

3.      Olson KR, Durwood L, DeMeules M, McLaughlin KA. Mental health of transgender children who are supported in their identities. Pediatrics. 2016;137(3):e20153223.

4.      Clark TC, Lucassen MF, Bullen P, Denny SJ, Fleming TM, Robinson EM, et al. The health and well-being of transgender high school students: results from the New Zealand adolescent health survey (Youth ’12). J Adolesc Health 2014 Jul;55:93-99.

About PATHA

The Professional Association for Transgender Health Aotearoa (PATHA) is an interdisciplinary professional organisation working to promote the health, wellbeing, and rights of transgender people. We are a group of professionals who have experience working for transgender health in clinical, academic, community, legal and other settings.

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