We’ll be posting the contents of his presentation over the next few weeks, in tasty bite sized morsels, and the full paper (with all its references intact) will be available to download as soon as its been confirmed complete.

The story so far:

1 Introduction and Terms

2 What does sex and gender diversity have to do with Men’s Health?

3 Medical Professionals involvement in Making Men

4 Issues with Primary Health Care

5 Specific Health Issues

Todays post, and the final post in the series is beyond the cut

Funding Community-Specific Health Services

There is almost no national or state based funding for services responding to sex and gender diverse people’s health needs. One reason for the lack of funding is that sex and gender diverse people are rarely identified in government strategy or policy. This absence or invisibility at the strategy level means that those in positions to make funding decisions do not include sex and gender diverse people, as there is no requirement for them to do so and/or they fear they will not be supported in their funding decisions by those above.

Organisations anchored in the LGBT community have historically often provided the only services addressing the health of sex and gender diverse people. Many of these organisations struggle to obtain competitive funding for health programs and/or are forced to invest significant resources into fundraising and grant applications. In addition, many are not entirely comfortable with the inclusion of sex and gender diversity within a target group more actively focused around sexuality. This is reflected by the fact that many such organisations have ceased the inclusion of intersex people in their official target groups. This feeling is also reflected from many within the sex and gender diverse community – those who themselves identify as fiercely heterosexual, those who identiy as neither intersex nor transsexual and also those who are not comfortable with a further division of their community along the lines of intersex vs transsexual.

It is clear that sex and gender diverse communities have enough specific health needs to warrant specifically targeted and focused health services. The importance of such specific targeting has been recognized in other population groups as evidenced by the prevalence of womens health centres and indigenous health centres.

Given the high degree of specific knowledge required it is clearly more practical to train staff at specific gender centres of excellence than it is to provide all health services with the level of training required to bring them up to this level of expertise.

To be effective, it is critical that such services operate using Standards of Care based on informed consent and mutual respect models. There are currently no such services in Australia.

What you can do in your own service:
Sex and Gender specific health services are an essential but not the complete solution.

It is also critical that sex and gender diverse people are able to access adequate and appropriate health care from mainstream service providers.

On a practical level some things you can easily and quickly implement in your own services are:

• Review your intake/client form – do you currently ask “what is your sex?”. Do you really need to know the answer to that question? What difference does it make to your service delivery if someone ticks M as opposed to F? If you really do need to ask a question like this, change the way it is asked and encourage alternative answers (for example ask “How do you identify (male/female/other)?”
• Don’t make assumptions that someone is intersex/trans/neither/both based on their appearance/voice – instead, ask clients how they identify. If it is not appropriate to ask clients directly, the sex you indicate on data collection forms should be “unsure” unless the person has specifically aligned themselves as being male or female. Ask clients what their preferred pronouns are and respect their choice. If it is not appropriate to ask clients for their preferred pronouns, avoid using a pronoun until you hear the person use a pronoun themselves.
• Where a client identifies as sex/gender diverse respect their confidentiality.
• Ensure your resources don’t assume a necessary alignment between gender identity, legal sex, biological sex, genitals, sexuality or sexual practices
• Remember it is generally inappropriate to ask someone about the shape or functionality of their genitals – do not ask someone for medical diagnosis or surgical status merely out of curiosity.
• Seek out and provide training for staff on the basics of sex and gender diversity issues (such as the information included in this session).

We’ll be posting the contents of his presentation over the next few weeks, in tasty bite sized morsels, and the full presentation (with all its references intact) will be available to download at the end of the series.

The story so far:

1 Introduction and Terms

2 What does sex and gender diversity have to do with Men’s Health?

3 Medical Professionals involvement in Making Men

4 Issues with Primary Health Care

Todays post, is beyond the jump:

Understanding Health Risks
Another ongoing issue in health care is the high prevalence of (mis)understanding of risk factors that is based around a concept of sex and/or gender:

We all know for example that “men are at greater risk of heart disease” but does this mean a trans man is at greater risk than he was when he was a woman? Or that the trans woman continues to be at greater risk even after identifying and living as a woman? What about someone who is chromosomally neither male or female?

This issue also filters down to more general health and wellbeing issues that are part of targeted community health education programs. For example, how many standard drinks should a trans or intersex person have to fit within the recommended range? What safe sex information is most relevant for a lesbian trans woman who has not undertaken any surgical procedures? Whose responsibility is it to make this information available? Or to assess the effectiveness of its dissemination?

Too often it seems that health statistics and education campaigns are framed around the use of male and female as comparators simply because that is what we have come to expect. We must acknowledge that there is no inherent value in these comparators. Used inappropriately, they can serve to erase other perhaps more significant comparators (eg indigenous/non indigenous). We also need to acknowledge that using sex as a standard default comparitor is problematic for sex and gender diverse people to the degree that sex and gender diverse people are invisible within this framework – invisible to health services as individuals, invisible from health policy as a community, and provided with health information that is completely unintelligible to their reality.

Mental Health, Depression and Suicide
Very little research has investigated any health issues and outcomes relating to sex and gender identity, which poses serious problems for the development of robust and inclusive health policy. Here I will examine some of what we know about mental health issues specifically with relation to depression and suicide.

The rate of depression identified in the Tranznation report was particularly significant with 53.4% of the sample reporting one of the criteria for a current major depressive episode. Over 1/3rd of the respondents met the criteria for a current major depressive episode compared to 6.8% of the general population.

There is a long established and universally recognised association between depression and suicide. The Australian depression incidence indicated by the Tranznation report is in line with US and UK based research and that research shows around 1 in 3 trans people have attempted suicide at least once compared to approximately 1:380 for the general population.

Despite the rate of attempted suicide being approximately 125 times greater amongst sex and gender diverse individuals than the population as a whole, sex and gender diversity is not identified as a risk factor for suicide by any mainstream suicide prevention organizations in Australia.

For example, one national Australian organisation whose mission is to prevent depression states in a downloadable fact sheet that 50-60% of transgender people report having depression. Yet a search for “transgender” on the same website brings up only two other references – a brief fact sheet primarily focused on gay and lesbian issues, and a scoping study which contains no trans or intersex content at all.

The predominate focus of suicide prevention resources are currently targeted at men – on the basis of a suicide rate four times higher than the suicide rate amongst women. Personally I think that any men’s services receiving this funding has a moral and ethical duty to target at least some of these resources towards effective prevention strategies at the sex and gender diverse community who have suicide rates 125 times higher than the general population.

Broader Health and Wellbeing Issues

Most population level research in Australia has not included questions on the sex/gender diversity of respondents. Even where respondents have specifically indicated there status as gender diverse, most research ‘erases’ their response by randomly allocating their responses to either male or female categories. So while gender diverse people will have participated in this research, there is no way of analysing their responses compared to other population groups.

The 2006/2007 the Tranznation study found that on the SF36 scale, a standard measure of health, participants had poorer health ratings than the general population in Australia.

Tranznation also identified that although trans people were significantly higher educated than the general population, the largest proportion of participants earnt less than $20,000 pa. Unemployment rates, at 9.1% were more than double the national average of 4.4%. The Sydney Gender Centre quotes unemployment rates as high as 60% within the trans community.

Perhaps most importantly, Tranznation identified a clear relationship between the experience of discrimination and depression.

We’ll be posting the contents of his presentation over the next few weeks, in tasty bite sized morsels, and the full presentation (with all its references intact) will be available to download at the end of the series.

The story so far:
1 Introduction and Terms

2 What does sex and gender diversity have to do with Men’s Health?

3 Medical Professionals involvement in Making Men

Todays post, is beyond the jump:

Quality and Effectiveness of Primary Health Care

Despite the high interaction between health services and sex and gender diverse people, there is a remarkable lack of any research in relation to the quality or effectiveness of these interactions. Consistent with many findings within the Tranznation report, A Gender Agenda has also observed the following issues are commonplace:

Sex and gender diverse people tend to:

• have a general perspective of health providers as ‘gate-keepers’. This sense of a power imbalance leads to distrust and many sex and gender diverse people report that they are  not always comfortable being honest with their health service providers.
• have multiple GP’s most of whom are unaware of their sex/gender status
• are often treated inappropriately in public waiting rooms and/or are subjected to humiliating and unnecessary physical examinations
• are provided with inaccurate or misleading information including being provided with  pharmaceutical or surgical services without being informed of specific risks
• feel that they are often required to educate their health providers about sex/gender diversity before being able to receive health services
• have to travel interstate for common procedures because they are refused services by local doctors (this is true even from a capital city such as Canberra)
• avoid health services wherever possible because they are concerned about these issues
• be provided with inadequate and/or inappropriate health cover by Medicare and/or private health insurance (for example, Medicare will provide Testosterone under PBS for men but not women, and it will provide pap smear related rebates to women and not men. So, a person who has a cervix, but is legally male, is unable to obtain coverage to meet their needs.)

Our assumption is that most mainstream service providers want to be inclusive of sex and gender diverse people, but do not have the knowledge, skills, resources and leadership support to do so. Certainly we know that Sex and gender diversity are not usually covered in undergraduate training courses for health professionals, nor included in in-service training programs. There is little other professional development opportunities in the areas of sex and gender diversity. Organisational policies tend not to include issues for sex and gender diverse people, and there are few centres of excellence with the capacity to provide consultancy advice and support.

We’ll be posting the contents of his presentation over the next few weeks, in tasty bite sized morsels, and the full presentation (with all its references intact) will be available to download at the end of the series.

First post: Introduction and Terms

Second Post: What does sex and gender diversity have to do with Men’s Health?

Todays post, is beyond the jump:

The involvement of the medical profession in “creating men”

The starting premise in talking about mens health is that men “pre-exist” their interaction with health services. But I really want to challenge this position – because in my view, the medical profession plays an active and critical role in “making men” and in maintaining the illusion of binary sexes.

In the first few minutes of each of our lives, a doctor physically examined our genitals and ticked a box on a form – decalring to the world that we were either male or female. Why? Who was the patient? The mother? The newly born child? And what health need was being met by performing the examination? The answer is that there was no medical purpose at all – the only purpose was a legal one. And the examination itself was not performed on behalf of the patient, but on behalf of the state.

Many intersex infants with visibly atypical genitals have been subjected to surgery to more clearly ‘align’ them to a male or female physicality. Often this has occurred soon after birth – without the individuals express consent – and where there is no health related reason to perform the surgery1. Here the medical profession actively perpetuates the myth that all people are unquestionably either male or female, in this case, by surgically removing those body parts that prove that there is variation in human biology.

Some, but by no means all trans people have medical interventions to align their physicality with their gender identity . This may include hormones, and/or surgery such as mastectomy or genital reconstruction. Health services are necessarily involved in these interventions where they occur, and again, the role of those health care providers is fraught. Medical professionals here play the role of ‘gatekeeper’ – determining who can have surgery, under what conditions, what kind of surgery, and when access to that surgery will be permitted.

Many people in Australia are unable to change their legal sex from that assigned at birth. But for those who are able to apply for such a change (whether on the grounds of an intersex condition, or on the grounds of transsexuality), the new legal sex will only be recognised upon producing ‘medical proof’. Here the medical profession plays the role of ‘gatekeeper’ not just to the medical services provided to sex and gender diverse individuals, but also as to what legal rights their patients will have recognised by the state.

With the medical profession concurrently filling so many conflicting roles, they simply are not currently in a position that allows good health care provision to sex and gender diverse individuals.

We need to move from a medicalisation of identity, and acknowledge people as who they are without requiring state sanctioned medical intervention to ‘normalise’ their bodies.

We also need to adopt nationally consistent Standards of Care based on an informed consent model to assist health services to provide appropriate levels of care to sex and gender diverse communities.

We’ll be posting the contents of his presentation over the next few weeks, in tasty bite sized morsels, and the full presentation (with all its references intact) will be available to download at the end of the series.

The first post is First post: Introduction and Terms and todays post, is beyond the jump:

What does any of this have to do with men’s health?

When we use the term men’s health we deploy a range of assumptions about the biology, appearance, gender identity, lifestyle and health risks of the individuals we are talking about. But there are many people who do not meet some or all of these assumptions. Some men’s bodies do not conform to many assumptions of masculinity, some women have physicalities and face health issues that are commonly regarded as male-specific and some people simply can’t or won’t identify as either male or female.
In a national context where the development and assessment of future of health policy seems to be already framed in terms of “men’s health” and “women’s health” it is of significant importance that health services are cognicent of these issues.

The only purpose of specifically targeting mens health is to more correctly target health care services. But by doing this without acknowegdeing the diversity of men and of male identities we run the risk of further marginalising sex and gender diverse people who already suffer significantly worse health outcomes than most. I’m not arguing here against the targeting of mens health services – but rather that, in targeting “men’s health” services we need to challenge our everyday assumptions of sex and gender and be aware of not excluding services to sex and gender diverse individuals.

Why does it matter to men’s health?

Firstly it is worth noting that the prevalence of sex and gender diversity is far higher than usually acknowledged and that these issues therefore affect a far greater number of people than previously thought.

It matters to sex and gender diverse people because despite the fact that health studies erase our existence, and that only a very small number of studies focus on our needs, it is clear that the health risks and needs of the sex and gender iverse community are in urgent need of attention.

It matters to men’s health services more broadly because services that are able to recognise and respond effectively to issues of sex and gender diversity will as a necessary result provide more inclusive health services to all men.

We’ll be posting the contents of his presentation over the next few weeks, in tasty bite sized morsels, and the full presentation (with all its references intact) will be available to download at the end of the series.

Todays post, is beyond the jump:

Introduction
It’s been very interesting for me to have spent the last two days at a “mens’ health” conference – where I’ve heard lots of discussion and debate about the definition of “health”. But I’ve heard no discussion or debate around the definition of “men”. The reason for this, of course, is that most of us tend to assume that the definition of “man” is completely self evident and unproblematic.

That’s not the only thing we assume. We assume, when we say the word “man” that all people are, categorically, either male or female. We assume that the attributes that make a man a man are clear, definable, biological, fixed, and that they are categorically different from those characteristics that make somebody a woman. We believe these things to be true to such an extent that we assume that every time we meet someone, no matter how briefly, we will instantly “know” whether they are a man or a woman. And having just met a complete stranger and decided that they are a man, we assume that they identify as a man, that they are happy with this identity, that they always have been a man, that they always will be a man. We assume things about the chromosomes in every cell of their body; about the hormones that are inside their body; and about what their very body looks like underneath their clothes.

None of these assumptions are true all of the time, and this is what I’ll be talking about in this series.

Terminology and Prevalence

Intersex people can be defined as people for whom the development of chromosomal, gonadal, or anatomic sex is not aligned with our notions of a sexually binary biology. That is, there are biological physical differences that “can be seen as both male and female at once, not wholly male or female, neither male or female, or other ways of being that are not captured by current sex binary”. Estimates of the number of intersex people commonly vary from 1:100 to 1:2000 depending on the types of conditions included.

Gender identity is an individual’s internal sense of being a man, a woman, or another gender. Trans people can be defined as people whose gender identity is outside or crosses the social norms of ‘man’ or ‘woman’. I use the term “trans” here to explicitly include people identifying as transsexual, transgender, or genderqueer. Accurate estimates of the number of trans people are also difficult to obtain – most research uses a far narrower definition of “trans” and suggests the prevalence as somewhere between 1:4,500 and 1:8,000. A Gender Agenda’s membership in Canberra suggests that even this figure is an underestimate, and that estimates of 1:500 is probably more accurate.

Virtually no data is captured for trans people who do not seek medical treatment for gender affirmation. The growing number of people who identify as gender queer are essentially unacknowledged in any prevalence statistics. Due to the intense level of stigma associated with sex and gender variance, many intersex and trans people are often invisible to the general population and service providers for fear of discrimination and ridicule.

Terminology is hotly contested and culturally variable. For the sake of brevity and clarity I will be using the term “Sex and Gender Diverse”. This term is used with the specific intent of being inclusive not only of intersex and trans people but also of anyone who ‘falls through the gaps” of our binary sex model.

There is a common misconception that sex and gender diverse people can be identified “by the way they look”. This is generally untrue, and paradoxically, much of the inappropriate health care offered to sex and gender diverse people comes about because they are not visibly identifiable.

Some specific examples health services need to be aware of are that:

Someone presenting as male, who you identify as being unquestionably male may:

• have functioning female reproductive capacity
• require regular pap smears and/or be at risk of ovarian cancer
• identify as a woman

Someone presenting as female, who you identify as being unquestionably female may:

• be at risk of prostate cancer
• be at high risk levels for other ‘mens health” issues
• want to be perceived as male