Transgender Health Care: Caring for Trans Patients

This four week course is currently available for free on FutureLearn and was developed by St George’s Hospital, University of London.

Week 1 – Introduction to transgender healthcare

Firstly we are introduced to the team who have produced the materials, though it quickly becomes clear that they have mainly cut and pasted information from Stonewall’s website and other freely available resources from the internet. Seven health professionals were allegedly involved in the production of this course, including Rog who ‘isn’t going by any specific gender currently but uses they/she pronouns’. Sounds perfectly sane to me.

The core element of the first week’s course was the above short film made by My Genderation (aka Fox Fisher and Owl – famous straight/trans couple) which was commissioned by the University of Glasgow and NHS Greater Glasgow and Clyde. If you have ever listened to any propaganda about transgender ‘healthcare’, it is all present – demands for GPs to prescribe hormones and blockers and describing the same as if they weren’t exogenous. Cries of unfairness at having to reveal themselves as trans when asking for a cervical screen (quite how one gets round that I don’t really know). And, of course, the ‘trans broken arm’ – denial that hormones cause any side effects.

Terminology

Transphobia

This term refers to hostile attitudes and discrimination towards trans people in society. Including the fear or dislike of someone because they are trans, including denying their gender identity or refusing to accept it. Transphobia may be targeted at people who are, or who are perceived to be, trans.

From Key Terminology section – my emphasis

Many of the definitions used are from Stonewall’s List of LGBTQ+ terms.

In the ‘Understanding Sex’ section we are told that there are five separate components that make up biological sex in humans; chromosomes, gonads, sex hormones, internal reproductive anatomy and external genitalia and that the World Health Organisation describes gender as a social construct. Again, Stonewall materials are relied upon to provide definitions for gender identity and gender expression.

Pronouns

Pronouns forms another section and links to an external website when grappling with the thorny topic of neopronouns. Someone in the comments in this section said they didn’t feel comfortable using pronouns and preferred to use their name instead, to which another generously responded: ‘Not using pronouns/using your name instead is perfectly reasonable – go for it!’

Despite this supposedly being about transgender healthcare, detailed advice on how to change your name by unenrolled deed poll is given. Participants are also informed that ‘a request for a gender marker change is all that is required – you don’t need a Gender Recognition Certificate’ for the majority of documentation, including a UK passport.

Some of the information about the Gender Recognition Act is false, for example, this claim:

The final section provided questionable crime statistics about hate crime towards trans and non-binary people, but the best yet, a group of ‘trans actors’ playing out a fictional scene in an audio play.

The first scene is taken up fully by them announcing their pronouns. The learner is asked to think of three questions they would like to ask zes/zirs, and then we are told what we must not ask.

Don’t ask them about their genitalia!
Don’t assume that symptoms might be related to cross sex hormones!
There have been trans people for centuries!
If you don’t know any trans people it’s probably because they don’t feel comfortable around you!

But don’t worry about making mistakes!
No one will want to talk to you about their trans status if they think you’re horrible!
But again, don’t worry about making mistakes though!

Or something like that.

Extraordinarily one of the scenarios is that one of them is suffering from a psychosis and that their trans identity is nothing to do with their psychosis. There is also a longish segment where one talking head justifies ‘self-medicating’ from internet suppliers. Zir sounds completely mad.

Example of the type of things the actors say in the audio clips – from the fourth segment (1.21)

Another tells us that physiotherapy wasn’t working, but when a new health professional came along and starting using the correct pronouns, she was able to avoid having an operation and made a full recovery. Fancy that!

Week 2 – Trans-specific healthcare considerations

There was the issue of ‘gate keeping’ in healthcare, with the case of Julia Grant, a man who ‘transitioned’ in 1979 being cited. Things had moved on a lot since then, but on the other hand had barely moved on either.

The pathway to ‘transition’ is described, including the need to store gametes, without additional clarification that ‘gender affirming care’ ends natural fertility once and for all.

Anecdotally, some trans people have reported that they felt pressured to change their responses to questions asked by healthcare professionals at a Gender Identity Clinic (GIC) in order to meet this perceived criteria.

From Gender Dysphoria Diagnosis section

Binding

Binding is described as a ‘gender-affirming practice’ not currently covered by the NHS. An example of a commercial binder is used from a real supplier of binders – SpectrumOutFitters. It is emphasised that binding with commercial binders is safe, but using duct tape and bandages may cause ‘ribcage deformity, type 2 respiratory failure, lung infection, and skin damage’. If you find one of your patients is using their own methods, guide them to a commercial option instead. If they can’t afford a binder, join a binder exchange scheme.

A study had shown that 97.2% of women had experienced negative physical effects using binders – see here. Which begs the question why this course is promoting the use of them at all.

Tucking

On the subject of tucking (i.e. where men tuck their penis and testicles away), the advice is ‘you should educate them in a non-judgemental way about the risks involved and signpost them to safer alternatives’.

Peckers and Packers

Unbelievably a link to another company who provides the same is given – Transthetics (link will open to explicit imagery).

Voice therapy

Please note that there is nothing inherently female or male about anyone’s voice. Such labels are merely attached to personal attributes by society and are upheld by cisnormative values and beliefs.

Voice training section
It actually links to the website of disgraced doctors Drs Michael and Helen Webberley – extraordinary

Cross sex hormones

These are referred to as ‘gender-affirming hormone therapy (GAHT)’. A new acronym on me. We are told that people do not need psychiatric evaluation prior to these and, because of the long wait times to be seen in the GIC, GP surgeries are the perfect place to start getting your prescriptions from, and provides the criteria under which GPs are advised to dispense.

In contradiction to an earlier statement about hormones not causing any serious side effects, we are told that liver and kidneys can be adversely affected, there is a risk of stroke, endometrial cancer and the need for regular ultrasounds of the uterus.

‘Puberty blockers’

They are very safe, reversible and have been used for a long time in ‘cisgender’ children. There is no evidence of increased risk of osteoporosis or reduced fertility. So nur. Again Gender GP is cited and a link to an article from their website posted.

On the left side is the information on the use of puberty blockers for cisgender children to stop/delay puberty in the case of early (precocious) puberty.

On the right side is the information outlining the use of puberty blockers (same medication) for trans children and young people to delay puberty.

What do you think about the content and tone of the two webpages outlining the use of the same medication (puberty blockers) for these different patient populations?

Puberty blockers section

Sudden withdrawal of sex hormones

Despite ‘puberty blockers’ being entirely safe, we are told that the sudden withdrawal of oestrogen use in men can cause osteoporosis and that ‘Sex hormones are essential for the maintenance of bone density and cardiovascular health’.

Self-medicating

People do it and here’s how you can (i.e. a visit to CliniQ who will do the blood testing for you).

Also some of the risks associated with this are explained briefly, the obvious point that it could lead to death missed out.

Impact of gender affirming healthcare

Only the positives.

Surgeries

Described in gender affirming language rather than clinically (remember this is a course aimed at doctors and believe me, there are many healthcare professionals in the comments), when it comes to describing the aftercare we learn that some people might experience a bit of swelling and tenderness which might restrict movement for a bit. Having baths might be difficult immediately following genital surgery. Though it is admitted that women who have had a radial forearm graft might need occupational therapy to get their hands moving again due to nerve damage.

This is one of the recommended videos – a woman who still has fine motor problems in her affected hand and who couldn’t sit on her bum for weeks.

Again, impact of gender affirming healthcare

Only the positives. Again.

Fertility for trans people

An archived document from 2013 is referred to – an Interim Protocol developed by the NHS. Trans people should be offered gamete storage and it should be funded. The current position held by the NHS (if there is one) is not linked.

Tayler is used an example of a child who has thrived on ‘puberty blockers’

A trans activist spin is given on the recent case that Keira Bell bought against the Tavistock and participants are asked to consider what impact there is on trans young people if they can’t access treatment. Nothing is mentioned about why Keira Bell felt the need to bring the case in the first place.

End of week summary

I literally have no idea why this video forms part of the course.

Josie had a botched vaginoplasty surgery fixed by the infamous Marci Bowers. Josie, a 70 year old, discusses this with an 11 year old boy and tells him he might one day be able to have a baby.

That we can become what some awful people in this life call ‘real women’. Do you know what I mean? We are real women, we are real girls.

Josie to Poppy

Week 3 – Trans inclusive services

Tabby Lamb is treated ‘rudely’ by a clinic receptionist. Tabby is wearing a boob tube and wants to change his name but the clinic receptionist, curiously dressed in scrubs, refuses. If you want to find out more about Tabby, we are told, follow him on Instagram.

Pronouns, pronouns, pronouns

If you don’t know someone’s pronouns, refer to them as they/them. You know it’s right. Avoid any sort of gendered language and don’t, whatever you do, use anatomical terms. Challenge colleagues who appear not to comply with this.

Non-binary oppression

They aren’t recognised in database systems you know! If you work in the NHS find your LGBTQI+ network group today! Even if you’re an ally!

Toilets

People have the ‘right’ to use whatever toilet they want. Putting sanitary bins in men’s cubicles also helps ‘cisgender men dispose of incontinence products’. Grim and a totally incorrect use of a waste bin designed to store waste menstrual products only. PHS won’t be amused.

Rainbow badges

Don’t forget to wear one.

Confidentiality

You aren’t allowed to share with anyone else if you know someone is trans by law and therefore don’t do it. None of the associated healthcare implications are considered. Just don’t do it (to be contradicted later). Respect the person’s identity. If a trans person status is suddenly revealed, consider putting them in a side room. Non-binary people may also prefer this option.

Wards

Not putting trans people on the ward of their choice is a breach of the Equality Act 2010, unless you’re a woman having a hysterectomy because testosterone has shrunk your womb and you are now in chronic pain which only surgery can relieve, then you have to go onto the women’s ward.

Trans broken arm

Don’t assume that someone’s medical problem is in anyway related to sex cross hormone use, especially if they have broken bones, because, as we’ve learnt, these do not thin the bones.

Week 4 – Culturally competent clinical communications

Peter picks a peck of picked peppers.

Case studies

Travis

Out of the blue we are presented with a complex medical picture. Travis, a 30 year old woman has presented with a past medical history of cerebral palsy, sex change surgery, is on high dose pain medication for left hip pain, antidepressants and receives intramuscular testosterone injections on a monthly basis. She is wheelchair-bound and has a motor speech disorder. Travis’s pronouns are zir/ze. We are asked if we think the delivery of testosterone is appropriate for the patient.

Comments from the students range from ‘we didn’t need to know that zir was trans’ to ‘it sounds like a car maintenance referral’. I really have no idea why these people are pursuing a career in medicine if phrases like ‘wheelchair bound’ and a list of medications are freaking them out.

We go into quite a lot of detail about zirs life, including watching ze in a consultation with an occupational health therapist, who then discusses zir at an MDT meeting. The therapist shares Travis’s pronouns to the meeting without permission. Um. That’s bad. But actually, no, ‘hormones can affect bone health’ so we learn it is actually okay after all. But maybe not. They really can’t make up their minds.

James

Then we meet James, a young woman who visits her GP to request antidepressants. James has been ‘self-medicating’ with testosterone off the internet already and her family are ‘hardcore Catholics’. The GP advises against buying stuff of the internet and that she needs regular blood monitoring, James response is ‘it’s my body, my choice, I’m not going to stop doing it’. Then we are given a leading question, should the GP provide a bridging prescription?

James then reveals that she has self-harmed by cutting her arm and has suicidal ideation. The GP makes a referral for counselling and organises for James to come in to have monitoring blood tests, i.e. defacto taking over the care of the prescription of cross sex hormones. Enjoy getting sued in ten years’ time love.

Later James experiences a sprained wrist playing rugby. With the boys. The boys had no idea she was trans but are really cool with it. The GP makes a referral for physiotherapy and tells James she will be seen in a ‘couple of weeks’. What planet are they on?

Diana

Of course, there had to be a trans woman of colour engaged in sex work. Diana thinks he might have been infected by a client with an STD. He takes oestrogen and testosterone blockers. The healthcare professional recommends PrEP to him. The incident arose as a result of the client removing a condom during sex without permission. This is technically recognised as sexual assault under UK law and thus Diana is asked if he is safe. Diana ends up on PrEP to save him from getting HIV.

And that is the end of the course.

Summary

Hopefully someone at St George’s Hospital is going to be professionally embarrassed by this utter cack. On the topic of bone thinning alone the course materials gives conflicting information a number of times. This is nothing but thinly veiled political agitation. There is no attempt whatsoever to come to grips with the relevant medical problems. Talking therapy for those who might resolve their gender dysphoria is not mentioned once. The fact that several commercial services are signposted surely breaks some of code and the recommendations we follow the actors on Instagram fatuous (though not for the individuals concerned I suspect).


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