Transitions: Reflecting on Trans-Affirmative Health Care

Disclaimer: The following transcript has been autogenerated and may contain occasional errors or inaccuracies resulting from the automated transcription process.

Host (00:01):

Hi there. Welcome to Mental Health Professionals Network podcast series MHPN’s aim is to promote and celebrate interdisciplinary collaborative mental health care.

Dr Monica Moore (00:17):

Welcome to Transitions, a series of conversations between two clinicians where we share our perspectives on life’s transitions, the challenges, the gifts, and what we find fascinating and helpful. I’m Monica Moore, a GP with a special interest in mental health. Today I’m really excited to introduce a special guest, Dr. Martina Gleason. And Martina and I have known each other for more years than I can count, and I’m so looking forward to doing a deep dive. So Martina, you and I, we’ve been chatting about this deep dive and we are working today to talk about the transitions that occur when people discover that perhaps the agenda that they’ve been assuming or being is not actually their gender. And it’s such an interesting thing, this transgender space. But before we do that deep dive, tell us a little bit about yourself.

Dr Martina Gleeson  (01:14):

Oh, hi Monica. As you say, we’ve known each other for a long time. I’m a GP practicing in the Sutherland Shire of Sydney, and I’ve been practicing as a GP for about 30 years. I’ve always had, as most GPs, quite a proportion of my practice that is in the mental health space. I realised that I needed to increase my knowledge in the transgender area when one of my patients who I had known since childhood came out as transgender and I didn’t have the skills to help them transition. So I took responsibility for myself and increased my education and now caring for transgender people is a small part of my practice that I really enjoy.

Dr Monica Moore (02:01):

So it’s such a sort of an interesting field because it’s kind of new, but it’s not new. I mean, I know when we were chatting you were kind of going, yeah, but Monica is not that new.

Dr Martina Gleeson  (02:15):

No. Transgender people have been around all throughout history and pre-history and across all cultures. It’s not new. What is new is the visibility and giving people, I think the words to be able to express their experience. People that have come out in public, like Caitlyn Jenner and Elliot Page, giving people a chance to see someone else owning that experience and maybe helping them to understand what’s been going on inside them. Although, of course, many people express that desire to be recognised as a gender that wasn’t assigned to them at birth from quite a young age. But because it hasn’t been socially acceptable, people tend to say, no, no, no, you are not a boy.

Dr Monica Moore (03:13):

You’re a girl. Yeah. How young?

Dr Martina Gleeson  (03:15):

Well, some children really express that desire to be something that they haven’t been labelled from three or four. As soon as they have words, they’re

Dr Monica Moore (03:23):

Quite young.

Dr Martina Gleeson  (03:24):

Yeah,

Dr Monica Moore (03:24):

Yeah.

Dr Martina Gleeson  (03:27):

Although not all people have expressed that desire. So it doesn’t have to have been present since that young age. But many will say to you, I wanted them to cut my hair short and I wanted to be a boy.

Dr Monica Moore (03:44):

One of the things that we were talking about when you were telling me about this new interest of yours, and I was thinking about when we are thinking about the mental health sort of aspect of it, you mentioned something called gender dysphoria, and I just wondered because you had to explain to me what it was and what it wasn’t and all that. So can you tell us more about that? Sure, sure.

Dr Martina Gleeson  (04:10):

Maybe I’d like to start first off just by talking about what is transgender?

Dr Monica Moore (04:14):

That would be, yes.

Dr Martina Gleeson  (04:15):

Because people who are cisgendered, like you and me,

(04:20):

Our experience of our gender is the same as the experience of our sex. Our sex is what we are biologically chromosomally defined as. So when they look at our nappy area when we are born, they say, oh, it’s a girl. In our case, and for a lot of the time, that ends up being that our gender experience, which is our expression of who we feel like inside, which is more in our brain, does align with the biology that we have. But for transgender people, their experience of gender is different to their sex assigned at birth and gender dysphoria is probably a medical way of trying to explain that experience or that expression. It’s been an interesting journey because if you look at various versions of the DSM over time, I think at one stage it was called transvestism,

(05:30):

Then gender dysphoria became the next iteration, which it was a mental health disorder. Whereas most people who are trans will tell you that they’re not necessarily mentally unwell just because their experience of gender is different to their sex assigned at birth. But gender dysphoria is the distress someone would feel at that experience of having their gender being different to their sex assigned at birth. Interestingly, the ICD 10, which is another way of, I think it’s the 11, has now taken gender dysphoria out of the mental health chapter, and it’s put it into the sexual health chapter so that it’s no longer thought of as necessarily a mental health disorder, but more of a difference in sex and gender, but not sexuality because sexuality is different. Again, that’s who you’re attracted to, so it can get a bit confusing sometimes.

Dr Monica Moore (06:41):

And so sexuality, so there’s physical chromosomal sex, there’s gender, which is what we identify as in terms of whether we feel feminine or masculine, and then sex

Dr Martina Gleeson  (06:54):

Or somewhere in between

Dr Monica Moore (06:55):

Or somewhere in between. That’s right. And in different situations, look, there’s such a variety of human experience, isn’t it?

Dr Martina Gleeson  (07:08):

If you are struggling with it, sometimes it’s helpful to look at the model. There’s two different models that are used to explain it. One is the genderbread man and the other is the gender unicorn. And if our listeners were to look that up, they would find these lovely illustrations that show that sex is about your biological bits and your chromosomes and gender more lives in the brain and how you feel. And then you have romantic attraction or sexual attraction. So it explains, and then there’s also the expression, so you may well feel like a man, but to wear dresses or present in a more, I hate to say feminine way, because it really is the binary, and hopefully we’re moving through past that.

Dr Monica Moore (08:02):

When I wear jeans and a jacket or something like that, I’m not really expressing a masculinity. It’s actually like it’s just really practical to wear pants. But when I’m wearing a dress or a skirt, it’s kind of a bit flowy and there’s more air. And so why should it just be a gendered thing?

Dr Martina Gleeson  (08:21):

So maybe the message is don’t judge people by the outside, but check in with them

Dr Monica Moore (08:27):

Exactly. So this leads me to the next thing, because sometimes I think in my personal life, I feel a bit awkward sometimes because it’s all, how do I create a sense of inclusion and a sense of not offending someone and not putting my foot wrong, but also as a clinician, how can we change our language? How about we start with their language?

Dr Martina Gleeson  (08:54):

Yeah, sounds good. So as a clinician, when you’re meeting someone for the first time, you ask them their name, don’t you?

(09:02):

And if, well, if their name is you can’t pick, then you can, one way of saying it is introduce yourself. So I’ll introduce, my name is Martina and my pronouns are she / her. And that gives someone an indication that, and some people who are not used to that kind of language go, why would you tell me that? But a transgender person will acknowledge that you recognise that some people’s pronouns are different, and we’ll often offer you their pronouns. Sometimes if I’m meeting a new patient and they’ve been booked in as a transgender patient, but our computer systems have trouble dealing with, I would just say my pronouns are she her. What pronouns do you use? And that gives us a chance to just establish where we’re at. And I don’t question what a person declares themself to be. Not my job really.

Dr Monica Moore (10:05):

No, no. Is if you were to define out our job as clinicians, I mean you as a GP, but also anyone who’s more in that mental health space, what are we actually trying to do?

Dr Martina Gleeson  (10:18):

Well, if a transgender person comes to you, I guess you have to work out what their goals are in coming to you and start with the goals that they declare. There are some interesting legacies from some ways of providing gender affirming care. So one of the models of care is that before you start gender affirming treatment, you need documentation from two different mental health professionals that you are transgender. And that’s been a kind of gatekeeping. Thankfully, in Australia, we have a different model of care for medical, not surgical, but for medical approaches that people might want. And so it’s called informed consent, and it doesn’t require a mental health professional to sign off

(11:20):

And say, which I’m very pleased that we don’t require that. We’re still needed for surgical procedures. So that’s one thing. You might find someone coming, but it’s more often that the person with the transgender experience is also experiencing some mental distress, perhaps as a result of their transgender experience, perhaps a result of if they’ve come out as an adult, they’re transitioning in their relationship, they’re transitioning their workspace or their educational space or with their friends. And there may be distress not caused by the fact that they’ve decided to come out, but by their fear of rejection or their experience of rejection, hopefully more these days there’ll be more embracing rather than rejection, but still, people are frightened of what will happen to them. And so they may need support with that.

Dr Monica Moore (12:22):

And they might be coming for something just random,

Dr Martina Gleeson  (12:25):

Might be something completely different.

Dr Monica Moore (12:26):

Completely different. They’ve had a trauma at work or they’ve just Yeah, so it could actually be any, I mean, I remember you told the way you put it, it’s like the clinically broken arm, Monica, and I just thought, oh, what a great way of, so yeah,

Dr Martina Gleeson  (12:47):

So trans people talk about the broken arm syndrome, and what they are referring to is if someone goes to hospital with a broken arm, you want to deal with their broken arm. And sometimes if it becomes, it comes out that your transgender, all of a sudden the questions are about what’s in your pants and what your gender experience has been, and all of a sudden some symptoms you’re experiencing might be blamed on the hormone treatment you’re on. That’s gender affirming hormone. It’s actually got nothing to do with the broken arm. So as clinicians, it’s really important for us to keep the focus on the presenting thing and respect the person in front of us and really only explore that part of it, the gender part of it when it becomes relevant. So for example, I have some transgender men as patients who still have cervixes.

(13:46):

And so when I’m talking to them about their whole of person care, and that includes cancer screening, it is necessary for me to say, well, do you have cervix? Because if you do, we need to talk about cervical screening. But if they’ve come in with a sore throat, I don’t need to know if they’ve got a cervix. So yeah, it’s just about respecting the person where there is. And as a mental health clinician, if someone comes in about depression, you don’t necessarily blame it on their gender experience. You explore with them their whole of person experience just like you would with anybody else.

Dr Monica Moore (14:28):

And I was thinking, I remember in our discussion something that I thought about that happened or maybe happened to someone else. I don’t think it happened to me, but you know how your stories get incorporated into your own lifeline. Anyway, it was a story about someone who presented with quadriplegia in hospital, and they had maybe, I can’t remember what it was, but it wasn’t related to their sex life. But suddenly the medical students and the doctors we’re all interested in how do you have sex?

Dr Martina Gleeson  (15:00):

We’re very privileged in an intimate space with our patients, with the people who come to see us. We do get to talk about very personal things with them, but we do need to be careful that we are not abusing that privilege

(15:18):

And seek permission, and we also need to be careful to not make the person in front of us responsible for our education. So if you are seeing someone who is transgender and you’re not quite sure what’s going on about being transgender, then it’s important that you go and educate yourself, find some resources and read so that you understand things from their point of view. And it’s a fine line. You want to be respectful of their experience and learn about their experience, but at the same time, you don’t spend your therapy sessions learning about transgender in general. You go and you read up about it just like you don’t. Can I think of another alternative? Well, if I was dealing with somebody who was Aboriginal, I wouldn’t necessarily expect them to educate me on everything to do with their experience because of being Aboriginal. I would go and read and become informed for myself.

Dr Monica Moore (16:36):

Where have you learned your stuff from?

Dr Martina Gleeson  (16:38):

Lots of reading.

Dr Monica Moore (16:40):

What sort of reading?

Dr Martina Gleeson  (16:43):

When I first started, I actually took myself off to some whole weekend education events, and I’ve been to lots of education events for GPs to learn about it. I’ve joined the Australian Society for People providing transgender care called Spath and learned from people in those groups. I go to a peer support meeting with other doctors where we get into the nitty gritty of the hormone prescribing and stuff like that. There is also, since just in the last few years, there are some really good websites in Australia, and ACON in New South Wales has developed a fantastic website called Trans Hub, and it’s got a lot of information for people experiencing gender issues and for their allies and for clinicians involved in their care, and also information on the legal aspects of changing your markers and things like that. So I’ve learned a lot from that. It’s been a very well developed resource. There’s also an organisation in Melbourne that’s doing a lot of research, and you can read their papers. I think that’s called trans research.org. So once you’ve got an interest in something, it’s pretty easy to finding stuff.

Dr Monica Moore (18:08):

Keep reading up on it. Yeah.

(18:14):

One of my interests is that when I was really young and a clinician, I wasn’t even aware of my faux pas, and then I became aware of my faux pass, and then I would just go, okay, I just can’t do this, so I’m just not going to work in that space. And I would set some boundaries, and now I still set some boundaries, but I’m more like, if I make mistakes, I will go, okay, well how can I learn from this and also apologise to the person. But there are times how do we negotiate our own discomfort? Because sometimes it can be like, now they don’t have any brain space for this. You know what I mean? I think we have to acknowledge, I’m really interested in the clinician experience as well. I mean, I know we need to think about the patient or the client, but what do you think about that?

Dr Martina Gleeson  (19:10):

I struggle most when I met someone in the gender assigned at birth, and then that was my initial struggle changing the pronouns that I used, changing my thoughts and even the name. I might meet someone with one name and then they take on the new name. And so before each consultation, I used to have to say to myself, okay, now I’m about to see Jack. I remember Jack’s name previously as such and such, and I won’t say that name because often people say, that’s dead name and Jack has a cervix and jack’s on testosterone, and just get my head around so that I then am less likely to make a faux pas.

Dr Monica Moore (19:58):

You clearly don’t make as many faux pas as I do

Dr Martina Gleeson  (20:00):

It gets easier, and I’ve got in my notes what pronouns they use, but I still sometimes make a mistake. And if I do, I just say, look, I’m sorry. And we move on. And most of my clients are quite forgiving if I make a mistake and apologise immediately. But not just, you don’t make it about you when you’re apologising. You don’t require lots and lots of reassurance. You just, respectfully, I’m really sorry I got that wrong. And then state the right thing and then move on. And hopefully by showing that you are making the effort to get things right, that’s an experience for the person that’s in your room with you.

Dr Monica Moore (20:51):

And I remember when we first graduated, and I’m older than you, so the idea that prescribing the pill was still a thing or even referring for a termination, and that there were some people who were hugely uncomfortable with that. And so they were then required to have a sign in the waiting room to say, doctor X doesn’t prescribe the pill or doesn’t refer for termination. So if this is what you’ve come for, don’t see Doctor X. I mean, I really want to sort of honour both sides of the equation. You know what I mean? When we are thinking of, because we still, it’s the thing about transitions, isn’t it? Like that sort of liminal space in between the before and the after is just so uncomfortable. How can we do it in such a way that is respectful of both sides?

Dr Martina Gleeson  (21:45):

I think, I mean, I’m the only doctor in my practice at the moment that prescribes gender affirming hormone treatment. But I still, I’ve asked all of the doctors in my practice to be aware of using correct pronouns and all of my admin staff, and actually my admin staff are wonderful. They’re very keen to get it right. They’re checking in with me to make sure that right,

Dr Monica Moore (22:11):

And even the toilet sign, making it a unisex toilet. So we don’t have that whole,

Dr Martina Gleeson  (22:15):

What’s wrong with having toilet, rather than male and female, especially in a general practice.

Dr Monica Moore (22:21):

That’s right. They look exactly the same for goodness sake.

Dr Martina Gleeson  (22:25):

And we have change tables in both of the toilets.

Dr Monica Moore (22:27):

Yes, that’s right. Yeah.

Dr Martina Gleeson  (22:30):

So that sort of thing. So the other doctors in my practice maybe don’t feel that they have the medical skills to provide the hormone prescription. Or especially to initiate the hormone prescription. And so we all have our areas of special interest. There’s a doctor in my practice who does a lot of skin surgery, and if I get a difficult one that I think is beyond my scope, I’ll ask him to look after that patient. And so I expect him to be respectful of my trans patient’s identity, but not to do their hormone prescribing if he’s not comfortable with that. That’s my area of specialty, and I’m very happy to provide that part of the care, but basically that basic human respect for this is who you are and it’s not really my job to question. So you might’ve been assigned female at birth, but if you say your name is Jack and you are a man, then that’s what you are. It’s not hard.

Dr Monica Moore (23:36):

And I think when I’m thinking of what people get up against, you know what I mean, just from being different. And what about if I not necessarily working within that space, but I meet someone and I’m trying to go and see someone who’s got more expertise, but in the meantime, is there anything I can say to that person that they can help themselves? Because you know how sometimes when I’m working with someone, say for example, they’ve got anxiety or depression and they need to do something, or I haven’t got an appointment straight away, and I’ll refer them to a website or they can start doing some things online and some apps. And is there anything that you would recommend that as clinicians we can give to people that would be helpful?

Dr Martina Gleeson  (24:25):

I would, again, using the Trans Hub website, it has links to peer support and that can be very helpful if people are feeling like they’re the only person in the town that’s got the issue. There are Facebook social media support groups as well. There are actually, it’s interesting. There are people living in the community having transitioned, just living as that gender not out, don’t really want anything to do with the transgender community in inverse commas because they’re actually, they’ve embraced the binary on the other side of what they were assigned and don’t really need to have the peer support because they’re living a very suburban lifestyle.

Dr Monica Moore (25:16):

Nothing wrong with the suburban life, but that’s right, isn’t it? It’s like it’s the ones who need it are the ones all of us, all us who are transitioning. I’m thinking when I had my children that

Dr Martina Gleeson  (25:30):

You needed mother support,

Dr Monica Moore (25:31):

I needed mother support,

Dr Martina Gleeson  (25:33):

And we are both menopausal now. I might’ve needed a bit of support from women going through a similar experience.

Dr Monica Moore (25:37):

We do. That’s right. The conversations get interesting. And so it’s that thing

Dr Martina Gleeson  (25:42):

That transition thing. So yeah, looking for peer support. There’s a place in Sydney called the Gender Centre that provides some supportive counselling that people can reach out to. There are quite a few mental health clinicians who have expertise in supporting people, and they can be found on the Trans Hub website, there’s a list of gender affirming doctors.

(26:08):

And Aus Path has a list of gender affirming clinicians including speech therapists and psychologists. And you can also, I think even looking at in that find a psychologist website, you can ask that someone has experience in gender and they can find that if they feel that they need the support of a mental health clinician. So those sorts of things, I think peer support is very important.

Dr Monica Moore (26:38):

Yeah, it makes such a difference. I think I was thinking about the issue of language, just sort of harking back to that. And do you think we’ll ever get to the stage where, because creating new words all the time, and in English, the pronoun they is being used within that space. You know what I mean? But sometimes it can get kind of clumsy. And I know I’ve read a book by Becky Chambers or some books by Becky Chambers where she uses the pronoun ZXYR to designate a human being. And then you don’t have to know what’s in their pants or their gender or anything else. You just know, oh, that’s a human being. It’s another, it’s another human, or it’s another, actually, it’s another sentient being, I think because the aliens are sort of included as well. But it just seemed, do you think we’re ever going to formulate or is it too difficult? Is it like the flag or the anthem?

Dr Martina Gleeson  (27:41):

I think we are moving in that direction. There are people who are not focusing as much on gender as they raise their children, just allowing their children to choose the clothes they want, choose the haircut they want, choose the toys they, and not policing. Oh no, boys don’t play with dolls. You can’t have that. And I think people are aware of language and there’s resistance because some people don’t like change. But I think we see with the generation coming up that they’re more comfortable with using gender neutral terms. And hopefully we’ll see that develop more. As you say, language always changes and there’s always pushback. But yeah, we are progressing. People are more comfortable with using they. That’s a good start.

Dr Monica Moore (28:36):

It’s a good start. It’s a very good start. So look, we’ve come to the end of our conversation, I think, unless there’s anything else you wanted to add.

Dr Martina Gleeson  (28:44):

Yeah, I think it’s just be aware of meeting the person in the space, making them welcome in your space, checking in with them about pronouns and then dealing with the problem and not making everything about gender, but meeting them where they’re at, some of their experience. The intersectional experience certainly can inform experience of trauma and reaction to traumatic experience. So be aware of that. It’s a great space to work in. I really enjoy working with these people.

Dr Monica Moore (29:23):

That’s what gave me the idea when you were telling me about it. And you go, oh, it’s just fantastic. It’s really put a spring in your step and a spark in your eye to sort of be doing this sort of work. And I thought, yeah,

Dr Martina Gleeson  (29:36):

You really make a difference to people’s lives when you can help them affirm what they know to be true inside themselves. And it’s really an experience for me of being very patient led. And that’s really lovely. I’ve had to learn so that I can support people in their journeys, but it’s very much about sitting down and saying, what are your goals? What are you hoping to achieve? How can I help you? And that’s a lovely way to be practicing.

Dr Monica Moore (30:02):

It is, isn’t it?

Dr Martina Gleeson  (30:03):

That’s right.

Dr Monica Moore (30:04):

Even though as GPs, we sort of thought that this is what you do. Okay. So look, it’s been lovely. Thank you very much for chatting with me, Martina. In the next two episodes, Julianne White Mental Health social worker will be rejoining me, and we are really going to be focusing on the importance of connection, of relationships, of transitions within relationships. And the last one will be a review session because we learn so much from each other. So please access the link in the show notes, tell us your comments, your ideas for future series. We’d really love to hear from you. So it’s goodbye from me, Monica Moore, a GP, and my friend and guest, Dr. Martina Gleason.

Dr Martina Gleeson  (30:49):

Goodbye from Me too. Thank you.

Dr Monica Moore (30:51):

Talk to you next time. Bye.

Host (30:54):

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