One of our GenderGP experts reviewed the free training modules offered by Health Education and Improvement Wales (HEIW). These interactive module uses case studies to introduces participants to trans people and several different presenting needs.
Gender Identity Module
The Gender Identity Module covers the basics of trans identity, and how to engage with trans people in a healthcare setting.
What worked
- The objectives are clearly laid out: Improved understanding of gender diversity; improved awareness of current terminology and language; learn to provide an affirmative consultation with patients; understand the legal considerations around gender reassignment and recognition.
- The module seems to be easily accessed, completed, and digestible.
- In line with good practice of gender-affirming care.
What could be improved
- The module doesn’t explain wrong answers, and could use these to give further information.
- Further information around the difference between identity terms like ‘non-binary’ and ‘intersex’, and why some people might identify differently.
- More specific/accurate information about the specifics of trans identity in healthcare systems. For instance, the module suggests that a deed poll is necessary to change your name at your GP, but this is not the case. Any official document with your current name on it can be used.
Full review
The module uses multiple-choice questions based on patient case studies to help the participant develop their understanding of gender diversity. The case studies are based on different patients presenting with different needs, including mental and physical health issues, and referrals to other specialists (transgender healthcare-related and otherwise). The initial case study centres non-binary identities, and the following modules include transfeminine, transmasculine, and non-binary people of varying ages. There is an emphasis on education around non-binary identities, which is often a blind spot for healthcare professionals. The module explains that the number of patients with a non-binary gender identity requesting access to Gender Identity Services is on the rise, and explains ‘non-binary’ as an umbrella term by people whose gender identity is something other than the binary option of ‘male’ or ‘female’. Gender neutral pronouns like ‘they/them’ are introduced, as well as the legal difficulties faced by non-binary people in the UK (which only allows male and female legal genders).
The module explains that referrals are increasing to both GIC (Gender Identity Clinics) and GIDS (Gender Identity Development Service), and that referrals in young people in particular are growing exponentially – this is reflects increasing ease of access to information and representation. As GPs will be the first port of call for people seeking gender-affirming medical intervention, it is important to ensure that they can talk comfortably about trans terminologies, identities and language. The module explains how transition can be social, hormonal, surgical, or any combination of the three, and describes the benefits of supporting transition.
The module describes gender identity as an internal sense of self, and acknowledges the wider range of identities beyond ‘male’ and ‘female’. It clarifies that gender identity is not the same as sex and is separate from to sexual orientation. Gender non-conformity refers to gender expression that does not conform to stereotypical gendered behaviour, and not all gender non-conforming people are transgender.
The module encourages affirmative consulting around gender expression with children and young people. Gender variance in childhood is a normal aspect of human development, but parents may consult their GP if a child expresses unhappiness, distress or anxiety around their gender identity. It is important not to be dismissive with gender-incongruent children. The module explains that trans children may express gender-related distress in the form of challenging behaviours, that a child’s self-expression might well change over time, and that validating a child’s identity promotes positive wellbeing. On the other hand, gender identity should not be the primary focus if this is not why a patient comes to see you.
The module dispels the misconception that trans identity is a mental illness. It references the WHO International Compendium of Diseases (ICD-11), in which the diagnostic term gender incongruence replaces transsexualism (ICD-10) and has been moved out of the chapter on mental and behavioural disorders. However, it acknowledges that trans people do experience higher rates of:
- self-harm
- suicidality
- anxiety
- depression
These issues are linked to social stressors and experiences of transphobia. There is also a high coincidence of gender-incongruence and autistic spectrum traits, although this should not be treated as a mental health issue. The module makes the case for gender-affirmation improving mental health outcomes for trans and non-binary people.
The module deals with issues faced by trans people in secondary care. For instance, where trans identity is not relevant to the presenting condition it is important to ensure that referrals contain only relevant information. However, some procedures, like hysterectomy in transmasculine people, require attention to both birth-assigned sex and gender identity. In these cases, it is important that hospitals are sensitive to patients’ personal as well as medical needs, like assigning a bed in an area that corresponds to their gender presentation. Gender Reassignment is one of the nine protected characteristics of the Equality Act 2010, and discriminatory behaviour from healthcare staff could lead to disciplinary procedures or legal consequences.
Transgender Health Module
The Transgender Health Module covers specific aspects of transgender healthcare, including hormone therapy and sexual health.
What worked
- The module is informative on hormone replacement therapies (HRT), as well as sexual health and screening
- The module provides a range of patient backgrounds in conventional trans healthcare scenarios
What could be improved
- The module included a non-binary example relating to menstrual suppression, but did not give any details relating to non-binary hormone use or microdosing.
- The module did not cover information relating to fertility
- The module gave straightforward examples, and could benefit from more diverse examples of healthcare needs, particularly around oestrogen and testosterone therapies.
Full Review
As with the gender identity module, the trans healthcare module is a series of questions based on case studies. It introduces the participant to different treatments and healthcare needs associated with gender-affirming care, including oestrogen and testosterone therapies, menstrual suppression for AFAB patients, sexual health and screening.
The questions on oestrogen therapy focus on an older trans woman who is registering with a new GP practice and concerned that her HRT has not been transferred onto her repeat prescription. The module then provides the basic facts about oestrogen therapy:
- Oestrogen therapy is the central element of feminising hormone treatment for transfeminine people
- Some non-binary people assigned male at birth (AMAB) opt for low dose oestrogen therapy, or microdosing
- Most people use HRT for their full lives unless medical complications arise
- Most transfeminine people who require testosterone suppression will need anti-androgen medication – this usually takes the form of a GnRH agonist injection. GnRH agonists are for the most part very well tolerated and are a pre-requisite to genital surgery. Some patients may require specialist guided add-back testosterone replacement.
The section also includes some alternatives to GnRH agonist injection, including Finasteride, and those with reported negative impacts, including Spironolactone (Aldactone) and Cyproterone acetate (Androcur, Cyprostat, Dianette).
The questions on testosterone therapy focus on a young trans man from Saudi Arabia who has come to the UK seeking asylum and who would like to switch to the longer-lasting preparation Nebido from self-injecting with Sustanon. The question includes information on his current wellbeing and social situation. The question proposes several concern scenarios/answers related to this request to which the outcome might not be clear to the participant. The questions are followed by the facts on testosterone therapy:
- The aim for most trans men is to achieve a serum testosterone level equivalent to the adult male range
- Some non-binary people assigned female at birth (AFAB) opt for low-dose testosterone gel therapy (N.B. Low-dose testosterone therapy can still have irreversible effects!)
- Sustanon is the most commonly used short-term injectable testosterone in the UK. For some a gel applied daily offers more control and less variability
- Transmasculine people using testosterone are eligible for gamete preservation
The section highlights a number of health risks associated with testosterone therapy, such as endometrial proliferation, and suggests recommendations.
The questions on menstrual suppression focus on a 31 year old transmasculine non-binary person assigned female at birth (AFAB). They’ve had chest surgery and do not want testosterone therapy, but they do want to to suppress their menstruation as this causes dysphoria. They are seeking their GPs advice about menstrual suppression and contraception. The question is then followed by a factual section on menstrual suppression:
- The term transmasculine is used in reference to trans people who were assigned female at birth, but who identify more with masculinity than femininity. This may include non-binary people as well as binary trans men
- Some transmasculine people find menstruation distressing and seek advice from their GP. Standard-dose testosterone therapy is usually sufficient to suppress menstruation after 3-6 months of treatment. High-dose Provera is very effective for those wanting low-dose testosterone or no testosterone at all
- Alternatives include progesterone-only contraceptive preparations
- Unexplained vaginal bleeding in trans masculine people requires investigation
The questions around sexual health focus on a young, socially transitioned, medically transitioning trans woman. In the scenario the woman approaches her GP with concerns that the new oestrogen she received from the pharmacist is causing an allergic reaction. Her usual brand had been out of stock. The question explains symptoms observed on examination and proposes several possible diagnoses and possible next steps. The question is then followed by a factual section on sexual health:
- Whether or not sexual health screening is undertaken in primary care, GPs have an important role to play. This is particularly important in identifying patients with unmet needs, given that stigma and discrimination often hinder uptake of services of this kind.
- Disparities of healthcare access are reflected in in global data for trans people, who are often under-represented in the data due to categorisation
- It’s important to be alert to the interaction between mental health vulnerabilities and sexual health.
- In the UK all trans people accessing sexual health services are offered an HIV and syphilis test, and some provide HIV PrEP.
- It is helpful to know if your patient has undergone any genital surgery, as hormone use can also influence the presentation of a sexual health symptom.
If you have suggestions on how HEIW can improve their training further, or want to share your own experience of accessing trans healthcare, you can reach out to us via our website. Alternatively, you can always find us on Twitter, Facebook, and Instagram.