In February, South Australian nurse practitioner and academic Toni Slotnes-O’Brien discovered that a person close to her was transgender and, sadly, the challenges they faced accessing basic healthcare.
“They went away from GP consults feeling suicidal due to the way they were being treated,” Toni reveals.
With South Australia’s sole adult public gender clinic, operating out of the Modbury Hospital, maintaining a two-year waiting list, Toni felt compelled to do something to provide greater access to quality, safe and inclusive healthcare for the state’s transgender and gender diverse community.
To upskill, she completed a University of Melbourne course covering primary healthcare for transgender diverse non-binary people. She also undertook placements at Modbury Hospital’s Transgender Clinic.
Not long after, she opened an innovative nurse practitioner-led transgender and gender diverse clinic for people aged 18 and over, based at the University of South Australia City West Health Clinic.
Opening in March and running two days per week, the clinic now has about 60 patients on its books.
According to Toni, its overarching aim is to provide inclusive healthcare to one of Australia’s most marginalised and socioeconomically disadvantaged groups. Far-reaching goals include improving clients’ mental health, preventing suicide and suicidal thoughts, and providing best practice gender-affirming care and coordination of care to enable TGD people to “live a life without barriers”.
Transgender (sometimes abbreviated as ‘trans’) is a term for people whose gender identity is different to the sex assigned to them at birth. Gender identity refers to a persons’ internal and personal concept of themselves as being male, female, a blend of both, or neither, explains Toni.
There is a growing awareness of transgender people in the community and increasing recognition of the importance of ensuring healthcare settings are inclusive and able to provide best practice care to all patients, regardless of their gender, she adds.
“Gender diversity has always been there throughout history but people are feeling safer to front up to seek healthcare,” Toni suggests, of the changing landscape.
“Yet, we’ve still got a lot of stigma attached to certain groups of people.
“When I started nursing thirty years ago, I worked in infectious diseases, and back in 1993 we had a lot of patients coming in with HIV and AIDS, and a lot of them were gay. Thirty years ago, they were stigmatised, and often outcast from their families; you really didn’t let anyone know that you were gay back then.
“Now, the climate’s changed. People aren’t so afraid to disclose what their sexual preference is.”
Despite inroads, however, Toni points to research showing that it takes an average of eight years from the time someone discovers that they’re transgender to actually seeking healthcare, meaning there is still a long way to go.
“I’ve heard some horrible stories,” Toni laments.
“The majority of my patients in the clinic don’t have a regular GP that they go to because their GP doesn’t understand what it means to be transgender.
“I’ve even heard stories of GPs recommending that their patients go to church to cure themselves.
“There’s also a lot of research saying that they are reluctant to front up to emergency departments until the last minute because they know they could come in with a broken foot, and then everything becomes focused on the fact that they’re transgender, and completely unrelated to why they’re seeking healthcare in the first place.”
At the new clinic, Toni offers bulk-billing for patients and connection to other disciplines on site.
While TGD people need access to many of the same healthcare services as other community members, gender affirming healthcare refers to a variety of social, psychological, behavioural, and medical interventions that are specifically designed to support and affirm an individual’s gender identity when it is different to the gender assigned to them at birth, explains Toni.
“Gender affirming healthcare begins at the first encounter with the individual who is seeking care. Healthcare providers can ideally state their own preferred pronoun (eg. ‘she’/’her’/’hers’) prior to asking the patient for their preferred pronoun and name. This helps to create a safe, inclusive environment and demonstrates an awareness of the significance of pronouns and names to gender identity.”
Toni says common health issues presenting to the clinic include depression and anxiety, mostly triggered from societal stigma.
“A lot of them feel shame for being transgender. A lot of them will not engage in regular healthcare to get preventative screenings, or just basic healthcare.”
While the clinic is making a difference, Toni concedes barriers remain, especially when it comes to accessing MBS and PBS medications.
“For example, we can prescribe estrogen, its PBS listed, but we can’t prescribe testosterone blockers, so gender affirming hormones are limited for nurse practitioners.
“Also, if someone wants to change their gender markers, such as their gender and their name on their birth certificate or Passport, NPs can’t sign off on that, only GPs can. And a lot of GPs will refuse to do it because they don’t understand what they’re signing.”
A further limitation is that NPs are not currently able to complete an enhanced primary care plan for clients to access speech pathology or other allied health if they need one. While a plan can be developed with an NP, the patient still needs to engage with a doctor to sign it to gain access to Medicare services.
More broadly, Toni believes more nurse practitioners need to be trained to work in transgender and gender diverse primary healthcare clinics to meet the growing need among the community.
At her own practice, she is hoping to secure funding to employ a peer support worker, as there is extensive research showing improved outcomes from having one tied to a clinic, particularly when it comes to reducing suicide rates. She would also like to establish a support group within the clinic so that clients, especially young ones often disconnected from society, can forge bonds and share their experiences.
“Whenever the media talk about transgender and gender diverse people, they’ve always got pics of alternative young people with piercings and coloured hair. However, in my experience, they come from all walks of life, from 18 up until the age of 75 in my clinic, so it can be very varied.
“Anyone can be transgender; it’s not just the media portrayal of alternative hippies wanting to express themselves.”
Above all, Toni, remains passionate about the need to eliminate barriers to healthcare and reduce the stigma and disparities experienced by transgender and gender diverse people when accessing primary healthcare. Everyone can make a difference.
“Even if people don’t understand what it means to be transgender, it’s still important to show kindness and compassion,” she says.