Dr Fiona Bisshop

Generally in life we think of the hospital as a place to go when we’re sick or injured where we will be treated respectfully and compassionately, and our health problems will be managed skillfully and efficiently.  But for transgender people, hospitals and other healthcare settings can actually be hazardous to their health and well-being.

There’s a phenomenon which is now commonly referred to as the “Trans Broken Arm Syndrome”, first used by Naith Payton at Pink News, where a trans person seeking medical help has their medical problems blamed on either their hormone therapy or their gender identity, or has their gender history discussed at length when completely irrelevant to their current health problem.  The analogy goes something like this – a young trans person presents to a hospital emergency room after falling and breaking their arm, and this happens:

a) “Oh your arm is broken?  Before I can fix it, I must get your complete history of hormones and surgery for transition” and/or

b) “Oh your arm is broken?  It’s probably because you’re on hormones”.

Sound ridiculous?  Well this is an extreme example of what I’m talking about, but I think you get the drift.  Trans people are asked about their gender history all the time when they see health professionals.  Sometimes the history is relevant, but much of the time it isn’t and can feel like a voyeuristic intrusion into their private lives.  The curiosity of hospital staff when it comes to trans patients ranges from tiresome irrelevant questions to downright invasion of privacy.  Patients can often appear very good-natured about all this inquisitiveness, but inside they are usually thinking really, do you need to know this? Why do I need to give my life history to so many complete strangers just to get antibiotics for a UTI? If you’re so interested in transgender people buy a book!

Now as a doctor myself, I do of course understand the importance of taking a proper history from a patient, and sometimes things that the patient thinks are irrelevant can be very important (for example, oral oestrogen when someone’s had a blood clot, or lack of oestrogen if someone has osteoporosis).  Unfortunately though, due to a virtual absence of education regarding trans medicine for medical students and doctors, many healthcare professionals simply don’t have enough knowledge regarding these areas, and the advice given is often wrong and sometimes downright dangerous.

• Here is a frightening example of team after team of doctors getting it wrong despite knowing the history.  A transgender man developed kidney failure.  His doctor advised him to stop his testosterone which he had been on for years. Let me just point out here that there is no evidence that testosterone affects the kidneys. Although his renal function was bad, his treating team decided it wasn’t bad enough to warrant dialysis.  They were using the male reference ranges for renal function.  His dialysis was delayed until he was very (life-threateningly) sick.  They then again used the male reference ranges to decide when he was eligible for a kidney transplant.  If they had used the correct female range for his kidneys, he would have made it to dialysis and transplant much sooner, and have avoided months of illness.
• There is a huge gap in the medical research literature when it comes to issues like laboratory reference ranges and risk calculators for transgender people on hormone therapy.  This means that even trans-friendly doctors can find it difficult to give appropriate evidence-based advice.

But back to the trans broken arm.  I can list dozens of examples from my own patients’ experiences.

Problem:  “I have ingrown toenails”

Answer: “It’s because you’re probably wearing high heels so stop it”

Ultimate solution: Surgical cure with no recurrence (she never wore stilettos anyway)

Problem: “I have awful headaches”

Answer: “It’s due to your hormones so stop them”

Ultimate solution: Migraine medication for several patients.  One patient had a new diagnosis of benign intracranial hypertension and was treated with diuretics. At some stage there will be someone with a brain tumour that is missed while hormones are blamed….

Problem: “My knees hurt”

Answer “Has it been since you started testosterone?”

Ultimate solution: Physiotherapy for runner’s knee.

Problem: “I have chest pain”

Answer: “What genital surgery have you had?”

Ultimate solution: Chest drain for spontaneous pneumothorax. 

Problem: “I’m feeling really down since my mother died”

Answer: “How much oestrogen are you on?  It’s probably too much”

Ultimate Solution: Acceptance and Commitment Therapy with a psychologist.

Mental health problems are also too frequently blamed on trans identity, when in fact there are usually many other factors to consider.  There are entire textbooks devoted to this topic, so it’s very frustrating when a psychiatry trainee in a public hospital treats the trans patient as purely a product of their gender struggles or their hormone treatment.

It seems quite widespread within the medical profession that as soon as a patient is revealed to be transgender and on hormone therapy, this somehow blinds the practitioner to other potential causes for their symptoms, especially if their problems are in the realm of mental health.  The problem stems from a terrible lack of trans-specific education – it’s missing in most medical school curricula or shoved into a tiny unit encompassing other topics such as intersex and homosexuality.  I still remember my one and only lecture in medical school that covered any of these topics, given by an aged psychiatry professor who lumped the gays and trans people in with the paedophiles and the foot fetishists.  All covered in 40 minutes, whilst paper planes flew overhead and general sniggering prevailed in the audience. Admittedly this was 20 years ago, and things have improved very slowly in Australian medical schools since then, but there is still no proper structured education when it comes to transgender issues or hormone management.

Unfortunately this often means that trans individuals have to be their own advocates, and have to educate their health professionals.  I’m the first to admit that I have learnt from my patients, and still do.  But it’s a shame that patients are put in a position where they end up feeling that it’s easier simply not to disclose rather than weather the inappropriate inquisition.  As one trans person said when interviewed by Pink News:

“It’s a calculated risk on our part: The 1% chance that it is relevant and you make it worse by hiding, versus the 99% chance that it’ll be used to push you out of the clinic with no diagnosis, and ending up made worse by that.”

Doctors flippantly talk about stopping hormones “to see if it helps” as though it’s as simple as stopping a multivitamin.  There is often little regard for the fact that hormone therapy is usually vital for the mental and physical health of the transgender person, and that suggesting it be stopped is likely to induce extreme anxiety, panic and fear, not to mention adverse physical consequences.

It’s also often recommended that patients stop their hormones prior to any surgery.  I have questioned this and received many different responses depending on the surgeon involved.  Generally I think it’s reasonable to remain on doses that are producing normal levels.  As one patient said to me “Well do they cut guys balls off before they have their knee replacement?”.  Good point.