FOI 4876 - Document 27
Consultation Survey on
MSAC Application 1754
Patient consultations and surgical procedures for gender
affirmation in adults with gender incongruence
MSAC welcomes input on MSAC applications for public funding from individuals, organisations representing
health professionals or consumers and/or carers, and from other stakeholders. Please use this template to
prepare your input. You may also attach additional information if you consider it may be useful in informing
MSAC and its sub-committees.
UNDER CARE
Sharing consultation input
1982
AGED
Submitted consultation input wil be routinely
shared with the applicant and with MSAC and its sub-committees.
ACT
• The applicant wil receive a summary of comments from individuals, with the
AND individual’s name and other
RELEASED
identifying information removed.
• MSAC and its sub-committees wil receive both the summary and copies of the comments, with the name
of the individual and other identifying information rem
BEEN oved.
HEALTH
• Consultation input from groups or organisations wil be provided in a complete form to both the applicant
HAS
OF
and to MSAC and its sub-committees.
INFORMATION
Consultation input may also be shared with HTA
OF Assessment Groups from time to time to inform their reports to
MSAC or with state and territory health representatives where the application is for a service to be delivered
through public hospitals. Please do not include information in your input that you do not want shared as outlined
above. In addition, to protect privacy, do not include identifying personal (e.g., name) or sensitive (e.g., medical
DOCUMENT
history) information about third parties, such as medical professionals or friends/relatives.
FREEDOM
DEPARTMENT
How consultation input is used
THIS THE
MSAC and its sub-committees
THE consider consultation input when appraising an application, including to better
understand the potential impac
BY t of the proposed medical technology/service on consumers, carers, and health
professionals. A summary of consultation input wil be included in the Public Summary Document (PSD)
published on the MSAC website once MSAC has completed its appraisal. The PSD may also cite input from
groups/organisations, including the name of the organisation. As such, organisations should not include
information or opinions in their consultation input that they would not wish to see in the public domain.
Consultation deadlines. Please ensure that your consultation input is submitted by the pre-PASC or pre-MSAC
consultation deadline for this application. Consultation deadlines for each PASC and MSAC meeting are listed in
the PASC, ESC, MSAC key dates available on the MSAC website. They are also published in the MSAC Bulletin.
Consultation input received after the respective deadlines may not be considered.
For further information on the MSAC consultation process please refer to the MSAC Website or contact the
Consumer Evidence and Engagement Unit on email: xxxxxxxxxxxx@xxxxxx.xxx.xx.
Thank you for taking the time to provide consultation input. Please return your completed survey to:
Email: xxxxxxxxxxxx@xxxxxx.xxx.xx
Mail:
MSAC Secretariat,
MDP 960, GPO Box 9848,
ACT 2601.
1 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 27
PART 1 – PERSONAL AND ORGANISATIONAL INFORMATION
1. Respondent details
Name:
MPH,
CCRN,
MSW, Dr
PhD, Assoc
Prof
MBBS (Hons), FRACP, PhD
Email: s47F
Phone No:
2. Is the feedback being provided on an individual basis or by a collective group?
Individual
Collective Group
If an individual, specify the name of the organisation you work for
If a col ective group, specify the name of the group
UNDER CARE
Trans Health Research
1982
AGED
3. How would you best identify yourself?
ACT
RELEASED AND
General Practitioner
Specialist
BEEN
Researcher
HEALTH
Consumer
HAS
OF
Care giver
INFORMATION
Other
OF
If other, please specify
DOCUMENT
Public health and social policy
FREEDOM
professional
DEPARTMENT
s
THIS THE
THE
BY
2 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
UNDER CARE
1982
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
UNDER CARE
1982
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
FOI 4876 - Document 27
A cost-effectiveness analysis (CEA) conducted in the USA compared the cost of state insurance
coverage for medical y necessary gender affirming care (which included but was not limited to
gender affirming surgeries among the intervention costed) compared to the status quo – a denial of
health coverage. Health states model ed for the non-intervention scenarios included an increased
risk of depression, suicidality and suicidal ideation, death by suicide (premature death), harmful
and/or dependent patterns of alcohol and/or drug use, unemployment, and HIV. In an Australian
context, with exception of HIV, the health states experienced in the no-intervention scenarios
would be similar even though prevalence and incidence between US and Australian populations is
different. Taking a US societal perspective, the CEA found that funding coverage for medically
necessary gender affirming care was cost-effective compared to the cost of refusal of coverage,
over a ten-year horizon (Padula et al. DOI: 10.1007/s11606-015-3529-6).
Internationally, there is limited published literature of cost-effectiveness analysis and a health
economic evaluation of medical y necessary gender affirming care in the Australian context has
never been conducted. However, we can make some informed assumptions that public funding of
the proposed intervention wil result in cost-savings to government, namely:
Health costs averted: reduced costs of psychological, psychiatric, and mental health care from
reduced rates of depression, suicidality, and suicidal thoughts; related alcohol and drug treatment
and care; among people receiving the intervention.
Social security costs averted: reduction in government transfers to individuals from increased rates
of employment among people receiving the intervention.
Tax revenue protected: mitigates tax foregone because of premature death through red
CARE
uced
UNDER
mortality rates, in addition to additional tax revenue from higher rates of employment among
people receiving the intervention.
1982
AGED
While not currently quantified, it is likely that the cost of the intervention is more cost-effective
than not funding the intervention due to higher costs associated w
ACT
ith the utility of probable
AND
negative health and social outcomes.
RELEASED
BEEN
HEALTH
HAS INFORMATION
OF
OF
8. What other services do you believe need to be delivered before or after this intervention, e.g.
Dietician, Pathology etc?
DOCUMENT
Due to the variability of proposed inter
FREEDOM
ventions, thi
DEPARTMENT
s is difficult to answer.
Speech pathology, phys
THIS
iotherapy, occupational therapy, counselling, nursing, pharmacy, and
THE
pathology may be involve
THE
d either pre or post intervention.
BY
PART 3 – INDICATION(S) FOR THE PROPOSED MEDICAL
SERVICE AND CLINICAL CLAIM
9. Do you agree or disagree with the proposed population(s) for the proposed medical service?
Strongly Agree
Agree
Disagree
5 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 27
Strongly Disagree
Specify why or why not:
The proposed medical service is suitable only for trans individuals – binary and non-binary
– who experience gender incongruence and seek to remedy incongruence by accessing
gender affirming surgery or surgeries. As stated in the PICO Set, not al trans people desire
or seek gender affirming surgery/ies.
10. Have al the associated interventions been adequately captured in the application summary?
Yes
No
Please explain:
The proposed medical service and associated interventions are captured and supported by the
evidence presented in the PICO set and our research outlined above. The amendment of existing
MBS items will also address the significant unmet need for gender affirming surgery, by increasing
access to patient consultation and multidisciplinary care planning items.
11.
Do you agree or disagree that the comparator (s) to the proposed medical service?
UNDER CARE
Strongly Agree
Agree
1982
AGED
Disagree
ACT
Strongly Disagree
RELEASED AND
Please explain:
MBS codes and services currently utilised fo
BEEN
r consulting and providing medical y necessary
HEALTH
gender affirming surgeries are not fit for purpose. Existing MBS codes create uncertainty
and inconsistency for health care pr
HAS
actitioners
OF
and individuals. In addition, there is a real
INFORMATION
risk of harm for trans people if the current MBS codes were to persist in use, likely
contributing to gender dysphoria f
OF
or some individuals.
12. Do you agree or disagree with the clinical claim made for the proposed medical service?
DOCUMENT
Strongly Agree FREEDOM
DEPARTMENT
Agree THIS
Disagree THE THE
Strongly Disagree
BY
Specify why or why not:
We do not see why there should be any differentiation between parties who have
undertaken gender affirmation through MBS for-purpose item numbers and those funded
through existing non-gender affirmation numbers or private out of pocket expenses.
6 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 27
PART 4 – COST INFORMATION FOR THE PROPOSED MEDICAL
SERVICE
13.
Do you agree with the proposed service descriptor?
Strongly Agree
Agree
Disagree
Strongly Disagree
Specify why or why not:
Trans Health Research wil not comment as we do not hold any expertise in this area.
14.
Do you agree with the proposed service fee?
UNDER CARE
Strongly Agree
1982
Agree
AGED
Disagree
ACT AND
Strongly Disagree
RELEASED
Specify why or why not:
BEEN
Trans Health Research wil not comment as we do not ho
HEALTH
ld any expertise in this area.
HAS
OF
INFORMATION
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
7 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 27
PART 5 – ADDITIONAL COMMENTS
15. Do you have any additional comments on the proposed intervention and/or medical condition
(disease) relating to the proposed medical service?
The out-of-pocket cost for individuals accessing gender affirming surgery is a significant barrier to
access. Experiences of unemployment, chronic health conditions, disability, neurodivergence, and
mental health concerns, coupled with experiences of discrimination, stigma, prejudice, and
vilification compound the earning potential of many trans people, which can result in people
postponing surgeries or turning to mutual aid such as crowdfunding surgeries. Some community
sources suggest that even with the highest level of private health insurance, there is stil a
significant gap in costs between what is charged and what is reimbursed. From a health equity
perspective, there are few health conditions that require fundraising to meet the costs of medically
necessary treatment.
While we acknowledge the limitations of MSAC in setting prices for specialists, we are concerned
that only those who wil be able to afford the intervention wil be able to access the intervention, if
access is primarily restricted to the private health system. Therefore, an individual's income,
education attainment, and employment may predict uptake of the intervention, leaving an unmet
need among some trans people.
UNDER CARE
Do you have any comments on this feedback survey? Please provide comments or
suggestions on how this process could be improved. 1982
AGED
ACT
The template formatting has been problematic to edit. We would suggest not including
AND
boxes/tables in the future in the Word template. RELEASED
BEEN
HEALTH
HAS
OF
INFORMATION
OF
DOCUMENT
Again, thank you for tak
FREEDOM
ing the tim
DEPARTMENT
e to provide valuable feedback.
THIS
THE THE
BY
8 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 27
LGBT Health
Volume 8, Number 1, 2021
Mary Ann Liebert, Inc.
DOI: 10.1089/lgbt.2020.0178
The Health and Well-Being of Transgender Australians:
A National Community Survey
Ingrid Bretherton, MBBS,1,2 Emily Thrower, MD,1 Sav Zwickl, MSexol,1 Alex Wong,1
Daria Chetcuti,1 Mathis Grossmann, PhD,1,2 Jeffrey D. Zajac, PhD,1,2 and Ada S. Cheung, PhD1,2
Abstract
Purpose: Transgender, including gender diverse and nonbinary (trans), people experience significant health dis-
parities. We aimed to better understand the health status and needs of Australian trans people to guide resources
and health and well-being programs.
Methods: This anonymous, cross-sectional online survey utilized nonprobability snowball sampling of
CARE
Australian adults (18 years and over) who self-identified as trans between September
UNDER
2017 and January 2018.
This descriptive study assessed demographic data, community views on access to health care, health burden,
1982
access to health resources, and priorities for government funding in transgender health.
AGED
Results: Of 928 participants, 37% reported female, 36% reported male, and 27% reported nonbinary gender iden-
ACT
tities. Despite 47% having tertiary qualifications, the unemployment rate was 19%, with 33% reporting discrim-
AND
ination in employment due to being trans. Discrimination in accessing
RELEASED health care was reported by 26% and
verbal abuse and physical assault were reported by 63% and 22%, respectively. Lifetime diagnosis of depression
was reported by 73% and anxiety by 67%. Sixty-three percent reported previous self-harm and 43% had attemp-
BEEN
ted suicide. Autism spectrum disorder and attention-deficit/hyperactivity disorder were reported by 15% and
HEALTH
11%, respectively. The most preferred method of receiving health information was through online resources,
HAS
OF
with the most popular source being Reddit, an online peer discussion board. Better training for doctors in
INFORMATION
trans health issues was the top priority for government funding.
OF
Conclusions: Barriers, including widespread discrimination and unemployment, contribute to health inequity
and prevalent mental health conditions. Better training for health professionals in the provision of safe, gender-
affirming and general health care for trans people is urgently required.
DOCUMENT
Keywords: barriers to care, gender-affirming endocrine
DEPARTMENT care, gender-affirming surgical care, gender dysphoria,
FREEDOM
transgender
THIS
THE THE
Introduction
prevalent among trans individuals for unclear reasons, with
BY
difficulties with attention or social interaction potentially pos-
The number of transgender, including gender diverse ing greater barriers by affecting the ability to understand
and nonbinary (trans), individuals seeking gender-
health information or engage in clinical care.1,9
affirming health care worldwide is rising,1 yet global studies
There are little data describing the health of the Austra-
have demonstrated that trans people face many barriers to
lian adult trans population. Due to a lack of population
accessing health care, including discrimination2 and the in-
data, it is unknown how many Australians identify as
ability to find doctors willing to provide care,3 as well as
trans. A nonpeer-reviewed publication described very
high rates of depression and attempted suicide.1,4 Mental
high levels of mental health conditions, particularly depres-
health distress is driven, in part, by barriers to accessing health
sion and anxiety syndromes, poor quality of life, and high
care as well as by discrimination.1,5 8 In addition, co-
rates of discrimination among Australian trans adults in
occurring autism spectrum disorders (ASD) and attention-
2013 (Ref.10). Similarly, high rates of mental health condi-
deficit/hyperactivity disorder (ADHD) may also be more
tions were observed in trans adults attending specialized
1Department of Medicine (Austin Health), The University of Melbourne, Victoria, Australia.
2Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia.
ª Ingrid Bretherton et al. 2020; Published by Mary Ann Liebert, Inc. This Open Access article is distributed under the terms of the Creative
Commons License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited.
42
FOI 4876 - Document 27
HEALTH AND WELL-BEING OF TRANSGENDER AUSTRALIANS
43
gender affirmation clinics in the state of Victoria; however,
casion only and duplicate responses from the same internet
these findings may not be generalizable.1
protocol address were excluded. All included individuals
Australia’s universal health care system provides free or
had discordance between their assigned sex at birth and
low-cost, government-subsidized general health services, in-
their gender identity. Other than the initial screening ques-
cluding general or specialist consultations, pathology collec-
tions, all subsequent survey questions were optional.
tion, and medications, including gender-affirming hormones.
However, in regions with fewer specialized gender services,
Demographic data
access to low-cost options may be limited.
Participants’ birth years and postcodes were obtained.
Access to gender-affirming interventions in Australia
Postcodes were coded as per the Australian Standard Geo-
typically follows one of two pathways; either a formal assess-
graphical Classification Remoteness Area (RA) coding13
ment and approval by a mental health professional as per the
to one of five groups; RA1 (inner cities) to RA5 (very re-
World Professional Association for Transgender Health Stand-
mote). Participants were asked to select their sex assigned
ards of Care11 or an alternative informed consent model of care
at birth (male, female, or intersex) and their gender identity
where a decision to commence gender-affirming hormones is
(see Table 1 for options). To enable meaningful statistical
shared between a primary care general practitioner and a
analyses, gender identities were then further categorized
trans individual without mandating a formal mental health re-
into three groups: trans man/trans male/trans masculine and
view.12 Due to a lack of publicly funded gender-affirming sur-
male gender identities were coded as male identities; trans
gery, this is provided almost entirely in the private health
woman/trans female/trans feminine and female were coded
sector, which carries significant out-of-pocket costs.
as female identities; and gender nonbinary, gender queer,
This community-based survey sought to better under-
gender neutral, gender fluid, intersex, and agender were
stand the health needs of Australian trans individuals to di-
coded as nonbinary gender identities. Those who selected
rect local health resources to best meet health care needs.
‘‘other’’ also entered free text and were reclassified accord-
We hypothesized that transgender individuals have signifi-
CARE
ingly. Formal education, requirement for government finan-
UNDER
cant barriers to accessing health care, including socioeco-
cial assistance, and employment status were assessed
nomic disadvantage, high burden of co-occurring mental
(responses as outlined
1982 in Table 1). Participants were able
health conditions, and discrimination. The aim of this de-
AGED
to select more than one employment status. To reflect en-
scriptive study was to assess the sociodemographic charac-
gagement with the workforce, if two options were selected,
ACT
teristics and medical and mental health conditions affecting
individuals were classified
AND
in the group that reflected the
adult trans Australians; to obtain views on health burden,
RELEASED
most workforce engagement. For example, if a person was
ability to access health care, and ability to access health re-
a student and casually employed, they were classified as ca-
sources; and to understand community views on funding
sually employed.
priorities for trans health.
BEEN HEALTH
Access to health care and health burden
HAS
OF
Methods
INFORMATION
Current smoking and past 12-month illicit drug use were
This anonymous community survey utilized a nonprob-
self-reported, and self-perception of overall health was evalu-
OF
ability snowball sampling approach to survey trans Austra-
ated (responses available outlined in Table 2). Participants
lian adults aged 18 years and over using an online survey
were asked about their access to various types of health care
platform (SurveyMonkey, Inc., USA) between September
providers, including availability of general practitioners and
1, 2017, and January 31, 2018. The full survey
DOCUMENT is listed in their confidence in discussing health issues of concern with
Supplementary Appendix SA1. Participants were recruited
DEPARTMENT their treating doctor. As discrimination has been identified
FREEDOM
through the Trans Health Research group Facebook page
as a barrier to health care in previous surveys,14 participants
THIS
and the study also was promoted at the Australian and
were asked if they had perceived discrimination in employ-
THE THE
New Zealand Professional Association for Transgender
ment, housing, accessing health care, and government
BY
Health Biennial Meeting in Sydney, Australia, in Septem-
services and/or whether they had experienced physical assault,
ber 2017 and at the Midsumma LGBTIQ+ Festival in Mel-
verbal abuse, and domestic violence because of their gender
bourne, Australia, in January 2018. Written informed
identity. trans individuals were asked whether they had expe-
consent was not possible given the anonymous online de-
rienced any difficulty accessing hormonal treatment (such as
sign; however, the survey preamble outlined that comple-
the inability to find a doctor who is willing to prescribe, finan-
tion of the survey implied consent. The survey link was
cial costs of prescriptions, financial costs of doctor’s appoint-
available as a URL and did not require access to a specific
ments, or other [specify]). Participants were also asked if they
social media account. The study was approved by the Aus-
had taken any hormonal treatments without a prescription.
tin Health Human Research and Ethics Committee
To assess the community’s value of mental health assess-
(HREC/17/Austin/372).
ments before commencing gender-affirming hormonal treat-
Inclusion criteria were assessed through a positive
ment, participants were asked ‘‘Do you feel that a mental
response to three screening questions: (1) residency in Aus-
health assessment for trans and gender diverse individuals
tralia; (2) identification as trans or had previously identified
should be performed prior to accessing hormonal treat-
as such; and (3) aged 18 years or over. The inclusion of
ment?’’ Assessment of access to and desire for gender-
those who had previously identified as trans was intended
affirming hormonal and surgical treatments and previous
to include those who identified as their affirmed gender
medical and mental health conditions relied on self-
(male or female) rather than with the term transgender.
reporting, and no specific diagnostic tools were used. History
Individuals were eligible to complete the survey on one oc-
of self-harm or attempted suicide was also ascertained.
FOI 4876 - Document 27
44
BRETHERTON ET AL.
Table 1. Sociodemographic Parameters
were assessed, including involvement in support groups
of the Participants
and websites used to locate information on trans health.
Desire for local, Australian-based, trans health resources
Number of
was also determined. Participants selected the areas of prior-
responses
Frequency,
ity to which they thought resources should be directed (edu-
Parameter
received
n (%)
cation about gender diversity, gender clinics, support groups,
trans advocacy groups, counseling, better training for doctors
State of residence
911
Victoria
282 (31)
in trans issues, transgender medical research, psychology/
New South Wales
195 (21)
psychiatry services, or other [free text]). Qualitative analysis
Queensland
143 (16)
results of several open-ended questions regarding health is-
Western Australia
126 (14)
sues of concern have been reported separately.15
South Australia
92 (10)
Tasmania
37 (4)
Statistical analysis
Australian Capital Territory
34 (4)
Northern Territory
2 (<1)
Statistical analysis was performed using SPSS Statistics,
Age group (years)
928
version 23 (IBM Corporation, Armonk, NY). Descriptive
18 24
289 (31)
frequencies are reported and medians (interquartile range)
25 29
216 (23)
are reported for non-normally distributed data.
30 39
193 (21)
40 49
125 (13)
Results
50 59
71 (8)
60 69
30 (3)
The survey social media post was shared by 275 individ-
70 79
4 (<1)
uals and transgender support groups on the social media
Sex assigned at birth
928
site Facebook. A total of 964 responses to the survey were
UNDER CARE
Female
520 (56)
obtained. After excluding duplicates from the same IP ad-
Male
403 (43)
dress, blank surveys, or those that did not meet the inclusion
1982
Intersex
5 (1)
criteria (based on the previously described screening ques-
AGED
Gender identity
928
tions), 928 eligible responses remained.
ACT
Male
91 (10)
AND
Female
140 (15)
Sociodemographic
RELEASED data
Trans man/trans male/trans
239 (26)
As shown in Table 1, responses were received from every
masculine
Trans woman/trans
202 (22)
Australian state and territory. The greatest number of partic-
BEEN
female/trans feminine
ipants (n = 282,
HEALTH 31%) resided in Victoria. Eighty-three per-
Gender nonbinary
133 (14)
cent (n = 752) of those that responded resided in inner city
HAS
OF
Gender queer
41 (4)
areas (RA1). Median age was 28 years (interquartile range
INFORMATION
Gender neutral
11 (1)
23 39). Thirty-seven percent (n = 342) reported female iden-
Gender fluid
19 (2)
OF
tities, 36% (n = 330) reported male identities, and 27%
Intersex
2 (<1)
(n = 256) reported nonbinary gender identities. Participants
Agender
20 (2)
had high levels of education, with 47% (n = 437) holding a
Other
30 (3)
university qualification. The unemployment rate was 19%
Education level
928
DOCUMENT
(n = 177). The majority (n = 376, 57%) reported receiving
Never attended school
1 (<1)
FREEDOM
DEPARTMENT some form of government financial assistance.
Primary school
0
THIS
Some high school
98 (11)
THE
Access to health care and health burden
Completed high school
THE
222 (24)
Trade/technical certificate
170 (18)
BY
Table 2 outlines responses describing access to health care
or apprenticeship
and health burden. Current smoking in 15% (n = 141) of par-
University or tertiary
437 (47)
ticipants is comparable with national data indicating that
qualifications
11.6% of Australian adults reported smoking cigarettes
Employment status
928
daily.16 Illicit drug use was high, with 33% (n = 305) of re-
Employed on a full-time basis
274 (30)
spondents reporting use of illicit drugs in the past 12 months
Employed on a part-time
224 (24)
and is approximately double the general Australian popula-
or casual basis
tion rate of illicit drug use of 16.4% in the preceding 12
Home duties full-time
13 (1)
Student
176 (19)
months in 2019 (reported in people aged 14 years and
Retired
20 (2)
over).17 Nearly 80% (n = 711) described at least good health
Unemployed
177 (19)
and 80% (n = 732) had a regular family doctor or general
Other (free text)
44 (5)
practitioner. When asked if individuals had ever experienced
any difficulty accessing hormonal treatment, 41% (n = 372)
selected ‘‘none.’’ A third (n = 284) reported that the pathway
Access to health resources and priorities
to accessing hormones was too difficult. Discrimination be-
for government funding
cause of gender identity was widespread, with 33%
Preferred methods (i.e., social media, online resources,
(n = 304) reporting discrimination related to employment
videos, forums, and print) of receiving health information
and 26% (n = 244) related to accessing health care. Verbal
FOI 4876 - Document 27
HEALTH AND WELL-BEING OF TRANSGENDER AUSTRALIANS
45
Table 2. Access to Health Care
Table 2. (Continued)
and Health Burden
Number of
Number of
responses
Frequency,
responses
Frequency,
Parameter
received
n (%)
Parameter
received
n (%)
Other
7 (1)
Self-perception of overall health
907
Feminizing hormone treatments in
402
Excellent
86 (9)
birth-assigned malesa
Very good
224 (25)
None
75 (19)
Good
401 (44)
Estradiol oral tablets
205 (51)
Poor
171 (19)
Estradiol transdermal patches
56 (14)
Very poor
25 (3)
Estradiol gels
33 (8)
Health care providers utilizeda
928
Estradiol implants
52 (13)
GP
779 (84)
Combined oral contraceptive
14 (3)
Psychologist
631 (68)
pill
Psychiatrist
508 (55)
Spironolactone
130 (32)
Endocrinologist
413 (45)
Cyproterone acetate
106 (26)
Surgeon
298 (32)
Bicalutamide
1 (<1)
Nurse
235 (25)
GnRH analogs
2 (<1)
Speech pathologist
117 (13)
Progestins or micronized
63 (16)
Gender clinic within a hospital
103 (11)
progesterone
Gynecologist
87 (9)
Other (i.e., finasteride or
11 (3)
None
89 (10)
estradiol injections)
Other (free text)
32 (3)
Overseas surgery
CARE 914
UNDER
Discriminationa
927
Yes
72 (8)
Discrimination in employment
304 (33)
No
841 (92)
1982
Discrimination in accessing
244 (26)
Unsure/prefer not to say
1 (<1)
AGED
health care
Medical conditions
914
Discrimination in government
149 (16)
ACT
Depression
663 (73)
AND
services
Anxiety
613 (67)
RELEASED
Discrimination in housing
95 (10)
Fractures (broken bone)
191 (21)
Verbal abuse
584 (63)
Autism spectrum or Asperger’s
137 (15)
Physical assault
200 (22)
syndrome
BEEN
Domestic violence
133 (14)
ADHD
HEALTH
96 (11)
Difficulty accessing hormonal
905
Bipolar disorder
75 (8)
HAS
OF
treatmenta
Diabetes mellitus
25 (3)
INFORMATION
None
372 (41)
Cancer
19 (2)
Unable to find a doctor to
148 (16)
Blood clots (pulmonary
16 (2)
OF
prescribe
embolus or deep vein
Financial costs of prescriptions
124 (14)
thrombosis)
Financial costs of doctor’s
156 (17)
Liver disease
13 (1)
appointments
Stroke
11 (1)
DOCUMENT
Pathway to accessing hormones
284 (31)
HIV/AIDS
5 (<1)
FREEDOM
DEPARTMENT
was too difficult
Ischemic heart disease
4 (<1)
Other (specify)
THIS
100 (11)
Emphysema
3 (<1)
THE
Views on informed consent THE
913
Kidney or renal disease
3 (<1)
Should trans people undertake a
None of the above options
136 (15)
BY
formal mental health
selectedb
practitioner assessment?
aMultiple responses were allowed for this question, so total re
Yes, in all cases
285 (31)
sponses do not sum to 100%.
Yes, but only in some
392 (43)
bNone was not an option in the survey but was presumed if no med
circumstances
ical conditions were selected but answers were completed to the
No
187 (20)
remaining questions in Section 2: Your Health of the survey.
Unsure
48 (5)
ADHD, attention deficit/hyperactivity disorder; GnRH, gonadotropin
Masculinizing hormone treatments
509
releasing hormone; GP, general practitioner; trans, transgender, including
gender diverse and nonbinary.
in birth-assigned femalesa
None
191 (38)
Testosterone injections
267 (53)
abuse because of their trans status was reported by 63% of
Testosterone creams, gels, or
45 (9)
respondents and physical assault because of their trans status
patches
was reported by 22%.
Testosterone implants
2 (<1)
There were mixed responses to the need for a formal men-
GnRH analogs
2 (<1)
tal health assessment prior to commencement of hormonal
Progestins
4 (<1)
therapy and it is acknowledged that wording of this question
may have contributed to ambiguity (Table 2). There was a
(continued)
very high prevalence of self-reported depression and anxiety
FOI 4876 - Document 27
46
BRETHERTON ET AL.
FIG. 1.
Self-reported diagnoses in
trans individuals versus the Australian
population (age-matched).18 20 ADHD,
attention-deficit/hyperactivity disorder;
trans, transgender, including gender
diverse and nonbinary.
as well as ASD and ADHD (Fig. 1).18 20 Intentional self-
Discussion
harm was reported by 63% (n = 577) of participants and
This large community-based survey involving 928 partici-
43% (n = 394) reported having previously attempted suicide.
pants described persistent, concerning health statistics
Gender-affirming surgical interventions are summarized
among trans Australian adults: high rates of self-reported men-
in Table 3. Genital reconstruction surgery was the most
tal health morbidities, such as anxiety and depression, as well
common procedure undertaken by those assigned male at
CARE
as high rates of self-reported self-harm (63%) and attempted
UNDER
birth (n = 71, 18%); however, a further 64% (n = 243) de-
suicide (43%). There were widespread experiences of discrim-
sired this surgery in the future. The most frequent proce-
ination, especially in health care settings (26%). Moreover, a
1982
dure undertaken by those assigned female at birth was
AGED
majority of the participants had experienced verbal abuse
bilateral mastectomy or chest reconstruction (n = 159,
(63%), with fewer reporting physical assault (22%) because
ACT
31%). Similarly, a further 58% (n = 297) desired this proce-
of their trans status. There were barriers to employment
AND
dure in the future.
RELEASED
(19% unemployed) despite high levels of tertiary education.
Additional barriers to accessing health care existed, such as
Access to health resources and priorities
difficult ambiguous pathways for accessing gender-affirming
for government funding
BEEN hormonaltherapy;difficulty findingdoctors toprescribe treat-
HEALTH
The most preferred method of receiving health informa-
ment; and the potentially high, out-of-pocket financial costs of
HAS
OF
tion was through online resources (n = 400, 50%) (Table 4).
surgical care. Although the use of gender-affirming hormone
INFORMATION
Forty-three percent (n = 369) of participants used existing
therapy was common, significant difficulties existed in access-
online sources for health information. The most popular
OF
ing gender-affirming surgery. Even though most of the partic-
source reported in this study was Reddit, an online discussion
ipants accessed health information from peer-generated online
board with user-generated content, followed by Facebook,
websites, there was support for development of reliable, local
Susan’s Place, FtM Australia, Wikipedia, YouTube, and
health resources. Better training for doctors in trans health
DOCUMENT
Tumblr. The majority (95%, n = 814) supported the develop-
issues was highlighted as the top priority for government fund-
DEPARTMENT
ment of a comprehensive online website with
FREEDOM
local,
ing by 32% of participants.
Australian-based, trans health resources,
THIS
and 89% of the par-
THE
ticipants (n = 768) used social media daily. Better training for
THE
Sociodemographic data
doctors in trans issues was the most frequently selected pri-
BY
ority for government funding (32%, n = 267); complete re-
We observed a breadth of gender identities in the trans
sponses are listed in Table 4.
community across Australia with approximately equal
Table 3. Access to and Desire for Gender-Affirming Surgery
Total number
Have had,
Want someday,
Don’t want,
of responses
n (%)
n (%)
n (%)
Surgical procedures in birth-assigned males (n = 403)
Breast augmentation
362
32 (9)
196 (54)
134 (37)
Genital reconstruction surgery
384
71 (18)
243 (64)
70 (18)
Facial feminization surgery
372
23 (6)
235 (63)
114 (31)
Voice surgery
348
6 (2)
149 (43)
193 (55)
Surgical procedures in birth-assigned females (n = 520)
Chest surgery/mastectomy
511
159 (31)
297 (58)
55 (11)
Genital reconstruction surgery
481
10 (2)
213 (44)
258 (54)
Voice surgery
405
1 (<1)
15 (4)
389 (96)
Percentages are rounded to whole numbers.
FOI 4876 - Document 27
HEALTH AND WELL-BEING OF TRANSGENDER AUSTRALIANS
47
Table 4. Access to Health Resources
Access to health care and health burden
and Priorities for Government Funding
Similar to prior reports,5 discrimination in all aspects of
life was frequently reported by trans Australians, which is
Number of
responses
Frequency,
not only harmful but also perpetuates inequity. Most con-
Parameter
received
n (%)
cerning is that safe access to health care, which should be
accessible to all, is not a reality for trans Australians and
Most preferred method of
799
this is supported by the participants’ selected top priority
receiving health information
for government funding being better training for doctors in
Online (websites and e-mail,
400 (50)
trans health issues. Access to surgery is a major challenge
etc.)
in Australia, with (anecdotally) few surgeons experienced
Social media (e.g., Facebook)
150 (19)
in providing gender-affirming surgery. Moreover, surgery
Videos or podcasts
57 (7)
is predominantly provided in the private health system,
Telephone contact
43 (5)
Hardcopy print materials (e.g.,
41 (5)
which is associated with prohibitive financial costs. There
brochures)
is a need for education and training to target the number of
Small local community
39 (5)
surgeons providing gender-affirming surgery.
talks/seminars
Self-reported depression and anxiety were highly preva-
Apps (on mobile devices)
35 (4)
lent in *70% of individuals, as were self-reported diagnoses
Online group forums (e.g.,
24 (3)
of ASD and ADHD (Fig. 1). These are consistent with data
webinars)
from individuals attending specialized gender clinics1 as
Larger group gatherings (e.g.,
10 (1)
well as from international reports.24 Notably, a diagnosis
conferences)
of ADHD in childhood is associated with a higher risk of
Social media use
859
having at least one mental health condition and a higher
Daily
768 (89)
CARE
risk of death by suicide.25 As positive screening tools for
UNDER
Couple of times a week
55 (6)
ASD may reflect elevated social anxiety experienced by
Occasionally (e.g., once a week)
19 (2)
trans people, data describing the coexistence of ASD are con-
Rarely (e.g., once a fortnight)
10 (1)
1982
AGED
Not at all
7 (<1)
flicting and further research is needed.9
The most concerning data are the self-reported self-harm
Top priority for government
824
ACT
and attempted suicide
AND rates, a reflection of the severe distress
funding
RELEASED
Better training for doctors in
267 (32)
and despair that many trans individuals have faced. These
trans issues
suicidality rates are much higher than the lifetime prevalence
Gender clinics
205 (25)
of suicide attempts in Australian adults (3.3%).26 Our Aus-
BEEN
Education about gender
197 (24)
tralian data mirror
HEALTH findings in the U.S. National Transgender
diversity (i.e., community or
Discrimination Survey of 6450 trans Americans, which first
schools)
HAS
OF
highlighted widespread discrimination in many aspects of
INFORMATION
Trans or gender-related medical
83 (10)
life, including double the rate of unemployment; 19%
research
OF
being refused medical care due to their trans status; and
Psychology or psychiatry
32 (4)
41% of suicide attempts (compared with 1.6% of the general
services
population).27 Lack of acceptance in the community and, at
Support groups
18 (2)
Trans advocacy groups
14 (2)
times, among health professionals leaves few resources for
DOCUMENT
Counseling
8 (1)
trans individuals to access help and support. This is a signif-
DEPARTMENT
Other (free text)
FREEDOM 0
icant public health concern and there is an urgent need for a
THIS
coordinated and combined suicide prevention response.
THE THE
thirds of the participants having female, male, and nonbi-
Health resources and priorities for government funding
BY
nary identities. This contrasts with historical reports that
the prevalence of trans female individuals outnumbered
The top priority for government funding was better training
trans male individuals.21 The high proportion of people
in trans health issues for doctors. Although greater awareness
with nonbinary gender identities is consistent with rates ob-
of and more coordinated training in trans health need to occur,
served in our primary care clinics in Australia1 and may re-
in response to findings from this study, an evidence-based
flect increasing societal views that challenge binary gender
local position statement was published regarding the hor-
stereotypes.
monal management of trans adults to provide a point-
The unemployment rate of 19% was three times that of
of-care resource for doctors caring for trans individuals.12
the Australian general population rate of 5.5% in May
In response to the community desire for Australian-based
2018 and well above the youth unemployment rate
trans health information, we contributed to the development
(12.2%).22 Notably, 33% of respondents perceived dis-
of trans community-led online health resources (Trans
crimination in employment. Unemployment may also
Health Research and TransHub).28,29
occur due to difficulty with name and identity documents,
Limitations
discrimination in basic housing and health care,5 and the
impact of mental health conditions such as depression
There are multiple limitations to this study. The online-
and anxiety on an individual’s ability to seek or maintain
based recruitment may explain why a greater proportion of
employment. Conversely, levels of depression and anxiety
responders were younger individuals and may not accurately
may be higher due to unemployment.23
reflect the views of the older trans community. There may be
FOI 4876 - Document 27
48
BRETHERTON ET AL.
self-selection bias and not all areas of Australia were equally
Funding Information
represented as recruitment was not targeted. There was a pre-
I.B. receives salary support from an Australian Govern-
dominance of respondents from southeastern states, which
ment Research Training Program Scholarship and a Rowden
may be related to physical promotion of the study at one
White Scholarship (application ref: 184409), The University
event in Victoria and one in New South Wales. However,
of Melbourne. A.S.C. receives salary support from an Aus-
distribution of respondents was similar to a previous 2013
tralian Government National Health and Medical Research
Western Australian-based survey.10 Ethnicity data were not
Council Early Career Fellowship (No. 1143333) and research
collected, so we were unable to ascertain if this was a factor
support from the Austin Medical Research Foundation.
associated with additional barriers when accessing health
care. Medical conditions were self-reported, and we were
not able to utilize any diagnostic measures to confirm diag-
Supplementary Material
noses. Furthermore, we did not gauge temporal trends in di-
Supplementary Appendix SA1
agnoses and did not distinguish current from past medical
conditions, which may be particularly relevant in the inter-
pretation of the prevalence of ADHD. Participants were
References
asked whether a mental health assessment for trans and gen-
1. Cheung AS, Ooi O, Leemaqz S, et al.: Sociodemographic
der diverse individuals should be performed prior to access-
and clinical characteristics of transgender adults in Aus
ing hormonal treatment. There was likely a response bias in
tralia. Transgend Health 2018;3:229 238.
favor of the mental health assessment model as we did not
2. White Hughto JM, Rose AJ, Pachankis JE, Reisner SL: Bar
make it clear that we were referring to a formal mental health
riers to gender transition related healthcare: Identifying un
assessment by a psychologist or psychiatrist rather than by
derserved transgender adults in Massachusetts. Transgend
the primary care physician in the wording of this question.
Health 2017;2:107 118.
However, this survey provided a platform for participants to
3. Sanchez NF, Sanchez JP, Danoff A: Health care utilization,
UNDER CARE
express their views anonymously, which potentially facilitated
barriers to care, and hormone usage among male to female
the expression of more honest responses than a face-to-face in-
transgender persons in New York City. Am J Public Health
1982
terview or government statistics form. The fact that many of
2009;99:713 719.AGED
our findings, although self-reported (such as rates of self-
4. Adams NJ, Vincent B: Suicidal thoughts and behaviors
ACT
harm), replicate those from prior similar studies conducted
among transgender adults in relation to education, ethnicity,
AND
with other transgender populations supports both the validity
and income: A systematic review. Transgend Health 2019;
RELEASED
4:226 246.
and the generalizability of our findings. Despite the limitations,
5. Bradford J, Reisner SL, Honnold JA, Xavier J: Experiences
this is one of the largest published studies of adult trans indi-
of transgender related discrimination and implications for
viduals in the Australian population and provides valuable in-
BEEN health:ResultsfromtheVirginiaTransgenderHealthInitia
HEALTH
sight on the status of health and health needs of a traditionally
tive Study. Am J Public Health 2013;103:1820 1829.
marginalized community that is underrepresented in research.
HAS
OF 6. Christian R, Mellies AA, Bui AG, et al.: Measuring the
INFORMATION
health of an invisible population: Lessons from the Colo
Conclusions
rado Transgender Health Survey. J Gen Intern Med 2018;
OF
33:1654 1660.
This large community survey highlights a myriad of chal-
7. Lykens JE, LeBlanc AJ, Bockting WO: Healthcare experi
lenges faced by trans adult Australians, including discrimina-
ences among young adults who identify as genderqueer or
tion, abuse, unemployment, and inability to find doctors to
DOCUMENT
nonbinary. LGBT Health 2018;5:191 196.
access general health care and gender-affirming care. Reduc-
DEPARTMENT 8. Giblon R, Bauer GR: Health care availability, quality, and
FREEDOM
ing the high attempted suicide rate and burden of mental
unmet need: A comparison of transgender and cisgender resi
THIS
health conditions needs to be prioritized. The participants
dents of Ontario, Canada. BMC Health Serv Res 2017;17:283.
THE
in this study identified the training
THE of doctors in trans health 9. Thrower E, Bretherton I, Pang KC, et al.: Prevalence of au
as a priority. This should be one of the first steps to ensure
BY
tism spectrum disorder and attention deficit hyperactivity
that basic health needs are met. Urgent action is required
disorder amongst individuals with gender dysphoria: A sys
from a policy perspective to address the concerning health
tematic review. J Autism Dev Disord 2020;50:695 706.
disparities described herein and to ensure that all trans people
10. Hyde Z, Doherty M, Tilley PJM, et al.: The First Australian
are safe and empowered to live a life without barriers.
National Trans Mental Health Study: Summary of Results.
2014. School of Public Health, Curtin University, Perth,
Acknowledgments
Australia.
11. Coleman E, Bockting W, Botzer M, et al.: Standards of care
The authors would like to acknowledge members of the
for the health of transsexual, transgender, and gender
transgender community who reviewed and contributed to
nonconforming people, Version 7. Int J Transgend 2012;
the survey design.
13:165 232.
12. Cheung AS, Wynne K, Erasmus J, et al.: Position statement
Author Disclosure Statement
on the hormonal management of adult transgender and gen
der diverse individuals. Med J Aust 2019;211:127 133.
A.S.C. has received speaker’s honoraria from AstraZeneca
13. Australian Government Australian Institute of Health and
and Merck Sharp and Dohme Corp. M.G. has received re-
Welfare 2016. The Australian Statistical Geography Stan
search funding from Bayer, Weight Watchers, and Eli Lilly
dard (ASGS) Remoteness Structure. Canberra AIHW.
and speaker’s honoraria from Besins Healthcare and Novar-
Available at https://www.abs.gov.au/websitedbs/d3310114
tis. All other authors have no conflicts of interest to declare.
.nsf/home/remoteness+structure Accessed October 1, 2020.
FOI 4876 - Document 27
HEALTH AND WELL-BEING OF TRANSGENDER AUSTRALIANS
49
14. Jaffee KD, Shires DA, Stroumsa D: Discrimination and
22. Australian Bureau of Statistics. Labour Force, Australia,
delayed health care among transgender women and men:
May 2018. Available at https://www.ausstats.abs.gov.au/
Implications for improving medical education and health
ausstats/meisubs.nsf/0/4A6AF94624BEB836CA2582AB0
care delivery. Med Care 2016;54:1010 1016.
016949D/$File/62020 may 2018.pdf Accessed July 30, 2020.
15. Zwickl S, Wong A, Bretherton I, et al.: Health needs of trans
23. Crowe L, Butterworth P: The role of financial hardship,
and gender diverse adults in Australia: A qualitative analy
mastery and social support in the association between em
sis of a national community survey. Int J Environ Res Public
ployment status and depression: Results from an Australian
Health 2019;16:5088.
longitudinal cohort study. BMJ Open 2016;6:e009834.
16. Greenhalgh EM, Bayly M, Scollo MM. 1.3 Prevalence of
24. Reisner SL, Biello KB, White Hughto JM, et al.: Psychiatric
smoking
adults. In: Tobacco in Australia: Facts and
diagnoses and comorbidities in a diverse, multicity cohort of
Issues. Edited by Greenhalgh EM, Scollo MM, Winstanley
young transgender women: Baseline findings from Project
MH. Melbourne: Cancer Council Victoria, 2020. Available
LifeSkills. JAMA Pediatr 2016;170:481 486.
at www.tobaccoinaustralia.org.au/chapter 1 prevalence/1 3
25. Barbaresi WJ, Colligan RC, Weaver AL, et al.: Mortality,
prevalence of smoking adults Accessed October 1, 2020.
ADHD, and psychosocial adversity in adults with childhood
17. Australian Institute of Health and Welfare 2020. National
ADHD: A prospective study. Pediatrics 2013;131:637 644.
Drug Strategy Household Survey 2019. Drug Statistics
26. Slade T, Johnston A, Teesson M, et al.: The mental health of
series no. 32. PHE 270. Canberra AIHW. Available at
Australians 2. Report on the 2007 National Survey of Men
https://www.aihw.gov.au/getmedia/3564474e f7ad 461c
tal Health and Wellbeing. 2009. Canberra, Australia: The
b918 7f8de03d1294/aihw phe 270 NDSHS 2019 .pdf
Department of Health, Australian Government.
Accessed October 1, 2020.
27. Grant JM, Mottet LA, Tanis J, et al.: Injustice at Every Turn:
18. Australian Bureau of Statistics. National Health Survey:
a Report of the National Transgender Discrimination Sur
First Results, 2017 18. 2018. Available at https://www.abs
vey. 2011. Washington, DC: National Center for Transgen
.gov.au/statistics/health/health conditions and risks/national
der Equality and National Gay and Lesbian Task Force.
health survey first results/2017 18/4364055001do003
28. Trans Health Research. 2020. Available at https://www
UNDER CARE
20172018.xls Accessed July 30, 2020.
.transresearch.org.au Accessed July 30, 2020.
19. Ebejer JL, Medland SE, van der Werf J, et al.: Attention def
29. TransHub. 2020. Available at https://www.transhub.org.au
1982
icit hyperactivity disorder in Australian adults: Prevalence,
Accessed July 30, 2020.
AGED
persistence, conduct problems and disadvantage. PLoS
One 2012;7:e47404.
ACT AND
20. Australian Bureau of Statistics. Survey of Disability, Age
Address correspondence to:
RELEASED
ing and Carers (SDAC) 2018. Available at https://www
Ada S. Cheung, PhD
.abs.gov.au/statistics/health/disability/disability ageing and
Department of Endocrinology
carers australia summary findings/latest release Accessed
Austin Health
BEEN
October 29, 2020.
145 Studley Road
HEALTH
21. Bouman WP, Claes L, Marshall E, et al.: Sociodemographic
Heidelberg, Victoria 3084
HAS
OF
variables, clinical features, and the role of preassessment
Australia
INFORMATION
cross sex hormones in older trans people. J Sex Med 2016;
13:711 719.
OF
E-mail: xxxx@xxxxxxx.xxx.xx
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
FOI 4876 - Document 27
UNDER CARE
1982
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
FOI 4876 - Document 27
Zwickl et al. BMC Psychiatry (2021) 21:81
Page 2 of 10
Background
and improves quality of life [31, 32]. Similarly, trans
Transgender, including gender diverse and non-binary
adults who desire and are able to access gender affirming
(trans) people are a highly marginalised group in our
surgery report stronger mental health as compared to
community with alarmingly high rates of suicidality
trans adults who cannot access surgeries [33]. Social
(ideation and non-fatal behaviours) and mental health
support from family, friends and connection with the
morbidities [1–3]. High quality empirical evidence and
trans community and experiencing lower levels of struc-
data (such as from a census) describing the size of the
tural discrimination are further protective factor against
trans population are limited, but a systematic review of
suicidality and suicide attempts [13–17].
studies published internationally from 2009 to 2019
Gender plays a role. In Australia, young cisgender men
found estimates ranged from 0.5 to 4.5% of the adult
and those presumed to be men who live in non-
population [4]. Within an Australian-context, despite
metropolitan areas have the highest suicide rates and are
universal public health care and anti-discrimination laws
less likely to seek assistance for depression or other
at the State and Federal level, trans adults experience
mental health problems [34]. Data from many countries
high levels of discrimination and are four times more
worldwide show that people presumed male have higher
likely than the general population to be diagnosed with
rates of suicide compared to people presumed female
depression, with over 40% self-reporting previous suicide
[35]. The precise reasons for the gender discrepancy are
attempts [5–7]. Various human rights challenges remain;
unclear, however possible explanations for higher rates
in many Australian States and Territories, it is not pos-
of suicide in people presumed male include more vio-
sible to obtain legal gender recognition without first hav-
lent, immediately lethal means of
CARE suicide, higher levels
UNDER
ing gender affirmation surgery. Moreover, access to
of suicidal intent and greater reticence to seek assistance
gender affirmation surgery is not covered by the national
from doctors for mental
1982 health support [36, 37].
AGED
Medicare public health scheme and is cost prohibitive
In the general population, it is known that unemploy-
for many people.
ment, physical
ACT assault and perceived discrimination in-
AND
Suicide attempts and suicide deaths occur due to a
creases risk for suicide ideation and suicide attempts
RELEASED
complex interaction between biological, psychological
[12, 38, 39]. We hypothesised that people who reported
and psychosocial risk factors. This may include genetic
known risk factors for suicidal behaviour; residing in
BEEN
predisposition to depression and anxiety [8, 9], minority
rural areas, unemployment, experienced difficulty acces-
HEALTH
stress and stressful life events, unemployment and finan-
sing gender-affirming interventions, known history of
HAS
OF
cial stress [10–12], quality of support networks [13–17],
depression or anxiety, had perceived discrimination and
INFORMATION
discrimination, violence [18–20] and barriers to acces-
experiences of assault, would have a higher odds of
OF
sing healthcare and support services [21].
reporting a history of suicide attempts. Given the lack of
Trans-specific factors for suicidality is an under-
data describing risk or protective factors among Austra-
researched area, but several risk and protective factors
lian trans adults, this exploratory analysis aimed to as-
have been identified. Research has increasingly
DOCUMENT focused sess factors associated with a lifetime history of
on how cissexism, or the belief that cisgender people are
DEPARTMENT attempted suicide in order to guide suicide prevention
FREEDOM
‘normal’, ‘natural’ and ‘superior
THIS ’ delimits opportunities strategies and interventions.
THE
for trans health and wellbeing [22]. Gender-based vic-
THE
timisation, including verbal abuse, peer rejection, threats
Methods
BY
of violence and physical assault has been well docu-
This anonymous online survey of trans adults utilised a
mented among trans adults [3, 23, 24]. Similarly, there is
non-probability snowball sampling technique. Inclusion
growing evidence of institutionalized cissexism, mani-
criteria for participants were assessed by a positive re-
festing as heightened rates of trans unemployment, re-
sponse to three screening questions: a) Australian resi-
duced access to housing, education and healthcare
dency; b) aged 18 years or older and c) self-identify as
(including gender affirming healthcare), which contrib-
trans or gender diverse (defined as a ‘yes’ response to
utes to diminished mental health and wellbeing by way
the question ‘Do you currently identify or have you pre-
of elevated feelings of shame, hopelessness and isolation
viously identified as transgender or gender diverse?’).
[24–29]. Systemic barriers are associated with increased
The inclusion of those who had previously identified as
risk of housing instability, financial stress and violence
trans was intended to include those who identified as
[30].
their affirmed gender (male, female or non-binary) ra-
Rather than focusing on the deleterious effects of cis-
ther than with the term transgender. Individuals were
sexism, research has begun to illuminate factors that
eligible to complete the survey on one occasion only and
protect against suicidality and mental health comorbidi-
duplicate responses from the same Internet Protocol ad-
ties. For example, in trans people who wish to access
dress were excluded. All included individuals had dis-
hormones, being able to do so reduces mental distress,
cordance between their assigned sex at birth and their
FOI 4876 - Document 27
Zwickl et al. BMC Psychiatry (2021) 21:81
Page 3 of 10
gender identity. Survey questions were all optional. Sur-
7) Self-reported diagnosis of anxiety. Participants were
veyMonkey (SurveyMonkey Inc. San Mateo, California,
asked if they had ever been medically diagnosed
USA) was used to collect responses to the survey be-
with anxiety (yes/no).
tween 1st September 2017 and 31st January 2018. Given
8) Access to trans support groups. Participants were
that this was an anonymous survey, written informed
asked if they were a member of any trans support
consent was not possible and was waived by the institu-
groups, including on social media (yes/no or
tional ethics committee; however, the survey preamble
unsure).
outlined that completion of the survey implied consent.
9) Perceived discrimination from employment,
The study was approved by the Austin Health Human
housing, healthcare and/or government services.
Research and Ethics Committee (HREC/17/Austin/372).
Participants were asked ‘Because of your trans
Participants were asked a range of questions, with data
status have you ever experienced any of the
pertaining to the health care needs and priorities of par-
following (select all that apply)?’ with multiple
ticipants which are published elsewhere [7, 40]. The full
choice options of ‘Discrimination from employment
version of the survey is available in the supplementary
(i.e. lost a job or overlooked for a job)’,
appendix at https://doi.org/10.1089/lgbt.2020.0178 [7].
‘Discrimination from housing (i.e. denied a rental
Participants were asked ‘Have you ever intentionally self-
application)’, ‘Discrimination from accessing
harmed?’ (response options of ‘yes’, ‘no’ or ‘prefer not to
healthcare’, and ‘Discrimination from government
say’) and ‘Have you ever attempted suicide?’ with re-
services (i.e. Centrelink)’, ‘Physical assault’, ‘Verbal
sponse options of ‘yes’, ‘no’ or ‘prefer not to say’. We
abuse’, ‘Domestic violence’, and
CARE ‘None’. For the
UNDER
specifically assessed if the following 10 factors were risk
purposes of analyses positive responses to any of
or protective factors for a positive (‘yes’) response for a
the four discrimination
1982
options (discrimination
AGED
lifetime history of attempted suicide.
from employment, housing, accessing healthcare
and gover
ACT nment services) were combined to create
AND
1) Location of residence (metropolitan or rural), which
one factor called ‘institutional discrimination’.
RELEASED
was determined by coding postcodes as per the
10) Physical assault. Participants indicated whether they
Australia Standard Geographical Classification
had ever experienced physical assault because of
BEEN
Remoteness Area (RA). Rural location of residence
their trans status (yes/no).
HEALTH
was classified as anyone living outside of a major
HAS
OF
city area corresponding to Remoteness Areas 2 to 5.
Statistical analysis was performed using R version 3.6.3
INFORMATION
2) Presumed gender at birth (male, female).
(R Foundation for Statistical Computing). Participant
OF
3) Employment status (unemployed, compared to
characteristics are reported as frequency (percentage).
employed on full-time basis, part-time basis, home
Logistic regression was used to estimate the effects of
duties full time, student, retired, other)
the 10 factors listed above on the risk of attempted sui-
4) Access to gender affirming hormones. Part
DOCUMENT icipants
cide. The 10 factors considered in the regression were
were asked if they experienced any difficulty
DEPARTMENT selected prior to performing the analysis on the basis of
FREEDOM
accessing gender affirming hormones with positive
previous known risk factors for suicidal behaviour. Re-
THIS THE
responses to the following multiple choice options:
sults are reported as odds ratios (OR) with correspond-
THE
unable to find a doctor to prescribe; unable to
ing 95% confidence intervals (CI). Factors with low
BY
afford costs of prescriptions; unable to afford cost
frequency categories were included in the regression,
of doctors’ appointments; or pathway to accessing
and a sensitivity analysis excluding low-frequency cat-
hormones too difficult, compared to no difficulty
egories was performed where there is evidence of in-
accessing gender affirming hormones.
flated standard errors and ORs. This is a complete case
5) Desire for gender affirming surgery in the future.
analysis with an alpha level of 5% (P < 0.05) to be consid-
Participants indicated whether they wanted
ered statistically significant.
gender affirming surgery someday, had already
had surgery or did not want surgery, from the
Results
four options
bilateral mastectomy/chest
There was a total of 964 responses to the survey, how-
reconstruction surgery, breast augmentation,
ever, after excluding participants who did not fit the se-
bottom surgery, voice surgery. Those that desired
lection criteria and duplicate responses, there was a total
at least one type of gender affirming surgery
of 928 eligible survey responses.
were compared with other groups that did not.
Participant characteristics are shown in Table 1. Re-
6) Self-reported diagnosis of depression. Participants
sponses were received from all states and territories of
were asked if they had ever been medically
Australia, with the majority residing in major city areas.
diagnosed with depression (yes/no).
The
median
age
of
participants
was
28 years
FOI 4876 - Document 27
Zwickl et al. BMC Psychiatry (2021) 21:81
Page 4 of 10
Table 1 Participant characteristics
Parameter
Number of responses received
Frequency n(%)
State of residence
911
Victoria
282 (31%)
New South Wales
195 (21%)
Queensland
143 (16%)
Western Australia
126 (14%)
South Australia
92 (10%)
Tasmania
37 (4%)
Australian Capital Territory
34 (4%)
Northern Territory
2 (< 1%)
Location of residence (rural status)
905
Major city areas (Remoteness Area 1)
752 (83%)
Inner regional areas (Remoteness Area 2)
122 (13%)
Outer regional areas (Remoteness Area 3)
25 (3%)
Remote and Very Remote areas (Remoteness Area 4 and Remoteness Area5)
6 (< 1%)
UNDER CARE
Age group (years)
928
18 24
289 (31%)
1982
AGED
25 29
216 (23%)
30 39
ACT
193 (21%)
AND
40 49
RELEASED
125 (13%)
50 59
71 (8%)
60 69
30 (3%
BEEN HEALTH
70 79
4 (< 1%)
OF
Presumed sex at birth
HAS
928
INFORMATION
Female
520 (56%)
OF
Male
403 (43%)
Intersex
5 (1%)
Gender identity
928
DOCUMENT
Trans Man/Trans Male/Transmasculine
239 (26%)
FREEDOM
DEPARTMENT
Trans Woman/Trans Female/Transfeminine
202 (22%)
THIS THE
Female
140 (15%)
THE
Gender Non Binary
BY
133 (14%)
Male
91 (10%)
Gender Queer
41 (4%)
Agender
20 (2%)
Gender Fluid
19 (2%)
Gender Neutral
11 (1%)
Intersex
2 (< 1%)
Other
30 (3%)
Employment status
928
Employed on a full time basis
274 (30%)
Employed on part time or casual basis
224 (24%)
Home duties full time
13 (1%)
Student
176 (19%)
Retired
20 (2%)
FOI 4876 - Document 27
Zwickl et al. BMC Psychiatry (2021) 21:81
Page 5 of 10
Table 1 Participant characteristics (Continued)
Parameter
Number of responses received
Frequency n(%)
Unemployed
177 (19%)
Other (freetext)
44 (5%)
Depression and Anxiety
914
Depression
663 (73%)
Anxiety
613 (67%)
Discriminationa
927
Discrimination from employment
304 (33%)
Discrimination from accessing healthcare
244 (26%)
Discrimination from government services
149 (16%)
Discrimination from housing
95 (10%)
Verbal Assault
584 (63%)
Physical Assault
200 (21%)
Domestic violence
133 (14%)
Difficulty accessing hormonal treatmenta
905 UNDER CARE
None
372 (41%)
Pathway to accessing hormones was too difficult
284 (31%)
1982
AGED
Unable to find a doctor to prescribe
148 (16%)
Financial costs of prescriptions
ACT
124 (14%)
AND
Financial costs of doctors appointments
RELEASED
156 (17%)
Other (specify)
100 (11%)
Member of Trans Peer Support Groups
860
BEEN HEALTH
Yes
689 (80%)
OF
No
HAS
153 (18%)
INFORMATION
Unsure/Prefer not to say
18 (2%)
OF
amultiple responses allowed for this question so total responses do not sum to 100%
[interquartile range 23–39]. Sixty three percent of trans
of reporting a lifetime history of suicide attempts.
adults reported a lifetime history of intentio
DOCUMENT nal self- Due to the low number of intersex individuals (n = 5),
harm (n = 577), while 43% reporting ever having
DEPARTMENT a valid odds ratio cannot be estimated and hence was
FREEDOM
attempted suicide (n = 394). This compares to a lifetime
not reported in Table 2. A sensitivity analysis was
THIS THE
prevalence of self-injury in the Australian general popu-
performed excluding those 5 participants and the re-
THE
lation of 8.1% and previous suicide attempts of 3.3% [41,
sults remains unchanged.
BY
42]. From univariate analysis, there was no statistically
significant difference in the proportion of suicide (p =
Discussion
0.6) or self-harm (p = 0.08) between different states of
This large community survey provides preliminary
residence. Access to and desire for gender affirming
insight into the factors associated with suicidality in the
surgeries are presented in Table 2.
Australian trans community. Being unemployed, report-
Variables which were associated with increased odds
ing a diagnosis of depression, desiring gender affirming
of a lifetime history of suicide attempts are shown in
surgery, a history of physical assault and experiences of
Table
3.
Self-reported
unemployment,
desiring
institutional discrimination were all factors associated
gender-affirming surgery in the future, depression,
with increased odds of a lifetime history of suicide at-
physical assault, and institutional discrimination were
tempts. Being presumed male at birth was associated
all associated with higher odds of reporting a previous
with lower odds of suicide attempt.
suicide attempt. There was no association with anx-
While the self-reported suicide attempt rate of trans
iety, difficulty accessing hormones or location of resi-
participants is 10-times higher than that reported for the
dence (rural versus metropolitan), nor was access to
general Australian population, this rate converges with
trans support groups a protective factor. Being pre-
data on Australian trans youth and similar cohort stud-
sumed male at birth was associated with lower odds
ies conducted in Euro-Western settings [6, 41–43]. This
FOI 4876 - Document 27
Zwickl et al. BMC Psychiatry (2021) 21:81
Page 6 of 10
Table 2 Access to and desire for gender affirming surgery
Number of responses recieved
Have had, n (%)
Want someday, n (%)
Don’t want, n (%)
Surgical procedures in people presumed male at birth
Breast augmentation
362
32 (9)
196 (54)
134 (37)
Genital reconscrutive surgery
384
71 (18)
243 (63)
70 (18)
Facial feminization surgery
372
23 (6)
235 (63)
114 (31)
Voice surgery
348
6 (2)
149 (43)
193 (55)
Surgical procedures in people presumed female at birth
Chest reconstructive surgery / mastectomy
511
159 (31)
297 (58)
55 (11)
Genital reconscrutive surgery
481
10 (2)
213 (44)
258 (54)
Voice surgery
405
1 (< 1)
15 (4)
389 (96)
amultiple responses allowed for this question so total responses do not sum to 100%
pattern of convergence suggests that health disparities
suicide attempt than a physical assault not attributed to
and systemic social inequities are not confined to a spe-
prejudice, or experiencing institutional discrimination
cific developmental time frame nor geographic locality.
alone without assault [45].
Notably, we found intentional self-harm rates (63%)
Additionally, experiences of
CARE institutionalised dis-
UNDER
were even higher than the rate of suicide attempt, but
crimination were reported at a high frequency. In
previous evidence has shown that in the Australian
our study, this included
1982
discrimination while acces-
AGED
population, self-harm can occur in the absence of sui-
sing healthcare (including gender affirming health-
cidal thoughts, often used as a means of managing diffi-
care),
in
employment,
ACT
housing,
and
accessing
AND
cult emotions [42]. While beyond the scope of the
government services. In a US-based study of 6450
RELEASED
current analysis, it may be that persistent social exclu-
trans people, an extraordinary 90% reported experi-
sion and acts of erasure result in elevated feelings of
encing harassment, mistreatment or discrimination
BEEN
shame, hopelessness and isolation-factors associated
in workplaces, housing and in healthcare settings
HEALTH
with self-harm [24–29].
due to prejudice related to their trans-status or took
HAS
OF
Due to widespread cissexism and transphobia, physical
actions such as hiding their identity to mitigate risk
INFORMATION
assault is an all-too-common experience within the trans
[3]. Specifically, service denial in healthcare has a
OF
community. It was reported by 21% of respondents and
profound impact correlated with elevated rates of
was associated with a 100% increase in the odds of a life-
attempted suicide [21]. Social and institutional dis-
time suicide attempt. Physical assault has consistently
crimination has been found to negatively impact
been associated with poor mental health outcom
DOCUMENT es and a trans people’s mental health and has been consist-
higher risk of suicide [19, 20, 44]. Critically, being phys-
DEPARTMENT ently demonstrated to be a risk factor for attempted
FREEDOM
ically assaulted because of a perpetrator
THIS
’s transphobic
suicide, underscoring the need for multi-level inter-
THE
prejudice is associated with a higher probability of
ventions to enable timely, rights-based and culturally
THE
BY
Table 3 Variables and association with a lifetime history of suicide attempts
Variable
Unadjusted OR (95% CI)
P
Adjusted OR (95% CI)
P
Location (Living outside of a major city area in Remoteness Areas 2 5).
0.97 (0.68, 1.38)
0.8
0.93 (0.61, 1.41)
0.7
Presumed Male at Birth
0.65 (0.50, 0.85)
0.002
0.62 (0.45, 0.85)
0.003
Unemployment
1.88 (1.35, 2.63)
0.0002
1.54 (1.04, 2.28)
0.03
Access to gender affirming hormone therapy (difficulty accessing)
1.65 (1.25, 2.18)
0.0004
0.97 (0.70, 1.34)
0.8
Access to gender affirming surgery (wanting in future)
1.71 (1.20, 2.43)
0.003
1.71 (1.13, 2.59)
0.01
Depression
4.64 (3.27, 6.58)
< 0.0001
3.43 (2.16, 5.46)
< 0.0001
Anxiety
2.85 (2.11, 3.84)
< 0.0001
1.13 (0.74, 1.73)
0.6
Access to Trans Support Group
0.92 (0.66, 1.30)
0.7
0.79 (0.54, 1.16)
0.2
Physical Assault
2.55 (1.85, 3.51)
< 0.0001
2.00 (1.37, 2.93)
0.0004
Institutional Discrimination
1.91 (1.47, 2.49)
< 0.0001
1.59 (1.14, 2.22)
0.007
OR odds ratio, Unadjusted OR (95% CI) from univariate Logistic regression; Adjusted OR (95% CI) from Logistic regression with all variables included (complete
case analysis n = 785), mutually adjusted for each other
FOI 4876 - Document 27
Zwickl et al. BMC Psychiatry (2021) 21:81
Page 7 of 10
safe access to gender affirming and general health-
association is influenced by other confounders, such as
care, end discrimination and protect the trans popu-
depression. This is inline with some general population
lation across every domain of life [18, 29, 46, 47].
studies that have found that anxiety disorder alone is
In addition to discrimination, unemployment was as-
not associated with suicidality [59].
sociated with a 54% higher odds of lifetime suicide at-
We demonstrate that trangender individuals who de-
tempt. The trans unemployment rate of 19% is three
sire gender affirming surgery in the future experience
times higher than the general Australian population
71% increased odds of reporting a lifetime suicide at-
(5.5%) [48]. In general population studies, unemploy-
tempt. This is likely related to a number of intrapersonal
ment and financial precarity has been linked to suicidal-
and interpersonal factors, and barriers to healthcare ac-
ity, with the length of unemployment compounding the
cess. Those individuals who desire gender affirming sur-
risk of suicide [10–12]. The impact of employment on
gery generally experience body and/or social dysphoria
mental and physical health, socioeconomic status and
related to that part of their body, resulting in mental
quality of life is profound [49, 50]. Perceived stress in
health distress. Gender affirming surgeries may result in
everyday life is known to increase the risk of unemploy-
significant body changes that increase the likelihood that
ment, yet unemployment and sustained economic hard-
trans individuals will be read and understood by others
ship
can
also
directly
negatively
affect
physical,
as their affirmed gender. Those who desire but are yet to
psychological and cognitive functioning [51–54]. Poverty
access surgeries may experience higher rates of misgen-
arising from unemployment may additionally limit an in-
dering, discrimination and violence due to gender non-
dividual’s ability to access gender-affirming healthcare,
conformity or ambiguous appearance
CARE
[3, 60], which in
UNDER
particularly gender-affirming surgery which is associated
turn may have an impact on mental health.
with large out-of-pocket costs [3, 55]. Notably, there are
Access to gender-affi
1982 rming surgery has been shown to
AGED
many potential barriers to employment for trans people
improve mental health and quality of life indicators for
such as persistent challenges being affirmed and
those who have
ACT undertaken a surgical intervention to
AND
respected by employers and colleagues using the correct
affirm their gender. [5, 33, 61] In an Australian study
RELEASED
name, gender and pronouns, to being terminated, looked
regarding surgery experiences and satisfaction, depression
over for promotions and facing discrimination and vio-
was reported in 34% of those individuals who had under-
BEEN
lence at work, to discrimination in basic housing and
gone at least some form of gender-affirming surgery, com-
HEALTH
healthcare and the impact of mental health conditions
pared to 51% in those who desired but had not undergone
HAS
OF
such as depression and anxiety on an individual’s ability
surgery. [33] Our findings concur with previous research
INFORMATION
to seek or maintain employment [29, 56]. Moreover,
that those who want surgery but have yet to access it, are
OF
33% reported perceived discrimination from employ-
at significantly increased risk of suicide.
ment, and whilst it was not directly assessed in the sur-
Desire for gender affirming surgery in the future may
vey questions, workplace environments that expose
also be related to healthcare access. One of the biggest
individuals to discrimination have been found
DOCUMENT elsewhere barriers reported by trans individuals is a lack of access
to impact on an individual’s mental health and ability to
DEPARTMENT to healthcare due to the lack of healthcare professionals
FREEDOM
maintain employment [29].
skilled in gender affirming healthcare [62]. Access to
THIS THE
Self-reported lifetime diagnoses of depression were
gender affirming surgery, in particular, poses significant
THE
high in our participants, and this was associated with an
barriers due to a lack of experienced surgeons, high cost,
BY
over 200% increased odds of reporting a lifetime suicide
the lack of public funding and “gate-keeping” require-
attempt. Similarly, a lifetime history of major depressive
ments, which can typically involve multiple, detailed as-
disorder has been significantly associated with increased
sessments with two mental health professionals prior to
risk of suicidal ideation and attempted suicide in trans
surgery. Barriers to access, may therefore also contribute
people worldwide [8, 9]. Depression in trans people is
to mental health distress and suicality, as individuals are
multifaceted, and there are various contributing factors;
faced with long, complicated and often prohibitively ex-
including discrimination, disclosure, social support, ac-
pensive options for gender affirming surgeries.
cess to gender affirming healthcare, substance use and
Greater training, programs and clinical supervision for
socioeconomic factors [57]. As such, strategies to lower
surgeons already conducting or wishing to conduct gen-
the high rates of depression will need to be multifaceted,
der affirming surgery, along with full public funding for
supported by accessible, specific and safe mental health
all gender-affirming surgeries is critical to address this
support services for trans individuals, and improved ac-
healthcare gap in access to such medically necessary
cess to gender affirming healthcare [58].
interventions.
Anxiety, which is highly prevalent in the trans com-
Interestingly our findings show that trans women and
munity, was not significantly associated with lifetime sui-
non-binary participants presumed male at birth ap-
cide attempt after adjustment, suggesting that the
peared to have a lower odds of suicide attempt and the
FOI 4876 - Document 27
Zwickl et al. BMC Psychiatry (2021) 21:81
Page 8 of 10
converse is true for trans men and non-binary partici-
is difficult to determine the independent effects of hor-
pants presumed female at birth. Whilst suicide deaths in
mone therapy on quality of life [32]. There is also evidence
the Australian population occur at higher rates in those
that any form of gender affirming transition is beneficial,
recorded as male, there is a higher rate of suicidal idea-
such as social transition and social acceptance [67].
tion and suicide attempt in those presumed female at
birth [63]. Certainly studies assessing suicide attempts in
Limitations
the trans community have shown variable gender distri-
There are multiple limitations to this online study utilis-
butions and inferences are unclear [64].
ing a non-probability snowball sampling approach. The
In the Australian general population, the rates of sui-
online-based recruitment may explain the proportion of
cide tend to increase with increasing rurality. This is
younger participants and the views of older trans people
commonly associated with several factors, including es-
may not be accurately reflected. There may be self-
sential services such as healthcare and mental health
selection bias and not all areas of Australia were repre-
support. [65, 66] This study however, showed no statisti-
sented equally as recruitment was not targeted. There
cally significant difference in lifetime suicide attempt be-
was a predominance of respondents in South-Eastern
tween trans people living in inner city areas and those
states, which may be related to physical promotion of
living in regional and remote areas. Protective factors
the study at one event in Victoria and New South Wales.
that might mitigate the expected association between
However, distribution of respondents was similar to a
rurality and suicidality include reasons for living, the in-
previous 2013 Western Australian-based survey [5]. De-
dividual’s resilience and ability to self-regulate suicidal
pression, self-harm and suicide
CARE attempts were self-
UNDER
thoughts and feelings, familial and social support and
reported. Hence, it is not possible to confirm diagnosis
optimism. [67, 68] However, there is relatively little re-
or determine how individuals
1982
define their experiences
AGED
search directly examining protective factors in the trans
(e.g. what constitutes self-harm versus a suicide attempt;
population and the experience of trans individuals and
diagnosis of clin
ACT ical depression). We did not study com-
AND
communities in regional and remote areas, an effect
pleted suicide, however suicide attempts are a risk factor
RELEASED
termed the ‘metronormative’ bias of trans research. [69]
for suicide and reflect significant distress experienced.
Seminal qualitative research conducted in the USA illu-
The survey was also designed to broadly explore health-
BEEN
minates how trans experiences of resilience in regional
care and wellbeing in the trans community and as such,
HEALTH
and rural places rests upon other social positions (e.g.,
did not focus extensively on mental health and suicidal-
HAS
OF
race, queerness, disability and sexuality). [70]
ity. This survey was, however, a platform for trans
INFORMATION
Previous research suggests that a lack of social support
people in Australia to express their experiences and
OF
is associated with higher odds of psychological distress
opinions anonymously and honestly. It provides valuable
and lifetime suicide attempts, and that social support
insight on the health needs and wellbeing of a margina-
from the trans community is a protective factor against
lised community.
suicidal ideation and suicide attempts [17, 71].
DOCUMENT Contrary
to those studies, our study indicates that there is no sig-
DEPARTMENT Conclusion
FREEDOM
nificant association between being part of a trans sup-
This large community survey highlights the high rates of
THIS THE
port group and suicide attempts. Notably, our survey did
attempted suicide, self-harm and depression in the trans
THE
not ask about community connection which is different
community. Suicide attempts occur due to a complex
BY
from being a member of a support group, nor did the
interaction between socio-political, environmental, inter-
survey assess other forms of social support, such as that
personal and structural risk factors. Rather than suicidal-
from family and friends, which has been shown to be a
ity perceived as inherent to the trans experience, trans
protective factor [13, 14, 16, 68].
people appear to exhibit higher rates of suicidality as a
Not all trans people desire gender affirming hormones
manifestation of social discrimination. Addressing these
in their transition. However, for those people who do, the
factors that contribute to suicidality and the mental
ability to access hormones reduces mental distress [31,
health burden in the trans community must be made a
32]. The highest rates of depression in trans people are in
priority. Dismantling barriers to gender affirming health-
those who want hormones but have yet to use them or are
care is paramount; as is tackling pervasive cissexism in
unable to access them [5]. Despite the strong link between
order
to
reduce
incidents
of
discrimination,
depression and suicidality, this study found no significant
stigmatization and violence. There is also an ongoing
difference in suicidality solely based on access to hor-
need to shift the discourse of the health and health
mones. Given that there may be many confounding fac-
needs of trans people away from a focus on risk and def-
tors that impact mental health independently of hormone
icit, to align with a strength-based approach to illumin-
therapy, such as access to other gender affirming medical
ate factors that protect against suicidality and to
procedures and psychotherapy, as well as social support, it
promote resilience.
FOI 4876 - Document 27
Zwickl et al. BMC Psychiatry (2021) 21:81
Page 9 of 10
Authors’ contributions
9.
Chen R, Zhu X, Wright L, Drescher J, Gao Y, Wu L, et al. Suicidal ideation
Conceptualization, S.Z., A.F.Q.W., I.B., E.D., J.D.Z., and A.S.C.; Methodology, S.Z.,
and attempted suicide amongst Chinese transgender persons: national
A.F.Q.W., E.D., I.B., T.C., and A.S.C.;; Investigation, S.Z., A.F.Q.W., and I.B.; Formal
population study. J Affect Disord. 2019;245:1126 34.
Analysis, S.Z., A.F.Q.W., S.Y.L., P.S.F.Y., and A.S.C.; Writing
Original Draft, S.Z.,
10.
Blakely TA, Collings SCD, Atkinson J. Unemployment and suicide. Evidence
A.F.Q.W., and A.S.C.; Writing
Review & Editing, S.Z., A.F.Q.W., E.D., S.Y.L., I.B.,
for a causal association? J Epidemiol Commun Health. 2003;57(8):594.
T.C., J.D.Z., P.S.F.Y., and A.S.C.; Funding Acquisition, A.S.C.; Supervision, A.S.C.
11.
Classen TJ, Dunn RA. The effect of job loss and unemployment duration on
The authors read and approved the final manuscript.
suicide risk in the United States: a new look using mass layoffs and
unemployment duration. Health Econ. 2012;21(3):338 50.
Funding
12.
Nordt C, Warnke I, Seifritz E, Kawohl W. Modelling suicide and
Ada Cheung is supported by a National Health and Medical Research
unemployment: a longitudinal analysis covering 63 countries, 2000 11.
Council of Australia Early Career Fellowship (Grant number: 1143333) and
Lancet Psychiatry. 2015;2(3):239 45.
received research support for this project from the Endocrine Society of
13.
Goldsmith SK, Pellmar TC, Kleinman AM, Bunney WE. Reducing suicide: a
Australia, Austin Medical Research Foundation, RACP Foundation and Viertel
national imperative. Washington (DC): National Academies Press (US); 2002.
Charitable Foundation. Ingrid Bretherton is supported by an Australian
14.
Gutierrez PM, Osman A. Adolescent suicide. DeKalb: Northern Illinois
Postgraduate Award.
University Press; 2008.
15.
Moody C, Smith NG. Suicide protective factors among trans adults. Arch Sex
Behav. 2013;42(5):739 52.
Availability of data and materials
16.
Ross Reed DE, Reno J, Peñaloza L, Green D, FitzGerald CJJAH. Family, school,
The datasets used and/or analysed during the current study are available
and peer support are associated with rates of violence victimization and
from the corresponding author on reasonable request.
self harm among gender minority and cisgender youth. J Adolesc Health.
2019;65(6):776 83.
Ethics approval and consent to participate
17.
Sherman AD, Clark KD, Robinson K, Noorani T, Poteat T. Trans* community
The study was approved by the Austin Health Human Research and Ethics
connection, health, and wellbeing: a systematic review. LGBT Health. 2020;
Committee (HREC/17/Austin/372). All methods were carried out in
7(1):1 14.
accordance with relevant guidelines and regulations. Given that this was an
CARE
18.
Clements Nolle K, Marx R, Katz M. Attempted suicide among transgender
UNDER
anonymous survey, written informed consent was not possible and was
persons: the influence of gender based discrimination and victimization. J
waived by the institutional ethics committee; however, the survey preamble
Homosex. 2006;51(3):53 69.
1982
outlined that completion of the survey implied consent.
19.
Nuttbrock L, Hwahng S, Bockting W, Rosenblum A, Mason M, Macri M, et al.
AGED
Psychiatric impact of gender related abuse across the life course of male to
Competing interests
female transgender persons. J Sex Res. 2010;47(1):12 23.
ACT AND
No competing financial interests exist. No conflict of interest.
20.
Rood BA, Puckett JA, Pantalone DW, Bradford JB. Predictors of suicidal
RELEASED
ideation in a statewide sample of transgender individuals. LGBT Health.
Author details
2015;2(3):270 5.
1Trans Health Research Group, Department of Medicine (Austin Health), The
21.
Romanelli M, Lu W, Lindsey MA. Examining mechanisms and moderators of
University of Melbourne, Melbourne, Victoria 3084, Australia. 2College ofBEEN
the relationship between discriminatory health care encounters and
HEALTH
Medicine and Public Health, Flinders University, Adelaide, South Australia
attempted suicide among U.S. transgender help seekers. Admin Pol Ment
5042, Australia. 3Department of Endocrinology, Austin Health, 145 Studley
Health. 2018;45(6):831 49.
HAS
OF
Road, Heidelberg, Victoria 3084, Australia. 4ACON Health, Surry Hills, New
22.
Bauer GR, Hammond R, Travers R, Kaay M, Hohenadel KM, Boyce M. “I don't
INFORMATION
South Wales, Australia. 5Centre for Suicide Research and Prevention, The
think this is theoretical; this is our lives”: how erasure impacts health care
University of Hong Kong, Hong Kong, China.
for transgender people. J Assoc Nurses AIDS Care. 2009;20(5):348 61.
OF
23.
Couch MA, Pitts MK, Patel S, Mitchell AE, Mulcare H, Croy SL. TranZnation: a
Received: 19 September 2020 Accepted: 23 December 2020
report on the health and wellbeing of transgender people in Australia and
New Zealand. Melbourne: Australian Research Centre in Sex, Health and
Society, La Trobe University; 2007.
DOCUMENT
References
24.
Lombardi EL, Wilchins RA, Priesing D, Malouf D. Gender violence:
DEPARTMENT
1.
Zucker KJ. Epidemiology of gender dysphoria and transgender
FREEDOM identity. Sex
transgender experiences with violence and discrimination. J Homosex. 2002;
Health. 2017;14(5):404 11.
42(1):89 101.
THIS
2.
Ahs JW, Dhejne C, Magnusson C, Dal H, Lundin A, Arver S, et al. Proportion
25.
Harper GW, Schneider M. Oppression and discrimination among lesbian,
THE THE
of adults in the general population of Stockholm County who want gender
gay, bisexual, and transgendered people and communities: a challenge for
BY
affirming medical treatment. PLoS One. 2018;13(10):e0204606.
community psychology. Am J Community Psychol. 2003;31(3 4):243 52.
3.
Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at
26.
Rodriguez A, Agardh A, Asamoah BO. Self reported discrimination in health
every turn: a report of the national transgender discrimination survey.
care settings based on recognizability as transgender: a cross sectional
Washington: National Center for Transgender Equality and National Gay and
study among transgender US citizens. Arch Sex Behav. 2018;47(4):973 85.
Lesbian Task Force; 2011.
27.
Mustanski B, Liu RT. A longitudinal study of predictors of suicide attempts
4.
Zhang Q, Goodman M, Adams N, Corneil T, Hashemi L, Kreukels B, et al.
among lesbian, gay, bisexual, and transgender youth. Arch Sex Behav. 2013;
Epidemiological considerations in transgender health: a systematic review
42(3):437 48.
with focus on higher quality data. Int J Transgender Health. 2020;21(2):125
28.
Dean L, Meyer IH, Robinson K, Sell RL, Sember R, Silenzio VM, et al. Lesbian,
37.
gay, bisexual, and transgender health: findings and concerns. J Gay Lesbian
5.
Hyde Z, Doherty M, Tilley PJM, McCaul KA, Rooney R, Jancey J. The first
Med Assoc. 2000;4(3):102 51.
Australian national trans mental health study: summary of results. Perth:
29.
Bradford J, Reisner SL, Honnold JA, Xavier J. Experiences of transgender
Curtin University; 2014.
related discrimination and implications for health: results from the Virginia
6.
Strauss P, Cook A, Winter S, Watson V, Wright Toussaint D, Lin A.
transgender health initiative study. Am J Public Health. 2013;103(10):1820 9.
Associations between negative life experiences and the mental health of
30.
Blosnich JR, Marsiglio MC, Dichter ME, Gao S, Gordon AJ, Shipherd JC, et al.
trans and gender diverse young people in Australia: findings from trans
Impact of social determinants of health on medical conditions among
pathways. Psychol Med. 2020;50(5):808 17.
transgender veterans. Am J Prev Med. 2017;52(4):491 8.
7.
Bretherton I, Thrower E, Zwickl S, Wong A, Chetcuti D, Grossmann M, et al.
31.
Nguyen HB, Chavez AM, Lipner E, Hantsoo L, Kornfield SL, Davies RD, et al.
The health and well being of transgender Australians: a national community
Gender affirming hormone use in transgender individuals: impact on
survey. LGBT Health. 2021;8(1):42 9.
behavioral health and cognition. Curr Psychiatry Rep. 2018;20(12):110.
8.
Azeem R, Zubair UB, Jalil A, Kamal A, Nizami A, Minhas F. Prevalence of
32.
White Hughto JM, Reisner SL. A systematic review of the effects of
suicide ideation and its relationship with depression among transgender
hormone therapy on psychological functioning and quality of life in
population. J Coll Physicians Surg Pak. 2019;29(4):349 52.
transgender individuals. Transgend Health. 2016;1(1):21 31.
FOI 4876 - Document 27
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International Journal of Transgender Health
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/wijt21
The impact of the first three months of the
COVID-19 pandemic on the Australian trans
community
Sav Zwickl, Lachlan M. Angus, Alex Wong Fang Qi, Ariel Ginger, Kalen Eshin,
Teddy Cook, Shalem Y. Leemaqz, Eden Dowers, Jeffrey D. Zajac & Ada S.
Cheung
CARE
To cite this article: Sav Zwickl, Lachlan M. Angus, Alex Wong Fang Qi, Ariel Ginger, Kalen
UNDER
Eshin, Teddy Cook, Shalem Y. Leemaqz, Eden Dowers, Jeffrey D. Zajac & Ada S. Cheung
(2023) The impact of the first three months of the COVID-19 pandemic on the Austr
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alian
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trans community, International Journal of Transgender Health, 24:3, 281-291, DOI:
10.1080/26895269.2021.1890659
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FOI 4876 - Document 27
JGIM
Padula et al.: Cost-effectiveness of Transgender Health Insurance
395
In 2014, the U.S. Department of Health and Human Ser-
Costs were adjusted to 2013 U.S. dollar values and discounted
vices lifted a 33-year ban on coverage of transitional care for
at 3 % along with utilities, and analyzed over 5 and 10 years.16
Centers for Medicare and Medicaid Services (CMS) benefi-
The analysis was conducted from a U.S. societal perspec-
ciaries, citing that existing literature demonstrates the efficacy,
tive. Effectiveness was measured as quality-adjusted life years
safety, and effectiveness of “sex reassignment surgery” and
(QALYs) derived from EuroQol Group EQ-5D index scores.20
that “exclusions of coverage are not reasonable.”4,5 This
Patient costs in the provider coverage arm were considered
stance stemmed from the U.S. Department of Justice’s inter-
along with probabilities for negative outcomes and any asso-
pretation of Title VII of the Civil Rights Act that sex discrim-
ciated costs for psychiatric rehabilitation. Patients in the pro-
ination prohibitions extend to health benefits of transgender
vider coverage arm were assumed to receive individualized
people.9 This federal decision could influence how public and
transition therapy.7 With no health benefit, patients were as-
commercial payers define medically necessary services.
sumed to have lower upfront costs, but higher risks for nega-
The most effective approach to transition uses individual-
tive outcomes, long-term costs, and lower life expectancy.
ized treatment plans,10 which may require hormone replace-
ment therapy (HRT), mastectomy, phalloplasty, vaginoplasty,
Model
psychotherapy, or other services.8 The prevalence of sex reas-
signment surgery is 1:100,000 population, or approximately
The Markov model (Fig. 1) was built using TreeAge (TreeAge
3000–9000 in the U.S.4,8 In 2001, 866 male-to-female (MTF)
Software, Inc., Williamstown, MA, USA; 2009). With provid-
primary surgeries (bottom surgery) and 336 female-to-male
er coverage, 100 % of patients were modeled to have autho-
(FTM) primary surgeries (top surgery) were documented in
rized transitional therapy care in accordance with the World
the U.S., and the prevalence has likely increased since then,
Professional Association for Transgender Health (WPATH)
UNDER CARE
despite considerable under-reporting.4,8,11 These procedures
standards of care.3
are costly to uninsured patients. In addition, many costs for
Patients could experience a continuous progression of out-
1982
AGED
gender-specific preventive care (i.e., prostate screening, mam-
comes in escalating stages over 1-year cycles for up to 10
mograms) are not covered by insurance if a patient legally
years. Patients
ACT in escalated states required costly rehabilitation
AND
changes their sex on their birth certificate.11,12 According to
to cycle through job loss/depression in order to return to a
RELEASED
Gorton et al., providing insurance coverage would appear
preferable baseline state. Patients who cycled into escalated
cost-effective,2 whereas negative outcomes associated with
states had increased risk of drug abuse, suicidality, and HIV.21
BEEN
denial of coverage could be costly to payers because of in-
The risk of death included all-cause mortality22 and specific
HEALTH
creased morbidity.13 For instance, studies by Lundstrom and
mortality rates from suicide and drug overdose.23 25 Follow-
HAS
OF
by Kuiper and Cohen-Kettenis estimated that suicidality in
ing transi
INFORMATION tional therapy, the model included costs for provider
transmen dropped from 20 % to 1 % after treatment.14,15 No
coverage to reduce negative outcomes.
OF
studies, however, have measured the economic benefit of
health insurance coverage to transgender enrollees for medi-
No Health Benefit
cally necessary and preventive services.
The structure of the no health benefit arm accounted for denial
DOCUMENT
Our objective was to analyze the cost-effectiveness of
DEPARTMENT of coverage to transgender patients for medically necessary
FREEDOM
health insurance coverage for medically necessary and pre-
and preventive care, as well as adverse implications. Patients
THIS
ventive services compared to no coverage in the U.S. adult
THE
began either at baseline or a job loss/depression state accord-
THE
transgender population. This study was designed from a U.S.
ing to the unemployment rate associated with anti-transgender
BY
societal perspective and evaluated outcomes over 5- and 10-
bias.1 Patients at baseline and in the job loss/depression state
year periods.16 We hypothesized that provider coverage is
were modeled as having high rates of escalating issues, in-
cost-effective.
cluding death.1 Alternatively, patients at baseline accrued no
cost.
Provider Coverage
METHODS
Patients with health insurance with provider coverage could
Study Design
navigate through transitional therapy or denial. Patients denied
Using a Markov model, we compared the cost-effectiveness of
coverage following a mental health evaluation transitioned to
health insurance for provider coverage (i.e., access to primary,
baseline or escalated states. This sub-tree accounted for vari-
secondary, and tertiary services provided by a physician and/or
ations in policy and practice, including barriers raised through
advanced practitioner) of medically necessary services in the
insurance claims and coding processes. For example, if a
U.S. adult transgender population.17,18 Model parameters
female-to-male (FTM) patient changed his legal gender mark-
were extracted from the National Transgender Discrimination
er and then submitted billing for a Pap smear, coverage was
Survey (NTDS) of adults,1 and provider costs for transition-
modeled as denied based on his gender marker despite the
related care were extracted from the Healthcare Bluebook.19
provider’s adherence to WPATH guidelines.
FOI 4876 - Document 27
396
Padula et al.: Cost-effectiveness of Transgender Health Insurance
JGIM
UNDER CARE
1982
AGED
ACT
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DEPARTMENT
THIS
Figure 1 A simplified Markov diagram comparing no health benefit to provider coverage of medically necessary services for the U.S.
THE
transgender population.
THE
BY
Provider coverage was modeled as having higher
Data Collection
costs and improved quality of life. The model also
Data were collected from a systematic review of over 30
incorporated probabilities for negative health outcomes.
randomized controlled trials, observational data, and
Most patients were assumed to receive a full range of
case series detailing types of gender-confirming care,
services indicated by WPATH, including reconstructive
whether transphobic-related events triggered negative
procedures.3,7
outcomes, and the existence of a defined outcome for
Assumptions
each related state. Many probabilities were from the
NTDS (Table 1).1
The model included several assumptions. First, provider
coverage paid for the following procedural combina-
Costs
tions: surgery, HRT, surgery and HRT, discontinued
transition, and costs associated with baseline prevalence
Transition costs were gathered from the GIC public record and
of job loss/depression. Second, costs for provider cov-
the literature (Table 2).11 Existing DRGs weighted by proce-
erage were equivalent to reimbursed rates for procedural
dural prevalence were used for initial and incremental costs of
diagnosis-related groups (DRGs). Third, transitional ther-
services. Thus, costs were reflective of the most common
apy would maintain its baseline utility.
procedures (e.g. mastectomy) compared to rare procedures
FOI 4876 - Document 27
JGIM
Padula et al.: Cost-effectiveness of Transgender Health Insurance
397
Table 1 Probabilities for the cost effectiveness analysis
Other treatment costs were based on DRGs. Escalated
states following baseline were based on employment sta-
Probabilities
Base
Range for
Source
Case
Sensitivity
tus. The NTDS found that 78 % of respondents who
Analyses
successfully transitioned reported improved job perfor-
No Health Benefits
mance.1 Conversely, respondents who experienced job
Baseline
0.74
0.629 0.851
1
loss were 70 % more likely to abuse substances than
Baseline
0.7
0 595 0.805
1
Job Loss/Depression*
0.199
0.169 0.229
1
employed respondents. HIV rates among the transgender
Escalation
0.1
0.085 0.115
1
population were 400 % higher than in the general popu-
Suicidality*
0.82
0.697 0.943
1
HIV
0.048
0.039 0.053
1
lation, and doubled with unemployment.
Drug Abuse
0.13
0.1105 0.1495
1
Death
0.00012
0.000102
22
0.000138
Utilities
Active
0.26
0 221 0.299
1
Baseline
0.58
0.493 0.667
1
QALYs were extracted from U.S.-based sources (Table 3).
Active
0.26
0 221 0.299
1
Baseline utility was taken as the U.S. average according to
Escalation
0.13
0.1105 0.1495
1
Suicidality*
0.739
0.628 0.849
1
Sullivan et al.20 This index also provided utilities for depres-
HIV
0.101
0.086105
1
sion (ICD-9 311) and suicidality (assumed as ICD-9 296).
0.116495
Drug Abuse
0.16
0.136 0.184
1
Utility for HIV was referenced from Wu et al., and Coffin
Death*
0.00012
0.000102
22
et al. provided utility data for drug abuse.30,31 Surgery had a
0.000138
Death
0.00012
0.000102
22
disutility.32 Benefit coverage for transition and successful
0.000138
endpoints were weighted as 0.867 QALYs, given primary
Suicidality
UNDER CARE
Job
0.47
0 399 0.541
1
preferences for these outcomes aligned with the U.S. popula-
Loss/Depression*
tion average.30,31
Suicidality
0.33
0 281 0.380
24
1982
AGED
Drug Abuse
0.08
0.068 0.092
1
Death
0.12
0.102 0.138
24
Sensitivity Analyses
ACT
Drug Abuse
AND
Job
0.383
0 326 0.441
1
Univariate and multivariate sensitivity analyses were used to
RELEASED
Loss/Depression*
Drug Abuse
0.448
0 381 0.515
1
test model uncertainty. These sensitivity analyses were per-
HIV
0.026
0.022 0.030
1
formed by varying all base case estimates by reported distri-
Suicidality
0.14
0.119 0.161
23 25
BEEN butions (e.g., confidence intervals, standard deviations) or by
Death
0.0017
0.0014 0.0019
23 25
HEALTH
Provider Coverage
varying estimates ±15 % of the mean when distributions were
Mental Health
HAS
OF not repo
INFORMATION rted.
Evaluation
Denied Coverage
0.07
0.059 0.081
1
In one particular univariate analysis, the probability of
OF
HRT
0.62
0 527 0.713
1
patients starting in job loss/depression ranged from 0
Escalation
0.66
0.412 0.841
1
–
Surgery*
0.31
0 264 0.357
1
29.9 % in the provider coverage arm, since the model assumed
Escalation
0.0895
0.076 0.103
23
some baseline prevalence of depression or unemployment not
MTF
0.5
Assumed
DOCUMENT
w/HRT
0.8
0.68 0.92
1
negated by transition therapy, leading to downstream
DEPARTMENT
w/no HRT*
0.2
0.17 0.23
1
FREEDOM
escalations.
FTM
0.5
Assumed
THIS
w/HRT
0.69
0 586 0.793
1
A Bayesian multivariate probabilistic sensitivity analysis
THE THE
w/no HRT*
0.03
0.025 0.034
1
applied distributions for each variable to characterize uncer-
BY
* Represents a remainder so that all probabilities add up to 1.0; FTM
tainty on all parameters simultaneously using 10,000 Monte
female to male transition, HRT hormone replacement therapy, MTF
Carlo simulations. Beta distributions were used for probabili-
male to female transition
ties and utilities (i.e., values of 0.0–1.0), and gamma distribu-
tions were used for costs (i.e., positive values).
(e.g. phalloplasty).11,17 There were no costs attributed to base-
Budget Impact Analysis
line state or death. Depression, suicidality, and drug abuse
states resulted in rehabilitative costs.26 28 The U.S. cost of
The budget impact of transgender coverage was measured
illness for HIV was extracted from Walensky et al.29
relative to the total U.S. population, thereby gauging equity
Cost of provider coverage was dependent on combina-
of absorbing costs of coverage in a small population.33 Budget
tions of surgery and HRT. HRT was a fixed cost. The MTF
impact was calculated on a per-member-per-month basis for
group represented combinations of penectomy, breast aug-
an approximate 2014 U.S. population of 320 million (U.S.
mentation, labiaplasty, and vaginoplasty. The FTM repre-
Census Bureau, 2014). The calculation assumed that follow-
sented combinations of mastectomy, hysterectomy,
ing implementation of blanket provider coverage, there would
abdominoplasty, and genital augmentation. Under provider
be an influx of about 30,000 transgender persons seeking
coverage, there was an annual cost of $2175 associated with
transitional care in the first 5 years (i.e., 6000/year taken as
medically necessary services and preventive care.
the midpoint of 3000–9000 procedures per year according to
FOI 4876 - Document 27
398
Padula et al.: Cost-effectiveness of Transgender Health Insurance
JGIM
Table 2 Costs for the cost effectiveness analysis
State
Cost Type
ICD 9
Base Case
Range for
Source
Code
Costs ($)
Sensitivity
Analyses
Baseline
n/a
n/a
Anchor
Job Loss
Depression
Annual
311
565.06
63.00 3781.10
28
Attempted Suicide
Annual
296
21,671.00
18420.35 24921.65
27
HIV (generic therapy)
Annual
042
11,600.00
9860.00 13340.00
29
Drug & Substance Abuse
Annual
304
11,448.00
9730.80 13165.20
26
Cost for Mental Health Evaluation
Fixed
n/a
2175.00
1848.75 2501 25
19
HRT
Fixed
n/a
4350.00
3697.50 5002 50
19
Surgery
MTF w/HRT
Fixed
n/a
22,025.00
18721.25 25328.75
19
MTF w/o HRT
Fixed
n/a
17,675.00
15023.75 20326.25
19
FTM w/HRT
Fixed
n/a
14,658.00
12459.30 16856.70
19
FTM w/o HRT
Fixed
n/a
10,308.00
8761.80 11854.20
19
Cost for Continuous Coverage
Annual
n/a
2175.00
1848.75 2501 25
19
Death
n/a
n/a
Anchor
FTM female to male transition, HRT hormone replacement therapy, MTF male to female transition
Walsham).32 The additional cost would be the difference in
assumed the role of paying an additional $10,614 for each
cost of benefit coverage from the model.
person seeking benefit coverage, the U.S. population could
CARE
absorb these costs for just cents per month.
UNDER
Sensitivity and Th
1982 reshold Analyses
AGED
RESULTS
Variations in expected values of all cost, probability, and utility
ACT
Expected Cost and Effectiveness
estimates did not ch
AND ange expected results. Univariate sensitiv-
RELEASED
Provider coverage resulted in higher cost and greater effec-
ity analyses indicated that the model was most sensitive to (1)
tiveness, and was cost-effective relative to no health benefits at
probability of suicidal death, (2) probability of drug abuse, and
BEEN
5 and 10 years from a willingness-to-pay (WTP) threshold of
(3) utilities of baseline, depression, and drug abuse. However,
HEALTH
$100,000/QALY (Table 4). These results were driven by the
univariate and two- and three-way sensitivity analyses did not
HAS
OF
cohort without health benefits, which had less favorable out-
alter results.
INFORMATION
comes, including depression, HIV, and death. The 5-year
The results did not change in sensitivity analysis of patients
OF
incremental cost effectiveness ratio (ICER) was greater than
with provider coverage starting at a baseline with job loss or
that at 10 years, since upfront costs for transitional therapy
depression. The maximum probability of 29.9 % job
were not yet offset by costly long-term endpoints of excluded
loss/depression produced a 10-year ICER of only $20,942/
DOCUMENT
coverage (e.g., HIV, drug abuse).
QALY.
FREEDOM
DEPARTMENT
The 5-year budget impact analysis determined a cost of
The probabilistic sensitivity analysis showed that provider
THIS
$0.016 per member per month, meaning that if U.S. society
coverage was cost-effective compared to no health benefit in
THE THE
8477 of 10,000 Monte Carlo simulations at a mean ICER of
BY
Table 3 Utilities for the cost effectiveness analysis
$8655/QALY (median ICER of $8593/QALY). In 389 of these
simulations, provider coverage dominated the alternative (Fig. 2).
Utilities
ICD 9
Base
Range for
Source
Code
Case
Sensitivity
Utility
Analyses
DISCUSSION
Baseline*
n/a
0.867
0.737 0.997
20
Job Loss
311
0.732
0.622 0.842
20
These findings suggest that the removal of transgender exclu-
Depression
Attempted Suicide
296
0.693
0.589 0.797
20
sions is affordable and efficient with respect to the U.S.
HIV
042
0.800
0.680 0.920
31
population. Provider coverage is a cost-effective policy at a
Drug & Substance
304
0.800
0.730 0.900
30
Abuse
willingness-to-pay threshold of $100,000/QALY. The ICER of
Hormone
n/a
0.867
0.737 0.997
Assumed
provider coverage for medically necessary services and pre-
Replacement
Therapy
ventive care at 10 years is about $9300/QALY, which suggests
(HRT)
that this policy would be comparatively efficient on a per-
Surgery (transition
n/a
0.155
0.178 to
32
utility from
0.132
patient basis. Even at 5 years, this type of program still holds
baseline)
good value. These findings appear robust to model uncertainty
End State
n/a
0.867
0.737 0.997
Assumed
Death
n/a
0.0
0.0 0.0
Anchor
according to sensitivity analyses. In addition, the results of the
budget impact analysis imply that this policy is affordable,
*The benefit of having transitional therapy is no disutility from baseline
status
with a cost of only about $0.016 per member per month.
FOI 4876 - Document 27
JGIM
Padula et al.: Cost-effectiveness of Transgender Health Insurance
399
Table 4 Expected results of the base case cost effectiveness analysis
Cost (USD 2013)
Δ Cost
Health Utility (QALYs)
Δ Utility
ICER ($/QALY)
5 Year Time Horizon
No Health Benefit
10,712.00
3.71
Provider Coverage
21,326.00
10,614.00
3.98
0.27
39,311.11
Male to Female (MTF)*
22,545.00
11,833.00
3.98
0.27
43,825.93
Female to Male (FTM)*
20,107.00
9395.00
3.98
0.27
34,796.30
10 Year Time Horizon
No Health Benefit
23,619.00
6.49
Provider Coverage
31,816.00
8197.00
7.37
0.88
9314.77
Male to Female (MTF)*
33,034.00
9415.00
7.37
0.88
10,698.86
Female to Male (FTM)*
30,597.00
6978.00
7.37
0.88
7929.55
(*) Compared to no health benefit; QALY quality adjusted life year
This case presents an economical coverage policy that can
to CF patients.36 By the absorption of the cost of ivacaftor
be likened to patients in the U.S. facing similar challenges of
across the U.S. population for people who are uninsured or
access to necessary care, such as those with rare diseases who
have annual incomes less than $150,000, the budget impact is
have access to necessary health technology as a result of the
only about $0.05 per member per month.37
Orphan Drug Act of 1983.34 For instance, cystic fibrosis (CF)
While justice, legality, and a desire to avoid discrimination
affects a population of only 30,000 individuals in the U.S., but
should drive decisions about benefit coverage, this case for the
has evolved into a successfully treatable chronic disease with
transgender population also appears economically attractive.
CARE
the availability of new pharmaceuticals.35 While the cost of
The budget impact analysis calculates the expected value of
UNDER
ivacaftor for CF ($300,000/year) is neither affordable nor
costs for a state with an average population of 700 instances of
efficient (ICER>$ 1million/QALY), this act makes it available
1982
transition therapy each year. Thus, if state governments require
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
Figure 2 A scatter plot of a Bayesian multivariate probabilistic sensitivity analysis measuring the incremental cost effectiveness ratios (ICERs)
of 10,000 Monte Carlo simulations. Under no health benefit, people who are transgender navigate issues such as employment discrimination
and depression, which can escalate to more severe health states such as suicidality, drug abuse, and HIV, according to the 2011 National
Transgender Discrimination Survey. A lack of provider coverage under this arm increases the risk of these issues. In the other arm, provider
coverage improves access to primary and preventive care, as well as medically necessary services that in most cases lead to transitional therapy
such as hormone replacement therapy and surgery. The majority of people with provider coverage achieve preferred health states with greater
utility, at an increased cost per year of about $2175. The risks of escalated issues such as depression and suicidality still exist for the provider
coverage arm, since not all people qualify for all benefits, and transitional therapy does not completely insulate against these issues.
FOI 4876 - Document 27
400
Padula et al.: Cost-effectiveness of Transgender Health Insurance
JGIM
that payers offer coverage, insurance companies need to ac-
adults experience alleviation of gender dysphoria and im-
count for approximately $7.5 million per state. While cost-
provement in psychological functioning following gender re-
effective on a societal level, there is some upfront investment
assignment.42 Given this promise, the field could benefit from
required of payers. A return-on-investment (ROI) calculation
additional outcomes research among youth.
for this figure shows that it would take a payer approximately
Another challenge of this study involves the premise
63 years to break even on an investment in this type of benefit
that outcomes research is able to justify transgender
program.
benefit coverage. QALYs in this study come from soci-
However, legal and administrative barriers can hinder the
etal preferences for chronic conditions. People are not
implementation of new policy informed by these results. First,
asked to consider a state of being for a transgender
commercial payers are accustomed to negotiating contracts
person who is depressed or HIV-positive, for example,
and benefit packages in ways that may resist change. It may
nor are transgender individuals represented. According
be difficult to instantaneously adopt changes in provider cov-
to Lyons et al., there is a stigma attached to the inclu-
erage when exclusions are enforced by a third party or if state
sion of transgender-stratified preferences and outcomes
in trials and observation,43 which speaks to the broader
law defines health services to exclude transgender benefits.38
issue of gaining consensus within U.S. society in
Fortunately, transgender exclusions were recently removed by
accepting that unique services covered by transgender
states, commercial payers, and CMS.4,7
benefits are as necessary as care for people not seeking
According to the Human Rights Commission, 57 of the
a transition.
approximately 200 major employers offering at least one
By removing transgender exclusions, society could
transgender-inclusive health care coverage plan were law firms,
CARE
change the trajectory of health for all transgender per-
UNDER
possibly reflecting the growing legal consensus that transgender
sons. It is worth considering that other costly surgeries
exclusions are discriminatory in practice.7,39 At least 17 major
1982
(e.g., breast reduction;, spinal fusion for chronic back
insurance carriers administer or provide coverage for at least
AGED
one employer or student plan offering transgender benefits
pain), procedures (e.g., in vitro fertilization), and health
ACT AND
(e.g., Aetna, Cigna, Harvard Pilgrim, United Healthcare, and
technologies (e.g., drugs such as sildenafil citrate for
RELEASED
Blue Cross Blue Shield Massachusetts).40 Additionally, numer-
erectile dysfunction) that consensus dictates as not med-
ous public employers offer provider coverage (e.g., University
ically necessary are still covered by payers. Overall,
BEEN
of California, University of Michigan, City of Minneapolis,
payers may provide the motivation for progress in a
HEALTH
City of New York, and City of San Francisco).15,40 However,
field when there is the potential of reimbursement for
HAS
OF
most U.S. health insurance policies still contain transgender
improved performance. This concept could be likened to
INFORMATION
exclusions, even though treatment of gender identity disorder is
poor outcomes of phalloplasty in MTF transitions: sur-
OF
neither cosmetic nor experimental.40,41
geons might invest in trials that improve outcomes of
This study has several limitations. First, data were lacking
these complicated procedures if they knew they would
on whether transition-related therapy completely prevents
be reimbursed.44 A law protecting transgender benefit
DOCUMENT
negative endpoints such as depression/suicidality, or whether
coverage is not only medically necessary, but is morally
FREEDOM
DEPARTMENT
a baseline prevalence still exists. Second, some data in this
imperative.
THIS
analysis were representative not of the transgender population,
Ultimately, removing a clause expressly prohibiting cover-
THE THE
but of the general population. Third, no empirical evidence
age for medically necessary care in the transgender population
BY
exists on the time-dependency of escalated issues, so expert
is economical at a U.S. societal level. State laws that define
opinion guided transition probabilities. Fourth, no true health
“health services,” thereby dictating benefit exclusions, should
utilities were available for outcomes triggered by anti-
be amended to reflect contemporary medical evidence.4,38,45
transgender bias.11 Fifth, some costs were derived from an
Affiliated contracting agencies and bodies should remove their
ad hoc survey of provider affiliates to the GIC. Although these
corresponding exclusions given that provider coverage is af-
results should be widely applicable to most institutions, some
fordable, efficient, and equitable.
insurance carriers have third-party payers or self-payers that
could change the relevance of these results. Sixth, while
depression and job loss are grouped together in the model,
ACKNOWLEDGMENTS: The authors wish to thank Dolores Mitchell
there may be some element of exclusivity in these two states
at the Commonwealth of Massachusetts Group Insurance
that cannot be well-discerned by health utility. Seventh, HIV
Commission.
William Padula’s time for this study was supported in part by an
and drug abuse represent two of many possible negative
AHRQ F32 National Research Service Award (1 F32 HS023710 01)
outcomes; the choice to highlight these in the model was based
as well as an unrestricted University of Chicago Medicine Small Grant
in Diversity Research. Shiona Heru was supported by a merit
on reported prevalence in the NTDS.
fellowship from Western New England University School of Law in
Finally, this study did not include children or adolescents,
affiliation with the Gender and Sexuality Center.
and focused on an adult-only population, based on the age of
This study was presented as a poster at the Annual Meeting of the
Society of Medical Decision Making in Miami, Florida, in October
respondents in the NTDS. According to de Vries et al., young
2014.
FOI 4876 - Document 27
JGIM
Padula et al.: Cost-effectiveness of Transgender Health Insurance
401
Compliance with Ethical Standards
22. Kung HC, Hoyert DL, Xu JQ, Murphy SL. Deaths: Final data for 2005.
National Vital Statistics Reports; vol 56 no 10. Hyattsville, MD: National
Conflict of Interest: The Authors have no conflicts of interest to
Center for Health Statistics; 2008.
declare. Authorship of this manuscript follows ICMJE guidelines; each
23. Cochran SD, Mays VM. Mortality risks among persons reporting same-sex
author is associated with conceptualization, writing, final approval,
sexual partners: evidence from the 2008 General Social Survey-National
and accountability for the work.
Death Index data set. Am J Public Health. 2015;105(2):358–64. doi:10.
2105/ajph.2014.301974.
Corresponding Author: William V. Padula, PhD MS MSc; Depart
24. Dhejne C, Lichtenstein P, Boman M, Johansson AL, Langstrom N,
ment of Health Policy and Management, Johns Hopkins Bloomberg
Landen M. Long-term follow-up of transsexual persons undergoing sex
School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA
reassignment surgery: cohort study in Sweden. PLoS One. 2011;6(2),
(e mail: xxxxxxx@xxx.xxx).
e16885. doi:10.1371/journal.pone.0016885.
25. Lombardi E. Enhancing transgender health care. Am J Public Health.
2001;91(6):869–72.
26. Bishai D, Sindelar J, Ricketts EP, Huettner S, Cornelius L, Lloyd JJ,
REFERENCES
et al. Willingness to pay for drug rehabilitation: implications for cost
recovery. J Health Econ. 2008;27(4):959–72. doi:10.1016/j.jhealeco.2007.
1. Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M.
11.007.
Injustice at Every Turn: a Report of the National Transgender Discrimina-
27. Czernin S, Vogel M, Fluckiger M, Muheim F, Bourgnon JC, Reichelt M,
tion Survey. Washington: National Center for Transgender Equality and
et al. Cost of attempted suicide: a retrospective study of extent and
National Gay and Lesbian Task Force; 2011.
associated factors. Swiss Med Wkly. 2012;142:w13648. doi:10.4414/smw.
2. Gorton RN. Transgender Medicine. San Francisco: Lyon-Martin Health
2012.13648.
Services; 2010.
28. Padula WV, Allen RR, Nair KV. Determining the cost of obesity and its
3. Coleman E, Bockting W, Bozter M, Cohen-Kettenis P, DeCurpere G,
common comorbidities from a commercial claims database. Clin Obes.
Feldman J, et al. Standards of care for health of transsexual, transgender,
2014;4(1):53–8.
and gender nonconforming people. Int J Transgenderism. 2011;13(4):165–232.
29. Walensky RP, Sax PE, Nakamura YM, Weinstein MC, Pei PP, Freedberg
4. Departmental Appeals Board Appellate Division. Transsexual Surgery.
KA, et al. Economic savings versus health losses: the cost-effectiveness of
Washington, D.C.2014. Report No.: Docket No. A-13-87, Decision No. 2576.
generic antiretroviral therapy in the United States. Ann Intern Med.
CARE
5. Notice of Proposed Regulations: MassHealth. The Commonwealth of
2013;158(2):84–92. doi:10.7326/0003-4819-158-2-201301150-00002.
UNDER
Massachusetts. Executive Office of Health and Human Services. Public
30. Coffin PO, Sullivan SD. Cost-effectiveness of distributing naloxone to
Notice, 130 CMR 405.000, 130 CMR 406.000, 130 CMR 410.00-AOH, 130
heroin users for lay overdose reversal. Ann Intern Med. 2013;158(1):1–9.
1982
CMR 410.000-COH, 130 CMR 415.000, 130 CMR 423.000, 130 CMR
doi:10.7326/0003-4819-158-1-201301010-00003.
AGED
424.000, 130 CMR 433.000 (October 8, 2014); Public Notice, 130 CMR
31. Wu AW, Jacobson KL, Frick KD, Clark R, Revicki DA, Freedberg KA,
450.000 (September 12, 2014).
et al. Validity and responsiveness of the Euroqol as a measure of health-
ACT
6. Daniel H, Butkus R. Lesbian, gay, bisexual, and transgender health
AND
related quality of life in people enrolled in an AIDS clinical trial. Qual Life
RELEASED
disparities: executive summary of a policy position paper from the
Res. 2002;11(3):273–82.
American College of Physicians. Ann Intern Med. 2015. doi:10.7326/
32. Padula WV, Mishra MK, Makic MB, Sullivan PW. Improving the quality of
m14-2482.
pressure ulcer care with prevention: a cost-effectiveness analysis. Med
7. Friedman K, Robinson A, Fidas D, Cooper L, Leibowitz E. In: Fidas
Care. 2011;49(4):385–92.
BEEN
DGJ, Wilson A, eds. Transgender-Inclusive Healthcare Coverage and the
HEALTH
33. Sullivan SD, Mauskopf JA, Augustovski F, Jaime Caro J, Lee KM,
Corporate Equality Index. Washington, D.C: Human Rights Campaign
Minchin M, et al. Budget impact analysis-principles of good practice:
OF
Foundation; 2013.
HAS
report of the ISPOR 2012 budget impact analysis good practice II
INFORMATION
8. Walsham K. De-gendering health insurance: a case for a federal insurance
task force. Value Health. 2014;17(1):5–14. doi:10.1016/j.jval.2013.
nondiscrimination act. 24 Hastings Women's Law J. 2013 Winter;197:12.
08.2291.
OF
9. Macy v. Department of Justice, U.S. Equal Employment Opportunity
34. Reaves ND. A model of effective health policy: the 1983 Orphan Drug Act. J
Commission, Appeal No. 0120120821, (2012 Apr 20).
Health Soc Policy. 2003;17(4):61–71.
10. Primary Care Protocol for Transgender Patient Care. San Francisco: Center
35. Strausbaugh SD, Davis PB. Cystic fibrosis: a review of epidemiology and
of Excellence for Transgender Health, University of California, Department
pathobiology. Clin Chest Med. 2007;28(2):279–88. doi:10.1016/j.ccm.
DOCUMENT
of Family and Community Medicine; 2011 Apr.
2007.02.011.
11. Horton M. Cost of Transgender Health Benefits. Out and Equal Workplace
DEPARTMENT 36. Whiting P, Al M, Burgers L, Westwood M, Ryder S, Hoogendoorn M,
FREEDOM
Summit. 2008 Sep; Retrieved from: http://www.tgender net/taw/thbcost.
et al. Ivacaftor for the treatment of patients with cystic fibrosis and the
THIS
html. Accessed on 17 Sept 2015.
G551D mutation: a systematic review and cost-effectiveness analysis.
THE
12. Herman JL. The Cost of Employment Discrimination against Transgender
THE
Health Technol Assess (Winchester, England). 2014;18(18):1–106. doi:10.
Residents of Massachusetts. The Williams Institute, UCLA School of
3310/hta18180.
BY
Law. 2011.
37. Schultz NM, Malone DC. PSY14 - a probabilistic budget impact analysis of
13. Lundström B. Gender Dysphoria: a Social-Psychiatric Follow-Up Study of
cystic fibrosis therapy on health plan pharmacy budgets. Value Health.
31 Cases not Accepted for Sex Reassignment. Gothenburg, Sweden:
2014;17(3):A226.
University of Gothenburg; 1981.
38. Massachusetts General Law 118E §64. 2012.
14. Kuiper B, Cohen-Kettenis P. Sex reassignment surgery: a study of 141
39. Rosenbaum S. Insurance discrimination on the basis of health status: an
Dutch transsexuals. Arch Sex Behav. 1988;17(5):439–57.
overview of discrimination practices. Law J Med Ethics. 2009;37:103–9.
15. Lundstrom B, Pauly I, Walinder J. Outcome of sex reassignment surgery.
40. Coleman SC, et al. Hidden Costs, Value Lost: Uninsurance in America.
Acta Psychiatr Scand. 1984;70(4):289–94.
Washington, DC: Institute of Medicine; 2003.
16. Lipscomb J, Weinstein MC, Torrance GW. Time preference. In: Gold M,
41. Meyer W III, Bockting WO, Cohen-Kettenis P, Coleman E, Diceglie D,
Siegel JE, Russell LB, Weinstein MC, eds. Cost-Effectiveness in Health and
Devor H, et al. The Harry Benjamin international gender dysphoria
Medicine. New York: Oxford University Press; 1996:214–35.
association's standards of care for gender identity disorders, sixth version.
17. Beck JR, Pauker SG. The Markov process in medical prognosis. Med Decis
J Psychol Hum Sex. 2002;13(1):1–30.
Mak. 1983;3:419–58.
42. de Vries AL, McGuire JK, Steensma TD, Wagenaar EC, Doreleijers TA,
18. Luce B, Manning WG, Siegel JE, Lipscomb J. Estimating costs in cost-
Cohen-Kettenis PT. Young adult psychological outcome after puberty
effectiveness analysis. In: Gold M, Siegel JE, Russell LB, Weinstein MC,
suppression and gender reassignment. Pediatrics. 2014;134(4):696–704.
eds. Cost-Effectiveness in Health and Medicine. New York: Oxford Univer-
doi:10.1542/peds.2013-2958.
sity Press; 1996:176–213.
43. Lyons T, Shannon K, Pierre L, Small W, Krusi A, Kerr T. A qualitative
19. Healthcare Bluebook. Brentwood, TN: CAREOperative; 2015.
study of transgender individuals' experiences in residential addiction
20. Sullivan PW, Ghushchyan V. Preference-based EQ-5D index scores for
treatment settings: stigma and inclusivity. Subst Abuse Treat Prev Policy.
chronic conditions in the United States. Med Decis Mak. 2006;26:410–20.
2015;10:17. doi:10.1186/s13011-015-0015-4.
21. Gorton RN, Buth J, Spade D. Medical Therapy and Health Maintenance
44. Nexon D, Ubl SJ. Implicaitons of health reform for the medical technology
for Transgender Men: A Guide for Health Care Profiders. San Francisco:
industry. Health Aff (Millwood). 2010;29(7):1325–29.
Lyon-Martin Health Services; 2005.
45. Mass. Legis. Serv. Ch. 151 (H.B. 6100) (Ch. 118G §1). 1996.
