FOI 4876 Document 11 for release.pdf

FOI 4876 - Document 11
OFFICIAL
MSAC Application 1754
Surgical procedures for gender affirmation in
CARE
adults with gender incongruence  UNDER
1982
AGED
ACT
RELEASED AND
Pre-PASC PICO Confirmation
BEEN  HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE  THE
BY
Pre-PASC PICO Confirmation – December 2023 PASC Meeting
1
Application 1754 – Surgical procedures for gender affirmation in adults with gender incongruence
Page 1 of 43

UNDER   CARE
1982
AGED
ACT
RELEASED AND
BEEN  HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE  THE
BY

link to page 10 link to page 15

UNDER   CARE
1982
AGED
ACT
RELEASED AND
BEEN  HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE  THE
BY

link to page 11

OFFICIAL
Service) had closed books during 2021 due to lengthy waitlists, so the actual demand for services is likely
to be even higher. An earlier survey of young Australian
trans people (aged 14-25 years) reported that
s4
6.3%
trans people up to 25 years of age had undergone prior gender affirming surgery, and a
s47C
further 20.9% wanted surgery in the future (Strauss et al. 2017). From these data it was estimated that
between 108 and 545 18- to 24-year-olds would be seeking gender affirmation surgery in SA in the future
(after 2017) (SA Health 2023). However, the current annual demand in SA is unknown.
It is difficult to determine how many of the
trans population are likely to take up surgeries in the first
s4
year following an approval of MBS funding, as the proportion of individuals undergoing surgery each year
has not been reported in the referenced studies. In addition, some items likely mastectomy, can already be
accessed, but the number undergoing this procedure for gender incongruence in Australia cannot be
determined from MBS statistics.
Impact of gender incongruence on mental health and measures of equity
The survey by Cheung et al (Cheung et al. 2018) analysed data from a Melbourne general practice clinic
(Equinox Gender Diverse Health Centre) and endocrine specialist clinics. Referral from a GP is required to
CARE
attend an endocrine specialist. The data of 283
trans adults attending endocrine clinics and 257 new
s4
UNDER
trans patients registered at the GP clinic were compared, and in some analyses clinic data were
s4
compared with general Australian population statistics. They provide a snapshot of the
trans 1982
s4
AGED
population in Melbourne.
ACT
The median age of the 540 patients was 27 (range 16-72) years, and 23.8% of the whole group had
RELEASED AND
experienced homelessness. Of those attending the endocrine clinics 31% lived in rural or remote areas.
The level of education of the
trans group was overall higher than an Australian age-matched
s4
population (53.4% vs 38.5% holding a university degree). Despite the higher education level, 21.3% were
BEEN  HEALTH
unemployed – four times higher than the general unemployment rate in Australia. In addition, 36% of the
group were smokers, three times higher than the age-matched Australian mean. While hazardous alcohol
HAS
OF
usage was higher in those attending endocrine clinics compared to those at the GP clinic, it
INFORMATION  was still lower
than the general Australian population.
OF
Of those seeking hormone therapy at an endocrine clinic, 88.3% were assessed by a psychiatrist or
psychologist experienced in gender dysphoria prior to therapy. The prevalence of depression was 55.7%,
and anxiety was 40.4%, both higher than the aged matched Australian population (7.9% and 16.3%
DOCUMENT
respectively). A summary of prevalence of psychiatric conditions amongst the 540
trans people
DEPARTMENT  s4
FREEDOM
compared to the general Australian population is given in Table 3.
THIS
THE  THE
Table 3 Prevalence of psychiatric conditions compared between
trans adults and the general Australian population
s4
BY
(Cheung et al. 2018)
Condition
Australian population prevalencea
Prevalence in 540
trans GP
s4
(%)
and endocrine clinic attendees n
(%)
Major depression
7.9%b
301 (55.7%)
Anxiety
16.3%b
218 (40.4%)
Bipolar disorder
1.8-3.6%
18 (3.3%)
Post-traumatic stress disorder
6.4%
24 (4.4%)
Obsessive compulsive disorder
1.9%
11 (2.0%)
Borderline personality disorder
2.7%-6%
35 (6.5%)
Pre-PASC PICO Confirmation – December 2023 PASC Meeting
11
Application 1754 – Surgical procedures for gender affirmation in adults with gender incongruence
Page 11 of 43

UNDER   CARE
1982
AGED
ACT
RELEASED AND
BEEN  HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE  THE
BY

link to page 14

UNDER   CARE
1982
AGED
ACT
RELEASED AND
BEEN  HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE  THE
BY

link to page 15

UNDER   CARE
1982
AGED
ACT
RELEASED AND
BEEN  HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE  THE
BY

link to page 15

UNDER   CARE
1982
AGED
ACT
RELEASED AND
BEEN  HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE  THE
BY

OFFICIAL
UNDER   CARE
1982
AGED
ACT
RELEASED AND
BEEN  HEALTH
HAS INFORMATION
OF
OF

Figure 1 A suggested gender affirming hormone therapy algorithm (Cheung et al. 2019) (permission to reproduce this
DOCUMENT
Figure has been requested from John Wiley and Sons)
FREEDOM
DEPARTMENT

THIS
s47C
THE  THE
BY
Outcomes
The assessment of the effectiveness of surgical procedures for gender affirmation compared to no gender
affirming surgersurgical proceduresy (non surgical care only) will be focused on should consider patient
Pre-PASC PICO Confirmation – December 2023 PASC Meeting
19
Application 1754 – Surgical procedures for gender affirmation in adults with gender incongruence
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UNDER   CARE
1982
AGED
ACT
RELEASED AND
BEEN  HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE  THE
BY

OFFICIAL

s47C

CARE

UNDER


1982

AGED

ACT AND

RELEASED

BEEN  HEALTH

HAS
OF

INFORMATION

OF

DOCUMENT
FREEDOM
DEPARTMENT

THIS

THE  THE
suicidal attempt (reported separately for individuals with and without a history of suicide
attempt)
BY

Safety
Procedure-related adverse events, rate of surgical complications
Revision rates and reasons for revision (i.e.e.g. revisions that are not planned as stages of a primary
surgical procedure)
Cost-effectiveness
Pre-PASC PICO Confirmation – December 2023 PASC Meeting
21
Application 1754 – Surgical procedures for gender affirmation in adults with gender incongruence
Page 21 of 43

UNDER   CARE
1982
AGED
ACT
RELEASED AND
BEEN  HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE  THE
BY

s47C
UNDER   CARE
1982
AGED
ACT
RELEASED AND
BEEN  HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE  THE
BY

link to page 27

UNDER   CARE
1982
AGED
ACT
RELEASED AND
BEEN  HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE  THE
BY

link to page 29

UNDER   CARE
1982
AGED
ACT
RELEASED AND
BEEN  HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE  THE
BY

link to page 30

UNDER   CARE
1982
AGED
ACT
RELEASED AND
BEEN  HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE  THE
BY

link to page 34 link to page 37

UNDER   CARE
1982
AGED
ACT
RELEASED AND
BEEN  HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE  THE
BY

link to page 38

UNDER   CARE
1982
AGED
ACT
RELEASED AND
BEEN  HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE  THE
BY

OFFICIAL
References
Bretherton, I, Thrower, E, Zwickl, S, Wong, A, Chetcuti, D, Grossmann, M, et al. 2020, 'The Health and Well-
Being of Transgender Australians: A National Community Survey', LGBT Health, vol. 8, no. 1, 2021/01/01,
pp. 42-49.
Cheung, AS, Ooi, O, Leemaqz, S, Cundill, P, Silberstein, N, Bretherton, I, et al. 2018, 'Sociodemographic and
Clinical Characteristics of Transgender Adults in Australia', Transgend Health, vol. 3, no. 1, pp. 229-238.
Cheung, AS, Wynne, K, Erasmus, J, Murray, S & Zajac, JD 2019, 'Position statement on the hormonal
management of adult transgender and gender diverse individuals', Medical Journal of Australia, vol. 211,
no. 3, pp. 127-133.
Coleman, E, Radix, AE, Bouman, WP, Brown, GR, de Vries, ALC, Deutsch, MB, et al. 2022, 'Standards of Care
for the Health of Transgender and Gender Diverse People, Version 8', Int J Transgend Health, vol. 23, no.
Suppl 1, pp. S1-s259.
Goodman, M, Adams, N, Corneil, T, Kreukels, B, Motmans, J & Coleman, E 2019, 'Size and Distribution of
CARE
Transgender and Gender Nonconforming Populations: A Narrative Review', Endocrinol Metab Clin North
UNDER
Am, vol. 48, no. 2, Jun, pp. 303-321.
1982
Hill, AO, Cook, T, McNair, R, Amos, N, Carman, M, Hartland, E, et al. 2023, 'Demographic and psychosocial
AGED
factors associated with recent suicidal ideation and suicide attempts among trans and gender diverse
ACT
people in Australia', Suicide and Life-Threatening Behavior, vol. 53, no. 2, 2023/04/01, pp. 320-333.
RELEASED AND
MBS Review Taskforce 2019, Taskforce Report for Plastic and Reconstructive Surgery Items, Final report
from the Plastic and Reconstructive Surgery Clinical Committee.
BEEN
SA Health 2023, SA Health Model of Care for Gender Diversity, SA Health, South Australia.
HEALTH
Strauss, P, Cook, A, Winter, S, Watson, V, Wright Toussaint, D & Lin, A 2017, Trans Pathways: the mental
HAS
OF
health experiences and care pathways of trans young people, Telethon Kids Institute, Perth,
INFORMATION   Australia.
Zwickl, S, Wong, AFO, Dowers, E, Leemaqz, SY, Bretherton, I, Cook, T
OF  , et al. 2021, 'Factors associated with
suicide attempts among Australian transgender adults', BMC Psychiatry, vol. 21, no. 1, Feb 8, p. 81.

DOCUMENT

FREEDOM
DEPARTMENT

THIS
THE  THE

BY

Pre-PASC PICO Confirmation – December 2023 PASC Meeting
41
Application 1754 – Surgical procedures for gender affirmation in adults with gender incongruence
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OFFICIAL
s47C







UNDER   CARE


1982
AGED



ACT AND


RELEASED


BEEN  HEALTH


HAS INFORMATION
OF

OF


DOCUMENT

FREEDOM
DEPARTMENT

THIS
THE  THE

BY

Bretherton, I, Thrower, E, Zwickl, S, Wong, A, Chetcuti, D, Grossmann, M, Zajac, JD & Cheung, AS 2020, 'The
Health and Well-Being of Transgender Australians: A National Community Survey', LGBT Health, vol. 8, no.
1, 2021/01/01, pp. 42-49.
Pre-PASC PICO Confirmation – December 2023 PASC Meeting
42
Application 1754 – Surgical procedures for gender affirmation in adults with gender incongruence
Page 42 of 43

OFFICIAL

Cheung, AS, Ooi, O, Leemaqz, S, Cundill, P, Silberstein, N, Bretherton, I, Thrower, E, Locke, P, Grossmann,
M & Zajac, JD 2018, 'Sociodemographic and Clinical Characteristics of Transgender Adults in Australia',
Transgend Health, vol. 3, no. 1, pp. 229-238.

Cheung, AS, Wynne, K, Erasmus, J, Murray, S & Zajac, JD 2019, 'Position statement on the hormonal
management of adult transgender and gender diverse individuals', Medical Journal of Australia, vol. 211,
no. 3, pp. 127-133.

Coleman, E, Radix, AE, Bouman, WP, Brown, GR, de Vries, ALC, Deutsch, MB, Ettner, R, Fraser, L, Goodman,
M, Green, J, Hancock, AB, Johnson, TW, Karasic, DH, Knudson, GA, Leibowitz, SF, Meyer-Bahlburg, HFL,
Monstrey, SJ, Motmans, J, Nahata, L, Nieder, TO, Reisner, SL, Richards, C, Schechter, LS, Tangpricha, V,
Tishelman, AC, Van Trotsenburg, MAA, Winter, S, Ducheny, K, Adams, NJ, Adrián, TM, Allen, LR, Azul, D,
Bagga, H, Başar, K, Bathory, DS, Belinky, JJ, Berg, DR, Berli, JU, Bluebond-Langner, RO, Bouman, MB,
Bowers, ML, Brassard, PJ, Byrne, J, Capitán, L, Cargill, CJ, Carswell, JM, Chang, SC, Chelvakumar, G, Corneil,
T, Dalke, KB, De Cuypere, G, de Vries, E, Den Heijer, M, Devor, AH, Dhejne, C, D'Marco, A, Edmiston, EK,
CARE
Edwards-Leeper, L, Ehrbar, R, Ehrensaft, D, Eisfeld, J, Elaut, E, Erickson-Schroth, L, Feldman, JL, Fisher, AD,
UNDER
Garcia, MM, Gijs, L, Green, SE, Hall, BP, Hardy, TLD, Irwig, MS, Jacobs, LA, Janssen, AC, Johnson, K, Klink,
DT, Kreukels, BPC, Kuper, LE, Kvach, EJ, Malouf, MA, Massey, R, Mazur, T, McLachlan, C, Morrison, SD,
1982
Mosser, SW, Neira, PM, Nygren, U, Oates, JM, Obedin-Maliver, J, Pagkalos, G, Patton, J, Phanuphak, N, AGED
Rachlin, K, Reed, T, Rider, GN, Ristori, J, Robbins-Cherry, S, Roberts, SA, Rodriguez-Wallberg, KA, Rosenthal,
ACT
SM, Sabir, K, Safer, JD, Scheim, AI, Seal, LJ, Sehoole, TJ, Spencer, K, St Amand, C, Steensma, TD, Strang, JF,
AND
Taylor, GB, Tilleman, K, T'Sjoen, GG, Vala, LN, Van Mello, NM, Veale, JF, Vencill, JA, Vincent, B, Wesp, LM,
RELEASED
West, MA & Arcelus, J 2022, 'Standards of Care for the Health of Transgender and Gender Diverse People,
Version 8', Int J Transgend Health, vol. 23, no. Suppl 1, pp. S1-s259.  BEEN

HEALTH
Goodman, M, Adams, N, Corneil, T, Kreukels, B, Motmans, J & Coleman, E 2019, 'Size and Distribution of
OF
Transgender and Gender Nonconforming Populations: A Narrative Rev
HAS  iew', Endocrinol Metab Clin North
INFORMATION
Am, vol. 48, no. 2, Jun, pp. 303-321.
OF

Hill, AO, Cook, T, McNair, R, Amos, N, Carman, M, Hartland, E, Lyons, A & Bourne, A 2023, 'Demographic
and psychosocial factors associated with recent suicidal ideation and suicide attempts among trans and
gender diverse people in Australia', Suicide and Life-Threatening Behavior, vol. 53, no. 2, 2023/04/01, pp.
DOCUMENT
320-333.
FREEDOM
DEPARTMENT

THIS
SA Health 2023, SA Health Model of Care for Gender Diversity, SA Health, South Australia.
THE  THE

BY
Strauss, P, Cook, A, Winter, S, Watson, V, Wright Toussaint, D & Lin, A 2017, Trans Pathways: the mental
health experiences and care pathways of trans young people, Telethon Kids Institute, Perth, Australia.

Zwickl, S, Wong, AFO, Dowers, E, Leemaqz, SY, Bretherton, I, Cook, T, Zajac, JD, Yip, PSF & Cheung, AS
2021, 'Factors associated with suicide attempts among Australian transgender adults', BMC Psychiatry, vol.
21, no. 1, Feb 8, p. 81.

Pre-PASC PICO Confirmation – December 2023 PASC Meeting
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Application 1754 – Surgical procedures for gender affirmation in adults with gender incongruence
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