On The Couch with Maggie Smith

[00:00:00] Jennifer Farinella: Hello, and welcome to an episode of On the Couch, where we collaborate with experts, practitioners, authors, advocates, and influencers to explore current social themes, sex positive topics, and share stories and insights that matter.

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While listening, we encourage you to practice good self care. Check the show notes for content details and references. Wherever you are, whatever you're doing, enjoy this episode of On the Couch.

[00:00:56] Naomi Viret: Maggie, we are so honored to have you on the couch with us this morning, Maggie. Thank you so much for joining us. This bio, I feel like it does not do any amount of justice to the amazing work that you are doing. But I'm going to read out a little bit to set the context for our audience and that they can acknowledge how fortunate we are to have you here today.

So Maggie is a clinical nurse consultant at the T150 clinic based out of the Albion Centre in Sydney. Maggie has over 20 years experience working in HIV, sexual health, as well as transgender health. Maggie co developed and successfully launched T150 um, one of Australia's first publicly funded trans specific HIV and sexual health services in 2018.

They are a current board member for the Australian Professional Association for Transgender Health. Also on the Australian Sexual Health and HIV Nursing Association and a past board member, including past presidency ship for the Gender Centre, New South Wales. Maggie is a academic nut. I can see from this holding a Master's of medicine, um, in Nursing, HIV and Sexual Health speciality, and is currently completing their Master's of nursing as a nurse practitioner.

So when we casually had a chat with Maggie and we were like, what are you reading? What are you watching right now? It's a whole heap of academia. Yes. So thank you. We, we have no doubt that that academia's gonna add large volumes of information to today's session. So welcome Maggie. Welcome to the couch.

[00:02:30] Maggie Smith: Thank you for having me here. I, it makes me sound far more competent and amazing than I am, but I'm very humbled by it and it's lovely to be invited here. Brilliant. Thank you Naomi.

[00:02:41] Naomi Viret: You are very welcome. So Maggie, I feel like it would be a really nice way to kick us off and just sharing what it is that you feel comfortable to share about yourself and how it is that you've become such an advocate for trans health and trans care, um, in the setting and I guess starting off that T150 clinic.

[00:02:57] Maggie Smith: Sure, I'd love to. And I'd just do a bit of a backtrack when we Acknowledge country, something else I like to do is Acknowledgement of country and also just Acknowledge that because, you know, our First Nations people have the longest ongoing connection and culture in the world and trans and gender diversity, our Brotherboys and Sistergirls have existed with our First Nations people. It also means this country we white fellas call Australia has the longest ongoing connection to gender diversity in history as well.

Um, for me, oh my goodness, where did it start? So, an area of nursing, or in general, you know, my nursing values end up aligning with my personal values, but an area I always wanted to be a part of was sort of reducing stigma and making areas of health that even sometimes clinicians found uncomfortable, accessible, and just normalizing it for people.

So various nursing, I sound very old when I tell you my full extent of nursing, but then about 1999 started in the HIV sector. Um, and around 2003 moved to sexual health. And the way then that I got involved in trans health was, literally someone ringing up asking if they could book men in for what were called pap smears then and used to get some very odd requests and I was about to say something like what and then realized that there was a service, the gender center was near where I worked and it was the start of trying to promote cervical screening with this group of trans men and from there realized that this was an area of health, you know, I already worked in HIV and sexual health, which are kind of taboo and stigmatized both personally and by healthcare professionals and then realizing this amazing area of, of need, which is transgender health.

So I've approached it, there's many different ways, always from being within the HIV and sexual health sector. Um, but just kind of from there, I was then lucky enough and have been privileged enough to be invited onto boards, and I just learned because it was an area of need, so I just started to educate myself.

Um, advocacy has come from, in all those areas I work with, but especially in trans health, which is, you kind of have to end up being an advocate, you're an ally. But you know I'm not a staunch go out, you know, raising the flag for everything, but you realize the level of discrimination and inequity is, is heartbreaking at times.

And in health, we have done a really poor job historically of providing basic human needs services to this community. So I guess advocacy just came from interest and then being privileged enough to end up on things like the Gender Centre Board, now AusPATH where you're in a position where you can advocate for others.

And that's such an amazing position to be in.

[00:05:41] Naomi Viret: Yeah, I love it. And I think, you know, that advocacy, it gives a voice to people who are often unheard or misunderstood within society.

I think if we keep that word advocacy at the front of our mind, it will probably take us a really long way in terms of thinking about how it is that we can continue to work in this space and support community. So thank you for sharing that and, you know, I think also just drawing on those experiences and sometimes that we come to, to be working in these spaces out of those passion projects become really obvious when we're working in that space for a time, and I think just the importance of trans health and the diversity of needs, but also acknowledging, as you say, that unfortunately some of the worst experiences people have had have actually been in services where they expected to get the best, um, service. So, um, That's also, yeah, thank you for acknowledging that as well.

So, I think it really is important to set the scene in terms of discussing some of the terminology that is used in the space. So, to set the context of the discussion, could you please define transgender and gender diversity for us?

[00:06:43] Maggie Smith: Yes. Absolutely. Um, and this is a very basic, I'm not going to do the full 101. Um, so my way of putting it is when a baby is born, a doctor, a nurse, someone usually looks at their external genitals and decides that that person at that point is a boy or a girl. Um, or intersex, a very small amount of community that's obvious from the outside.

But based on that, you're a boy or a girl, from someone just looking at what they can see, um, that's the way your life is meant to progress, is your gender identity. And as a person grows up, as a child, an adult, at any point in their life, if your internal sense of yourself, if a person's gender identity, who they know they are, is not this sex assigned for them at birth, you're consider transgender.

Now whether that's a binary trans masculine trans feminine or a non binary somewhere in between, but basically what's decided for you at birth. As you grow up, they don't align. They're not the same. You're transgender. That's like my simplest way of putting it.

[00:07:42] Naomi Viret: I like it. I like it. Thank you so much. I just think it's really important for us to have that context before moving forward.

 So I'd just like to know how it's that the service came to be, and I suppose especially how it came to be a part of the Albion Centre Services. With Albion Centre for those of you who aren't aware, being a very specialized HIV and sexual health, um, center right in the heartland of Sydney. So how was it that, um, T1 50 came to be a part of that service?

[00:08:10] Maggie Smith: Good question. So for years, um, realizing that trans health wasn't really accessible, but where I specialize is HIV and sexual health. So basically I just annoyed a lot of people for a long time, um, realizing that there was such a vulnerability and so little known. So the area of health I had some sort of input in was HIV and sexual health, but then also realizing the vulnerability of trans people when it came to HIV, and that there was absolutely very little research. No, no health promotion or targeted services to provide a quite vulnerable and at risk community, services for these. Um, and I'm talking about going back to, you know, many years ago and then slowly started to meet up with other people who believed in the same thing. So, you know, you get to know other people.

Then thank goodness around , about 2015, 16, some really good research, started to come out because the other way you need to bring about change, there was no data. So you'd say to people there's a risk of HIV in the trans community. But there's no data on it because we can't capture the data because the system's flawed, because no one's looking at it.

So you would have these round and round conversations, but then we started to get some research which showed a disturbingly high prevalence of HIV globally in such as trans women of color, so that gave you some evidence to put behind you. And in Australia, we just didn't know. And finally, I met a great ally and co worker in Dr. Mel Kelly, who came to work at the Albion Centre. So I had a colleague and a medico who was also passionate about it.

[00:09:48] Naomi Viret: And, you know, I think you touched on some really interesting points there in terms of that evidence base and how, flawed systems can be when we do become such an evidence based society. And it's like, it's hard for us to get the evidence because they can typically be a difficult community to engage with and because of the lack of trust that has developed among services, it's like, what do you want this information for? What are you going to do with it? So how do we get that data?

[00:10:11] Maggie Smith: And historically, especially in, in medicine or medical areas, capturing gender or sex is totally flawed because it's very binary. So there's no way of even identifying someone as trans at a purely data level. But don't get me going on my data nerd side. So there's so many, so many issues with getting decent data to support it.

[00:10:32] Naomi Viret: Yeah, and the other point that I really take away from that, and I think it's something that we definitely are considering often as health promotion officers, but it's like how important it is to have that specific information for varying and diverse communities, because if the messaging doesn't directly apply to them, it's not taken on board, it's overlooked or it's overseen as that does not apply to me.

So we know that, you know, the early HIV or even the AIDS messaging around, who was at risk, um, had a really big impact then on who was coming forward for testing and screening.

So having run now for five years successfully, yay. Um, I just wonder if there's been any significant changes in like service modeling or guidelines that you've seen in that time?

[00:11:16] Maggie Smith: Um, absolutely. And the past five years, just in general, globally, nationally, and locally, like the change in just even the acknowledgement of trans health has been phenomenal.

So, from that, an awareness for community, and also healthcare professionals, so there were always informed consent, which we'll talk about later on, but AusPATH and others, based on international guidelines came out with formalized Informed Consent guidelines that we could start to draw upon official documentation.

Um, the model of care we do at T150 has remained relatively the same. We change around how we provide it just because of demand and staffing levels. I guess the biggest changes have been just the awareness, of both health clinicians, health practitioners and community of, of what trans is. So not just for the community, thank goodness, but this emerging knowledge of people just needing care.

Internationally, there's been, you know, some guidelines brought out and an update, which has been wonderful. I think it's more just the overall, ability to access, there is starting to be a bit more evidence, more guidelines being promoted and acknowledgement that they're there is some evidence because the hardest bit in trans health was with WPATH, World Professional Association Transgender Health would bring out guidelines, AusPATH would bring out guidelines, but it was like, well, this is based on, you know, there's no real data behind it.

So we are now starting to be able to go, this is evidence based, you know, trans health, is not a new area of medicine. Not just providing gender affirming hormone therapy, this is not new, this has been going on for 30, 40 years, so this isn't just made up information. We are now starting to be able to show longitudinal long term positive health outcomes by providing positive gender affirming care.

So I guess it's more just the ability to have things behind you. And just the increasing demand. That's been the other thing.

[00:13:14] Naomi Viret: Which we will definitely touch on in just a moment actually, I, I really think around the fact that knowing there are now services where, um, trans clients can be referred to and know that they're going to be treated holistically, with dignity, with respect. That must just be so reassuring for community now.

[00:13:33] Maggie Smith: Yeah, there's still not enough, you know, we can talk about access and equity that there are a few, and the same with GPs and any service that provides positive gender affirming or trans health care like GPs are wonderful. There's not heaps doing it yet, but then get inundated so the services waiting times or clinicians just get blown out. So I wish there were more. It's great, that in the past, even two years, there's been an increase in services, but we need, we need more.

[00:14:04] Naomi Viret: Yeah. So I really love how, um, T150 is led by the belief that in working with partnership with the gender and sexuality diverse community, you're providing that safe, welcoming and inclusive environment and that in and of itself, like you said, that improves health outcomes and it also improves our access to medical care and quality medical care.

So I just wanted to, um, yeah, sort of reiterate that. And as we've just touched on, we have seen a marked increase in the specialist transgender specific clinics. Um, for example, services such as yourselves and Maple Leaf House based up in the Hunter New England area. I guess I'd like to explore the uniqueness of those services.

So why is it that having separate clinical spaces is pertinent to the experience and the clinical treatment or management of transgender patients?

[00:15:03] Maggie Smith: I will start by going, the T150 was set up specifically as a trans only safe space, I guess it's about being culturally and safe, so, I will answer the first bit, um, trans only spaces are important because healthcare, or anywhere, but healthcare has been so unsafe for community for so long, that providing people with reassurance, that it's, you know, that you're not going to walk into a waiting room and sit there with someone who, even in the clinical space, might, you know, harass you, give you, even give you a dirty look.

So trans health, because we've done a poor job historically, is just providing that safety, knowing that you're in a safe place, helps people get their foot in the door. The end game of that is, I know at T150 isn't going, well, you have to come to the trans only space forever, is that as people realize, that a service or some services are actually the whole place is safe to come into and get that confidence, they'll engage in health care more and now we have clients who are quite happy to be seen anywhere in the service and that's that's amazing.

So it's more just to provide assurance and especially that those clinicians. You know, if you're working in a big, say, GP practice or a big public health sector, everyone needs to be trained. Everyone, you know, this is what I say to people is your reception, your admin people are actually the most important people of a service. Because they're the first people that anyone is going to meet and if you are trans.

And I should have said at the beginning when I say trans I'm inclusive of binary and non binary and I think we talked about that later on identity so I'm being inclusive of all people when I say trans should have said that at the beginning.

But if someone walks in the first people they're going to meet is your admin or your reception staff and if there is any , if there is any perceived problem, you've lost that person, that's your one chance gone. So that education and safety goes throughout. And if you're in a bigger service to start, it's much easier to have clinicians and a certain amount of people who, you know, are safe for those clients, patients, community. And then as it spreads, people just start to become more comfortable.

You know, they just get a bit more confidence within themselves as well. And one of the wonderful things is you don't want it to be a trans only space. You actually want community to feel safe going, you know, the end game is you don't need trans only spaces because everyone has safety and confidence.

Yeah, absolutely. The other bit of that, I guess, is because there are, you know, the debate goes on, especially within the sexual health field is by and large, usually pretty safe, both gender and sexuality diverse, because that's the area I, you know, we work in. Does it have to be trans only? No, that's a specific service set up to, to engage people who might be a bit more hesitant.

But if you've got a safe, whole service where people can walk in, that's amazing and awesome. And if it means you can actually provide a, bigger service with that doesn't have to be trans only, go for it. It's more what works for the community and what you're trying to gain.

[00:18:09] Naomi Viret: Yeah. And I love that approach too.

And I think it is one example of that holistic healthcare. And I guess just to, are you able to sort of touch on some of the staff that might be associated with, um, your service or Maple Leaf just in terms of that diversity and holistic approach?

[00:18:27] Maggie Smith: Yeah. Um, absolutely. So, different, and T150 is holistic within HIV and sexual health care, but be really upfront, what we would love to have is, is mental health input, not because the trans community have mental health issues, just they are more at risk because of, you know,. microaggressions, stigma, discrimination . Being trans is not a mental health condition, it's just that trans people face a lot of opposition and end up having high rates of depression and anxiety because the world doesn't treat you very well. Um, so holistically, it would be amazing to have, you know, a full service be at mental health clinicians on site, maybe some social work and other things that that would be the dream holistic.

What we have is at T150 admin staff, who are trained up, nursing and medical who do trans specific training as well as being skilled in the area. We have a peer on site and how important that is but especially for people, peers do amazing work and places like ACON do a lot of the the work themselves.

At T150 it's more about, we know, we are probably capturing people who it's their first time either accessing gender affirming care or coming in for HIV or sexual health testing. So it's really important to have someone there who you can relate to, who can just help guide you through your first few appointments.

So we always have a peer on site. Um, Maple Leaf House is a bit different because it's specifically set up, you know, NSW Ministry of Health.

So, Maple Leaf House and the ones being developed in Sydney for the other LHDs are a holistic gender affirming service. So they do have. psychologists, social workers, um, dietician, speech pathologist, as well as that medical and nursing side.

All still with fairly limited funding. I wish there was more.

[00:20:16] Naomi Viret: I think that helps our audience understand what that holistic care looks like. And this is part of the health journey that we'll start to move into in just a moment, but it's, it's more than just working with one clinician.

[00:20:27] Maggie Smith: I get absolutely and multidisciplinary, I guess, holistic within HIV and sexual health. The reason we've put it that way is part of what's important for some trans people is that access, which we'll talk about to gender affirming medication and to offer people, if you're HIV positive, just that, but then you go somewhere else for your, your hormones, if you're on hormones, or just come in for, for HIV pre exposure PrEP, you know, prevention medicine, but then you get your hormones somewhere else.

If you actually put them together, one, people are more likely to engage, strangely enough, and two, they, they work together so well. So that's providing a vulnerable at risk community for those in the community who are, with access to all those sexual health and HIV needs within the one place.

[00:21:11] Naomi Viret: Yeah. And I love it because again, I think it's that holistic view of a person.

Like we're made up of so many different parts and if there's a service that can meet the needs of several of your parts, it just makes sense that you pair them together. So forward thinking in a lot of ways.

[00:21:26] Maggie Smith: And it's been amazing because people are always coming in for, you know, hormones. We've done surveys and done data and it's the first thing coming in for his hormones and maybe sexual health testing or other things.

But what has come out time and time again is people who didn't really realize they were at risk of, HIV or STIs, especially HIV, hadn't even thought of HIV Pre Exposure Prophylaxis, PrEP, or anything else yet, diagnosed with a couple of STIs, or just through having a talk to them, you go, you know, there's this thing that we can help prevent, and just not even being aware it existed or on offer, and that ability to offer preventative medicine while you're providing gender affirming hormone care is incredibly satisfying.

[00:22:06] Naomi Viret: Yeah, absolutely. So I guess just moving forward, I think you've kind of touched on it in the fact that there's a few service development actions in the pipeline, but surely the increase in service means that there's absolutely been a significant increase in demand for these services. Are you able to talk to that a little?

[00:22:26] Maggie Smith: Yes. That's the little talk about it. Increase in demand, absolutely. I'm not sure of the wait time at T150. You know, even, there, for most, even smaller services, we're not a big service, it's a couple of months. For somewhere like Maple Leaf House, I think they're looking at five to six months and that's not through lack of wanting to offer it, it is just the demand from community. So yeah, there is an increase in demand. Hopefully that will equate to increasing services. Um, but yeah, there's a lot of demand, there's not enough services, waiting times blow out. And as soon as services are open, you've got a waiting list, which, you know, when you work in the area, you don't want to have you want to be able to do everything now.

[00:23:13] Naomi Viret: Yeah, but I think that also touches on a point and we come to this in terms of talking about that care and it being a journey, it's not an overnight thing. Is also that I suppose when people are engaging with services, it's not a like one appointment, like. The waiting list, I guess, blow out, not just because of the demands, but also because you're needing to work with individuals on an ongoing, consistent basis. It's not like one appointment, never see you again.

[00:23:36] Maggie Smith: Yeah, absolutely.

[00:23:37] Naomi Viret: So we've had discussions, I guess, uh, referred to the care and services that you're providing, um, and the term you've used gender affirming care. Are you able, I suppose, to talk to that terminology for us first and foremost? What's gender affirming care?

[00:23:52] Maggie Smith: Yeah. Um, and this is where I'm not allowed to get too sidetracked with my own little rant. So gender affirming care is often used medically and is a very acceptable term and one that, we use ourselves. Um, gender affirming care is often seen as a more medical side, so offering hormones and other things.

A term I really like to use, and I'm trying to use it more and more, and would love to see it used more and more, is trans health. Because I know I sidetracked, but using the term trans health helps remove and debunk some of the power because sometimes people, anti trans, there's a small group of anti trans lobbyists who are trying to cause a lot of trouble for a community that they have nothing to do with.

So when they hear gender affirming care it's like, oh it's hormones, and you know, you're offering hormones because there's that fear that people will harm themselves, so you're offering hormones. So it's this whole negative deficit dialogue, not that gender affirming care is a deficit, but they're somehow equating that with the use of hormones and hormones for young people and you get into these ridiculous anti trans nonsense things that you read in newspapers.

Um, whereas if you frame it as trans health, which includes possibly affirming someone's gender with hormones, trans health, health is just a basic human right. So it helps remove some of that power from the argument. If we say trans health, trans people just want equal access to healthcare as everyone else in the world does.

It's a lot harder to argue that if that makes sense. So that's my little advocacy change in linguistics, even I'm trying to do. But gender affirming healthcare is basically just affirming someone being positive about the person presenting to you. Um, but affirming someone's gender for themselves or us affirming it for them, you know, there's different things a person can go through. It is not linear.

So I will talk through some of the ways you can do it. A trans person can do all of these things. They can do none of these things. That doesn't negate who they know they are or their gender. Um, often one of the first steps, first steps, I'd say it's steps but it's not, um, is through social recognition.

So someone might change their name, might start to dress, this is where you get into, we could get into all that gender performativity and socialization, well we won't, so, but start to dress as the perceived other gender, you know, more masculine or feminine clothing, change your name, alter your pronouns, things like that, that more, just starting to try and fit in socially, through social transition and be accepted as that. That's affirming someone's gender. Using the right pronouns is affirming someone's gender. Um, the other part which really is an area that gets a lot of focus is the provision of gender affirming hormone therapy, and I've talked about that before.

So at T150 that's something we do as well as the HIV and sexual health care. Um, and that's using, hormones or medication to help bring about the physical changes. Um, perceived as the gender opposite to what was assigned to you at birth, or somewhere in between. So for someone who was assigned male at birth, but who knows they are a woman, is offering possibly oestrogen therapy, or um, anti androgen testosterone blockers to help bring about more physical changes of, you know, feminine physical changes.

Someone who was assigned female at birth, so when they were born someone said, "you're a female". They know they're not. Um, the use of testosterone to bring about masculinizing physical changes. And people who are non binary is the use to sort of whatever degree a person wants to go to. So that's sort of 101 of hormones, which I can give people a whole talk on if you want, but I won't, I'll just reel it back.

Um, there are surgical options. So surgery, ugh, and this is an area that people just get fixated on. People often think about genital reassignment surgery when it comes to a trans person. And just to debunk that, genital surgery is actually the least done surgery and not that many trans people have genital reassignment surgery.

So it seems to be, and it just gets perpetuated in media and bad movies and other things, the first thing people think about is what's going on in someone's pants. Reassignment surgery is the least surgery done for gender affirmation. Some surgical things are done, and most are actually about things that will help you pass or be seen visibly to the outside world.

So for someone assigned male at birth might be something like a tracheal shave to reduce down an Adam's apple or feminizing surgery or top surgery if, if you're transmasculine, you know, um, having breasts removed and shaped into a masculine chest. So more things that are visible to others. As I said before, it's not a I've socially transitioned, now I can go on to hormones, now I can have surgery. That means I'm the perfect trans person in passing. None of that is true, someone might use one of the steps. Someone might start on hormones and go, I'm comfortable with the changes now and stop. Someone might do none of it, but they are still the gender they know they are.

[00:29:09] Naomi Viret: Yeah.

[00:29:10] Maggie Smith: I hope that helped make sense.

[00:29:11] Naomi Viret: Yeah, it does and I think that comes back to that importance of, you know, asking somebody their name, asking them for their pronoun.

 And I guess we had this discussion about people affirm their gender every day in lots of ways, regardless of if you identify as being trans or not, do you want to talk to that a little bit?

[00:29:28] Maggie Smith: We all do it some way. You know, someone who likes to look feminine, who may be, you know, assigned female at birth might put on some lipstick, might put different shoes on, you might use, uh, masculine body wash, you know, the crazy things like that, but that is actually how you affirm your gender every day. Do you go and get your hair dyed, do you get a blow dried, do you wear nail polish? I guess the main thing is cis people, so cis are non trans people, don't think about it, cause you don't have to think about it because it's just part of who you are. And there's never this questioning of, um, am I doing this so I, I, I'm, I'm now being more perceived in this gender?

But, you know, people affirm their gender each and every day, throughout the day, over and over again. Just a lot of people don't even have to think about it.

[00:30:19] Naomi Viret: Yeah, it's those unconscious thoughts and things because, like you said, yeah, we're not spending time thinking about it. It just happens subconsciously.

Thank you for explaining the differences between affirming from that social perspective, as well as from more of that physical perspective. I think that really helps to gain a broader understanding within the audience. So thank you. Um, I guess one of the things that we, we touched on was, assigned male at birth, assigned female at birth, is there a larger percentage of one of those groups seeking out gender affirming care? And if so, is there any assumptions or researches into why that might be?

[00:30:55] Maggie Smith: Oh God, that's a great question. Um, once again, globally trying to find statistics, just in general, on how many, one, how many trans people there are, then two, what your gender identity is atrocious. And even if you look at the Australian census. The couple of goes they've had at trying to identify gender, it's just dogs breakfast. Um, it's a really good question. So historically there has been more trans women who've probably accessed health services more because throughout history seen more and have been able to access care.

Look, it's a pretty even mix. And when we first started, um, historically it was usually trans women going for feminizing surgery, but is that because it was more known about and more accessible in a very limited access space? Probably, um, trans men, so the amount accessing care when we first started was a pretty even mix.

Historically, you've got more data on trans women, and what I would say in the past, since we opened, but in the past two or three years is non binary presentation.

I think at T150, and I think this is reflected across many, um, trans healthcare spaces, it's presentation of non binary, at T150 so, you know, you've got men and women, 50 percent and non binary is the other whole half presenting to services. A non binary person is someone who might identify as somewhere in between because gender is a spectrum like everything else. Um, so you're not on either binary, you're non binary end of it.

So when it comes to gender, whether you are cis or trans, there are some people who are very masculine and feminine, very binary on the spectrum . Non binary people. I am non binary. There's different terms that can be used, gender diverse, like that, there's a whole umbrella of terms that can be used. Non binary covers those, is how I'm using it. Someone might swing in between, sometimes they're masculine, sometimes they're feminine, might be androgynous, might not identify any of those terms.

In the past few years, especially the amount of non binary people accessing care has greatly increased. Research on it probably, no, and I would say the reason that that's happening is, and I'm quite happy to talk about my personal experience, because I'm old, there wasn't even language for it.

When I was growing up, you know, hearing about trans was amazing, but there wasn't a term for non binary. And there's certainly been an increase in awareness of you're not masculine, you're not feminine, you're somewhere in between. So the non binary identity. And with that, when people start to be able to go, wow, that's me, that makes sense to me. Can then start to affirm themselves in that way, if that makes sense.

[00:33:40] Naomi Viret: Yeah, it really does. Is there a difference between the gender affirming care or the trans health a non binary person would receive versus someone who identifies as typically trans?

[00:33:51] Maggie Smith: Great question. No. Um, no, not at all. So use pronouns, they, them, whatever, they, she, he, you know, whatever pronoun a person wants and their name. As far as, I guess, if we're looking at the specifics of hormones, which is maybe what some people were talking about, Is no, you mightn't use doses that fully masculinize or feminize a person.

So it's the same hormones just at different doses.

[00:34:16] Naomi Viret: Right.

[00:34:17] Maggie Smith: What we do say, and one of the first things if someone is seeking hormones to affirm their gender, is you have a conversation about where the person expects to end up. And that can change for everyone. That can change. Um, but sometimes you have to manage expectations and you can't bespoke hormones.

So you can offer sort of lowered doses so someone doesn't fully feminize or masculinize, but say for something like testosterone to masculinize someone. It's like, I want to, I want to have bigger muscles and hair, body hair, you know, But I don't want my voice to change. And it's like, we can't do that because these things happen at different stages of the hormone.

So we can't totally bespoke things. There's things we can offer to help tailor it. And the other thing is there are some people who want to remain very androgynous and on very small micro doses of, of the hormones and that's fine, but we always have to protect bone and cardiac health. That's my nerdy medical side going, we can't have someone running at no hormones. You need one or the other just to maintain health. But the care offered is exactly the same. It's just sometimes managing expectations of, we can't help your breast development without having body fat change. Like there's certain things that happen at different levels.

[00:35:30] Naomi Viret: Yeah. Yeah. And again, it just paints that picture about how, um, intricate this care is and how it happens across multiple disciplinaries, like you mentioned before. Yeah.

[00:35:41] Maggie Smith: And, and multiple visits. The informed consent is great because it means we don't have to send people off to endocrinologists and psychiatrists to sign them off and say, yes, this person is trans and knows how to affirm themselves.

Probably wrecking your future questions here.

[00:35:55] Naomi Viret: No, not at all. But that does make me think, when did that model change when somebody no longer had to go to a psychiatrist to be able to start that affirming care?

[00:36:04] Maggie Smith: It's been supported for a number of years, probably WPATH, World Professional Association Transgender Health, for a while, but has really started to gain support and acceptance.

Oh, 2015, 16 It's been around before then, started to, but then when AusPATH came out in Australia with a, you know, a guideline and a proper protocol on it, really helped. So certainly, when did we open, 18, 2019, 20, um, started to improve. And basically what it means is, so the informed consent model means that, like we do in everything else, in healthcare or certainly in medicine, you have an individual come into you. I'm talking about over 18 here. We won't get into the tricky under 18 area just yet. You're over 18, you are explained, here's some treatment options for you. Here are some risks. Here are some permanent effects. Here's some things that aren't permanent. Here's the risks.

Here's the benefits. Have a little think, go off and have a think about it. And you're allowed to make the decision whether that treatment is right for you or not, as we do with everything else in health. It's crazy. So what used to happen is people would have to go and see a psychiatrist to get signed off or a psychologist to say, yes, this person is trans and needs to have these hormones.

And then you'd have to go and see an endocrinologist to get special medication prescribed. And one, it was expensive, it's, it's really difficult to access, there were limited people who did it, incredibly expensive, and people aren't stupid. So the other thing is, if you knew there were certain psychiatrists who did it, and people just gave each other the way you'd answer questions, so it's removing some of those barriers, and acknowledging that an individual, a trans person, you know, is able to know what is right for their body, and for them.

[00:37:51] Naomi Viret: And I think that it further pathologizes the trans experience, doesn't it, in terms of saying, you have to have a psychiatrist sign off, and it goes back to that point that you made before, about trans in and of itself is not a mental health condition concern.

So, yeah, that's really interesting. And I guess just while we're here in this space in terms of talking about hormone therapy, the clinical services that T150 are providing are free. Are the hormones free or is there a cost associated with that?

[00:38:21] Maggie Smith: Hormones aren't free because we, wouldn't be able to keep the service going. Uh, it's a good question, so not so much Medicare because Medicare covers sort of appointments. So it's the PBS, the Pharmaceutical Benefits Scheme, which supports, supplements, the cost of medications in Australia. Um, the PBS does cover the costs of hormones. If you have a healthcare card, I can't tell you what the copayment is now. I can't remember. So it would come in under that. If you don't have a healthcare card, um, It's the standard cost of a prescription. So if you do it through PBS on license and prescribe something like oestrogen, it usually comes or it depends how you're taking it as well.

So something like an implant, which we don't do at T150 is expensive. So it's an insertion of an oestrogen pellet under the skin in the subcutaneous. That's about $600 for the visit, but that will last you six to 12 months.

The cost for something like oral oestrogen can be anywhere from 30 to 40 dollars a month. There are things, if someone's taking a testosterone blocker, if you do that through PBS, It's about the same as that, but some of these are actually cheaper on what's called a private script. So sometimes you, you can write a private script and it comes through cheaper. Um, testosterone blockers are anywhere from 20 to 30 a month, but you use smaller doses of them.

Testosterone, testosterone is a bit tricky. Um, so estrogen you can have as a gel, tablets and implants in Australia. There are injectables, they are not available in Australia. So. Um, can't talk on them. Testosterone has to be prescribed, by an endocrinologist, sexual health physician, or a urologist.

That is not about restricting trans people into it, that basically comes about from cis men for years, abusing testosterone and using it for bodybuilding and other things. So you need to consult one of those specialists for it to get PBS reimbursement. That then drops it down to, I think it's, I think without a healthcare card, I can't remember the copayment, about 45 dollars for a Reandron, which is an injection that will last 8 to 12 weeks for most people. There's no oral testosterone, so it's usually a shorter injection or Reandron. If you don't have Medicare or if you see someone who doesn't have access to one of those specialists, testosterone is expensive.

Um, and you're probably looking at, I think Reandron testosterone and Decanoate is I think about 120 dollars and the shorter injections would, and that will probably cover like three months. So. It's a bit tricky. It is, you know, we try to make things affordable, but unfortunately, I'd love to be able to cover the cost of people's hormones, we just don't have the funding for it.

And advocacy around PBS and some of the surgical interventions such as top surgery is certainly being pushed by people like AusPATH and clinicians. So there is an ongoing and current movement about trying to get some of those things changed as well.

[00:41:23] Naomi Viret: Yeah, excellent. Great insight. Thank you so much. Um, I guess, just to move into a little bit of that clinical experience and you touched on it already in terms of the importance that the peers as part of the T150 experience provide.

Do you want to talk a little bit more to that in terms of the importance of that role and how they're assisting clients accessing the service?

[00:41:43] Maggie Smith: Yeah, peers everywhere, it doesn't matter what you're working in, have community there. The community voice and representation, and not tokenistically, are an integral part of every service.

But one of the things that was identified, we did a lot of community consultation for the setup of T150 was having a peer there. And there's different ways to do it in some places the peers do the testing and everything else. We actually don't have the space in T150 we basically got given a floor and a couple of rooms that needed renovating, here if you can make this work, do it, it's up a whole pile of stairs.

So we made, it work because that's all we'll ever get so we don't have a private space for peers, but they're able to, if it's someone's first visit there just have a chat, just be welcoming, you know, once you get to know the nurses and doctors who work at T150 we're lovely. I'm lovely. But you don't know that.

You're like, Oh my God, especially if you're coming for hormones, they're going to ask me all these questions and I might get it wrong and they're really scary. And in the past when I've gone somewhere, people look at me, you know, so it's just having a friendly face there. Our peers can also then chat to people and help link them in with services and other community things. So community groups, because one of the things, mental health support in the informed consent is not mandatory. Someone doesn't have to have mental health support.

It's great, if you are starting any form of affirming your gender, but especially hormones to have some sort of support, whether that's mental health or community peer groups. So the peer can help link them in with other groups, not because there is a problem with you, but there are some changes that are going to happen and the world is a bit crap still, like how are you going to go at work as you start to affirm your gender.

So just the peer can also give them that one on one, but then help link them in with community groups. Like here's a women's group who might be able to help you, here's a young non binary group who you can go and chat to online or face to face just to provide that support from community. Because clinicians are amazing. It's really different to have someone you can talk to about what's actually going on for you.

[00:43:45] Naomi Viret: Absolutely and I think those social connections become incredibly important and being with like minded others or those who have had the experience and yeah, can talk to that. Like, how do you, you know, come out and discuss this with friends or family or workplace, as you just said, and I can imagine that that just adds a whole level of um, that sense of belonging, that sense of being seen, being heard, and how incredible it is that peers can play that role alongside clinicians.

[00:44:10] Maggie Smith: Yeah, absolutely.

[00:44:11] Naomi Viret: Yeah, fantastic. So I guess just moving into, and we've already touched on some of these, but some of the barriers and challenges that are still existing in the trans health space. Sadly, we know that many transgender people have had negative experiences within services and in particular health services, as you mentioned earlier, many medical information systems are not on board with changes to things such as names. And this obviously then provides really big challenges.

Um, when a listed name doesn't match the name on a person's Medicare card, for example. What is it that we as workers can do or what is it that as clinicians you're doing to keep advocating in that space to ensure the best outcomes for clients?

[00:44:53] Maggie Smith: Yeah, um, I work in the public health space and in New South Wales, many of us use EMR, Electronic Medical Records system, the state one, which Is just so not trans friendly.

Um, finally after many years and what I was doing is I'd go around and cause trouble wherever I went and go just put complaints in. And if you have people who get misgendered or called the wrong name or they're in hospital and their family out like put in official complaints.. It's boring, but use the system, just start to put in complaints.

And there is now actually a workforce, and I think it probably won't happen for a little while, but they're actually looking at the Statewide Electronic Medical Record System, because it's horrible as a clinician, if you're affirming, say you're working in ED and you are the admin person or the nurse there, and what pops up on your screen is this honking great dead name, but that's their Medicare name, you know, and there might be some little sidebar somewhere that says the person's name. It's, it's atrocious. You'll go out and go, "Hey, is Joe here?" And it's some poor woman. It's just horrible. So identifying and using the systems, put in ERMS put in IMS get people to complain.

[00:46:01] Naomi Viret: That's what's going to change.

[00:46:02] Maggie Smith: Absolutely. Um, but then there's on a smaller level put, put your pronouns on your signature, your email signature, um, start to be an ally.

If you're from community and you're not comfortable doing that, totally respect that. And this is where our allies are so incredibly important in bringing about change and, and supporting community is if everyone puts their pronouns on their email signature, it doesn't become an issue or you wear a little pronoun badge and trans people are really good, it's not tokenistic, at seeing if they're someone is safe or a place is safe. They'll suss out if it's rubbish, you know, if you're like, yeah, we're trans friendly and they walk in.

[00:46:42] Naomi Viret: Yeah and they're not

[00:46:43] Maggie Smith: They will work that out really quickly and the word will spread. But just things like have a pronoun badge, have it on your signature, ask, even if you can't yet document it officially, ask everyone their name their gender and their pronouns. So instead of going, Oh, I think this person's trans, I'm going to do it. One of the things we've started to do for the whole of Albion is ask everyone, what's your pronouns, what's your gender identity. And it removes, so you'll have some of the cis you know, for us, some of the cis gay boys come and go, "what the hell", but it's great cause it gives you that opportunity to provide that feedback. And then people like, Oh yeah, cool, I get that. So just offering that for, for everyone.

But it normalizes it, right? It's kind of like using, um, precautions for Bloodborne Viruses. It's like, don't assume something based on how someone looks, use gloves for everybody.

You know, I just think it normalizes those conversations, doesn't it? And something really small yet meaningful that we can be doing in all of our services, starting from right now to make those really, significant changes to the community but small for us in terms of time and effort, but it's helping them to feel safe, it's helping them to feel included and it's showing that we are a sensitive service, like we're mindful, we're mindful of this.

So I just like to see if you had any comment in regards to the news that came out from the MDA National, which said "it was no longer going to cover private practitioners prescribing gender affirming care to adolescents, not for moral or ethical reasons, but because we don't think that we can accurately and fairly price the risk of regret."

 I'm trying very hard not to swear, um, so for people who don't understand they're the largest medical indemnity insurance, so for doctors, especially GPs, they are the biggest insurer. Saying it is not, this is where I will get a bit political, not ethical or moral It's based on basically risk aversion. Because someone's, trans people are going to come and sue us down the track that, you know, you're on these hormones, especially the adolescents, because, anyway, we could spend a whole other podcast talking about the issues with adolescents accessing care.

It's a load of rubbish, because the same insurers, will cover someone like an obstetrician who have millions of dollars indemnity because if something goes wrong with the birth of a baby that's bad , and poor outcomes happen over and over again in obstetrics. This same insurer will cover an obstetrician but they won't cover a GP wanting to prescribe hormones.

So I, I, I disagree. I think there is something behind it. It's not just risk aversion. Um, there has been a lot of advocacy and I know AusPATH and other services have really been trying to support GPs and there are other insurers. So basically there's a move like from some of the largest national medical students associate, they're just starting to move away from that insurer.

So hopefully what, as a nurse, we're not insured by the same thing, but hopefully money talks and there'll be enough support that doctors take their insurance elsewhere. It's, it's, because it does put a lot of pressure on GPs and GPs are the cornerstone to providing trans health. If you can get a good GP, they can do everything and then link in with specialist services, but to not provide them with the basic insurance support is is is criminal. And I think there was more to it. It's not just risk aversion. I don't accept that.

[00:50:00] Naomi Viret: I guess on that risk aversion. And when they point out that, you know, risk of regret, I think what they're talking about and referring to there is the small percentage. And I'd like you to just quickly touch on it. I think it's so important.

[00:50:12] Maggie Smith: It's especially used for adolescents and young people coming through, but also for adults. So this, this fear that someone, a trans person, you'll give them hormones or affirm their gender and whatever, and they're going to turn around and regret it is actually less than one percent.

It's less than that. It's anywhere from 0. 3 to 0. 6 percent of people will regret or change their initial decision about going on hormones or the things that have happened. And if you look at less than 1 percent as a regret for anything in medicine, that is insanely small. Um, but it's this argument that get used in trans health, which is you'll sacrifice the 99 percent for the possible less than 1%.

And that, that's just not fair. People are allowed to make mistakes with their health, no matter what it is. You might be diabetic and you're not taking your insulin. You might regret that later. We don't talk about that. It's used for trans health. And I think a lot of it comes down to political , but you know, young women, and it's about fertility, and there's a whole other topic we could get into there, but the amount of people who go on to regret affirming their gender is tiny, less than 1%.

[00:51:18] Naomi Viret: Thank you so much for sharing that.

Um, I just want to wrap up by a couple of final takeaway messages from yourself, Maggie. How can we better work with trans community in our services, in our space?

How can we keep being allies and advocates? How do we not fall into the judgment trap?

[00:51:34] Maggie Smith: Yeah. I heard a lovely thing recently. Um, that the opposite of judgment is compassion. And if you work in health, you're often coming from a place of compassion.

So approach everyone just being a human being, you know, with compassion. And if you do a slip, acknowledge it. Don't turn it in that person's problem with pronoun, just be honest and sincere and respect everyone who comes in for the individual they are. Use your pronouns, wear a badge. Just be a decent human being and come from a place of compassion and respect for everyone. And, you know, you'll, you'll help everyone feel valued and seen.

[00:52:13] Jennifer Farinella: Thanks for listening to On The Couch. We create this podcast because we are allies in actively challenging discrimination, microaggressions, and exclusionary behaviors. We want to create spaces where people feel safe to share their thoughts, knowing they will be heard and respected. Such an environment fosters collaboration, innovation, and contributes to a more inclusive society.

Connect with us on Instagram and Facebook where you can share On The Couch with your colleagues, friends, and family. On The Couch is made by Jennifer Farinella, Naomi Viret, Maddy Stratten and Winnie Adamson.

Until next time, peace, love and protection.