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Transgender Attempts surgery At home Due To Lack Of Access

A transgender young person's attempt to perform top surgery on himself is a clear result of historical underfunding and inequitable access to gender affirming healthcare, an expert says.

The 18-year-old turned up at an emergency department after attempting to perform a bi-lateral mastectomy, also known as top surgery, at home. He was several hours through the procedure when he became concerned he would cause nerve damage.

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The case was published in the New Zealand Medical Journal on Friday and was described as an "act of desperation".

The young person was facing long wait times for a surgery referral in the public health system and was unable to afford to go private - which can cost up to $35,000.

"This is a clear result of the historical underfunding and inequitable access to gender affirming care around the country," said Jennifer Shields, president of the Professional Association for Transgender Health Aotearoa (PATHA).

"Research shows that gender affirming hormones and surgeries are essential for the wellbeing of many trans people," she said.

Not all trans and gender diverse people experience gender dysphoria or seek medical affirmation such as surgeries or hormones.

But in 2019, almost half of all trans and non-binary people who wanted top surgery said they had an unmet need.

The Counting Ourselves survey found cost, alongside not knowing where to go and waitlist times, were the biggest barriers they faced.

Preliminary data from the 2022 Counting Ourselves survey, due to be published later this year, shows little movement in these levels of unmet need.

Lack of access 'unacceptable'

The Medical Journal paper said having experienced gender dysphoria, this young person was suffering from "significant psychological stress" because of his chest ahead of an upcoming pool party.

The teen was found by an acute mental health team to have "no active mood disorder, psychosis or suicidality" and could consent to surgery, which was subsequently undertaken.

He healed well after the surgery and "reported improvement in self-esteem and self-confidence and his ability to complete school work".

"Young people are being forced to choose between other essential costs and fundraising to pay for medically necessary healthcare. This means forgoing or delaying education or staying in unsafe housing because it's all they can afford," Shields said.

Access to gender affirming healthcare, including surgeries, varies from region to region. In some areas of the country there is no public pathway at all to access gender affirming top surgery.

Shields said this was unacceptable.

"When trans people don't get referred for medically necessary gender affirming healthcare because there is no service available, their health needs are ignored, and go uncounted, leading to further inequities and under-resourcing."

'Extremely concerning'

Wellington clinician and PATHA executive member Dr Rona Carroll said it was "extremely concerning" to hear that inadequate access to medically necessary care through the health system led to the significant distress this young person experienced.

Carroll regularly sees trans people at her clinic who have been unable to access top surgery.

They describe "struggling to leave the house, being constantly misgendered and feeling deeply uncomfortable in their body and not able to feel or be seen as their true self", she said.

PATHA "absolutely does not recommend attempts at self-surgery, which can be life-threatening", Shields said.

"Trans people deserve nothing less than safe, timely, access to medically necessary healthcare."

In a briefing to the incoming Minister of Health Dr Shane Reti in December, PATHA called for investment in a targeted national approach to improve trans health.

Of its priorities for action given to the minister was that there be "adequate provision of gender-affirming surgeries and wrap-around support, including for the national genital surgery service" and a nationally-coordinated approach that addressed unacceptable levels of unmet need.

Reti has been approached for comment.

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