NZ political parties’ transgender health plans

NZ political parties’ transgender health plans

Access to gender affirmation surgery in New Zealand is abysmal, with waiting lists that are decades long. I’ve asked our major political parties what they will do about it if elected.

On the 27th of July, I sent emails to four political parties outlining the issue of access to gender affirmation surgery*. I contacted the healthcare spokespersons for the Green, Labour, and National parties, and the co-leaders of the Māori party since I couldn’t find any health spokesperson for them. They each received a version of this email:

Tēnā koe,

Since the US president Donald Trump announced this morning that transgender Americans would not be allowed to join the US military, saying that their healthcare is too expensive[1], I have been reminded of a similar issue that we face here in New Zealand.

For many transgender people, gender affirmation surgery is potentially life-saving. Transgender people are a minority population in New Zealand who are at higher risk of depression and suicide[2]. It’s important that their needs are not forgotten.

I’m writing to you as the spokesperson for health for the XXXX Party, because this matter is something I want to be sure is addressed in the coming election. It is something I will be considering carefully before choosing which party will receive my party vote.

Currently, gender affirmation surgeries are funded out of the Ministry of Health’s special high cost treatment pool, at an intended rate of one “female to male” surgery and three “male to female” surgeries every two years[3]. However, since New Zealand’s only surgeon who could perform these surgeries retired in 2014[4] the surgeries appear to have stopped.

In response to a request made by Jennifer Shields, the Ministry of Health revealed in May this year that:

“There are currently 71 people waiting for male to female gender reassignment surgery and 19 people waiting for female to male surgery.”[5]

They also noted in their response that:

“There are no plans to increase the rate of surgery. A mathematical calculation suggests that the 71st person on the male to female waiting list will be operated on in around 47 years if the rate remains the same. Similarly, the 19th person on the female to male waiting list will be operated on in 38 years.”[5]

Currently, this situation is fairly untenable. Transgender people seeking gender affirmation surgery are left to pay out of their own pocket to travel overseas for surgery, or wait for decades in the hope that the government might eventually get around to them. It should frankly be cause for international embarrassment.

Which is why I’d like to ask you how the XXXX Party would address the health issues faced by transgender New Zealanders if you are voted into government in September.

I also know many other people who consider this an important issue and would like to know your answer. It would be great if the XXXX Party’s plan on this issue could be released publicly. In any case, I intend to share the response I receive with others who care about this.

Ngā mihi nui,
Mark Hanna

[1] https://www.nytimes.com/2017/07/26/us/politics/trump-transgender-military.html
[2] http://www.sciencedirect.com/science/article/pii/S1054139X13007532
[3] http://www.health.govt.nz/system/files/documents/publications/gender-reassignment-health-services-for-trans-people-in-nz-v3oct14.pdf
[4] http://www.radionz.co.nz/national/programmes/morningreport/audio/20148752/plastic-surgeon’s-retirement-leaves-sex-change-surgery-in-limbo
[5] https://twitter.com/jenkshields/status/867126476675481600

Later, after watching the Rainbow Wellington Election Forum video on Facebook, I also sent the email to Damian Light, the diversity spokesperson of the United Future Party. During the forum, he had mentioned something I hadn’t heard before about this issue:

I stand to be corrected on this if I’m wrong, but I understand that the waiting list [for GRS] could be cleared for as little as five million dollars by using overseas [surgeons]

So as well as asking for his response to the original email, I asked if he was able to point to his source for that statement, since I hadn’t been able to find one.

Though to put that number in a bit of context, ACC spent $8.6 million on acupuncture for lumbar sprain in 2014/15. This is despite their most recent review on acupuncture for musculoskeletal pain in 2011 finding that the evidence in this area was “inconclusive”.

Getting any response from some parties has unfortunately been like getting blood from a stone, and not all have responded by the time this article was published. If I receive more responses in the future, I will update the article to include them.

Here are the responses I have received so far. You can click the links below to jump to a particular party’s response:


Green Party

My email to the Green Party was sent to Julie-Anne Genter, as their spokesperson for health, but it was forwarded to Jan Logie’s office as it’s an issue she’s worked on.

Kia ora Mark,

Apologies for the delay, and thanks so much for your email. Julie Anne’s office passed this to Jan Logie’s office because Jan has been working very hard on issues of healthcare for trans people, but I’m cc-ing in Julie Anne’s EA Stuart as Julie also wants to stay connected to these issues.

Jan and the Green Party agrees with you about the huge, life-saving importance of gender reassignment surgery and that the waiting list is utterly unacceptable.

The Green Party agrees with the recommendations made by a coalition of groups to the panel of MPs on the International Day against Homophobia, Biphobia and Transphobia on May 17th this year, which were the following:

  • Require district health boards to ensure trans and gender diverse people’s access to gender affirming health services available in NZ, based on an informed consent model of healthcare
  • Provide sufficient funding to enable timely access to gender reassignment surgeries not provided through the NZ public health system
  • Support the development of training and resources on an informed consent model of healthcare for trans and gender diverse people, and provide information and resources for communities and individuals about accessing gender affirming services.

We also note that the aim should be to create a New Zealand based national surgical service for gender reassignment surgery, and to ensure that we have this specialist knowledge in New Zealand (as well as the interim measure of funding being available for people to travel for the surgery).

You might be interested to read the Green Party minority report on the select committee report on a petition around trans health care from 2015: https://www.parliament.nz/resource/en-NZ/51DBSCH_SCR69574_1/1911770f0cb53490fadba8dbcfb09d7c24955763

Jan is really passionate about this issue and will continue to work to advocate to ensure transgender and gender nonconforming people get access to the healthcare they need.

Please feel free to get in touch with any further questions.

Kind regards

Jessie Dennis, Senior Executive Assistant to Jan Logie MP

I also sent a follow-up question about what “timely access” means more precisely, after Jennifer Shields raised the question on Twitter:

Hi Mark,

I talked with Jan about this. As far as numbers, just like any urgently needed surgery, the ideal wait time is none at all. Of course, while that might not always be realistic, we’d work to get it as close to that as possible.

Many Thanks

Jessie Dennis, Senior Executive Assistant to Jan Logie MP

The Green Party also has a Sexual Orientation and Identity Policy.

At the time I wrote this section, that policy was last updated in 2014 and does not mention the issue of access to gender affirmation surgery. However I believe some updates are being worked on so there may now be a more recent version.


Labour Party

I’ve yet to hear back from Labour. Originally I contacted their health spokesperson Dr David Clark, but after seeing Grant Robertson speak on the topic at the Rainbow Wellington Election Forum I forwarded the email to him on the 23rd of August. I’ve had an acknowledgement from his EA, but no response yet.

Update 2017/09/21 I’ve heard back from Grant Robertson about this. Here is his response:

Hi Mark

Apologies that you have not had a detailed reply, it is the result of a bit of confusion over who was responding and then just general busyness. As you said in your email you are aware of our Rainbow Policy. Here is the link again for ease of reference. http://www.labour.org.nz/rainbow

It is worth pointing out the specifics of that in terms of transgender health issues in particular

  • improve access to affordable primary care based on the informed consent model, particularly for younger, trans, and intersex New Zealanders. This also includes training and resources for health professionals about sexual orientation and gender diversity
  • provide targeted suicide prevention funding to build capacity of rainbow community support organisations and mainstream crisis support and services.
  • increase resourcing for youth mental health
  • support and ensure all district health boards reduce barriers for trans and gender diverse people to access gender affirming healthcare, transition related medical support (including hormones, social support and other cosmetic interventions), and an assessment of the need for gender reassignment surgery as an elective service
  • ensure fair access to publicly funded gender affirming surgical options for trans and gender diverse people based on need.

Labour has allocated an additional $8 billion over four years to the health sector to meet these, and other, priorities. We will invest in the high cost treatment pool so that we are able to send people to get the surgery they need but we will also focus on building capacity back up in New Zealand to perform surgery, because we need to do both to make an impact on the waiting list.

I hope that answers your questions.

Regards

Grant

Grant Robertson

While waiting for my response, an article was published in the New Zealand Herald that gave some detail around Labour leader Jacinda Ardern’s response to a question from a student about access to gender affirmation surgery:

One of the students asked Ardern what Labour’s stance was on helping more people have sex reassignment surgery, and providing other support.

The Labour leader agreed greater support was needed, at which point [Annette] King added that one problem was a lack of specialist surgeons in New Zealand, and more training was needed.

“I also was married to a transgender person,” King said.

“So I understand very much the issues for transgender people, and the need to have access to surgery and to counselling and drugs and support. We are very supportive of that in our policy.”

NZ Herald

Labour has a Rainbow policy, which has this to say on access to gender affirmation surgery and other healthcare for trans New Zealanders:

Labour will:

  • improve access to affordable primary care based on the informed consent model, particularly for younger, trans, and intersex New Zealanders. This also includes training and resources for health professionals about sexual orientation and gender diversity
  • support and ensure all district health boards reduce barriers for trans and gender diverse people to access gender affirming healthcare, transition related medical support (including hormones, social support and other cosmetic interventions), and an assessment of the need for gender reassignment surgery as an elective service
  • ensure fair access to publicly funded gender affirming surgical options for trans and gender diverse people based on need.

Also, the minority view on a petition on this topic noted in Jan Logie’s response from the Green Party was apparently from both the Green and Labour parties (it’s written from the perspective of the Green Party but in the heading it notes it’s also the view of the Labour Party): https://www.parliament.nz/resource/en-NZ/51DBSCH_SCR69574_1/1911770f0cb53490fadba8dbcfb09d7c24955763


Māori Party

I contacted Māori Party co-leaders Marama Fox and Te Ururoa Flavell, and received this response from Marama Fox:

Tēnā koe Mark

Thank you for your letter to me regarding the health issues faced by New Zealand’s transgender community. I appreciate you writing to me and I apologise for the delay in responding.

Regarding the concerns you note about the availability of gender affirmation surgery, I too share your concerns as this leaves many of our whanaunga in an untenable position. As such I have referred your email to the Minister of Health, Hon Dr Jonathan Coleman for his response.

Mark, the Māori Party has not developed a specific transgender policy or a wider LGBT policy for the 2017 General Election. However I note that as a Party born of the dreams and aspirations of tangata whenua, a large proportion of whom identify with the LGTB and transgender communities, the Māori Party seeks to engage with all whānau to enable them meet their aspirations whatever they may be, as well as address any problems that they may be experiencing. To this end we welcome organisations and individuals that wish to engage with our party so that we may better support the transgender and LGBT communities.

Thank you again for writing to me and again I apologise for the delay in responding from you. I look forward to hearing from you in the future.

Nāku noa, nā

Marama Fox
Co-leader of the Māori Party and List MP for Ikaroa-Rāwhiti

I received this response as a PDF and wasn’t able to copy/paste text from it, so typed it out by hand. Please assume any mistakes in the above text are mine.


National Party

I contacted Health Minister Dr Jonathan Coleman about this. I was told he had asked Ministry of Health officials to advise him on the topic before he responded, and though I haven’t received his response yet I was told on the 28th of August that I should have it within “the next week or so”.

If the National Party has an LGBT-specific policy, I haven’t been able to find it.

Update 2017/09/11 I’ve heard back from Dr Jonathan Coleman about this. Here is his response:

Dear Mr Hanna

Thank you for your email of 27 July 2017 about transgender health services.

The Ministry of Health considers that transgender health services are best organised and developed on a regional basis. I am advised that the Ministry is aware of developments being undertaken by some district health boards.

The Northern region in particular has been putting effort into this, and the Ministry supports the approach being taken. The region’s intention is to develop a linked health service for transgender people, creating clear pathways for health by putting forward a plan based on collaboration across the region and through levels of community, specialist and hospital health services.

Work to date has included establishing a regional transgender steering group and clinical and consumer advisory group, and appointing a Clinical Lead and Project Manager. A series of consumer workshops have been held across the Auckland metropolitan region, and care pathways and service specifications are being developed. A Northern Region Transgender Health Work Plan has recently been adopted in order to progress this work.

As the Northern region makes progress, the Ministry will encourage other regions to observe this and to strengthen their own regional approach to transgender services.

Thank you for writing.

Yours sincerely

Hon Dr Jonathan Coleman
Minister of Health


United Future Party

I emailed Damian Light, as the United Future Party’s spokesperson for diversity, after seeing him speak at the Rainbow Wellington Election Forum. As well as sending him a version of the same email other parties received, I asked him if he would be able to send me the source for a statement he made during the forum:

I stand to be corrected on this if I’m wrong, but I understand that the waiting list [for GRS] could be cleared for as little as five million dollars by using overseas [surgeons]

Damian Light

He was quick to respond with a link to the United Future Party’s LGBT policy:

Thanks Mark,

As spokesperson for diversity I had the pleasure of launching our policy on 8 August (31 year anniversary of the homosexual law reform coming into effect).

We’ve published it on our website under policies (http://unitedfuture.org.nz/lgbt/) but here are the key points around healthcare;

  • Ensure health providers have appropriate plans, practice standards and funding to responsiveness to the health needs of rainbow communities.
  • Ensure trans and gender diverse people’s access to gender affirming health services based on an informed consent model of healthcare. Where not available in New Zealand, provide sufficient funding to enable timely access.

The $5m detail came from an article online but I can’t find it right now (away from my Pc with all my files used to create our policies).

I’ll try track it down and send it through.

Kind regards,

Damian Light
Party Leader + Candidate for Botany
Spokesperson for Auckland Issues and Diversity

Update 2017/09/10 After following up, I’ve been told that Damian Light hasn’t been able to find the source for the $5m statement. If anyone else knows where this number might have come from, it would be great if you could share a link in the comments or email me about it.


I should also mention that Claire Black has published an article about various parties’ approaches to trans rights as part of Andrew Chen’s A Policy A Day series. Claire looked at the issues of trans healthcare in New Zealand and amending the Human Rights Act to explicitly outlaw discrimination on the basis of gender identity. She also included more of the minor political parties that I haven’t contacted. You can find her article here: A Policy A Day: Trans Rights

* Often referred to as “gender reassignment surgery” or GRS, I prefer not to use this term because of its false implication that someone’s gender can be changed through surgery. Alternatives include “gender confirmation surgery” and “gender affirmation surgery”. I prefer the latter because I think it carries less of an implication that it is somehow necessary for trans people to have surgery in order to “confirm” their gender.

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Green Party Health Policy

There was a thread recently in one of the Facebook groups I’m a member of in which, among other election-related things, the Green Party’s Health Policy was being discussed. It was mentioned that the Green Party had been essentially pro-CAM, at least in the past. As I’d been considering voting for the Greens, this was something I thought I should look into further.

Here’s a link to their Health Policy. My first impressions of this document were quite positive, especially seeing that one of their “Key Principles” seems to echo the mission statement of the Society for Science Based Healthcare where it states that:

Decisions about health services should be based on the strongest possible evidence.

However, I found myself worried that this might just be paying lip service to evidence-based policy. Particularly considering the comments I’d seen regarding past policy, and some other sections of the current Health Policy such as:

The Green Party will… Find ways to integrate complementary therapies that have a sound evidence base into health services.

The Green Party will … Increase resources for physical and mental rehabilitation in… complementary practices.

Of course, complementary therapies that have a sound evidence base should be “integrated” into real medicine. That’s exactly what medicine should be – therapies with a sound evidence base. However, as I said before, I felt worried this mention of evidence may just be lip service, or perhaps that the standard of evidence required might be low (as I’ve typically seen when it comes to the promotion of complementary therapies).

As you’ll have seen if you’ve clicked on the Health Policy link, Kevin Hague is listed as the spokesperson for this policy, as well as the person to contact. So that’s what I did. Below is the email I sent him, and the response I received (much faster than anticipated – within 2 hours):

Hello Mr Hague,

My name is Mark Hanna. I don’t think we’ve met, although we were both at the New Zealand Skeptics conference in Wellington last year. I’m currently considering giving my party vote to the Greens this election but I wanted to email you first to clarify something about one of the policy statements.

I spend a lot of my spare time working with regulatory systems to combat misinformation about health and healthcare in the public sphere. The vast majority of this misinformation comes from sources that promote “complementary therapies”.

To this end, I’ve made dozens of successful complaints to the Advertising Standards Authority and Medsafe, and have recently co-founded the Society for Science Based Healthcare as part of this continued effort. I’ve also written on some aspects of publicly funded healthcare in New Zealand that I find troubling and would very much like to see change, such as ACC’s stance on acupuncture (http://sciblogs.co.nz/honestuniverse/?p=41).

I’ve read the Green Party’s Health Policy (https://home.greens.org.nz/policy/health-policy); I’m glad to see an emphasis on evidence and I strongly support with [sic] party’s focus on equality in healthcare and making it as accessible as possible. However, I’m also wary that I don’t want my party vote to inadvertently support the kind of thing I spend so much of my time fighting against. Most particularly, I am worried about point 7 under the “Whole-of-System Healthcare” section:

“Find ways to integrate complementary therapies that have a sound evidence base into health services.”

As you may be aware, the majority of complementary therapies have a very poor evidence base. Even in cases where there is a large amount of research, in general it is of poor quality, and in very many cases the use of complementary therapies is simply not supported by sound evidence.

Other sections of the Health Policy add to my concern here, such as the 1st point under “9. Post-Acute Care” which says “The Green Party will… Increase resources for physical and mental rehabilitation in… complementary practices”. Before I commit my party vote, I’d appreciate it if you could assuage my fear that the reference to sound evidence may be no more than lip service.

In general terms, what would the Green Party consider the minimum standard of a sound evidence base in this context? Could you describe what the evidence for a treatment that does not meet this standard might look like?

As part of their commitment, will the Green Party also make an effort to prevent the integration of therapies (whether “complementary” or otherwise) into health services where there is not a sound evidence base?

I also note the party has pledged to:

“Support rongoa Māori (traditional Māori healing) practitioners and practices, and develop better linkages with other health services.”

I’m wary that when dealing traditional healing practices such as rongoa Māori and Traditional Chinese Medicine, the complex issues of science- and evidence-based healthcare and cultural sensitivity and inclusiveness can become entangled. Will the Green Party maintain their commitment to basing decisions about health services being based on the strongest possible evidence even when dealing with complex and often difficult issues such as these?

I’m under the impression that other people I know who are also considering giving their party vote to the Greens could also be swayed one way or the other depending on your response. I’d appreciate it if I could have your permission to publicly share any response you send me regarding this.

Sincerely
Mark Hanna

This is the response I received from Kevin Hague:

hi Mark,
I’m an admirer of your work. Thank you for it!

As you probably know, Green Party policy is developed by members, rather than MPs, and the Policy Committee strives for consensus if possible.

if you have compared the current Health policy with its predecessor (and my statements with those of my predecessor in the role) you will have noted substantial change that I think you would be pleased with.

The statement in the principles concerning complementary therapies, is a neat compromise I think (nobody can really argue for the use of public money on something that doesn’t work, but if it does work then it should be integrated), but does give rise to your question of what kind of evidence would be sufficient. In practice it would be me as spokesperson who would interpret the meaning of the policy (this is established practice in the Green Party). My first port of call would be Cochrane. If there is no guidance there, then it’s probably a no, but as someone who used to teach at postgrad level in research methods I would also be in a position to look at any papers that are proposed as providing evidence and make an assessment.

The obverse of this commitment does also apply ie if the state is currently funding therapies with poor or no evidence of effectiveness then it should stop doing so. This applies both to ‘complementary therapies, but also to mainstream treatments (my favourite instructive example being mammary arterial ligation as a treatment for coronary heart disease – it’s worse than ineffective).

In the case of rongoa I think matters actually are more complex. In addition to the cultural sensitivity matters to which you refer there are also Article II Treaty rights, so it’s not simply a matter of evidence. And when it comes to the evidence, far fewer studies have been undertaken. You probably know that there is significant evidence internationally that such indigenous treatment systems may be effective, even though their intervention logic and mechanism are quite different from traditional western approaches (eg Kleinmann in relation to mental illness in Taiwan). It could be that strongly held cultural beliefs may create a substantial placebo effect. Sometimes, even if we know the effect is just placebo, it could be worth having. So on this point I would interpret our policy as supporting the availability of rongoa, even though the evidence base for effectiveness may not be strong. I would also support further research to create a sound evidence base, where this doesn’t currently exist.

Hope that’s useful. Please feel free to share this if you want.

Best,

Kevin

Honestly, I’m quite happy to hear this answer. It sounds to me like the mentions of evidence are more than lip service, and hopefully indicative of a change in direction for the Greens in this area. The fact that Kevin Hague is their spokesperson on Health and ACC gives me hope as well. Especially comparing him to their past Health spokesperson Sue Kedgley, who has some ideas about healthcare that are rather wacky.

I would like to make one more comment regarding the issue of traditional medicine such as rongoa. First off, rongoa is not something I’ve looked into in much depth, I don’t know much about the state of the evidence and don’t mean to discuss it here. I would like to say though, that when I referred to issues like it being “complex and often difficult”, I meant to imply that it is not as simple as it may be in some other cases, where the only important question may be “what does the evidence say?”.

These traditions are often more than just for healing, they’re part of a wider culture and the people that use them are often already part of a disadvantaged group. If we care about what’s best for people, then we also need to care about the repercussions of discouraging or somehow diminishing such a part of their culture. As Kevin mentioned in his response, this is where things like the Treaty of Waitangi become important. There’s also an important distinction to be drawn between treatments for which there is negative evidence and those for which there is no evidence one way or the other.

I certainly wouldn’t claim to have all the answers when it comes to issues like this, and I think it’s a matter on which I would do better to listen than to speak. I do agree with Kevin that it’s not simply a matter of evidence, though, and I’d welcome a discussion on this particular issue if anyone else has anything to add.