An Open Letter to Minister Jo Etienne Abela on Trans healthcare

Aqra bil-Malti

We would like to address the recent comments on trans healthcare (gender-affirming care) made by Minister Prof. Jo Etienne Abela during his interviews with LovinMalta and Times of Malta. In particular, we wish to address the suggestion that trans healthcare is “complex”. 

Complexity is not a justification for inaction or denial of care. All areas of healthcare, from cancer treatment to mental health services, come with their own intricacies and challenges. That is precisely why professionals working in these fields are expected to be competent, well-trained and specialised. Despite the challenges and delays in other parts of our healthcare system, including the aforementioned ones, no one expects the state to shy away from providing care in these areas or to label them controversial. Gender-affirming care simply requires that we approach it with the same dedication, evidence-based practices, compassion, and a patient-centred approach; an approach we believed was being implemented successfully in Malta.

We would also like to address the concerns raised regarding the medico-legal challenges in the UK and the closure of the Tavistock Gender Clinic. It is essential to contextualise foreign events, as they have been misinterpreted by some to argue against access to gender-affirming healthcare for trans youth, which in turn is denying or delaying care for trans adults too. The closure of the Tavistock Gender Clinic was an outcome of the recommendations of the Hilary Cass Review, a report that supposedly called for a more regionalised and holistic approach to gender-affirming care for youths in the UK. 

However, many clinicians, activists and academics have criticised the review. Recently, a group of experts wrote to the UK Secretary for Health, urging them to halt implementation of the Cass Review’s recommendations. Their letter describes the review as an “absurd spectacle” which makes recommendations that “undermine trans people’s care by fear-mongering about the number of young people who seek to use it”. Moreover, the services provided at the Gender Wellbeing Clinic are based on an informed consent model of care guided by the WPATH (World Professional Association for Transgender Health) Standards of Care. WPATH itself has criticised the Cass review for various issues, including its methodology and exclusion of experts in the field of gender-affirming care. 

It is also important to highlight that gender-affirming care is not just medical interventions like hormone replacement therapy and gender reassignment surgeries; it encompasses a range of social, psychological, behavioural interventions, such as counselling, psychotherapy and speech therapy. Trans people of various ages, not just youths, who are still waiting to get an appointment at the clinic are being hindered from accessing any of these other services. Numerous studies and the Standards of Care by WPATH which are grounded in systematic reviews of research are clear; access to gender-affirming healthcare, including for youth, leads to better mental health outcomes, reduced anxiety, lower levels of depression, and a higher quality of life. Gender-affirming healthcare is life-saving, especially for younger people who are more vulnerable to feelings of isolation, discrimination, and despair when denied access to the care they need.

The Minister also mentioned that Malta’s healthcare system often models itself after the UK’s NHS. Malta has been independent from the UK for 60 years, and it is about time that we start challenging this colonial mindset that the UK must be our benchmark in every aspect. That being said, if we were truly committed to following the UK NHS model in its entirety, we would have a sexual health policy, and the Maltese NHS would be offering comprehensive access to HIV prevention drugs such as PEP and PrEP, which are readily available under the UK NHS but are still out of reach for many in Malta.

Our current reality is that trans people of all ages are being left in limbo, waiting for appointments that could drastically improve their mental and physical wellbeing. Malta has the opportunity to lead by example when it comes to trans healthcare, just as we did with our GIGESC law that depathologised trans identities, but in order to do so, we cannot afford to fall into the trap of biassed research, transphobic propaganda, and outdated or incomplete models of care from abroad. 

An integral part of the legislative strides Malta has made for the LGBTIQ community, were in part thanks to listening to and consultation with the community, activists and other stakeholders working with the LGBTIQ community. MGRM has reached out to the Minister four times in the past year, requesting a meeting to discuss and address the issues at the Gender Wellbeing Clinic, and we are still waiting for a response. If the Minister and professionals have concerns, then should not finding a solution with the LGBTIQ community and said professionals be considered a way forward?  

The welfare of the patient must always be at the centre of improving provision of healthcare; anything otherwise, is a dereliction of care and responsibility to ensuring all members of society have equal access to healthcare. We hope the Minister of Health has this at heart, and considers our request to meet. 

 

Studies and Resources

– Green, A. E., et al. (2022). Association of gender-affirming hormone therapy with depression, thoughts of suicide, and attempted suicide among transgender and nonbinary youth. JAMA Network Open, 5(3), e220978.

– van der Loos, M. A., Hellinga, I., Bouman, M.-B., & van der Sluis, W. B. (2022). Gender-affirming hormone therapy in adolescents and adults: A systematic review on mental health outcomes. European Psychiatry, 64(1), e18.

– Välimäki, M., & Söderström, I. (2021). Gender dysphoria in adolescence: Current perspectives. Adolescent Health, Medicine and Therapeutics, 12, 101-109.

– The Trevor Project. (2021). National Survey on LGBTQ Youth Mental Health 2021.

– van der Miesen, A. I. R., Steensma, T. D., de Vries, A. L. C., & Bos, H. M. W. (2020). Psychological functioning in transgender adolescents before and after gender-affirmative care compared with cisgender general population peers. Journal of Adolescent Health, 66(6), 699-704.

– Turban, J. L., et al. (2020). Pubertal suppression for transgender youth and risk of suicidal ideation. Pediatrics, 145(2), e20191725

– Durwood, L., McLaughlin, K. A., & Olson, K. R. (2017). Mental health and self-worth in socially transitioned transgender youth. Journal of the American Academy of Child & Adolescent Psychiatry, 56(2), 116-123.e2.