Friday, August 1, 2014

Mongolia’s medical community open to providing care for transgender individuals

By Margaux Maxwell and Mathilde Michaud

Mongolian transgender individuals say they are afraid to call on local health care providers for the medical procedures vital to their mental and physical health.

Despite popular perception, the majority of the Mongolian medical community says they are willing to administer transition-related care. Many private hospitals possess the facilities to live up to their claim, but training and education are still needed before transgender individuals undergoing female-to-male (FTM) or male-to-female (MTF) transitions can get the help they may seek. Ingrained fear stemming from a history of social persecution and a general sense of distrust in the underdeveloped Mongolian healthcare system is provoking this abstention.

The discussion surrounding transgender issues is young in Mongolia, even among the LGBT community. Transgender individuals have a fear of exposing themselves in a society where their reality does not yet seem to be understood.

“In today’s everyday life, I cannot dress as a woman and board a bus,” said Sarnai, a transgender woman who no longer wears clothing she feels expresses her gender after facing social pressures.

The psychological distress that accompanies social stigma can also lead to mental health issues for transgender individuals.

Mental health

According to the Institute of Medicine (IOM), transgender individuals are more susceptible to developing mental health problems, such as anxiety and depression, and are more likely to experience difficulties in relationships with peers and family members. However, it should be noted that these symptoms are socially induced and are not intrinsic to transgender identity.

Anaraa Nyamdorj, executive director of Mongolia’s LGBT Centre, commented on the matter, “There are many more cases of mental health issues, such as alcoholism and depression, all these things appear to be quite acute for LGBT people, starting from adolescence.”

The National Center of Mental Health in Mongolia (NCMH) has provided mental health services to LGBT individuals in the past, where LGBT patients can be treated for depression by the facility’s sexologist.
However, the low staff to patient ratio makes treatment difficult. For example, at the time of publishing this article, the NCMH sexologist was on a leave of several months, meaning that transgender people were left without access to mental health care.

Additionally, patients at NCMH are evaluated according to the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), where “transsexualism” and “dual-role transvestism” are listed under “gender identity disorders,” implying that these states of being are diseases.
This is not a uniquely Mongolian problem, as the IDC-10 is published by the United Nations World Health Organization and used internationally.

“We are not trying to correct LGBT people in any way, we are merely trying to treat them for depression and anxiety that come from what they experience. To us, they are just people like anyone else who need help,” said MD S.Munkhtuya , addictologist and specialist at the National Center of Mental Health, illustrating that judgment is not the issue but lies in a flawed international medical diagnostics code.

Hormone replacement therapy (HRT)

Although some facilities such as the Mongolian Menopause and Andropause Society and Songdo Hospital possess the equipment to provide HRT services in Mongolia, none currently offer treatment for transgender individuals.

Hormone replacement therapy (HRT) is central to the transition process, as sex hormones regulate the development of sex characteristics. It is often the only medical procedure undergone by a transsexual individual. Changing fat distribution, muscle mass, and hair growth can be part of this process.

Entering an HRT program can involve many risks, such as heart disease and breast cancer. Therefore, close medical monitoring is suggested by specialized institutions.

“As long as you are taking hormones (possibly for the rest of your life), you need to have regular physical exams and lab tests to monitor your overall health. The first year after starting hormones, the prescribing doctor/nurse will want to see you at least every three to four months; after that, you will have appointments at least every six months,” explains the Canadian Center for Addiction and Mental Health’s Hormone: a guide for MTFs.

“Personally, I sought help from a hormone doctor. And the doctor was not welcoming, he/she even advised me to become a man again!” exclaimed Mugi, a transgender woman living in Mongolia.

The LGBT Centre in Mongolia has created a program dedicated to trans issues to help them live a healthy life, mentally and socially. The centre gathers information from health professional groups such as the World Professional Association for Transgender Health (WPATH), allowing those pursuing HRT without the support of a doctor monitoring their hormonal levels to know approximately what their status should be in regards to their transition stage. But not everybody reacts the same way to hormones, as the dosage and type of hormones used should be determined by the levels of hormones already present in one’s body, impossible to regulate unless a patient seeks counsel from an endocrinologist.

The Mongolian transgender community encounters another obstacle in its attempt to access HRTs: high prices. Mugi explains that hormone products are extremely expensive and few in the community are wealthy enough to access them.

“We seek financial help but nobody except our family and friends will help us,” she says.
Although the law on civil registration provides opportunities for transgender individuals undergoing HRT to change their gender marker on official documents, the law does not mention access to HRT within the health care system. Mongolian transgender individuals are forced to buy hormones themselves, making it more difficult to control the variability of the type of hormones they use, another factor endangering their health.

Sex reassignment surgeries (SRS)

Mongolian doctors are far from reaching the international standard for training and education on transgender health care, as illustrated when many did not know the definition of “transgender” when asked by the UB Post.

Many health care centers, such as SongDo Hospital and Achtan Elite Hospital, told the UB Post that they have the facilities to provide medical assistance to transgender individuals, but merely have not been approached.

“Although we have never been approached, we would be happy to help any member of the community who comes to us,” said Sarangerel Luvsanvandan, the director of SOS Medica Mongolia Ulaanbataar International Clinic.

Even though the clinic can not perform any of the transition surgeries themselves, their first choice of referral would be Bumrungrad Clinic in Bangkok, where many transgender individuals go for sex reassignment surgery and hormone replacement therapy.

The clinics refer their trauma and emergency patients to hospitals in Mongolia such as the National Trauma & Orthopaedic Research Center of Mongolia, but told the UB Post that they would not recommend a Mongolian facility for transition-relation surgeries.

The Mongolian transgender community does not seem ready to trust its healthcare system, a feeling seemingly shared by the general public.

A Mongolian citizen, Bold, expressed his fear, “I would not get surgery in Mongolia, I do not trust the system for many reasons. For one, doctors drink vodka before performing surgery because it is seen as a brave act,” a claim for which we have not been able to find official confirmation.

“Misdiagnosis happens frequently, Mongolians feel that they should get checked multiple times from many different doctors. For example, a doctor will tell you that you have cancer when in fact you do not,” Bold added.

Transition related-surgeries vary from uterus removal to genital reconstruction. Most of them are pretty invasive surgeries with high risks of complication and postoperative bleeding, necessitating close monitoring and highly trained staff. Furthermore, they require a large array of specialists often collaborating on a single procedure. These surgeries can help transgender individuals feel more at ease in the presence of sex partners or in venues such as physicians’ offices, swimming pools, or health clubs. In some settings, it might even reduce risk of harm in the event of arrest or search by police or other authorities. Thus, they represent a really important step both in closely matching gender identity and ensuring their personal safety.

The first Mongolian LGBT Dialogue took the issue up in March 2014, where questions about the day-to-day health challenges of transgender individuals were discussed with Mongolia’s state and LGBT representatives.

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