PRISM: Human Rights issues relating to Sexual Orientation, Gender Identity and Expression, and Sex Characteristics (SOGIESC) in Aotearoa New Zealand - A report with recommendations guidelines for the provision of gender affirming healthcare for children, youth, and adults in New Zealand were published in 2018.265 ‘Gender affirming healthcare’ covers a wide range of interventions including counselling support, laser hair removal, voice therapy, hormone therapy, and surgeries. Contrary to the right to health, there remain major gaps in the availability and accessibility of services; while some services fail to meet an acceptable standard. Trans health services are needed in all parts of the country, and hui participants emphasised that a person’s geographic residence should not impact on the services they can access. There are many delays and long waiting lists to access interventions, as well as demand for procedures which are not provided at all through the public system.266 At the time of the Commission’s 2008 Transgender Inquiry, some individuals reported travelling long distances to access appropriate health care or support services.267 Recent research shows this ‘postcode lottery’ – differential access based on geographic location – still remains today.268 Such inequities are well described in Chapter 2 of the Counting Ourselves community report.269 The responsibility to provide gender affirming health care, including surgical procedures, lies within District Health Boards (DHBs).270 Unmet need, defined as those who want but have not had a type of care, was measured in the Counting Ourselves survey.271 The level of unmet need for non-medical (including laser hair removal, voice therapy, and counselling support) and medical (including hormone therapy and surgeries) care ranged between 19 – 48%. In particular, trans and non-binary people face significant wait times for access to surgical interventions. For many years, surgical referral pathways within individual DHBs have been unclear and confusing to navigate. Attempts to improve pathways are underway to clarify processes for accessing trans health services. In the Northern Region (Northland and Auckland metro DHBs),272 Wellington,273 and Canterbury,274 trans people have been involved in the service design and delivery of local pathways. Lower or genital surgeries are managed nationally rather than regionally and are even more difficult to access. From 2005, these surgeries were funded through the Ministry of Health’s Special High Cost Treatment Pool, when three feminising and one masculinising procedures were agreed to be funded every two years.275 As of October 2018, the 3 + 1 maximum became a minimum service specification.276 Jeannie Oliphant and others Guidelines for gender affirming healthcare for gender diverse and transgender children, young people and adults in Aotearoa, New Zealand (Transgender Health Research Lab, University of Waikato, Hamilton, 2018). 266 For example laryngeal shave and facial feminisation surgery. 267 New Zealand Human Rights Commission To Be Who I Am: Report of the Inquiry into Discrimination Experienced by Transgender People (Wellington, 2008) at Chapter 6. 268 Professional Association for Transgender Health Aotearoa “Is the provision of gender affirming health care equitable across the District Health Boards in Aotearoa, New Zealand?” (21 September 2019) PATHA <https://patha.nz/>; Gloria Fraser Queer and trans experiences of accessing mental health support in Aotearoa: Summary of findings for participants and community advisors (Victoria University of Wellington, Wellington, June 2018) at 9. 269 Jaimie Veale and others Counting Ourselves: The health and wellbeing of trans and non-binary people in Aotearoa New Zealand (Transgender Health Research Lab, University of Waikato, Hamilton, 2019). 270 Ministry of Health “Delivering health services to transgender people Advice for health professionals” <https://www.health.govt.nz/> 271 Jaimie Veale and others Counting Ourselves: The health and wellbeing of trans and non-binary people in Aotearoa New Zealand (Transgender Health Research Lab, University of Waikato, Hamilton, 2019). 272 Auckland District Health Board “July 2017 update: NRTCCAG Membership” <https://www.adhb.health.nz/>; Healthpoint “Hauora Tāhine - Pathways to Transgender Healthcare Services” (undated) <https://www.healthpoint.co.nz/> 273 Gender Minorities Aotearoa “Wellington Health Pathways Update” (9 October 2019) <genderminorities.com>. See also Victoria University of Wellington’s 2018 trans-affirmative healthcare pilot program run through Student Health Services. While not a regional pathway, the pilot provided six university students an alternative way of accessing hormone therapy. Alex Ker and others The trans-affirmative healthcare pilot clinic: A new approach to enabling equitable access to gender-affirming hormone therapy (Victoria University of Wellington, Wellington 2018). 274 Health Quality & Safety Commission and Ko Awatea Gender-affirming care in Canterbury: Simplifying the complexity (Christchurch, 2019). 275 This rate (3+1) was set by the Minister of Health in 2004 when 8 trans women and 2 trans men were on the wait list; and funding came into effect from 2005. See Ministry of Health “Gender reassignment media queries with responses: June 2017 – March 2018” (8 May 2018) (obtained under Official Information Act 1982 request to Jennifer Shields, fyi.org.nz) at 6. 276 Thomas Coughlan “Gender affirmation surgery cap lifted” Newsroom (New Zealand, 23 October 2018). 265 44