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Join Multisolving Institute Founder and Director Beth Sawin on Wed., May 4th at 12pm ET for a conversation with Nathaniel Smith, who serves as Founder and Chief Equity Officer of the Partnership for Southern Equity (PSE). PSE advances policies and institutional actions that promote racial equity and shared prosperity for all in metropolitan Atlanta and the American South. Nathaniel is also a member of the Multisolving Institute Advisory Board.

In the webinar we will explore Nathaniel’s definition of racial equity, why racial equity must be a central focus of multisolving, and learn more about PSE’s approach to advancing racial equity in health, energy, economic opportunity, and land use. This webinar is the first in Multisolving Institute’s series of conversations about multisolving with leaders in the US and internationally.

Register for Webinar

Read below to learn more about Nathaniel Smith and the work of PSE.

Authors: Dr Sav Zwickl, Eli Ward-Smith, and A/Prof Ada Cheung

Content warning: This blog contains reference to exclusion of, and discrimination against, trans people in sport.

A trans woman jogging. Credit: FG Trade via iStock.

In recent years, significant attention has been directed at trans women in sport. This has included the spread of misinformation and disinformation including inaccurate depictions of trans athletes in the media. In turn, some international, national, and local sporting bodies have developed policies regarding trans women that are based on opinion rather than scientific evidence.

Authors: Dr Sav Zwickl and Tomi Ruggles

Content warning: This blog focuses on anti-trans discrimination in healthcare settings, including personal stories from trans individuals about their discrimination experiences.

A trans person sitting on a hospital bed, while their doctor looks at a digital tablet. Image credit: FG Trade via iStock.

The Australian Charter of Healthcare Rights clearly states that all people in Australia have the right to be treated with dignity and respect and to have their culture, identity, beliefs and choices recognised and respected when receiving health care.  This includes trans and gender diverse (trans) people.

Author: A/Prof Ada Cheung

A woman applying an oestrogen patch to her leg. Image credit: svetikd via iStock.

Many cisgender and trans people rely on oestrogen hormone therapy – but the recurring national shortages of patches look set to continue.

Since 2020 or so, there have been recurring national shortages of oestrogen transdermal patches in Australia.

These easy-to-use skin patches are applied to the skin like a sticker and deliver oestrogen directly into the bloodstream. They contain the hormone oestradiol, an oestrogen that is naturally produced in the human body and in people recorded female at birth, it has a major role in maturing and maintaining the reproductive system. Oestradiol is also important for bone health, heart health, and maintaining mental health and wellbeing.

Authors: Dr Sav Zwickl, Tomi Ruggles, and Joël Murray

Content Warning: Brief mention of healthcare discrimination, gender-affirming surgeries using medical terms for body parts, and mental health. There is also a photograph of a non-binary person holding a syringe, about to inject testosterone.

Note: It is generally recommended that non-binary people are not divided up according to their sex recorded at birth, as this can shift the focus from gender towards sex in a way that can undermine non-binary identities and experiences. However, in some cases, this categorisation is important, including where there are notable differences based on sex recorded at birth that warrant acknowledgement and discussion.

A non-binary person hugging their agender non-binary partner. Image credit: Levi Meir Clancy via Unsplash.

Non-binary is a broad umbrella term for people who have a gender that does not fit exclusively into the woman/man gender binary. This includes a broad range of genders, including genderqueer, genderfluid, bigender, and agender.

Authors: Eli Ward-Smith and Dr Sav Zwickl.

Content Warning: This blog contains reference to exclusion of, and discrimination against, trans people in sport, and mention of minor medical procedures.

In recent years, significant attention has been directed to trans and gender diverse (trans) people in sport. Misinformation and disinformation about trans athletes are rife, and this has been highly damaging to trans people and their allies.

Part of the challenge in contesting this misinformation and disinformation is the lack of scientific evidence regarding whether gender affirming hormone therapy (GAHT) has a positive or negative impact on athletic performance. Our recently published reviews on the impact of GAHT on physical performance and sports participation clearly outline the limitations and gaps in research in this area.

This lack of evidence has allowed the spread of misinformation in the media about trans people in sport to continue, and sporting bodies have developed policies based on opinion rather than evidence.

What are we doing to address the gap in research?

Authors: Eli Ward-Smith and Dr Sav Zwickl.

Content Warning: Mention of mental health; discussion of COVID-19 vaccination and COVID-19 illness.

A non-binary person and a woman walking together, holding hands. Both are wearing face masks. Image credit: Disabled and Here.

2023 has been challenging as the trans community face unprecedented levels of anti-trans discrimination and violence. With so much of the harmful rhetoric based in misinformation and disinformation, this year we have prioritised science communication and have spent significant time and energy engaging with government, community organisations and other key stakeholders such as sporting bodies, to ensure accurate, evidence-based information directs policies that impact trans people.

Content Warning: This blog includes mention of mental ill-health and suicidality. 

The Australian Professional Association for Trans Health (AusPATH) is the national peak body for people working to improve the health, rights and well-being of trans and gender diverse (trans) people. This year, the biannual AusPATH Conference was held in Melbourne from 2-4 November.

The Trans Health Research Team presented 12 oral presentations and 3 posters over the 3-day conference, sharing both recently published and yet-to-be-published research to an audience of over 500 attendees. 

Dr Lachlan Angus presenting his research on anti-androgens at AusPATH Conference 2023. 

Clinical research presentations

Endocrinologist and researcher, Dr Lachlan Angus presented his latest clinical trial findings, including a randomised controlled trial (RCT) comparing spironolactone and cyproterone in trans people commencing oestradiol, and a cross-sectional study looking at bicalutamide as an antiandrogen.

Authors: Dr Sav Zwickl and A/Prof Ada Cheung.

Content Warning: This article contains brief mentions of psychological distress, life satisfaction and gender congruence.

A trans woman. Credit: Supitnan via Adobe Stock.

There is no consensus on optimal oestradiol levels for trans people using oestradiol gender-affirming hormone therapy (GAHT). International guidelines vary, suggesting goal oestradiol concentrations anywhere between 250 pmol/L and 1000 pmol/L, but these recommendations are based on expert opinion and the approximate range for cisgender women across the menstrual cycle, rather than clinical evidence.

Over the last few years, we have observed an increase in trans people in Australia seeking high doses of oestradiol, while their doctors understandably have reservations about prescribing oestradiol GAHT well above levels recommended in current Australian guidelines.

Authors: Dr Brendan Nolan and Dr Sav Zwickl.

Content Warning: Mention of depression, gender dysphoria and suicidality.

Trans Health Research recently published findings from our study on the impact of fast access to testosterone gender-affirming hormone therapy (GAHT) on mental health and wellbeing in the peer-reviewed journal, JAMA Network Open.

Reandron testosterone, which was used in this study. Credit: Steve Tritton via Shutterstock.

Results showed significant reductions in gender dysphoria, depression, and suicidality after 3 months with early testosterone GAHT use compared to standard care. Remarkably, over half of the study participants receiving testosterone experienced resolution of "thoughts of hurting themselves or that they were better off dead".

Authors: Dr Sav Zwickl and A/Prof Ada Cheung.

What are oestradiol implants?

An estradiol implant is a small, slow-release pellet containing the hormone oestradiol. Implants are inserted into the fatty tissue under the skin, preferably in the top of the buttock.

The Australian Informed Consent Standards of Care for Gender Affirming Hormone Therapy recommend a starting dose of 100mg every 6-12 months, and a maximum dose of 200mg every 6-12 months. In a recent survey, we asked trans people using oestradiol implants about the frequency of their implants, and the majority reported that their implant was replaced when their oestradiol blood concentrations fell below a certain level (57%), indicating the importance of regular blood tests. 15% of the people we asked, had their implant replaced 6 monthly, while 4% had it replaced every 9 months, and 8% yearly.

A trans woman speaking with a nurse. Credit: Renata Angerami via iStock.

Why do so few doctors prescribe implants?

Authors: Dr Julian Grace & Dr Sav Zwickl.

Content Warning: This article contains brief mentions of genitalia, and other body parts. When referring to specific parts of the body, we use anatomical/medical terms e.g., clitoris, breast.

I’m over 18 and thinking about gender-affirming hormone therapy. Where do I start?

There is a lot of information out there about gender-affirming hormone therapy (GAHT). Not all of it is correct, and some of it might be applicable elsewhere, but not in Australia. So, let’s start with the basics.

Trans and gender diverse people have all different types of feelings about GAHT. While some people want to start hormones and see big changes as quickly as possible, others want to take it slowly, and it may take years to decide that GAHT is right for them. Some people might pause their GAHT for different reasons (e.g., to achieve a pregnancy), some are happy to stop their GAHT after achieving certain physical changes, and others don’t want GAHT at all. All of these are valid pathways, and no one pathway makes a person more or less trans.

Author: Joël Murray (they/them), living and working on unceded Wangal Country, Eora Nation.

Content Warning: This blog discusses topics of sex, sex work, injecting drug use, stigma, and identity-based discrimination.

Credit: Maksym via Adobe Stock.

Dr Brendan Nolan (center) with international trans health colleagues at ENDO 2023.

ENDO is the leading global meeting on endocrinology (hormone) research and clinical care hosted by Endocrine Society. The annual meeting provides an opportunity for endocrinologists, health care practitioners, and scientists to come together and showcase cutting-edge advances in research and medicine, with presentations spanning the spectrum of science, clinical care, and social implications.

A/Prof Ada Cheung (left) with Dr Brendan Nolan (right) at ENDO 2023.

Two of our clinical researchers, A/Prof Ada Cheung and Dr Brendan Nolan, joined over 7,000 other attendees at ENDO 2023 in Chicago from June 15-18.

From left to right: Dr Angela Nicholas from the Centre for Mental Health, The University of Melbourne, Dr Sav Zwickl from Trans Health Research, and Leo Rhodanthe from DISCHARGED.

Content Warning: This article contains mention of suicidality and discrimination faced by the trans community.

The National Suicide Prevention (NSP) Conference is an annual conference hosted by Suicide Prevention Australia. The conference provides a space for suicide prevention experts to showcase evidence-based solutions and robust discussion, and is widely regarded as the premier event in the suicide prevention calendar.

Despite almost half of trans people attempting suicide at some point in their lives, trans suicidality has been notably absent from previous years’ conferences.

Teddy Cook (ACON Health and TRANSform collaborator) and Ariel Ginger (TRANSform researcher) presenting research findings at the Australian Professional Association of Trans Health Conference in Darwin, 2022.

What is TRANSform?

TRANSform: An Australian longitudinal gender health study is an ongoing research project that aims to produce priority-based and community-led research to improve the health and wellbeing of the trans and gender diverse community.

Anyone who has a gender that is different to what was presumed for them at birth, currently living in Australia, and aged 16+ can join TRANSform. Since its launched three years ago, over 2,000 trans and gender diverse (trans) people from all over Australia have taken part, making TRANSform the largest ever trans research project in Australia.

Not only is TRANSform the largest project in terms of participant numbers but it is also the largest ever trans-led project in Australia. Trans people lead every stage of the research, from design to implementation, data analysis and reporting.

Authors: Stephanie Sheahan & Tomi Ruggles.

Content Warning: This article contains reference to genitalia, sexual arousal (erections), fertility, and sexual health. When referring to specific parts of the body, we use anatomical/medical terms e.g., penis, testicles, nipples, sperm etc.

Note: Not all people want the same changes from using oestrogen, anti-androgens, and progesterone, and not all bodies will respond the same to hormone therapy. All the body changes described in this article are typical but not universal. You can watch some videos showing the diversity of individual experiences at the bottom of this post.

Credit: Igor Alecsander.

What is oestrogen?

Oestrogen, or estradiol, is a sex hormone that is produced naturally in our bodies, and in people who were born with ovaries it is the main sex hormone. Testosterone is produced by the testicles, so people born with testicles will tend to have a naturally higher level of testosterone, and it will be their main sex hormone.

Authors: Dr Sav Zwickl & Elliot O’Donoghue.

Content Warning: This article contains reference to genitalia, menstruation (periods), and sexual health. When referring to specific parts of the body, we use anatomical/medical terms e.g., clitoris, vaginal canal.

Note: Not all people want the same changes from using testosterone and not all bodies will respond the same to hormone therapy. All the body changes described in this article are typical but not universal. Lower doses of testosterone and lower levels of testosterone will likely impact the rate of changes, and whether some changes occur at all. You can watch some videos showing the diversity of individual experiences at the bottom of this post.

Authors: Dr. Sav Zwickl and Dr. Alex Wong.

Content Warning: This article contains descriptions and images of genitals. We also reference menstruation (periods), sexual activity, and other sexual health topics. When referring to specific parts of the body, we use anatomical/medical terms e.g., clitoris, vaginal canal.

Note: Not all people want the same changes from using testosterone and not all bodies will respond the same to hormone therapy. All of the body changes described in this article are typical but not universal. Lower doses of testosterone and lower levels of testosterone will likely impact the rate of changes, and whether some changes occur at all.

Image credit: Gender Spectrum Collection.

2022 has been a year of challenges but also opportunity and hope. We have experienced a climate of intense, harmful political 'debate', often contrary to scientific evidence and the lived-experience of the trans community. Whilst we are steadfastly focused on undertaking scientific research to improve trans health, in 2022, our voices as science communicators has never been more important.

As clinicians treating trans people and as researchers in trans health where >50% of our team are trans people with lived experience, we have a unique perspective to educate the public and influence policy debate. In 2022, we shared our research through media, peer-reviewed publications, national and international meetings, seminars, and conferences, and in training sessions with healthcare professionals. Refreshingly, we’ve seen Australians rebuke the politics of division at the Federal election and our resilient community come together.

Below are some highlights from our year.

I want to make a brief intervention here to highlight an aspect of degrowth climate mitigation strategy that has so far been inadequately developed.  It is widely understood that scaling down less-necessary forms of production can contribute substantially to decarbonization, in two direct and obvious ways. First, it directly reduces emissions in addition to what can be achieved through efficiency improvements and renewable energy deployment.  Second, it reduces total energy demand and therefore makes it possible to decarbonize the energy system much more quickly, because it is not necessary to install as much new infrastructure, and the process of doing it involves less extraction and emissions. These are powerful benefits.

But there are several other benefits to a degrowth scenario that are less widely understood and are worth considering.

Here is a list of studies, surveys and polling results that shed some light on popular perceptions of post-growth and post-capitalist ideas. I will seek to update this list periodically.

Scientists’ support for post-growth

1. A survey of nearly 800 climate policy researchers around the world found that 73% support post-growth (i.e., agrowth and degrowth) positions.  In the EU, 86% of climate policy researchers support post-growth positions.  Source: Nature Sustainability (2023). Also see press release: “Green growth loses favour with climate policy scientists”; and a write-up in The Conversation.

One of the central insights emerging from research on degrowth and climate mitigation is that universal public services are crucial to a just and effective transition.

Capitalism relies on maintaining an artificial scarcity of essential goods and services (like housing, healthcare, transport, etc), through processes of enclosure and commodification. We know that enclosure enables monopolists to raise prices and maximize their profits (consider the rental market, the US healthcare system, or the British rail system). But it also has another effect. When essential goods are privatized and expensive, people need more income than they would otherwise require to access them. To get it they are compelled to increase their labour in capitalist markets, working to produce new things that may not be needed (with increased energy use, resource use, and ecological pressure) simply to access things that clearly are needed, and which are quite often already there.

In 2020, the UNDP published a new metric that for the first time seeks officially to adjust the Human Development Index (HDI) for ecological pressure, accounting for countries’ carbon emissions and resource use on a per capita basis.  This is an important step forward; I support the effort and I applaud the work of those who are involved.  But the new metric, known as the Planetary pressures-adjusted HDI (or PHDI), also suffers from several significant limitations, and in the end does not tell us very much about sustainability.  

Rikard Warlenius has written an article on what he calls “the limits to degrowth”.  In it, he states that because degrowth researchers argue the climate crisis cannot be addressed by decoupling alone (which is true), the only conceivable alternative is to drastically reduce GDP (which is false). He also applies GDP reductions to developing countries. These are ill-informed approaches to climate mitigation that no serious academic would propose, and which scholarship on degrowth and climate justice explicitly rejects. 

The paper is based on false claims about the scientific literature, uses invalid methods, and yields cartoonish results: Warlenius says that to keep global warming to 1.5C, global GDP would have to decline by 86%.  In the UK, GDP per capita would have to decline by 97% (!). Indeed, he goes so far as to say that GDP per capita would have to decline for many lower-income countries too, including India by 39%, Indonesia by 68%, Brazil by 82%. 

These are bizarre figures that have nothing to do with what degrowth proposes. The scientific literature takes a categorically different approach to climate mitigation, with empirical evidence from degrowth scenarios that strongly contradicts Warlenius’ claims. Warlenius does not engage with this literature, or even cite it. This is not an acceptable approach to science.

In a recent article published in World Development, we drew on newly available data to calculate that India suffered 50-165 million excess deaths during the mortality crisis of 1881-1920 (an average of 1.3 to 4.1 million excess deaths per year over the period, depending on our assumptions about ‘normal’ mortality). Following recent scholarship, we attribute the crisis to British colonial policy, such as the use of asymmetrical tariffs and technology restrictions to undermine India’s manufacturing sector, and the forced drain of foodstuffs and raw materials out of India for export to England. In 1902, the Indian economist Romesh C. Dutt estimated that the annual outflow of goods from India was sufficient to meet the nutritional requirements of 25 million people. As Dutt put it: “If any of the prosperous countries of the world – America or England, France or Germany – had been subjected to such conditions, would not that country have been reduced to poverty, and visited by famines, within a few decades?”

We highlighted these figures in a short piece for Al Jazeera. Tirthankar Roy then challenged our claims in a series of tweets, which we respond to here. 

Over the past few years, this graph has become something of a sensation.  Developed by Our World In Data and promoted widely by Bill Gates and Steven Pinker, the graph gives the impression that virtually all of humanity was in “extreme poverty” as of 1820 (i.e., living on less than $1.90 per day, PPP; less than is required for basic food). OWID has used this figure to claim that extreme poverty was the natural or baseline condition of humanity, extending far back into the past: “in the thousands of years before the beginning of the industrial era, the vast majority of the world population lived in conditions that we would call extreme poverty today.”  In other words, virtually all of humanity, for all of history, was destitute until the 19th century, when at last colonialism and capitalism came to the rescue. 

Social media has been ablaze with this question recently.  We know we face a crisis of mass poverty: the global economy is organized in such a way that roughly half of humanity is left unable to meet basic needs.  But the question at stake this time is different.  A couple of economists on Twitter have claimed that the world average income is $16 per day (PPP).  This, they say, is proof that the world is poor in a much more general sense: there is not enough for everyone to live well, and the only way to solve this problem is to press on the accelerator of aggregate economic growth.

This narrative is, however, hobbled by several empirical problems. 

1. $16 per day is not accurate

First, let me address the $16/day claim on its own terms.  This is a significant underestimate of world average income.  The main problem is that it relies on household surveys, mostly from Povcal.  These surveys are indispensable for telling us about the income and consumption of poor and ordinary households, but they do not capture top incomes, and are not designed to do so. In fact, Povcal surveys are not even really legitimate for capturing the income of “normal” high-income households.  Using this method gives us a total world household income of about $43 trillion (PPP).  But we know that total world GDP is $137 trillion (PPP).  So, about two-thirds of global income is unaccounted for.