Lancet tackles worldwide lack of transgender healthcare

Despite the recent flurry of media attention that has been directed toward transgender people, they and their health needs remain poorly understood, experts say.

Yesterday The Lancet published a series of articles on the health, social and legal conditions in which transgender people live.

Many of the health challenges faced by transgender people are exacerbated by laws and policies that deny them gender recognition.

In no other community is the link between rights and health so clearly visible as in the transgender community. Faced with stigma, discrimination and abuse, transgender people are pushed to the margins of society, excluded from the workplace, their families and health care. Many are drawn into risky situations or behaviors, such as unsafe sex or substance abuse, which leave them at risk of further ill health.

--Dr. Sam Winter

The majority of countries worldwide do not offer legal or administrative measures enabling gender recognition for transgender people. In Europe, eight countries fail to offer legal recognition to transgender people, and 17 countries still impose sterilization on people who seek gender recognition.

As of June 2016, Argentina, Denmark, Malta, Ireland, and Norway had laws that allow transgender people to determine their gender through an administrative process. Furthermore, Argentina and Malta affirm the right of transgender people to appropriate healthcare.

New Zealand, Australia, Nepal, Pakistan, and India are beginning to recognize gender diversity beyond the binary.

A comprehensive public health approach to address the health of transgender people requires access to gender affirmation services, evidence-based health-care delivery systems, and effective partnerships with local transgender communities.

Although there are substantial gaps in empirical research on transgender issues, there are sufficient actionable data highlighting unique biological, behavioural, social, and structural contextual factors surrounding health risks and resiliencies for transgender people that need interventions.

--Dr. Sari L. Reisner

One might have to go back to the era of racial desegregation of U.S. bathrooms to find a time when toilets received so much attention. Recently, several states have debated or passed legislation requiring people to use the public bathroom corresponding to their sex as “identified at birth” or “stated on a person’s birth certificate.” Some supporters of these laws have focused on the fear that male stalkers will claim to be transgender women in order to victimize girls and women in restrooms. Others have expressed vitriol and revulsion toward transgender people, describing them as “sexual predators,” “voyeurs,” and “pedophiles.” Although transgender people have been characterized as dangerous, it is transgender people who have generally been the victims of verbal harassment and physical assaults when trying to use public bathrooms.

In 2015, a total of 375 Fortune 500 companies prohibited discrimination on the basis of gender identity, up from 15 in 2002. Nineteen states and the District of Columbia include gender identity in employment nondiscrimination laws.

Nevertheless, transgender people still face substantial discrimination.

Beyond bathroom accessibility, discrimination is associated with increased stress, anxiety, depressive symptoms, post-traumatic stress disorder, substance abuse, and suicide. It is also associated with increased risk of bullying, verbal harassment, sexual assault, and nonsexual violence, as well as decreased healthcare utilization.

Establishing legal protection for transgender people in the United States may take time. Eliminating the need for such protection will no doubt take much longer. But being transgender, like being left-handed, may someday be recognized as merely another inherent human quality, no longer conferring a need for protection.

Until that day the health care community can better address transgender health needs, help ensure that transgender people feel safe in seeking health care, promote resilience in the face of prejudice, and expand our knowledge of how best to promote transgender health and well-being.

--Reisner, et al., New England Journal of Medicine

The following are the articles and their abstracts:

Transgender health: an opportunity for global health equity, by Selina Lo and Richard Horton

It takes courage to grow up and be who you really are.

--e e Cummings

Synergies in health and human rights: a call to action to improve transgender health by Sam Winter, Edmund Settle, Kevan Wylie, Sari Reisner, Mauro Cabral, Gail Knudson, and Stefan Baral

Transphobia is a health issue.

--J V R Prasada Rao, UN Secretary-General's Special Envoy for AIDS in Asia and the Pacific

Transgender community voices: a participatory population perspective by Sari Reisner, JoAnne Keatley and Stefan Baral

Understanding the global health burden and needs of transgender communities necessitates meaningful engagement and involvement of transgender people. Against the backdrop of widespread social and economic exclusion facing people of diverse gender identities and experiences, community empowerment is essential for clinical services, public health programmes, and human rights efforts that seek to design and implement effective services and population-level interventions to improve the health and wellbeing of transgender people.

Sam Winter and Kevan Wylie: pioneers in transgender health by Richard Lane

Sam Winter clearly recalls the first time he became aware of the health needs of transgender people.

When working in Hong Kong I met a young person who had recently self-identified as a trans girl. She had been thrown out of the family home by her parents, and could not find a job because of her male ID card. She started to use drugs and developed mental health problems. I knew then that I had to change my life to do something to help. I saw the potential of being able to make a big difference in a new and specialised area.

--Sam Winter

Sari Reisner—making transgender health visible by Tony Kirby

Gender diversity exists in every culture and geographic context. It is to be celebrated, not pathologised 

--Sari Reisner

Reisner's work is helping to advance this agenda. Based in Boston, USA, he enjoys a varied career as Assistant Professor at Harvard Medical School and Boston Children's Hospital, with a secondary appointment at the Harvard T H Chan School of Public Health, and as Affiliated Research Scientist at The Fenway Institute at Fenway Health.

Transgender: why should we care? by Jamison Green

It was entirely coincidence that I changed employment in 1988 as I was awaiting confirmation from the doctors at Stanford University that I was a worthy candidate for sex reassignment. I had researched and soul-searched for years, struggling with the decision to apply to that programme. I had learned that their entrance criteria were rigorous, and I wanted the validation the programme would give me. I could tell my mother that I had been diagnosed by real doctors, and that there was no doubt my health would benefit from the transition from female to male.

--Jamison Green

GIRES: e-learning for transgender health training by Terry Reed

The Gender Identity Research and Education Society (GIRES) was established as a UK-based charity in 1997 by my husband Bernard Reed with the support of transgender activists. We both serve as Trustees. We are the parents of a trans woman who transitioned in a very hostile work environment where she was continuously bullied, causing her to attempt suicide. We helped her to mount a legal challenge against her employer, which she won. The aim of GIRES is to prevent such events happening to other transgender and gender non-conforming people, and to improve their lives.

Transgender people: health at the margins of society by Sam Winter, Milton Diamond, Jamison Green, Dan Karasic, Terry Reed, Stephen Whittle and Kevan Wylie

In this paper we examine the social and legal conditions in which many transgender people (often called trans people) live, and the medical perspectives that frame the provision of health care for transgender people across much of the world. Modern research shows much higher numbers of transgender people than were apparent in earlier clinic-based studies, as well as biological factors associated with gender incongruence. We examine research showing that many transgender people live on the margins of society, facing stigma, discrimination, exclusion, violence, and poor health. They often experience difficulties accessing appropriate health care, whether specific to their gender needs or more general in nature. Some governments are taking steps to address human rights issues and provide better legal protection for transgender people, but this action is by no means universal. The mental illness perspective that currently frames health-care provision for transgender people across much of the world is under scrutiny. The WHO diagnostic manual may soon abandon its current classification of transgender people as mentally disordered. Debate exists as to whether there should be a diagnosis of any sort for transgender children below the age of puberty.

Serving transgender people: clinical care considerations and service delivery models in transgender health by Kevan Wylie, Gail Knudson, Sharful Islam Khan, Mireille Bonierbale, Suporn Watanyusakul and Stefan Baral

The World Professional Association for Transgender Health (WPATH) standards of care for transsexual, transgender, and gender non-conforming people (version 7) represent international normative standards for clinical care for these populations. Standards for optimal individual clinical care are consistent around the world, although the implementation of services for transgender populations will depend on health system infrastructure and sociocultural contexts. Some clinical services for transgender people, including gender-affirming surgery, are best delivered in the context of more specialised facilities; however, the majority of health-care needs can be delivered by a primary care practitioner. Across high-income and low-income settings alike, there often remains a dearth of educational programming for health-care professionals in transgender health, although the best evidence supports introducing modules on transgender health early during clinical education of clinicians and allied health professionals. While these challenges remain, we review the increasing evidence and examples of the defined roles of the mental health professional in transgender health-care decisions, effective models of health service provision, and available surgical interventions for transgender people. 

Global health burden and needs of transgender populations: a review by Sari L Reisner, Tonia Poteat, JoAnne Keatley, Mauro Cabral, Tampose Mothopeng, Emilia Dunham, Claire E Holland, Ryan Max and Stefan D Baral

Transgender people are a diverse population affected by a range of negative health indicators across high-income, middle-income, and low-income settings. Studies consistently document a high prevalence of adverse health outcomes in this population, including HIV and other sexually transmitted infections, mental health distress, and substance use and abuse. However, many other health areas remain understudied, population-based representative samples and longitudinal studies are few, and routine surveillance efforts for transgender population health are scarce. The absence of survey items with which to identify transgender respondents in general surveys often restricts the availability of data with which to estimate the magnitude of health inequities and characterise the population-level health of transgender people globally. Despite the limitations, there are sufficient data highlighting the unique biological, behavioural, social, and structural contextual factors surrounding health risks and resiliencies for transgender people. To mitigate these risks and foster resilience, a comprehensive approach is needed that includes gender affirmation as a public health framework, improved health systems and access to health care informed by high quality data, and effective partnerships with local transgender communities to ensure responsiveness of and cultural specificity in programming. Consideration of transgender health underscores the need to explicitly consider sex and gender pathways in epidemiological research and public health surveillance more broadly.

Health-care access of transgender people: a medical student approach by Benedikt W Pelzer, Jonas Montvidas and Leon Rensen

In his In Focus piece in The Lancet Diabetes & Endocrinology,1 Jules Morgan discusses the change of law regarding self-determination of legal gender in Ireland and explores the topic in a global context. Although self-determination of legal gender seems to be a political and social issue on first sight, it has very concrete medical implications. Suicidal ideation and attempted suicide are a common problem in transgender people. Changing personal documentation to the appropriate gender can reduce both ideation and attempted suicides.

Self-determining legal gender: transgender right, or wrong? by Jules Morgan

Laws differ from country to country for transgender people. Jules Morgan reports on Ireland's recent change in legislation and how these laws operate in a wider global context.

Meeting the unique health-care needs of LGBTQ people by The Lancet

2015 was a landmark year in the USA for lesbian, gay, bisexual, transgender, and queer (LGBTQ) civil rights. In June, the US Supreme Court Obergefell vs Hodges decision upheld marriage equality for same-sex couples, suggesting a nationwide move toward the rejection of stigma associated with LGBTQ sexuality. In December, the US Department of Health and Human Services (HHS) released their annual report—Advancing LGBT Health & Well-being—which highlights substantial advances in health initiatives for LGBTQ people and their families, as well as outlining HHS objectives in LGBTQ health care for 2016.

Health equity for LGBTQ people through education by Robbert J. Duvivier and Elizabeth Wiley

We applaud The Lancet Editors (Jan 9, p 95)1 for drawing attention to new initiatives to improve the health and wellbeing of lesbian, gay, bisexual, transgender, and queer (LGBTQ) people worldwide. Many challenges remain, but the US Department of Health and Human Services report presents a strategy for change that could inform the efforts of other nations. However, one important aspect is missing from the worldwide conversation on addressing the health needs of LGBTQ—educating ourselves.

Trans* health: “diversity, not pathology” by Jules Morgan

Being transsexual, transgender, or gender non-conforming is a matter of diversity, not pathology.

--WPATH

Lost in transition: health of transgender people in Asia Pacific
by the Lancet

On May 17, International Day of Action Against Homophobia and Transphobia, a report—Lost in Transition: Transgender People, Rights and HIV Vulnerability in the Asia-Pacific Region—was released by the UN Development Programme and the Asia Pacific Transgender Network. Transgender people, defined as “individuals whose gender identity, and/or expression of their gender, differs from social norms related to their gender of birth”, have gained dramatically increased visibility and public acceptance in the past two decades globally.

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