Transgender health care

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Transgender health care refers to how medical institutions, communities and individuals approach the care of transgender people. It includes the prevention, diagnosis and treatment of physical and mental health conditions, as well as sex reassignment therapies.[1] In this article, you will find information about gender variance, sex reassignment therapy, health risks (in relation to violence and mental health), access to healthcare for trans people in different countries around the world, and specific information about transgender youth and transgender older adults.

Gender variance and Medicine[edit]

Gender variance is defined in medical literature as " gender identity, expression, or behavior that falls outside of culturally defined norms associated with a specific gender"[2].For centuries, gender variance was seen by medicine as a pathology.[3][4] The World Health Organization identified gender dysphoria as a mental disorder in the International Classification of Diseases (ICD) until 2018.[5] Gender dysphoria was also listed in the Diagnostic and Statistical Manual of Mental Disorders (DSMD-5) of the American Psychiatric Association , where it was previously called "transsexualism" and "gender identity disorder".[6][7]

In 2018, the ICD-11 included the term "gender incongruence" as "marked and persistent incongruence between an individual’s experienced gender and the assigned sex", where gender variant behaviour and preferences do not necessarily imply a medical diagnosis.[8] However, the difference between "gender dysphoria" and "gender incongruence" is not always clear in the medical literature.[9]

Some studies posit that treating gender variance as a medical condition has negative effects on the health of transgender people and claim that assumptions of coexisting psychiatric symptoms should be avoided.[3][10][11] Other studies argue that gender incongruence diagnosis may be important and even positive for transgender people at the individual and social level.[12]

Sex reassignment therapy[edit]

Various options are available for transgender people to pursue physical transition. There have been options for transitioning for transgender individuals since 1917.[1] Sex reassignment therapy helps people to change their physical appearance and/or sex characteristics to accord with their gender identity; it includes hormone replacement therapy and sex reassignment surgery. While many transgender people do elect to transition physically, every transgender person has different needs and, as such, there is no required transition plan.[13] Preventative health care is a crucial part of transitioning and a primary care physician is recommended for transgender people who are transitioning.[13]

Hormone replacement therapy[edit]

Main article: Hormone replacement therapy (transgender)

A transgender woman before and after two years of hormone replacement therapy.

Hormone replacement therapy is primarily concerned with alleviating gender dysphoria in transgender people.[13] Trans women are usually treated with estrogen and complementary anti-androgenic therapy. This therapy induces breast formation, reduces male hair pattern growth, and changes fat distribution, also leading to a decreased testicular size and erectile function.[14] Trans men are normally treated with exogenous testosterone, which is expected to cease menses, to increase facial and body hair, to cause changes in skin and in fat distribution, and to increase muscle mass and libido.[14] After at least three months, other effects are expected, such as the deepening of the voice and changes in sexual organs (such as atrophy of vaginal tissues, and increased clitoral size).[14] Regular monitoring by an endocrinologist is a strong recommendation to ensure the safety of individuals as they transition.[15]

Access to hormone replacement therapy has been shown to improve quality of life for people in the female-to-male community when compared to female-to-male people who do not have access to hormone replacement therapy.[16] Despite the improvement in quality of life, there are still dangers with hormone replacement therapy, in particular with self-medication. An examination of the use of self-medication found that people who self-medicated were more likely to experience adverse health effects from preexisting conditions such as high blood pressure as well as slower development of desired secondary sex characteristics.[17]

Hormone therapy for transgender individuals has been shown in medical literature to be safe, when supervised by a qualified medical professional.[18] Transgender people seeking surgery and not hormones may be pressured or coerced into using hormones in order to obtain surgeries.[19]

Monitoring of risk factors associated with hormone replacement therapy, such as prolactin levels in transgender women and polycythemia levels in transgender men, are crucial for the preventive health care of transgender people taking these treatments.[13]

Sex reassignment surgery[edit]

The goal of sex reassignment surgery, also known as gender reassignment surgery, is to align the secondary sexual characteristics of transgender people with their gender identity. As hormone replacement therapy, sex reassignment surgery was also employed as a response to diagnosis gender dysphoria [13][20]

The World Professional Association for Transgender Health (WPATH) Standards of Care recommend additional requirements for sex reassignment surgery when compared to hormone replacement therapy. Whereas hormone replacement therapy can be obtained through something as simple as an informed consent form, sex reassignment surgery can require a supporting letter from a licensed therapist (two letters for genital surgery such as vaginoplasty or phalloplasty), hormonal treatment, and (for genital surgery) completion of a 12-month period in which the person lives full-time as their gender. WPATH standards, while commonly used in gender clinics, are non-binding; many trans patients undergoing surgery do not meet all of the eligibility criteria.

Health risks[edit]

Violence[edit]

The heightened levels of violence and abuse that transgender people experience result in unique adverse effects on bodily and mental health.[21] Specifically, in resource-constrained settings where non-discriminatory policies may be limited or not enforced, transgender people may encounter high rates of stigma and violence which are associated with poor health outcomes.[22][23] Studies in countries of the Global North show higher levels of discrimination and harassment in school, workplace, healthcare services and the family when compared with cisgender populations, situating transphobia a key health risk factor for physical and mental health transgender people.[24]

There is limited data regarding the impact of social determinants of health on transgender and gender non-conforming individuals health outcomes.[25] However, despite the limited data available, transgender and gender non-conforming individuals have been found to be at higher risk of experiencing poor health outcomes and restricted access to health care due to increased risk for violence, isolation, and other types of discrimination both inside and outside the health care setting.[26]

Despite its importance, access to preventative care is also limited by several factors, including discrimination and erasure. A study on young transgender women's access to HIV treatment found that one of the main contributors to not accessing care was the use of incorrect name and pronouns.[27] A meta analysis of the National Transgender Discrimination Survey examined respondents who used the "gender not listed here" option on the survey and their experiences with accessing health care. Over a third of the people who chose that option said that they had avoided accessing general care due to bias and fears of social repercussions.[28]

Mental health[edit]

Rates of depression and anxiety in the transgender community are significantly higher than those found in the general population, affecting both transgender men and transgender women.[29][30] The heightened rates are caused in part by lack of effective social support for transgender people, especially those pre-transition or early on in their transition.[30][31]

Several studies have shown the relation between minority stress and the heightened rate of depression and other mental illness among both transgender men and women.[32] The expectation to experience rejection can become an important stressor for transgender and gender non-conforming individuals.[33] Mental health problems among trans people are related to higher rates of self-harm, drug usage, and suicidal ideations and attempts.[24]

Global access to transgender health care[edit]

Africa[edit]

South Africa[edit]

Access to transition care, mental care, and other issues affecting transgender people is very limited; there is only one comprehensive transgender health care clinic available in South Africa.[34] Additionally, the typical lack of access to transition options that comes as a result of gatekeeping is compounded by the relatively limited knowledge of transgender topics among psychiatrists and psychologists in South Africa.[34]

Asia[edit]

Thailand[edit]

Transgender women, known as kathoeys, have access to hormones through non-prescription sources.[35] This kind of access is a result of the low availability and expense of transgender health care clinics.[35] However, transgender men have difficulty gaining access to hormones such as testosterone in Thailand because it is not as readily available as hormones for kathoeys.[36] As a result, just a third of all transmen surveyed are taking hormones to transition whereas almost three quarters of kathoeys surveyed are taking hormones.[36]

Europe[edit]

Spain[edit]

Public health care services are available for transgender individuals in Spain, although there has been debate over whether certain procedures should be covered under the public system.[37] The region of Andalusia was the first to approve sex reassignment procedures, including sex reassignment surgery and mastectomies, in 1999, and several other regions have followed their lead in the following years. Multiple interdisciplinary clinics exist in Spain to cater specifically to diagnosing and treating transgender patients, including the Andalusian Gender Team.[37][38] As of 2013, over 4000 transgender patients had been treated in Spain, including Spaniards and international patients.[37][39]

Beginning in 2007, Spain has begun allowing transgender individuals who are eighteen years or older to change their name and gender identity on public records and documents if they have been receiving hormone replacement therapy for at least two years.[37]

Sweden[edit]

In 1972, Sweden introduced a law that made it possible to change a person’s legal gender, but in order to do that, transgender individuals were required to be sterilized and were not allowed to save any sperm or eggs. Apart from this, there were no other mandatory surgeries required for legal gender change.[40] In 1999, people who had been forcibly sterilized in Sweden were entitled to compensation. However, the sterilization requirement remained for people who changed their legal gender. In January 2013, forced sterilization was banned in Sweden.[41]

Depending on your health and wishes you can get a number of different treatments and surgeries. Today, no form of treatment is mandatory. An individual with a Transsexual or Gender Dysphoria diagnosis can, together with the assessment team and other doctors, decide what suits them. Although, in order to access medical and legal transitional treatment, (e.g. hormone replacement therapy and top surgery to enhance or remove breast tissue) you need to be diagnosed with Transexualism or Gender Dysphoria which requires at least 1 year of therapy.[42] To medically transition can cost a lot of money, but in Sweden, the whole treatment is covered by the high-cost protection for medications and doctor’s visits and there is no surgery fee. For non-binary persons younger than 18 years, the healthcare is very limited.[43] In Sweden, changing your name doesn't count as a part of transitioning (since anyone is allowed to change their name at any time).[44]

Up until January 27, 2017, being transsexual was classified as a disease. Just two months earlier In November 21, 2016, around 50 trans activists broke into and occupied the Swedish National Board of Health and Welfare (Swedish: Socialstyrelsen) premises in Rålambsvägen in Stockholm and demanded that their voices be heard regarding the way the country, healthcare, and the National Board of Health and Welfare treat transgender and intersex individuals.[45] If you'd like to change your legal gender marker and personal identity number to the new, correct, gender you have to seek permission from the National Board of Health and Welfare.[42] In many countries it´s really expensive to legally and/or medically transition. If you are in need of HRT, trans-related surgery and/or procedure (or any other surgery/procedure, except plastic surgery without medical motivation), high-cost protection and municipal taxes cover most costs. The fee you pay for a doctor’s appointment or other care represents only a small fraction of the actual costs.[46] For non-binary persons younger than 18 years, the healthcare is very limited. These individuals do not have access to a legal gender marker change or bottom surgery[43]

United Kingdom[edit]

A sign at a rally calling for equal access to health care for transgender people

A survey of gender identity clinic services provided by the UK National Health Service found that 94% of transgender people using the gender identity clinics were satisfied with their care and would recommend the clinics to a friend or family member.[47] Despite this positive response, however, other National Health Service programs are lacking; almost a third of respondents reported inadequate psychiatric care in their local area.[47] The options available from the National Health Service also vary with location; slightly differing protocols are used in England, Scotland, Wales and Northern Ireland. Protocols and available options differ widely outside of the UK.[47]

North America[edit]

Canada[edit]

A study of transgender Ontario residents aged 16 and over, published in 2016, found that half of them were reluctant to discuss transgender issues with their family doctor.[48] A 2013-2014 nationwide study of young transgender and genderqueer Canadians found that a third of younger (ages 14–18) and half of the older (ages 19–25) respondents missed needed physical health care. Only 15 percent of respondents with a family doctor felt very comfortable discussing transgender issues with them.[49]

All Canadian provinces fund some sex reassignment surgeries, with New Brunswick being the last of the provinces to start insuring these procedures in 2016.[50] Waiting times for surgeries can be lengthy, as few surgeons in the country provide them; a clinic in Montreal is the only one providing a full range of procedures.[51][52][53] Insurance coverage is not generally provided for the transition-related procedures of facial feminization surgery, tracheal shave, or laser hair removal.[54]

Blood donation[edit]

Canada's blood collection organization Canadian Blood Services has eligibility criteria for transgender people, which came into effect on August 15, 2016. This criteria states that transgender donors who have not had lower gender affirming surgery will be asked questions based on their sex assigned at birth. They will be eligible to donate or be deferred based on these criteria. For example, trans women will be asked if they have had had sex with a man in the last 12 months. If the response is yes, they will be deferred for one year after their last sexual contact with a man. And donors who have had lower gender affirming surgery will be deferred from donating blood for one year after their surgery. After that year, these donors will be screened in their affirmed gender.[55][56]

Mexico[edit]

A July 2016 study in The Lancet Psychiatry reported that nearly half of transgender people surveyed undertook body-altering procedures without medical supervision.[57] Transition-related care is not covered under Mexico's national health plan.[58] Only one public health institution in Mexico provides free hormones for transgender people.[57] Health care for transgender Mexicans focuses on HIV and prevention of other sexually transmitted diseases.[57]

The Lancet study also found that many transgender Mexicans have physical health problems due to living on the margins of society. The authors of the study recommended that the World Health Organization declassify transgender identity as a mental disorder, to reduce stigma against this population.[59]

United States[edit]

Transgender people face various kinds of discrimination, especially in health care situations. An assessment of transgender needs in Philadelphia found that 26% of respondents had been denied health care because they were transgender and 52% of respondents had difficulty accessing health services.[60] Aside from transition related care, transgender and gender non-conforming individuals need preventative care such as vaccines, gynecological care, prostate exams, and other annual preventative health measures.[1] Various factors play a role in creating the limited access to care, such as insurance coverage issues related to their legal gender identity status.[1]

The Affordable Care Act marketplace has improved access to insurance for the LGBT community through anti-discriminatory measures, such as not allowing insurance companies to reject consumers for being transgender.[25] However, insurance sold outside of the ACA marketplace does not have to follow these requirements. This means that preventative care, such as gynecological exams for transgender men, may not be covered.[61]

South America[edit]

Colombia[edit]

Transgender women sex workers have cited financial difficulties as barriers to accessing physical transition options.[62] As a result, they have entered sex work to relieve financial burdens, both those related to transition and those not related to transition.[62] However, despite working in the sex trade, the transgender women are at low risk for HIV transmission as the Colombian government requires education about sexual health and human rights for sex workers to work in so-called tolerance zones, areas where sex work is legal.[62]

Health care for transgender youth[edit]

Transition options for transgender adolescents and youth are significantly limited compared to those for transgender adults. Prepubescent transgender youth can go through various social changes, such as presenting as their gender and asking to be called by a different name or different pronouns.[63] Medical options for transition become available once the child begins to enter puberty. Under close supervision by a team of doctors, puberty blockers may be used to limit the effects of puberty.[63]

Discrimination has a significant effect on the mental health of young transgender people. The lack of family acceptance, rejection in schools and abuse from peers can be powerful stressors, leading to poor mental health and substance abuse.[64] A study done on transgender youth in San Francisco found that higher rates of both transgender-based and racial bias are associated with increased rates of depression, post-traumatic stress disorder, and suicidal ideation.[65]

The use of puberty blockers as a form of treatment for transgender youth is in question. While the World Professional Association for Transgender Health recommends their use, the likelihood of issues of gender dysphoria resolving before adolescence and before the use of puberty blockers are quite high.[13][66] Concerns regarding the impact of puberty blockers on physical health, such as bone density, have also been raised.[66] Long-term use of puberty blockers has also gone relatively unstudied, bringing up questions about harmful long-term side effects.[66]

Health care for transgender older adults[edit]

Transgender older adults can encounter challenges in the access and quality of care received in health care systems and nursing homes, where providers may be ill-prepared to provide culturally sensitive care to trans people.[67] Trans individuals face the risk of aging with more limited support and in more stigmatizing environments than heteronormative individuals.[68] Despite the rather negative picture portrayed by medical literature in relation to the depression and isolation that many transgender people encounter at earlier stages of life, some studies found testimonies of older LGBT adults relating feelings of inclusion, comfort and community support.[69]

See also[edit]

References[edit]

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