Transgender health issues are beginning to come to the attention of many health practitioners and researchers. . . . Acknowledging health care discrepancies is only a start, however. To provide much-needed services to this population, researchers, educators, and health care professionals of all types need concrete, comprehensible information about transgender individuals. . . .
Transgender was originally used to differentiate those who seek medical intervention in changing their gender from those who do not; however, this term later changed to encompass a range of possible identities and behaviors, including transvestitism and transsexualism (the way in which transgender evolved in usage has not been examined fully). . . .
The use of terminology has not been consistent across time and among writers. The meaning of such terms varies among individuals as well, and as a result there is little understanding of what people mean when they say they are transgender or transsexual. For the sake of uniformity within this commentary, however, the label transgender is used in a global sense, encompassing transvestites, transsexuals, and self-identified transgender individuals.
Generally, people can be categorized across 4 characteristics: biological sex, legal– institutional sex, social gender, and psychologic gender. Biological sex is usually determined by people’s genitals but can encompass other factors such as chromosomes, hormonal makeup, secondary sex characteristics, and other physiologic variations. Furthermore, there are intersexed conditions that can create problems in regard to categorizing infants as male or female (e.g., children born with ambiguous genitalia, androgen sensitivity syndrome). These children may undergo surgical intervention so that their genitals more clearly resemble those found on traditionally male or female children.
Legal–institutional sex refers to people’s designation on identification, forms, and even questionnaires. There may be ways for people to change their legal–institutional sex; frequently this requires some sort of professional intervention (i.e., needing to submit a letter from one’s surgeon to change one’s birth certificate). However, different areas of the country (and across the world) have different regulations allowing for such changes.
Social gender refers to how people present themselves in public: the clothing they wear, their hairstyle, and their physical characteristics, even how they act and talk. Different cultures have different ways of explaining and dealing with gender variance; some Native American cultures refer to two-spirit people (aspects of both genders), and Hindu cultures include hidras (neither man nor woman). Social gender can also be influenced by medical interventions used to change aspects of people’s appearance. Many people go to great lengths to change aspects of their appearance (some of which is necessary to change their legal sex). In addition, individuals may be consistent or inconsistent in their gender presentation. People may have an inconsistent social gender because one aspect of their gender is used for performances, fun, or even sexual behavior.
Psychologic gender refers to a person’s self-identification as a man or a woman. However, these may not be the only options. Again, different cultures may allow for other alternatives in the way people identify themselves. In addition, individuals may create alternative identities. . . .
The preceding is only a short summary of the factors that can be used to describe sex and gender and to understand the ways in which they can vary. There are many other factors that can influence people, some of which have already been mentioned. Race, ethnicity, or culture can influence how people identify themselves and the social roles that they desire or have access to. Similarly, a person’s area of residence can involve variations in how sex is institutionalized and how legal sex can be changed.
Finally, the resources available to people can influence their ability to pay for medical interventions in addition to other strategies used to change their social gender or legal sex (or both). It is not enough to know the definitions of labels (e.g., What is a crossdresser? What is a transsexual?); it is more important to know that aspects of a person’s gender and physical form can vary widely and be influenced by different factors. Health care educators, researchers, policymakers, and clinicians need to know that transgender individuals can vary widely but that, in general, all are still at risk for problems in accessing and receiving health care.
HEALTH CARE ISSUES
Transgender individuals are likely to experience some form of discrimination or violence sometime in their lives. . . . [Additionally], increasing evidence demonstrates that the rate of HIV infection among transgender women is high. . . . These individuals may be difficult to target through traditional prevention campaigns, and they may fear discrimination should they seek services. . . . Indeed, . . . insensitive behavior among health care providers (e.g., referring to transgender women as “he” and “him” and not acknowledging or respecting their identity) suggest that services are severely lacking in terms of provision of culturally sensitive interventions and, potentially, provision of HIV-related health care.
Health care service providers have found that helping transgender individuals obtain the services they need (e.g., substance use treatment, housing, health care) is difficult. . . . Furthermore, lack of sensitivity on the part of health care providers who do not respect the expressed gender identity of transgender persons can adversely influence whether these individuals will access and stay in treatment.
Transgender persons may be resistant to seeking help because other transgender individuals have reported past discriminatory treatment on the part of service providers. . . . Overall, individuals who do not conform to traditional conceptions of sex and gender are likely to be at risk for many health-related problems, including, unfortunately, discrimination within the treatment setting.
ACCESS TO CARE
Often, transgender people have 2 different sets of health care providers: one involved with gender transition and one involved with regular health care visits. In addition to the problems experienced by transgender men and women within health care settings, traditional health care plans (public and private) do not cover the costs related to changing one’s gender. . . .
Suggestions for Improving the Health of Transgender Individuals
. . . [T]he following strategies can be used to begin improving the health of transgender individuals.
Acknowledge the authenticity of transgender individuals’ identities and lives in all areas (policy, research, and clinical practice). When in doubt, inquire in a respectful manner. Allow for complexities; people may not fall into neat categories. Do not become overly fixated upon the technical–medical aspects found in the Diagnostic and Statistical Manual of Mental Disorders or the Harry Benjamin International Gender Dysphoria Association standards of care.
Promote the view that discrimination and denial of services to transgender men and women will not be tolerated.
Allow young people some flexibility in questioning their gender identity.
Advocate for increased and better access to health care resources. This includes public and private third-party coverage of hormones and surgeries needed for people to change their legal sex, greater input of transgender individuals in their own care, and more education on transgender health care issues.
Advocate for cultural relevancy within research, policy, education and prevention programs, and direct care contexts. One strategy is to contact and develop partnerships with individuals and organizations within the local transgender community.
Advocate for more and better promotion of transgender-related research and for more innovation within transgender health care practices.
Advocate for greater awareness of intersexed individuals and against the practice of surgically altering children and infants for solely aesthetic reasons. This would include conducting more research on the effects (both short- and long-term) of medical interventions on intersexed infants and children and taking a critical stand against surgically altering children and infants purely for aesthetic reasons.