“Transphobia is a health issue.”
J V R Prasada Rao, UN Secretary-General’s Special Envoy for AIDS in Asia and the Pacific1
2015 was an unprecedented year in the recognition of transgender rights in some high-income countries. However, this recognition in the public domain has yet to translate to a concerted effort to support the right to health of transgender people around the world. Transgender people continue to face a range of challenges that deprive them of respect, opportunities, and dignity and have damaging effects on their mental and physical health and wellbeing, as shown in the Lancet Series on transgender health.2–4 These “situated vulnerabilities”, as they are called in the Series paper by Sari Reisner and colleagues,4 can prompt or aggravate depression, anxiety, self-harm, and suicidal behaviour among transgender people, which are exacerbated by biological risks, and social and sexual network-level risks, for HIV and other sexually transmitted infections.2 In their Lancet Series paper, Sam Winter and colleagues2 write of a “slope leading from stigma to sickness”. Moving forward, these health needs and vulnerabilities can be better addressed through improved understanding of the legal and social policies that promote harms and diminish the potential impact of health programmes. There is also a need for increased knowledge of the optimal content and models of clinical service provision, as highlighted by Kevan Wylie and colleagues’ Series paper,3 and of the epidemiology of communicable and non-communicable diseases in transgender people globally. Ultimately, action is needed at and across multiple levels and sectors to optimise the provision and uptake of health services for transgender people (panel).
Health policies must change to improve the health of transgender people. Transgender people worldwide report problems in accessing appropriate and equitable health care—whether related to gender affirmation, sexual and reproductive health, or more general health. Steps need to be taken to ensure that national health policies are as inclusive as possible with regard to transgender health care. Such health care, including access to feminising and masculinising hormones, should be funded on the same basis as other health care. Publicly funded health care should be extended to transgender people, including gender-affirming health care that can change, or indeed extend, the lives of the people concerned. Health care for transgender people should both affirm their human rights and be evidence-based.5–9 Governments should endeavour to eliminate gender reparative therapies for children, adolescents, or adults in their jurisdiction. Mainstream professional opinion judges these therapies unethical.5
Primary health care is the most common point of contact that transgender people have with the health system. Effective training for primary care providers, through medical education and continuing professional development, is needed to better support the needs of transgender people and understand their range of health needs. Primary care providers should be able and willing to provide mental health support for transgender people and gender-affirming hormone treatments that can alleviate gender dysphoria or allow gender expression. At the very least, they should be aware of these needs and consult additional specialty support if needed. However, in much of the world, such specialty services are partly or wholly unavailable, which reinforces the need for the integration of this training for all health providers.
Gender incongruence commonly leads to a mental disorder diagnosis. The precise diagnosis depends on the manual used, but in the case of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is prompted by the presence of distress about gender incongruence.10 These psychiatric diagnoses are now widely regarded as inappropriate, unhelpful, and potentially harmful.11 In the International Classification of Diseases Code (ICD)–11, WHO is proposing to relocate the relevant diagnoses for children, adolescents, and adults to a new chapter linked to sexual health.12 We encourage national medical associations to communicate to their governments their support for the placement of gender incongruence of adolescence and adulthood in the new sexual health chapter of ICD-11. However, we urge caution about the proposal for a diagnosis for children below puberty who have no need for hormone or surgical treatment, and who simply need support and information in exploring and learning to accept and socially express their gender identity.13 Indeed, greater acceptance and support of gender diversity and gender expansiveness throughout child development can be promoted through provision of resources to families, schools, and broader communities. We join others in urging WHO to reconsider its proposal.
Inclusive legal and social policies are essential for transgender people. Wherever they are—in school, at work, or in their local health clinic—transgender people should be free of enacted and perceived stigma. It is imperative that anti-discrimination laws and policies are inclusive of transgender people and provide protection against discrimination due to gender identity, gender expression, and bodily diversity. In much of the world, bullying, harassment, and violence against transgender people is common and is associated with poor health and wellbeing.14 Where anti-discrimination legislation is limited or absent, the practical result is often that discrimination is legal. Worse, some governments perpetrate discrimination themselves by enacting or supporting laws and practices that criminalise and demean gender expression as “cross-dressing”, or “impersonation”. All this needs to change.
Laws and legal reform play an important part in ensuring social inclusion, with consequent effects on the health and wellbeing of transgender people. But laws are only part of what is necessary. Governments and other entities must take a lead in promoting greater public understanding about transgender people, especially among individuals working in education, social services, law enforcement, the justice system, and health care. The aim should be equality and inclusion for transgender people in all areas of life.
Gender recognition is critical for the health and wellbeing of transgender people. All persons should be able to determine their gender freely, in legal documents and elsewhere, without arbitrary preconditions. Preconditions acting as barriers to gender recognition should be avoided. These barriers include requirements coercing some transgender people into invasive medical procedures they might not otherwise undergo. We emphasise that hormonal and surgical treatments should enhance health and wellbeing rather than be used as a response to arbitrary social and legal requirements.
In educational settings, it is important that transgender students are allowed to affirm their gender identity. Administrators and people in leadership positions in schools have key roles in ensuring that schools are safe spaces, free of transphobic bullying. Toilet, changing room, and other policies for transgender students should be fully inclusive. All teachers should be trained to work with, and teach about, transgender issues and gender diversity, and the importance of inclusion. Sexuality and health education should incorporate these issues.
Research gaps must be tackled to advance the health of transgender people. There remain substantial gaps in our knowledge of transgender health around the world. Additional research should be done to identify the social, economic, and legal determinants that create and sustain vulnerabilities among transgender people, and identify the interventions that can overcome them. With effective engagement of transgender people throughout the research process, study results are more likely to be valid and, equally importantly, capable of being used in the design of programmes and policies. There has been little work among subgroups within transgender populations, including transgender men, older people, those with an intersex history, rural groups, and those who do not identify with the female/male binary (eg, those with non-binary identities). Importantly, while gender diversity is a global phenomenon, much of the research work to date has been in high-income settings and parts of Asia. We call for increased investment into research into the needs of transgender people in Africa, the Middle East, Central Asia, and the former Soviet republics.
UN Sustainable Development Goal 3 indicates that societies should strive to ensure healthy lives and promote wellbeing for all at all ages. The world has a long way to go to achieve wellbeing for transgender populations. We call for a global concerted effort to achieve equity in health for all starting now.
Panel: Steps to improved health and wellbeing for transgender people
General
Improved understanding of legal and social policies that impact on vulnerability, and on the effectiveness of health programmes
Increased knowledge about effective clinical service provision
Increased epidemiological knowledge about diseases affecting transgender people
Health-care provision
Inclusive national health policies
Health care funded on same basis as other health care
Publicly funded gender-affirmative health care, where there is a publicly funded health system Health care resting on evidence and rights
Gender reparative therapies eliminated
Training for primary health-care providers:
basic knowledge about health needs,
providing mental health support and gender-affirming hormones
when to refer on to specialists
Diagnostic issues
The experience of being transgender no longer regarded as a mental disorder
Relocating relevant WHO diagnoses in ICD to a proposed chapter on sexual health
Reconsideration by WHO of its proposal for a “gender incongruence” diagnosis for children below the age of puberty
Legal and social policies
Laws and policies that protect against discrimination on the basis of gender identity, gender expression, or bodily diversity
An end to discriminatory laws, policies, and practices perpetrated by governments and their agencies (eg, “cross-dressing” and “impersonation” laws)
Promoting higher levels of public understanding, especially among those providing services to the public
Self-determined gender, in legal documents and elsewhere
An end to preconditions that act as barriers to gender recognition (including medical requirements)
Education
Schools as safe spaces. Fully inclusive toilet, changing room, and other policies
Teachers trained in working with transgender students
Sexuality education covering transgender issues
Research gaps
Research on social, economic, and legal factors that increase vulnerabilities, as well as on interventions that can overcome these vulnerabilities
Research on under-researched subgroups: transgender men; older people or those who live in rural places; those who are also intersex; those with non-binary identities
Transgender people involved in planning and implementation of research that relates to themselves
Increased research in Africa, the Middle East, central Asia, and the former Soviet republics
Footnotes
We declare no competing interests. SW and GK are members of the Board of the World Professional Association for Transgender Health (WPATH). GK is WPATH President-Elect. KW was previously on the Board of WPATH. SW, GK, and KW were all among the coauthors for the WPATH Standards of Care Version 7. SW was a member of the WHO Working Group on Sexual Disorders and Sexual Health. SW and MC were members of the GATE Civil Society Experts Group. MC is a Co-Director of GATE.
References
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