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"Sexual reassignment" redirects here. For the medical procedure, see Sex reassignment surgery.
Part of a series on
Transgender topics
     
Gender identities
Health care practices
Rights and legal status
Society and culture
Events and awareness
Culture
Theory and concepts
By country
Rights
History
See also
  Category

Transgender health care, also known as gender-affirming care, [1] includes the prevention, diagnosis and treatment of physical and mental health conditions, as well as sex reassignment therapies, for transgender individuals. [2] Questions implicated in transgender health care include gender variance, sex reassignment therapy, health risks (in relation to violence and mental health), and access to healthcare for trans people in different countries around the world.

Sex reassignment therapy or medical transition is the medical aspect of gender transitioning, that is, modifying one's sex characteristics to better suit one's gender identity. It can consist of hormone therapy to modify secondary sex characteristics, sex reassignment surgery to alter primary sex characteristics, and other procedures altering appearance, such as permanent hair removal for trans women.

In appropriately evaluated cases of severe gender dysphoria, sex reassignment therapy is often the best when standards of care are followed. [3]: 1570  [4]: 2108  There is academic concern over the low quality of the evidence supporting the efficacy of sex reassignment therapy as treatment for gender dysphoria, but more robust studies are impractical to carry out; [5]: 22  as well, there exists a broad clinical consensus, supplementing the academic research, that supports the effectiveness in terms of subjective improvement of sex reassignment therapy in appropriately selected patients. [5]: 2–3  Treatment of gender dysphoria does not involve attempting to correct the patient's gender identity, but to help the patient adapt. [3]: 1568 

Major health organizations in the United States and UK have issued affirmative statements supporting sex reassignment therapy as comprising medically necessary treatments in certain appropriately evaluated cases. [6] [7] [8] [9] [10]

Eligibility

In the International Classification of Diseases, the diagnosis is known as transsexualism. [11] The US Diagnostic and Statistical Manual of Mental Disorders (DSM) names it gender dysphoria (in version 5 [12]). Some people who are validly diagnosed have no desire for all or some parts of sex reassignment therapy, particularly genital reassignment surgery, and/or are not appropriate candidates for such treatment.

The general standard for diagnosing, as well as treating, gender dysphoria is outlined in the WPATH Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. As of February 2014, the most recent version of the standards is Version 7. [13] According to the standards of care, "gender dysphoria refers to discomfort or distress that is caused by a discrepancy between a person's gender identity and that person's sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics). Only some gender-nonconforming people experience gender dysphoria at some point in their lives". Gender nonconformity is not the same as gender dysphoria; nonconformity, according to the standards of care, is not a pathology and does not require medical treatment.

The informed consent model is an alternative to the standard WPATH approach which does not require a person seeking transition related medical treatment to undergo formal assessment of their mental health or gender dysphoria. Arguments in favor of this model describe required assessments as gatekeeping, dehumanizing, pathologizing, and reinforcing a reductive perception of transgender experiences. [14] Informed consent approaches include conversations between the medical provider and person seeking care on the details of risks and outcomes, current understandings of scientific research, and how the provider can best assist the person in making decisions. [15]

Local standards of care exist in many countries.

Eligibility for different stages of treatment

While a mental health assessment is required by the standards of care, psychotherapy is not an absolute requirement but is highly recommended. [13]

Hormone replacement therapy is to be initiated from a qualified health professional. The general requirements, according to the WPATH standards, include:

  1. Persistent, well-documented gender dysphoria;
  2. Capacity to make a fully informed decision and to consent for treatment;
  3. Age of majority in a given country (however, the WPATH standards of care provide separate discussion of children and adolescents);
  4. If significant medical or mental health concerns are present, they must be reasonably well-controlled.

Often, at least a certain period of psychological counseling is required before initiating hormone replacement therapy, as is a period of living in the desired gender role, if possible, to ensure that they can psychologically function in that life-role. On the other hand, some clinics provide hormone therapy based on informed consent alone. [13]

Eligibility of minors

While the WPATH standards of care generally require the patient to have reached the age of majority, they include a separate section devoted to children and adolescents. [13]

Psychological treatment

According to the WPATH SOC v7, "Psychotherapy (individual, couple, family, or group) for purposes such as exploring gender identity, role, and expression; addressing the negative impact of gender dysphoria and stigma on mental health; alleviating internalized transphobia; enhancing social and peer support; improving body image; or promoting resilience" is a treatment option. [13]

Some transsexual people may suffer from co-morbid psychiatric conditions unrelated to their gender dysphoria. In cases of comorbid psychopathology, the standards are to manage the psychopathology "prior to, or concurrent with, treatment of gender dysphoria". [13] Treatment may still be appropriate and necessary in cases of significant comorbid psychopathology, as cases have been reported in which the individual was both suffering from severe co-occurring psychopathology, and was a 'late-onset, gynephilic' trans woman, and yet experienced a long-term, positive outcome with hormonal and surgical gender transition. [5]: 22  The DSM-IV itself states that in rare instances, gender dysphoria may co-exist with schizophrenia, and that psychiatric disorders are not generally considered contraindications to sex reassignment therapy unless they are the primary cause of the patient's gender dysphoria. [16]: 108 

Hormone therapy

Main article: Transgender hormone therapy

For trans people, hormone therapy causes the development of many of the secondary sexual characteristics of their desired sex. However, many of the existing primary and secondary sexual characteristics cannot be reversed by hormone therapy. For example, hormone therapy can induce breast growth for trans women but can only minimally reduce breasts for trans men. HRT can prompt facial hair growth for transgender men, but cannot regress facial hair for transgender women. Hormone therapy may, however, reverse some characteristics, such as distribution of body fat and muscle, as well as menstruation in trans men.

Generally, those traits that are easily reversible will revert upon cessation of hormonal treatment, unless chemical or surgical castration has occurred, though for many trans people, surgery is required to obtain satisfactory physical characteristics. But in trans men, some hormonally-induced changes may become virtually irreversible within weeks, whereas trans women usually have to take hormones for many months before any irreversible changes will result.

As with all medical activities, health risks are associated with hormone replacement therapy, especially when high hormone doses are taken as is common for pre-operative or no-operative trans patients. It is always advised that all changes in therapeutic hormonal treatment should be supervised by a physician because starting, stopping or even changing dosage rates and levels can have physical and psychological health risks.

Although some trans women use herbal phytoestrogens as alternatives to pharmaceutical estrogens, little research has been performed with regards to the safety or effectiveness of such products. Anecdotal evidence suggests that the results of herbal treatments are minimal and very subtle, if at all noticeable, when compared to conventional hormone therapy.

Some trans people are able to avoid the medical community's requirements for hormone therapy altogether by either obtaining hormones from black market sources, such as internet pharmacies which ship from overseas, or more rarely, by synthesizing hormones themselves.

Medications

Testosterone therapy is typically used for masculinizing treatments. Effects can include thicker vocal cords, increased muscle mass, hair loss, and thicker skin. [17] [18] Intramuscular, subcutaneous, and transdermal options are available. [19] These include cypionate (Depo-Testosterone®), and the longer acting testosterone undecanoate ( Aveed®). Oral formulations are available in Europe, Andriol®, but are not available in the U.S. due to their pharmacokinetic properties. [20]

Estrogen and anti-androgen therapy are typically used for feminizing treatments. [21] [22] Estrogen is available in oral, parenteral, and transdermal formulations. Often, estrogen alone is insufficient for androgen suppression, and appropriate therapy will call for additional anti-androgen medications. [23] Anti-androgen medications include progesterone, medroxyprogesterone acetate, spironolactone, and finasteride. [20]

Sex reassignment surgery

Main articles: Sex reassignment surgery, Sex reassignment surgery (male-to-female), and Sex reassignment surgery (female-to-male)

Sex reassignment surgery (SRS) refers to the surgical and medical procedures undertaken to align intersex and transsexual individuals' physical appearance and genital anatomy with their gender identity. SRS may encompass any surgical procedures which will reshape a male body into a body with a female appearance or vice versa, or more specifically refer to the procedures used to make male genitals into female genitals and vice versa.

Other terms used for SRS include "gender confirmation surgery", "gender realignment surgery", and "transsexual surgery". These terms may also specifically refer to genital surgeries like vaginoplasty, metoidioplasty, and phalloplasty, even though more specific terms exist to refer exclusively to genital surgery, the most common of which is genital reassignment surgery (GRS). The term "genital reconstruction surgery" may also be used.

Chest surgery

Main articles: Male chest reconstruction and Breast augmentation

Many trans men seek mastectomy and male chest reconstruction.

Breast augmentations for trans women are done in a similar manner to those for cisgender women.

Effectiveness

The Merck Manual states, in regard to trans women, "In follow-up studies, genital surgery has helped some transsexual people live happier and more productive lives and so is justified in highly motivated, appropriately assessed and treated transsexual people, who have completed a 1- to 2-year real-life experience in a different gender role. Before surgery, transsexual people often need assistance with passing in public, including help with gestures and voice modulation. Participation in support groups, available in most large cities, is usually helpful." [3]: 1570  With regards to trans men, it states, "Surgery may help certain [trans men] patients achieve greater adaptation and life satisfaction. Similar to trans women, trans men should live in the male gender role for at least 1 yr before surgery. Anatomic results of neophallus surgical procedures are often less satisfactory in terms of function and appearance than neovaginal procedures for trans women. Complications are common, especially in procedures that involve extending the urethra into the neophallus." [3]: 1570 

Kaplan and Sadock's Comprehensive Textbook of Psychiatry states, with regards to adults, "When patient gender dysphoria is severe and intractable, sex reassignment is often the best solution." [4]: 2108  Regret tends to occur in cases of misdiagnosis, no Real Life Experience, and poor surgical results. Risk factors for return to original gender role include history of transvestic fetishism, psychological instability, and social isolation. In adolescents, careful diagnosis and following strict criteria can ensure good post-operative outcomes. Many prepubescent children with cross-gender identities do not persist with gender dysphoria. [4]: 2109–2110  With regards to follow-up, it states that "Clinicians are less likely to report poor outcomes in their patients, thus shifting the reporting bias to positive results. However, some successful patients who wish to blend into the community as men or women do not make themselves available for follow-up. Also, some patients who are not happy with their reassignment may be more known to clinicians as they continue clinical contact." [4]: 2109 

A 2009 systematic review looking at individual surgical procedures found that "[t]he evidence concerning gender reassignment surgery has several limitations in terms of: (a) lack of controlled studies, (b) evidence has not collected data prospectively, (c) high loss to follow up and (d) lack of validated assessment measures. Some satisfactory outcomes were reported, but the magnitude of benefit and harm for individual surgical procedures cannot be estimated accurately using the current available evidence." [24]

A 2010 meta-analysis of follow-up studies reported "Pooling across studies shows that after sex reassignment, 80% of individuals with GID reported significant improvement in gender dysphoria (95% CI = 68–89%; 8 studies; I2 = 82%); 78% reported significant improvement in psychological symptoms (95% CI = 56–94%; 7 studies; I2 = 86%); 80% reported significant improvement in quality of life (95% CI = 72–88%; 16 studies; I2 = 78%); and 72% reported significant improvement in sexual function (95% CI = 60–81%; 15 studies; I2 = 78%)." The study concluded "Very low quality evidence suggests that sex reassignment that includes hormonal interventions in individuals with GID likely improves gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life." [25]

A study evaluating quality of life in female-to-male transgender individuals found "statistically significant (p<0.01) diminished quality of life among the FTM transgender participants as compared to the US male and female population, particularly in regard to mental health. FTM transgender participants who received testosterone (67%) reported statistically significant higher quality of life scores (p<0.01) than those who had not received hormone therapy." [26]

A recent Swedish study (2010) found that “almost all patients were satisfied with sex reassignment at 5 years, and 86% were assessed by clinicians at follow-up as stable or improved in global functioning” [27] A prospective study in the Netherlands that looked at the psychological and sexual functioning of 162 adult applicants of adult sex reassignment applicants before and after hormonal and surgical treatment found, "After treatment the group was no longer gender dysphoric. The vast majority functioned quite well psychologically, socially and sexually. Two non-homosexual male-to-female transsexuals expressed regrets." [28]

A long-term follow-up study performed in Sweden over a long period of time (1973–2003) found that morbidity, suicidality, and mortality in post-operative trans people were still significantly higher than in the general population, suggesting that sex reassignment therapy is not enough to treat gender dysphoria, highlighting the need for improved health care following sex reassignment surgery. 10 controls were selected for each post-operative trans person, matched by birth year and sex; two control groups were used: one matching sex at birth, the other matching reassigned sex. The study states that "no inferences can be drawn [from this study] as to the effectiveness of sex reassignment as a treatment for transsexualism," citing studies showing the effectiveness of sex reassignment therapy, though noting their poor quality. The authors noted that the results suggested that those who received sex reassignment surgery before 1989 had worse mortality, suicidality, and crime rates than those who received surgery on or after 1989: mortality, suicidality, and crime rates for the 1989-2003 cohort were not statistically significant compared to healthy controls (though psychiatric morbidity was); it is not clear if this is because these negative factors tended to increase a decade after surgery or because in the 1990s and later improved treatment and social attitudes may have led to better outcomes. [29]

The abstract of the American Psychiatric Association Task Force on GID's report from 2012 states, "The quality of evidence pertaining to most aspects of treatment in all subgroups was determined to be low; however, areas of broad clinical consensus were identified and were deemed sufficient to support recommendations for treatment in all subgroups." [5] The APA Task Force states, with regard to the quality of studies, "For some important aspects of transgender care, it would be impossible or unwise to engage in more robust study designs due to ethical concerns and lack of volunteer enrollment. For example, it would be extremely problematic to include a 'long-term placebo treated control group' in an RCT of hormone therapy efficacy among gender variant adults desiring to use hormonal treatments." [5]: 22  The Royal College of Psychiatrists concurs with regards to SRS in trans women, stating, "There is no level 1 or 2 evidence (Oxford levels) supporting the use of feminising vaginoplasty in women but this is to be expected since a randomised controlled study for this scenario would be impossible to carry out." [9]

Following up on the APA Task Force's report, the APA issued a statement stating that the APA recognizes that in "appropriately evaluated" cases, hormonal and surgical interventions may be medically necessary and opposes "categorical exclusions" of such treatment by third-party payers. [6] The American Medical Association's Resolution 122 states, "An established body of medical research demonstrates the effectiveness and medical necessity of mental health care, hormone therapy and sex reassignment surgery as forms of therapeutic treatment for many people diagnosed with GID". [7]

The need for treatment is emphasized by the higher rate of mental health problems, including depression, anxiety, and various addictions, as well as a higher suicide rate among untreated transsexual people than in the general population. Many of these problems, in the majority of cases, disappear or decrease significantly after a change of gender role and/or physical characteristics. [30] [31]

In 2021, a review published in Plastic And Reconstructive Surgery found that less than 1% of people who undergo gender-affirming surgery regret the decision, although the authors said more research was needed, as the pool of sources was heterogeneous and many were viewed at "medium-to-high" risk of bias. [32]

Ethical, cultural, and political considerations

Sex reassignment therapy is a controversial ethical subject. Notably, the Roman Catholic church, according to an unpublished Vatican document, holds that changing sex is not possible and, while in some cases treatment might be necessary, it does not change the person's sex in the eyes of the church. [33] Some Catholic ethicists go further, proclaiming that a "sex change operation" is "mutilation" and therefore immoral. [34]

Paul R. McHugh is a well-known opponent of sex reassignment therapy. According to his own article, [35] when he joined Johns Hopkins University as director of the Department of Psychiatry and Behavioral Science, it was part of his intention to end sex reassignment surgery there. McHugh succeeded in ending it at the university during his time. [36] However, a new gender clinic at Johns Hopkins has been opened in 2017. [37]

Opposition was also expressed by several writers identifying as feminist, most famously Janice Raymond. Her paper was allegedly instrumental in removing Medicaid and Medicare support for sex reassignment therapy in the US. [38]

Sex reassignment therapy, especially surgery, tends to be expensive and is not always covered by public or private health insurance. In many areas with comprehensive nationalized health care, such as some Canadian provinces and most European countries, SRT is covered under these plans. However, requirements for obtaining SRS and other transsexual services under these plans are sometimes more stringent than the requirements laid out in the WPATH Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, and in Europe, many local Standards of Care exist. In other countries, such as the United States, no national health plan exists and the majority of private insurance companies do not cover SRS. The government of Iran, however, pays for such surgery because it is believed to be valid under Shi'ite Belief. [39]

A significant and growing political movement exists, pushing to redefine the standards of care, asserting that they do not acknowledge the rights of self-determination and control over one's body, and that they expect (and even in many ways require) a monolithic transsexual experience. In opposition to this movement is a group of transsexual persons and caregivers who assert that the SOC are in place to protect others from "making a mistake" and causing irreversible changes to their bodies that will later be regretted – though few post-operative transsexuals believe that sexual reassignment surgery was a mistake for them. [40]

The United States

See also: Transgender rights in the United States § Healthcare

From 1981 until 2014, the Centers for Medicare and Medicaid Services (CMS) categorically excluded coverage of sex reassignment surgery by Medicare in its National Coverage Determination (NCD) "140.3 Transsexual Surgery," but that categorical exclusion came under challenge by an "aggrieved party" in an Acceptable NCD Complaint in 2013 and was subsequently struck down the following year by the Departmental Appeals Board (DAB), the administrative court of the U.S. Department of Health and Human Services (HHS). [41] [42] In late 2013, the DAB issued a ruling finding the evidence on record was "not complete and adequate to support the validity of the NCD" and then moved on to discovery to determine if the exclusion was valid. [43] CMS did not defend its exclusion throughout the entire process. On May 30, 2014, HHS announced that the categorical exclusion was found by the DAB to not be valid "under the 'reasonableness standard,'" allowing for Medicare coverage of sex reassignment surgery to be decided on a case-by-case basis. HHS says it will move to implement the ruling. As Medicaid and private insurers often take their cues from Medicare on what to cover, this may lead to coverage of sex reassignment therapy by Medicaid and private insurers. [41] [42] The evidence in the case "outweighs the NCD record and demonstrates that transsexual surgery is safe and effective and not experimental," according to the DAB in its 2014 ruling. [44]

A 2014 article published in American Journal of Public Health called on third-party payers to cover sex reassignment therapy in appropriately selected cases. [45]

Mandatory sterilization

In Sweden until 2012, sterilization was mandatory before sex reassignment in Sweden. [46]

Consent and the treatment of intersex people

Main article: Intersex human rights

In 2011, Christiane Völling won the first successful case brought by an intersex person against a surgeon for non-consensual surgical intervention described by the International Commission of Jurists as "an example of an individual who was subjected to sex reassignment surgery without full knowledge or consent". [47]

In 2015, the Council of Europe recognized, for the first time, a right for intersex persons to not undergo sex assignment treatment. [48] In April 2015, Malta became the first country to recognize a right to bodily integrity and physical autonomy, and outlaw non-consensual modifications to sex characteristics. The Act was widely welcomed by civil society organizations. [49] [50] [51] [52] [53]

Gender variance and medicine

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". [54] For centuries, gender variance was seen by medicine as a pathology. [55] [56] The World Health Organization identified gender dysphoria as a mental disorder in the International Classification of Diseases (ICD) until 2018. [57] Gender dysphoria was also listed in the Diagnostic and Statistical Manual of Mental Disorders ( DSM-5) of the American Psychiatric Association, where it was previously called "transsexualism" and "gender identity disorder". [58] [59]

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. [60] However, the difference between "gender dysphoria" and "gender incongruence" is not always clear in the medical literature. [61]

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. [55] [62] [63] Other studies argue that gender incongruence diagnosis may be important and even positive for transgender people at the individual and social level. [64]

As there are various ways of classifying or characterizing those who are either diagnosed or self-affirm as transgender individuals, the literature cannot clearly estimate how prevalent these experiences are within the total population. The results of a recent systematic review highlight the need to standardize the scope and methodology related to data collection of those presenting as transgender. [65]

Sex reassignment therapy

Various options are available for transgender people to pursue physical transition. There have been options for transitioning for transgender individuals since 1917. [2] 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. [66] Preventive health care is a crucial part of transitioning and a primary care physician is recommended for transgender people who are transitioning. [66]

Hormone replacement therapy

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. [66] 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. [20] 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. [20] 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). [20] Regular monitoring by an endocrinologist is a strong recommendation to ensure the safety of individuals as they transition. [67]

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. [68] 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. [69]

Hormone therapy for transgender individuals has been shown in medical literature to be safe, when supervised by a qualified medical professional. [70]

Transgender people seeking surgery may be informed they will need to take hormones for the rest of their life if they want to maintain the feminizing effects of oestrogen or the masculinizing effects of testosterone. Their dose of hormones will usually be reduced, but it should still be enough to produce the effects that they need and to keep them well, and to protect them against osteoporosis (thinning of the bones) as they get older. If they are still on hormone blockers, they will stop taking them altogether. [71]

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. [66]

Sex reassignment surgery

Main article: Sex reassignment surgery

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 [66] [72]

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.

Issues affecting transgender patients

Violence

The heightened levels of violence and abuse that transgender people experience result in unique adverse effects on bodily and mental health. [73] 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. [74] [75] 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 as a key health risk factor for the physical and mental health of transgender people. [76]

There is limited data regarding the impact of social determinants of health on transgender and gender non-conforming individuals health outcomes. [77] 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. [78]

Despite its importance, access to preventive 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. [79] 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. [80]

Mental health

Transgender individuals may experience distress and sadness as a result of their gender identity being inconsistent with their biological sex. This distress is referred to as gender dysphoria. [81] Gender dysphoria is typically most upsetting for the individual prior to transitioning, and once the individual begins to transition into their desired gender, whether the transition be socially, medically, or both, the distress frequently lessens. [82] [83] [84]

Those who are transgender are significantly more likely to be diagnosed with anxiety disorders or depression than the general population. [82] [83] [84] [85] A number of studies suggest that the inflated rates of depression and anxiety in transgender individuals may partially be because of systematic discrimination or a lack of support. [86] [87] Evidence suggests that these increased rates begin to normalize when transgender individuals are accepted as their identified gender and when they live within a supportive household. [86] [87] [88]

Many studies report extremely high rates of suicide within the transgender community. [82] [85] A United States study of 6,450 transgender individuals found that 41% of them had attempted suicide, as differing from the national average of 4.6%. The very same survey found that these rates were the most high for certain demographics, with transgender youth between the ages of 18 and 24 having the highest percent. [89] Individuals in the survey who were multiracial, had lower levels of education, and those with a lower annual income were all more likely to have attempted. [89] Specifically, transgender males as a group are the most likely to attempt suicide, more so than transgender females. [89] [90] Later surveys suggest that the rate of suicidal attempts for non-binary individuals is in between the two. [90] Transgender adults who have "de-transitioned", meaning having gone back to living as their sex assigned at birth, are significantly more likely to attempt suicide than transgender adults who have never "de-transitioned". [91]

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. [92] The expectation to experience rejection can become an important stressor for transgender and gender non-conforming individuals. [93] Mental health problems among trans people are related to higher rates of self-harm, drug usage, and suicidal ideations and attempts. [76]

Health experiences

Trans people are a vulnerable population of patients with negative experiences in health care contributing to stigmatization of their gender identity. As noted by a systematic review conducted by researchers at James Cook University, evidence reports that 75.3% of respondents have negative experiences during physician visits when seeking gender identity-based care. [94]

Clinic environment

Guidelines from the UCSF Transgender Care Center state the importance of visibility in chosen gender identity for transgender or non-binary patients. Safe environments include a two-step process in collecting gender identity data by differentiating between personal identity and assignments at birth for medical histories. Common techniques recommended are asking patients their preferred name, pronouns, and other names they may go by in legal documents. In addition, visibility of non-cisgender identities is defined by the work environment of the clinic. Front-desk staff and medical assistants will interact with patients, which these guidelines recommend appropriate training. The existence of at least one gender-neutral bathroom shows consideration of patients with non-binary gender identities. [95]

Clinicians may improperly connect transgender people's symptoms to their gender transition, a phenomenon known as trans broken arm syndrome. Trans broken arm syndrome is particularly prevalent among mental health practicioners, but it exists in all fields of medicine. Misguided investigation of transition-related causes can frustrate patients and cause delay in or refusal of treatment, [96] [97] [98] or misdiagnosis and prescription of a wrong treatment. [99] Misattribution of symptoms to transgender hormone therapy may also cause doctors to erroneously recommend the patient stop taking hormones. [100] Trans broken arm syndrome may also manifest as health insurance companies refusing to pay for treatments, claiming the treated condition is caused by the patient's transgender status, and thus is a pre-existing condition. [101] According to The SAGE Encyclopedia of Trans Studies, trans broken arm syndrome is a form of discrimination against transgender people. [102] A 2021 survey by TransActual shows that 57% of transgender people in the United Kingdom put off seeing a doctor when they were ill. [103] In 2014, 43% of transgender counselling clients in the UK said their counsellor "wanted to explore transgender issues in therapy even when this wasn't the reason they had sought help". [104]

Global access to transgender health care

Global access to healthcare across primary and secondary health settings remains fragmented for transgender people, [105] with access and services highly dependent on a political administration's support for trans health in policy as well as globally-engrained health inequalities largely shaped by financial wealth inequalities such as the Global North and Global South divide. [106] [107]

Africa

South Africa

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. [108] 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. [108]

Asia

Thailand

Transgender women, known as kathoeys, have access to hormones through non-prescription sources. [109] This kind of access is a result of the low availability and expense of transgender health care clinics. [109] 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. [110] As a result, just a third of all trans men surveyed are taking hormones to transition whereas almost three quarters of kathoeys surveyed are taking hormones. [110]

Mainland China

In Mainland China access to resources and HRT prescriptions are rare, and as a result most people resort to hormones through non-prescription resources. The resources of accessing hormone including Peking University Third Hospital, Dr.Liu(刘烨)and Dr. Pan(潘柏林), Zhongshan Hospital, Dr. Li (李小英), And Shanghai Ninth People's Hospital, Dr. Cheng (程辰). In Changhai Hospital of Shanghai (Hongkou division), Dr. Zhao (赵烨德) can do both HRT prescriptions and SRS. [111]

Europe

Spain

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. [112] 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. [112] [113] As of 2013, over 4000 transgender patients had been treated in Spain, including Spaniards and international patients. [112] [114]

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. [112]

Sweden

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. [115] 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. [116]

Depending on the persons health and wishes there are a number of different treatments and surgeries available. 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), the person will need to be diagnosed with transexualism or gender dysphoria, which requires at least one year of therapy. [117] 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. [118] The fee the individual pays for a doctor's appointment or other care represents only a small fraction of the actual costs. [119] If a person would like to change their legal gender marker and personal identity number they will have to seek permission from the National Board of Health and Welfare. [117] 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. [120]

In Sweden, anyone is allowed to change their name at any time, including for gender transition. [121]

Up until January 27, 2017, being transsexual was classed as a disease. 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. The activists demanded that their voices be heard regarding the way the country, healthcare, and the National Board of Health and Welfare mistreat transgender and intersex individuals. [122]

Netherlands

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

Gender care in the Netherlands is insured under the national health care of third part insurer’s, including lazer hair removal, SRS, facial feminization surgery and hormones. Hormones can be prescribed by licensed endocrinologist in a academic hospital from the age 16 and older. Blockers can be prescribed from age 12 when puberty usually starts.

United Kingdom

In 2018 Stonewall described UK transgender healthcare as having "significant barriers to accessing treatment, including waiting times that stretch into years, far exceeding the maximums set by law for NHS patients". [123] Patients have the legal right to begin treatment within 18 weeks of referral by their GP, however the average wait for patients to gender identity clinics was 18 months in 2020 with over 13,000 people on the waiting list for appointments at gender identity clinics. . [124]

A 2013 survey of gender identity clinic services provided by the UK National Health Service (NHS) 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. [125] This study focused on transgender people using the NHS clinics and so was prone to survivorship bias, as those unhappy with the NHS service are less likely to use it. 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. [125] 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. [125]

Scotland

There are four NHS Scotland Gender Identity Clinics providing services to adults and a separate service for younger people. [126] The National Gender Identity Clinical Network for Scotland reported in 2021 that some patients had waited in excess of two years from referral for their first appointment. [127] Minister for Public Health Maree Todd has stated that the Scottish Government wants to reduce "unacceptable waits to access gender identity services". [128] Research has indicated patient dissatisfaction with long wait times. [129] However, overall experience of treatment outcomes was largely positive, particularly for hormone therapy and surgery. [130]

North America

Canada

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. [131] 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. [132]

All Canadian provinces fund some sex reassignment surgeries, with New Brunswick being the last of the provinces to start insuring these procedures in 2016. [133] 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. [134] [135] [136] Insurance coverage is not generally provided for the transition-related procedures of facial feminization surgery, tracheal shave, or laser hair removal. [137]

Blood donation

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 sex with a man in the last 3 months. If the response is yes, they will be deferred for 3 months after their last sexual contact with a man. Donors who have had lower gender affirming surgery will be deferred from donating blood for 3 months after their surgery. After those months, these donors will be screened in their affirmed gender. [138] [139] [140]

Mexico

A July 2016 study in The Lancet Psychiatry reported that nearly half of transgender people surveyed undertook body-altering procedures without medical supervision. [141] Transition-related care is not covered under Mexico's national health plan. [142] Only one public health institution in Mexico provides free hormones for transgender people. [141] Health care for transgender Mexicans focuses on HIV and prevention of other sexually transmitted diseases. [141]

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. [143]

United States

See also: Transgender rights in the United States

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. [144] Aside from transition related care, transgender and gender non-conforming individuals need preventive care such as vaccines, gynecological care, prostate exams, and other annual preventive health measures. [2] Various factors play a role in creating the limited access to care, such as insurance coverage issues related to their legal gender identity status. [2]

The Affordable Care Act (commonly known as Obamacare) 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. [77] However, insurance sold outside of the ACA marketplace does not have to follow these requirements. This means that preventive care, such as gynecological exams for transgender men, may not be covered. [145]

South America

Colombia

Transgender women sex workers have cited financial difficulties as barriers to accessing physical transition options. [146] As a result, they have entered sex work to relieve financial burdens, both those related to transition and those not related to transition. [146] 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. [146]

Health care for transgender youth

See also: Suicide among LGBT youth

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. [147] 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. [147]

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. [148] 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. [149]

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. [66] [150] Concerns regarding the impact of puberty blockers on physical health, such as bone density, have also been raised. [150] Long-term use of puberty blockers has also gone relatively unstudied, bringing up questions about harmful long-term side effects. [150] While there is concern about the physical effects of puberty blockers, the mental effects are positive with treatment associated with significant improvements in multiple psychological measures, including global functioning, depression, and overall behavioral and/or emotional problems. [151]

Health care for transgender older adults

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. [152] Trans individuals face the risk of aging with more limited support and in more stigmatizing environments than heteronormative individuals. [153] 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. [154]

See also

Bibliography

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"Sexual reassignment" redirects here. For the medical procedure, see Sex reassignment surgery.
Part of a series on
Transgender topics
     
Gender identities
Health care practices
Rights and legal status
Society and culture
Events and awareness
Culture
Theory and concepts
By country
Rights
History
See also
  Category

Transgender health care, also known as gender-affirming care, [1] includes the prevention, diagnosis and treatment of physical and mental health conditions, as well as sex reassignment therapies, for transgender individuals. [2] Questions implicated in transgender health care include gender variance, sex reassignment therapy, health risks (in relation to violence and mental health), and access to healthcare for trans people in different countries around the world.

Sex reassignment therapy or medical transition is the medical aspect of gender transitioning, that is, modifying one's sex characteristics to better suit one's gender identity. It can consist of hormone therapy to modify secondary sex characteristics, sex reassignment surgery to alter primary sex characteristics, and other procedures altering appearance, such as permanent hair removal for trans women.

In appropriately evaluated cases of severe gender dysphoria, sex reassignment therapy is often the best when standards of care are followed. [3]: 1570  [4]: 2108  There is academic concern over the low quality of the evidence supporting the efficacy of sex reassignment therapy as treatment for gender dysphoria, but more robust studies are impractical to carry out; [5]: 22  as well, there exists a broad clinical consensus, supplementing the academic research, that supports the effectiveness in terms of subjective improvement of sex reassignment therapy in appropriately selected patients. [5]: 2–3  Treatment of gender dysphoria does not involve attempting to correct the patient's gender identity, but to help the patient adapt. [3]: 1568 

Major health organizations in the United States and UK have issued affirmative statements supporting sex reassignment therapy as comprising medically necessary treatments in certain appropriately evaluated cases. [6] [7] [8] [9] [10]

Eligibility

In the International Classification of Diseases, the diagnosis is known as transsexualism. [11] The US Diagnostic and Statistical Manual of Mental Disorders (DSM) names it gender dysphoria (in version 5 [12]). Some people who are validly diagnosed have no desire for all or some parts of sex reassignment therapy, particularly genital reassignment surgery, and/or are not appropriate candidates for such treatment.

The general standard for diagnosing, as well as treating, gender dysphoria is outlined in the WPATH Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. As of February 2014, the most recent version of the standards is Version 7. [13] According to the standards of care, "gender dysphoria refers to discomfort or distress that is caused by a discrepancy between a person's gender identity and that person's sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics). Only some gender-nonconforming people experience gender dysphoria at some point in their lives". Gender nonconformity is not the same as gender dysphoria; nonconformity, according to the standards of care, is not a pathology and does not require medical treatment.

The informed consent model is an alternative to the standard WPATH approach which does not require a person seeking transition related medical treatment to undergo formal assessment of their mental health or gender dysphoria. Arguments in favor of this model describe required assessments as gatekeeping, dehumanizing, pathologizing, and reinforcing a reductive perception of transgender experiences. [14] Informed consent approaches include conversations between the medical provider and person seeking care on the details of risks and outcomes, current understandings of scientific research, and how the provider can best assist the person in making decisions. [15]

Local standards of care exist in many countries.

Eligibility for different stages of treatment

While a mental health assessment is required by the standards of care, psychotherapy is not an absolute requirement but is highly recommended. [13]

Hormone replacement therapy is to be initiated from a qualified health professional. The general requirements, according to the WPATH standards, include:

  1. Persistent, well-documented gender dysphoria;
  2. Capacity to make a fully informed decision and to consent for treatment;
  3. Age of majority in a given country (however, the WPATH standards of care provide separate discussion of children and adolescents);
  4. If significant medical or mental health concerns are present, they must be reasonably well-controlled.

Often, at least a certain period of psychological counseling is required before initiating hormone replacement therapy, as is a period of living in the desired gender role, if possible, to ensure that they can psychologically function in that life-role. On the other hand, some clinics provide hormone therapy based on informed consent alone. [13]

Eligibility of minors

While the WPATH standards of care generally require the patient to have reached the age of majority, they include a separate section devoted to children and adolescents. [13]

Psychological treatment

According to the WPATH SOC v7, "Psychotherapy (individual, couple, family, or group) for purposes such as exploring gender identity, role, and expression; addressing the negative impact of gender dysphoria and stigma on mental health; alleviating internalized transphobia; enhancing social and peer support; improving body image; or promoting resilience" is a treatment option. [13]

Some transsexual people may suffer from co-morbid psychiatric conditions unrelated to their gender dysphoria. In cases of comorbid psychopathology, the standards are to manage the psychopathology "prior to, or concurrent with, treatment of gender dysphoria". [13] Treatment may still be appropriate and necessary in cases of significant comorbid psychopathology, as cases have been reported in which the individual was both suffering from severe co-occurring psychopathology, and was a 'late-onset, gynephilic' trans woman, and yet experienced a long-term, positive outcome with hormonal and surgical gender transition. [5]: 22  The DSM-IV itself states that in rare instances, gender dysphoria may co-exist with schizophrenia, and that psychiatric disorders are not generally considered contraindications to sex reassignment therapy unless they are the primary cause of the patient's gender dysphoria. [16]: 108 

Hormone therapy

Main article: Transgender hormone therapy

For trans people, hormone therapy causes the development of many of the secondary sexual characteristics of their desired sex. However, many of the existing primary and secondary sexual characteristics cannot be reversed by hormone therapy. For example, hormone therapy can induce breast growth for trans women but can only minimally reduce breasts for trans men. HRT can prompt facial hair growth for transgender men, but cannot regress facial hair for transgender women. Hormone therapy may, however, reverse some characteristics, such as distribution of body fat and muscle, as well as menstruation in trans men.

Generally, those traits that are easily reversible will revert upon cessation of hormonal treatment, unless chemical or surgical castration has occurred, though for many trans people, surgery is required to obtain satisfactory physical characteristics. But in trans men, some hormonally-induced changes may become virtually irreversible within weeks, whereas trans women usually have to take hormones for many months before any irreversible changes will result.

As with all medical activities, health risks are associated with hormone replacement therapy, especially when high hormone doses are taken as is common for pre-operative or no-operative trans patients. It is always advised that all changes in therapeutic hormonal treatment should be supervised by a physician because starting, stopping or even changing dosage rates and levels can have physical and psychological health risks.

Although some trans women use herbal phytoestrogens as alternatives to pharmaceutical estrogens, little research has been performed with regards to the safety or effectiveness of such products. Anecdotal evidence suggests that the results of herbal treatments are minimal and very subtle, if at all noticeable, when compared to conventional hormone therapy.

Some trans people are able to avoid the medical community's requirements for hormone therapy altogether by either obtaining hormones from black market sources, such as internet pharmacies which ship from overseas, or more rarely, by synthesizing hormones themselves.

Medications

Testosterone therapy is typically used for masculinizing treatments. Effects can include thicker vocal cords, increased muscle mass, hair loss, and thicker skin. [17] [18] Intramuscular, subcutaneous, and transdermal options are available. [19] These include cypionate (Depo-Testosterone®), and the longer acting testosterone undecanoate ( Aveed®). Oral formulations are available in Europe, Andriol®, but are not available in the U.S. due to their pharmacokinetic properties. [20]

Estrogen and anti-androgen therapy are typically used for feminizing treatments. [21] [22] Estrogen is available in oral, parenteral, and transdermal formulations. Often, estrogen alone is insufficient for androgen suppression, and appropriate therapy will call for additional anti-androgen medications. [23] Anti-androgen medications include progesterone, medroxyprogesterone acetate, spironolactone, and finasteride. [20]

Sex reassignment surgery

Main articles: Sex reassignment surgery, Sex reassignment surgery (male-to-female), and Sex reassignment surgery (female-to-male)

Sex reassignment surgery (SRS) refers to the surgical and medical procedures undertaken to align intersex and transsexual individuals' physical appearance and genital anatomy with their gender identity. SRS may encompass any surgical procedures which will reshape a male body into a body with a female appearance or vice versa, or more specifically refer to the procedures used to make male genitals into female genitals and vice versa.

Other terms used for SRS include "gender confirmation surgery", "gender realignment surgery", and "transsexual surgery". These terms may also specifically refer to genital surgeries like vaginoplasty, metoidioplasty, and phalloplasty, even though more specific terms exist to refer exclusively to genital surgery, the most common of which is genital reassignment surgery (GRS). The term "genital reconstruction surgery" may also be used.

Chest surgery

Main articles: Male chest reconstruction and Breast augmentation

Many trans men seek mastectomy and male chest reconstruction.

Breast augmentations for trans women are done in a similar manner to those for cisgender women.

Effectiveness

The Merck Manual states, in regard to trans women, "In follow-up studies, genital surgery has helped some transsexual people live happier and more productive lives and so is justified in highly motivated, appropriately assessed and treated transsexual people, who have completed a 1- to 2-year real-life experience in a different gender role. Before surgery, transsexual people often need assistance with passing in public, including help with gestures and voice modulation. Participation in support groups, available in most large cities, is usually helpful." [3]: 1570  With regards to trans men, it states, "Surgery may help certain [trans men] patients achieve greater adaptation and life satisfaction. Similar to trans women, trans men should live in the male gender role for at least 1 yr before surgery. Anatomic results of neophallus surgical procedures are often less satisfactory in terms of function and appearance than neovaginal procedures for trans women. Complications are common, especially in procedures that involve extending the urethra into the neophallus." [3]: 1570 

Kaplan and Sadock's Comprehensive Textbook of Psychiatry states, with regards to adults, "When patient gender dysphoria is severe and intractable, sex reassignment is often the best solution." [4]: 2108  Regret tends to occur in cases of misdiagnosis, no Real Life Experience, and poor surgical results. Risk factors for return to original gender role include history of transvestic fetishism, psychological instability, and social isolation. In adolescents, careful diagnosis and following strict criteria can ensure good post-operative outcomes. Many prepubescent children with cross-gender identities do not persist with gender dysphoria. [4]: 2109–2110  With regards to follow-up, it states that "Clinicians are less likely to report poor outcomes in their patients, thus shifting the reporting bias to positive results. However, some successful patients who wish to blend into the community as men or women do not make themselves available for follow-up. Also, some patients who are not happy with their reassignment may be more known to clinicians as they continue clinical contact." [4]: 2109 

A 2009 systematic review looking at individual surgical procedures found that "[t]he evidence concerning gender reassignment surgery has several limitations in terms of: (a) lack of controlled studies, (b) evidence has not collected data prospectively, (c) high loss to follow up and (d) lack of validated assessment measures. Some satisfactory outcomes were reported, but the magnitude of benefit and harm for individual surgical procedures cannot be estimated accurately using the current available evidence." [24]

A 2010 meta-analysis of follow-up studies reported "Pooling across studies shows that after sex reassignment, 80% of individuals with GID reported significant improvement in gender dysphoria (95% CI = 68–89%; 8 studies; I2 = 82%); 78% reported significant improvement in psychological symptoms (95% CI = 56–94%; 7 studies; I2 = 86%); 80% reported significant improvement in quality of life (95% CI = 72–88%; 16 studies; I2 = 78%); and 72% reported significant improvement in sexual function (95% CI = 60–81%; 15 studies; I2 = 78%)." The study concluded "Very low quality evidence suggests that sex reassignment that includes hormonal interventions in individuals with GID likely improves gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life." [25]

A study evaluating quality of life in female-to-male transgender individuals found "statistically significant (p<0.01) diminished quality of life among the FTM transgender participants as compared to the US male and female population, particularly in regard to mental health. FTM transgender participants who received testosterone (67%) reported statistically significant higher quality of life scores (p<0.01) than those who had not received hormone therapy." [26]

A recent Swedish study (2010) found that “almost all patients were satisfied with sex reassignment at 5 years, and 86% were assessed by clinicians at follow-up as stable or improved in global functioning” [27] A prospective study in the Netherlands that looked at the psychological and sexual functioning of 162 adult applicants of adult sex reassignment applicants before and after hormonal and surgical treatment found, "After treatment the group was no longer gender dysphoric. The vast majority functioned quite well psychologically, socially and sexually. Two non-homosexual male-to-female transsexuals expressed regrets." [28]

A long-term follow-up study performed in Sweden over a long period of time (1973–2003) found that morbidity, suicidality, and mortality in post-operative trans people were still significantly higher than in the general population, suggesting that sex reassignment therapy is not enough to treat gender dysphoria, highlighting the need for improved health care following sex reassignment surgery. 10 controls were selected for each post-operative trans person, matched by birth year and sex; two control groups were used: one matching sex at birth, the other matching reassigned sex. The study states that "no inferences can be drawn [from this study] as to the effectiveness of sex reassignment as a treatment for transsexualism," citing studies showing the effectiveness of sex reassignment therapy, though noting their poor quality. The authors noted that the results suggested that those who received sex reassignment surgery before 1989 had worse mortality, suicidality, and crime rates than those who received surgery on or after 1989: mortality, suicidality, and crime rates for the 1989-2003 cohort were not statistically significant compared to healthy controls (though psychiatric morbidity was); it is not clear if this is because these negative factors tended to increase a decade after surgery or because in the 1990s and later improved treatment and social attitudes may have led to better outcomes. [29]

The abstract of the American Psychiatric Association Task Force on GID's report from 2012 states, "The quality of evidence pertaining to most aspects of treatment in all subgroups was determined to be low; however, areas of broad clinical consensus were identified and were deemed sufficient to support recommendations for treatment in all subgroups." [5] The APA Task Force states, with regard to the quality of studies, "For some important aspects of transgender care, it would be impossible or unwise to engage in more robust study designs due to ethical concerns and lack of volunteer enrollment. For example, it would be extremely problematic to include a 'long-term placebo treated control group' in an RCT of hormone therapy efficacy among gender variant adults desiring to use hormonal treatments." [5]: 22  The Royal College of Psychiatrists concurs with regards to SRS in trans women, stating, "There is no level 1 or 2 evidence (Oxford levels) supporting the use of feminising vaginoplasty in women but this is to be expected since a randomised controlled study for this scenario would be impossible to carry out." [9]

Following up on the APA Task Force's report, the APA issued a statement stating that the APA recognizes that in "appropriately evaluated" cases, hormonal and surgical interventions may be medically necessary and opposes "categorical exclusions" of such treatment by third-party payers. [6] The American Medical Association's Resolution 122 states, "An established body of medical research demonstrates the effectiveness and medical necessity of mental health care, hormone therapy and sex reassignment surgery as forms of therapeutic treatment for many people diagnosed with GID". [7]

The need for treatment is emphasized by the higher rate of mental health problems, including depression, anxiety, and various addictions, as well as a higher suicide rate among untreated transsexual people than in the general population. Many of these problems, in the majority of cases, disappear or decrease significantly after a change of gender role and/or physical characteristics. [30] [31]

In 2021, a review published in Plastic And Reconstructive Surgery found that less than 1% of people who undergo gender-affirming surgery regret the decision, although the authors said more research was needed, as the pool of sources was heterogeneous and many were viewed at "medium-to-high" risk of bias. [32]

Ethical, cultural, and political considerations

Sex reassignment therapy is a controversial ethical subject. Notably, the Roman Catholic church, according to an unpublished Vatican document, holds that changing sex is not possible and, while in some cases treatment might be necessary, it does not change the person's sex in the eyes of the church. [33] Some Catholic ethicists go further, proclaiming that a "sex change operation" is "mutilation" and therefore immoral. [34]

Paul R. McHugh is a well-known opponent of sex reassignment therapy. According to his own article, [35] when he joined Johns Hopkins University as director of the Department of Psychiatry and Behavioral Science, it was part of his intention to end sex reassignment surgery there. McHugh succeeded in ending it at the university during his time. [36] However, a new gender clinic at Johns Hopkins has been opened in 2017. [37]

Opposition was also expressed by several writers identifying as feminist, most famously Janice Raymond. Her paper was allegedly instrumental in removing Medicaid and Medicare support for sex reassignment therapy in the US. [38]

Sex reassignment therapy, especially surgery, tends to be expensive and is not always covered by public or private health insurance. In many areas with comprehensive nationalized health care, such as some Canadian provinces and most European countries, SRT is covered under these plans. However, requirements for obtaining SRS and other transsexual services under these plans are sometimes more stringent than the requirements laid out in the WPATH Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, and in Europe, many local Standards of Care exist. In other countries, such as the United States, no national health plan exists and the majority of private insurance companies do not cover SRS. The government of Iran, however, pays for such surgery because it is believed to be valid under Shi'ite Belief. [39]

A significant and growing political movement exists, pushing to redefine the standards of care, asserting that they do not acknowledge the rights of self-determination and control over one's body, and that they expect (and even in many ways require) a monolithic transsexual experience. In opposition to this movement is a group of transsexual persons and caregivers who assert that the SOC are in place to protect others from "making a mistake" and causing irreversible changes to their bodies that will later be regretted – though few post-operative transsexuals believe that sexual reassignment surgery was a mistake for them. [40]

The United States

See also: Transgender rights in the United States § Healthcare

From 1981 until 2014, the Centers for Medicare and Medicaid Services (CMS) categorically excluded coverage of sex reassignment surgery by Medicare in its National Coverage Determination (NCD) "140.3 Transsexual Surgery," but that categorical exclusion came under challenge by an "aggrieved party" in an Acceptable NCD Complaint in 2013 and was subsequently struck down the following year by the Departmental Appeals Board (DAB), the administrative court of the U.S. Department of Health and Human Services (HHS). [41] [42] In late 2013, the DAB issued a ruling finding the evidence on record was "not complete and adequate to support the validity of the NCD" and then moved on to discovery to determine if the exclusion was valid. [43] CMS did not defend its exclusion throughout the entire process. On May 30, 2014, HHS announced that the categorical exclusion was found by the DAB to not be valid "under the 'reasonableness standard,'" allowing for Medicare coverage of sex reassignment surgery to be decided on a case-by-case basis. HHS says it will move to implement the ruling. As Medicaid and private insurers often take their cues from Medicare on what to cover, this may lead to coverage of sex reassignment therapy by Medicaid and private insurers. [41] [42] The evidence in the case "outweighs the NCD record and demonstrates that transsexual surgery is safe and effective and not experimental," according to the DAB in its 2014 ruling. [44]

A 2014 article published in American Journal of Public Health called on third-party payers to cover sex reassignment therapy in appropriately selected cases. [45]

Mandatory sterilization

In Sweden until 2012, sterilization was mandatory before sex reassignment in Sweden. [46]

Consent and the treatment of intersex people

Main article: Intersex human rights

In 2011, Christiane Völling won the first successful case brought by an intersex person against a surgeon for non-consensual surgical intervention described by the International Commission of Jurists as "an example of an individual who was subjected to sex reassignment surgery without full knowledge or consent". [47]

In 2015, the Council of Europe recognized, for the first time, a right for intersex persons to not undergo sex assignment treatment. [48] In April 2015, Malta became the first country to recognize a right to bodily integrity and physical autonomy, and outlaw non-consensual modifications to sex characteristics. The Act was widely welcomed by civil society organizations. [49] [50] [51] [52] [53]

Gender variance and medicine

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". [54] For centuries, gender variance was seen by medicine as a pathology. [55] [56] The World Health Organization identified gender dysphoria as a mental disorder in the International Classification of Diseases (ICD) until 2018. [57] Gender dysphoria was also listed in the Diagnostic and Statistical Manual of Mental Disorders ( DSM-5) of the American Psychiatric Association, where it was previously called "transsexualism" and "gender identity disorder". [58] [59]

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. [60] However, the difference between "gender dysphoria" and "gender incongruence" is not always clear in the medical literature. [61]

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. [55] [62] [63] Other studies argue that gender incongruence diagnosis may be important and even positive for transgender people at the individual and social level. [64]

As there are various ways of classifying or characterizing those who are either diagnosed or self-affirm as transgender individuals, the literature cannot clearly estimate how prevalent these experiences are within the total population. The results of a recent systematic review highlight the need to standardize the scope and methodology related to data collection of those presenting as transgender. [65]

Sex reassignment therapy

Various options are available for transgender people to pursue physical transition. There have been options for transitioning for transgender individuals since 1917. [2] 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. [66] Preventive health care is a crucial part of transitioning and a primary care physician is recommended for transgender people who are transitioning. [66]

Hormone replacement therapy

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. [66] 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. [20] 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. [20] 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). [20] Regular monitoring by an endocrinologist is a strong recommendation to ensure the safety of individuals as they transition. [67]

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. [68] 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. [69]

Hormone therapy for transgender individuals has been shown in medical literature to be safe, when supervised by a qualified medical professional. [70]

Transgender people seeking surgery may be informed they will need to take hormones for the rest of their life if they want to maintain the feminizing effects of oestrogen or the masculinizing effects of testosterone. Their dose of hormones will usually be reduced, but it should still be enough to produce the effects that they need and to keep them well, and to protect them against osteoporosis (thinning of the bones) as they get older. If they are still on hormone blockers, they will stop taking them altogether. [71]

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. [66]

Sex reassignment surgery

Main article: Sex reassignment surgery

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 [66] [72]

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.

Issues affecting transgender patients

Violence

The heightened levels of violence and abuse that transgender people experience result in unique adverse effects on bodily and mental health. [73] 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. [74] [75] 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 as a key health risk factor for the physical and mental health of transgender people. [76]

There is limited data regarding the impact of social determinants of health on transgender and gender non-conforming individuals health outcomes. [77] 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. [78]

Despite its importance, access to preventive 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. [79] 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. [80]

Mental health

Transgender individuals may experience distress and sadness as a result of their gender identity being inconsistent with their biological sex. This distress is referred to as gender dysphoria. [81] Gender dysphoria is typically most upsetting for the individual prior to transitioning, and once the individual begins to transition into their desired gender, whether the transition be socially, medically, or both, the distress frequently lessens. [82] [83] [84]

Those who are transgender are significantly more likely to be diagnosed with anxiety disorders or depression than the general population. [82] [83] [84] [85] A number of studies suggest that the inflated rates of depression and anxiety in transgender individuals may partially be because of systematic discrimination or a lack of support. [86] [87] Evidence suggests that these increased rates begin to normalize when transgender individuals are accepted as their identified gender and when they live within a supportive household. [86] [87] [88]

Many studies report extremely high rates of suicide within the transgender community. [82] [85] A United States study of 6,450 transgender individuals found that 41% of them had attempted suicide, as differing from the national average of 4.6%. The very same survey found that these rates were the most high for certain demographics, with transgender youth between the ages of 18 and 24 having the highest percent. [89] Individuals in the survey who were multiracial, had lower levels of education, and those with a lower annual income were all more likely to have attempted. [89] Specifically, transgender males as a group are the most likely to attempt suicide, more so than transgender females. [89] [90] Later surveys suggest that the rate of suicidal attempts for non-binary individuals is in between the two. [90] Transgender adults who have "de-transitioned", meaning having gone back to living as their sex assigned at birth, are significantly more likely to attempt suicide than transgender adults who have never "de-transitioned". [91]

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. [92] The expectation to experience rejection can become an important stressor for transgender and gender non-conforming individuals. [93] Mental health problems among trans people are related to higher rates of self-harm, drug usage, and suicidal ideations and attempts. [76]

Health experiences

Trans people are a vulnerable population of patients with negative experiences in health care contributing to stigmatization of their gender identity. As noted by a systematic review conducted by researchers at James Cook University, evidence reports that 75.3% of respondents have negative experiences during physician visits when seeking gender identity-based care. [94]

Clinic environment

Guidelines from the UCSF Transgender Care Center state the importance of visibility in chosen gender identity for transgender or non-binary patients. Safe environments include a two-step process in collecting gender identity data by differentiating between personal identity and assignments at birth for medical histories. Common techniques recommended are asking patients their preferred name, pronouns, and other names they may go by in legal documents. In addition, visibility of non-cisgender identities is defined by the work environment of the clinic. Front-desk staff and medical assistants will interact with patients, which these guidelines recommend appropriate training. The existence of at least one gender-neutral bathroom shows consideration of patients with non-binary gender identities. [95]

Clinicians may improperly connect transgender people's symptoms to their gender transition, a phenomenon known as trans broken arm syndrome. Trans broken arm syndrome is particularly prevalent among mental health practicioners, but it exists in all fields of medicine. Misguided investigation of transition-related causes can frustrate patients and cause delay in or refusal of treatment, [96] [97] [98] or misdiagnosis and prescription of a wrong treatment. [99] Misattribution of symptoms to transgender hormone therapy may also cause doctors to erroneously recommend the patient stop taking hormones. [100] Trans broken arm syndrome may also manifest as health insurance companies refusing to pay for treatments, claiming the treated condition is caused by the patient's transgender status, and thus is a pre-existing condition. [101] According to The SAGE Encyclopedia of Trans Studies, trans broken arm syndrome is a form of discrimination against transgender people. [102] A 2021 survey by TransActual shows that 57% of transgender people in the United Kingdom put off seeing a doctor when they were ill. [103] In 2014, 43% of transgender counselling clients in the UK said their counsellor "wanted to explore transgender issues in therapy even when this wasn't the reason they had sought help". [104]

Global access to transgender health care

Global access to healthcare across primary and secondary health settings remains fragmented for transgender people, [105] with access and services highly dependent on a political administration's support for trans health in policy as well as globally-engrained health inequalities largely shaped by financial wealth inequalities such as the Global North and Global South divide. [106] [107]

Africa

South Africa

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. [108] 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. [108]

Asia

Thailand

Transgender women, known as kathoeys, have access to hormones through non-prescription sources. [109] This kind of access is a result of the low availability and expense of transgender health care clinics. [109] 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. [110] As a result, just a third of all trans men surveyed are taking hormones to transition whereas almost three quarters of kathoeys surveyed are taking hormones. [110]

Mainland China

In Mainland China access to resources and HRT prescriptions are rare, and as a result most people resort to hormones through non-prescription resources. The resources of accessing hormone including Peking University Third Hospital, Dr.Liu(刘烨)and Dr. Pan(潘柏林), Zhongshan Hospital, Dr. Li (李小英), And Shanghai Ninth People's Hospital, Dr. Cheng (程辰). In Changhai Hospital of Shanghai (Hongkou division), Dr. Zhao (赵烨德) can do both HRT prescriptions and SRS. [111]

Europe

Spain

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. [112] 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. [112] [113] As of 2013, over 4000 transgender patients had been treated in Spain, including Spaniards and international patients. [112] [114]

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. [112]

Sweden

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. [115] 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. [116]

Depending on the persons health and wishes there are a number of different treatments and surgeries available. 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), the person will need to be diagnosed with transexualism or gender dysphoria, which requires at least one year of therapy. [117] 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. [118] The fee the individual pays for a doctor's appointment or other care represents only a small fraction of the actual costs. [119] If a person would like to change their legal gender marker and personal identity number they will have to seek permission from the National Board of Health and Welfare. [117] 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. [120]

In Sweden, anyone is allowed to change their name at any time, including for gender transition. [121]

Up until January 27, 2017, being transsexual was classed as a disease. 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. The activists demanded that their voices be heard regarding the way the country, healthcare, and the National Board of Health and Welfare mistreat transgender and intersex individuals. [122]

Netherlands

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

Gender care in the Netherlands is insured under the national health care of third part insurer’s, including lazer hair removal, SRS, facial feminization surgery and hormones. Hormones can be prescribed by licensed endocrinologist in a academic hospital from the age 16 and older. Blockers can be prescribed from age 12 when puberty usually starts.

United Kingdom

In 2018 Stonewall described UK transgender healthcare as having "significant barriers to accessing treatment, including waiting times that stretch into years, far exceeding the maximums set by law for NHS patients". [123] Patients have the legal right to begin treatment within 18 weeks of referral by their GP, however the average wait for patients to gender identity clinics was 18 months in 2020 with over 13,000 people on the waiting list for appointments at gender identity clinics. . [124]

A 2013 survey of gender identity clinic services provided by the UK National Health Service (NHS) 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. [125] This study focused on transgender people using the NHS clinics and so was prone to survivorship bias, as those unhappy with the NHS service are less likely to use it. 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. [125] 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. [125]

Scotland

There are four NHS Scotland Gender Identity Clinics providing services to adults and a separate service for younger people. [126] The National Gender Identity Clinical Network for Scotland reported in 2021 that some patients had waited in excess of two years from referral for their first appointment. [127] Minister for Public Health Maree Todd has stated that the Scottish Government wants to reduce "unacceptable waits to access gender identity services". [128] Research has indicated patient dissatisfaction with long wait times. [129] However, overall experience of treatment outcomes was largely positive, particularly for hormone therapy and surgery. [130]

North America

Canada

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. [131] 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. [132]

All Canadian provinces fund some sex reassignment surgeries, with New Brunswick being the last of the provinces to start insuring these procedures in 2016. [133] 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. [134] [135] [136] Insurance coverage is not generally provided for the transition-related procedures of facial feminization surgery, tracheal shave, or laser hair removal. [137]

Blood donation

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 sex with a man in the last 3 months. If the response is yes, they will be deferred for 3 months after their last sexual contact with a man. Donors who have had lower gender affirming surgery will be deferred from donating blood for 3 months after their surgery. After those months, these donors will be screened in their affirmed gender. [138] [139] [140]

Mexico

A July 2016 study in The Lancet Psychiatry reported that nearly half of transgender people surveyed undertook body-altering procedures without medical supervision. [141] Transition-related care is not covered under Mexico's national health plan. [142] Only one public health institution in Mexico provides free hormones for transgender people. [141] Health care for transgender Mexicans focuses on HIV and prevention of other sexually transmitted diseases. [141]

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. [143]

United States

See also: Transgender rights in the United States

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. [144] Aside from transition related care, transgender and gender non-conforming individuals need preventive care such as vaccines, gynecological care, prostate exams, and other annual preventive health measures. [2] Various factors play a role in creating the limited access to care, such as insurance coverage issues related to their legal gender identity status. [2]

The Affordable Care Act (commonly known as Obamacare) 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. [77] However, insurance sold outside of the ACA marketplace does not have to follow these requirements. This means that preventive care, such as gynecological exams for transgender men, may not be covered. [145]

South America

Colombia

Transgender women sex workers have cited financial difficulties as barriers to accessing physical transition options. [146] As a result, they have entered sex work to relieve financial burdens, both those related to transition and those not related to transition. [146] 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. [146]

Health care for transgender youth

See also: Suicide among LGBT youth

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. [147] 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. [147]

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. [148] 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. [149]

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. [66] [150] Concerns regarding the impact of puberty blockers on physical health, such as bone density, have also been raised. [150] Long-term use of puberty blockers has also gone relatively unstudied, bringing up questions about harmful long-term side effects. [150] While there is concern about the physical effects of puberty blockers, the mental effects are positive with treatment associated with significant improvements in multiple psychological measures, including global functioning, depression, and overall behavioral and/or emotional problems. [151]

Health care for transgender older adults

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. [152] Trans individuals face the risk of aging with more limited support and in more stigmatizing environments than heteronormative individuals. [153] 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. [154]

See also

Bibliography

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