Transgender health care
Transgender health care includes the prevention, diagnosis and treatment of physical and mental health conditions for transgender individuals.[1] A major component of transgender health care is gender-affirming care, the medical aspect of gender transition. 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.
Medical characterization of gender variance
Gender variance is defined in medical literature as "gender identity, expression, or behavior that falls outside of culturally defined norms associated with a specific gender".[2] For centuries, gender variance was seen by medicine as a pathology.[3][4] The World Health Organization identified gender dysphoria as a mental disorder in the International Classification of Diseases (ICD) until 2018.[5] Gender dysphoria was also listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) of the American Psychiatric Association, where it was previously called "transsexualism" and "gender identity disorder".[6][7]
In 2018, the ICD-11 included the term "gender incongruence" as "marked and persistent incongruence between an individual's experienced gender and the assigned sex", where gender variant behaviour and preferences do not necessarily imply a medical diagnosis.[8] However, the difference between "gender dysphoria" and "gender incongruence" is not always clear in the medical literature.[9]
Some studies posit that treating gender variance as a medical condition has negative effects on the health of transgender people and claim that assumptions of coexisting psychiatric symptoms should be avoided.[3][10][11] Other studies argue that gender incongruence diagnosis may be important and even positive for transgender people at the individual and social level.[12]
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.[13]
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.[40] 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.[41][42] 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.[43]
[44] Victimization is often the outcome to disclosure for transgender individuals. Transgender individuals are pressured to conform to gender norms which make them vulnerable for victimization by peers and parents. A study done by Grossman and D’Augelli reported that transgender youth feared that may face physical and sexual violence because of their experience with harassment and discrimination. The youth also express how individuals only see them for their gender and sexuality rather than their personal traits. Many of the youth have also dropped out or experience academic decline because of the constant harassment. Victimization started on average for transgender at the age of 13, while physical abuse started at an average age 14.[45]
Peitzmeier and colleagues conducted a study on partner violence; they found that transgender individuals are 3 times more likely than their counterparts to experience partner violence physical and sexual. Partner violence is a risk factor for numerous health outcomes like a decrease psychological well-being, a poor sexual health, etc.[46]
There is limited data regarding the impact of social determinants of health on transgender and gender non-conforming individuals' health outcomes.[47] 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.[48]
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.[49] 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.[50]
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.[51] 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.[52][53][54]
[55] Transgender individuals may be bullied as a result of the gender norm. Studies revolving around the effects of bullying have shown that bullying is associated with a declining mental health. Past experience predicted more depressive symptoms and a low self-worth. A study also revealed that those who came out to school peers or staff had a greater psychological well-being despite being bullied. The effects of bullying include higher risk for substance abuse, risky behaviors like drunk driving, and higher engagement in sexual risk behaviors. Being bullied also increases absenteeism and poor grades among LGTBQ individuals. Physical symptoms can also manifest as a result including abdominal pain, poor appetite, sleeping problems, increase in blood pressure, etc. These experiences as an adolescent can have negative consequence in adulthood as well. These consequence include depression, suicide attempts, lower life satisfaction, etc.[56][57][58][59][60][61][62][63][64][65]
Those who are transgender are significantly more likely to be diagnosed with anxiety disorders or depression than the general population.[52][53][54][66] 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.[67][68] 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.[67][68][69]
Many studies report extremely high rates of suicide within the transgender community.[52][66] 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.[70] 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.[70] Specifically, transgender males as a group are the most likely to attempt suicide, more so than transgender females.[70][71] Later surveys suggest that the rate of suicidal attempts for non-binary individuals is in between the two.[71] 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".[72]
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.[73] The expectation to experience rejection can become an important stressor for transgender and gender non-conforming individuals.[74] Mental health problems among trans people are related to higher rates of self-harm, drug usage, and suicidal ideations and attempts.[43]
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.[75]
Clinical 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.[76]
Clinicians may improperly connect transgender people's symptoms to their gender transition, a phenomenon known as trans broken arm syndrome.[77] Trans broken arm syndrome is particularly prevalent among mental health practitioners, 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,[78][79][80] or misdiagnosis and prescription of a wrong treatment.[81] Misattribution of symptoms to transgender hormone therapy may also cause doctors to erroneously recommend the patient stop taking hormones.[82] Trans broken arm syndrome may also manifest as health insurance companies refusing to pay for treatments, claiming that a mental or physical health problem is inevitable or untreatable due to the patient's transgender status or that a treatment would be too experimental because the patient is transgender.[83] According to The SAGE Encyclopedia of Trans Studies, trans broken arm syndrome is a form of discrimination against transgender people.[84] A 2021 survey by TransActual shows that 57% of transgender people in the United Kingdom put off seeing a doctor when they were ill.[85] 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".[86]
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.[142] Trans individuals face the risk of aging with more limited support and in more stigmatizing environments than heteronormative individuals.[143] 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.[144]