Transgender health care

Before and after shots of a male-to-female person after two years of hormone replacement therapy

Transgender health care is the health related care of preventative medicine, physical health, and mental health that transgender people experience.[1] The heightened levels of violence and abuse that transgender people experience result in unique adverse effects on bodily and mental health.[2]

Gender dysphoria is the sense of incongruity between a person's sex and their gender and is a motivator in some transgender people's decision to begin transitioning.[3] However, health care for transgender and gender non-conforming individual encompasses more than just transition related care; preventative care and sexual health are two aspects of transgender health care that are often overlooked.[3]

Additionally, transphobia in medicine has limited access to necessary health care for transgender people. The limited access applies to areas of physical health such as sexually transmitted infections and hormone replacement therapy, mental health, and preventative care.[4]

Physical health care

Various options are available for transgender people to pursue physical transition. There have been options for transitioning for transgender individuals since 1917.[1] While many transgender people do elect to transition physically, every transgender person has different needs and, as such, there is no required transition plan.[3] Preventative health care is a crucial part of transitioning and a primary care physician is recommended for transgender people who are transitioning.[3]

Hormone replacement therapy

Hormone replacement therapy is primarily concerned with alleviating gender dysphoria in transgender people.[3] Regular monitoring by an endocrinologist is a strong recommendation to ensure the safety of the individual as they transition.[5]

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.[6] 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.[7]

Sex reassignment surgery

Sex reassignment surgery, also known as gender reassignment surgery, has a goal of lessening dysphoria for transgender people, much like hormone replacement therapy.[3] Sex reassignment surgery carries additional requirements 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 requires a supporting letter from a licensed therapist and completion of a 12 month period in which the person lives full time as their gender.[3][8]

Preventative health care

Preventative care for transgender people includes the monitoring of risk factors that are associated with hormone replacement therapy, such as prolactin levels in transgender women and polycythemia levels in transgender men.[3]

Despite the importance of preventative care, access to preventative care is significantly 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.[9] A metaanalysis of the National Transgender Discrimination Survey examined respondents who used the "gender not listed here" option on the survery 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.[10]

Mental health care

Gender dysphoria

Gender dysphoria is a well-documented occurrence, with references to it dating back to 1894.[11] Gender dysphoria is currently classified as a mental illness in the DSM-5 and has been called "transsexualism" and "gender identity disorder" in past versions of the DSM.[12] Gender dysphoria is a significant motivator in transgender people's decisions to pursue transition.[3]

Mental illness

Mental illness and gender dysphoria have been linked to each other. In a study on the comorbidity of gender dysphoria and other mental problems, roughly 30 percent of both male-to-female and female-to-male populations reported substance abuse problems related to their gender dysphoria.[13]

Rates of depression and anxiety in the transgender community are significantly higher than those found in the general population.[14] The heightened rates are caused in part by lack of effective social support for transgender people, especially those pre-transition or early on in their transition.[14]

Access

There is limited data regarding the impact of social determinants of health on transgender and gender non-conforming individuals health outcomes.[15] 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 due to increased risk for violence, isolation, and other types of discrimination both inside and outside the health care setting.[16]

Africa

In 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.[17] 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.[17]

Asia

In Thailand, transgender women, known as kathoeys, have access to hormones through non-prescription sources.[18] This kind of access is a result of the low availability and expense of transgender health care clinics.[18] However, transgender men, known as toms, have difficulty gaining access to hormones such as testosterone in Thailand because it is not as readily available as hormones for kathoeys.[19] As a result, just a third of all toms surveyed are taking hormones to transition whereas almost three quarters of kathoeys surveyed are taking hormones.[19]

Europe

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

A survey of gender identity clinic services provided by the National Health Service found that 94% of transgender people using the gender identity clinics were satisfied with their care and would recommend the clinics to a friend or family member.[20] 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.[20] The options available from the National Health Service also vary with location; certain postal codes have easier access to more services.[20]

South America

In Colombia, transgender women sex workers have cited financial difficulties as barriers to accessing physical transition options.[21] As a result, they have entered sex work to relieve financial burdens, both those related to transition and those not related to transition.[21] 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.[21]

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.[22] Aside from transition related care, transgender and gender non-conforming individuals need preventative care such as vaccines, gynecological care, prostate exams, and other annual preventative health measures.[1] Various factors play a role in creating the limited access to care, such as insurance coverage issues related to their legal gender identity status.[1]

The Affordable Care Act marketplace has improved access to insurance for the LGBT community through anti-discriminatory measures, such as not allowing insurance companies to reject consumers for being transgender.[15] However, insurance sold outside of the ACA marketplace does not have to follow these requirements. This means that preventative care, such as gynecological exams for transgender men, may not be covered.[23]

Health care for transgender 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.[24] 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.[24]

Discrimination has a significant effect on the mental health of young transgender people. 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.[25]

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.[3][26] Concerns regarding the impact of puberty blockers on physical health, such as bone density, have altso been raised.[26] Long-term use of puberty blockers has also gone relatively unstudied, bringing up questions about harmful long-term side effects.[26]

See also

References

  1. 1 2 3 4 Gorton N, Grubb HM (2014). General, Sexual, and Reproductive health. In L. Erickson-Schroth. Trans Bodies, Trans Selves: A Resource for the transgender community (pp. 215-240). Nw York: Oxford University Press.
  2. ↑ Rood, Brian A.; Reisner, Sari L.; Surace, Francisco I.; Puckett, Jae A.; Maroney, Meredith R.; Pantalone, David W. "Expecting Rejection: Understanding the Minority Stress Experiences of Transgender and Gender-Nonconforming Individuals". Transgender Health. 1 (1): 151–164. doi:10.1089/trgh.2016.0012.
  3. 1 2 3 4 5 6 7 8 9 10 Coleman, E.; Bockting, W.; Botzer, M.; Cohen-Kettenis, P.; DeCuypere, G.; Feldman, J.; Fraser, L.; Green, J.; Knudson, G. (2012-08-01). "Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7". International Journal of Transgenderism. 13 (4): 165–232. doi:10.1080/15532739.2011.700873. ISSN 1553-2739.
  4. ↑ Lacombe-Duncan, Ashley. "An Intersectional Perspective on Access to HIV-Related Healthcare for Transgender Women". Transgender Health. 1 (1): 137–141. doi:10.1089/trgh.2016.0018.
  5. ↑ Moore, Eva; Wisniewski, Amy; Dobs, Adrian (2003-08-01). "Endocrine Treatment of Transsexual People: A Review of Treatment Regimens, Outcomes, and Adverse Effects". The Journal of Clinical Endocrinology & Metabolism. 88 (8): 3467–3473. doi:10.1210/jc.2002-021967. ISSN 0021-972X.
  6. ↑ Newfield, Emily; Hart, Stacey; Dibble, Suzanne; Kohler, Lori (2006-06-07). "Female-to-male transgender quality of life". Quality of Life Research. 15 (9): 1447–1457. doi:10.1007/s11136-006-0002-3. ISSN 0962-9343.
  7. ↑ Israel, Gianna (2001). Transgender Care: Recommended Guidelines, Practical Information, and Personal Accounts. Temple University Press. ISBN 1566398525.
  8. ↑ Dahl, Marshall; Feldman, Jamie (2006). Endocrine therapy for transgender adults in British Columbia: Suggested guidelines. Canadian Rainbow Health Coalition.
  9. ↑ Dowshen, Nadia; Lee, Susan S.; Castillo, Marné; Hawkins, Linda; Barg, Frances K. "Barriers and Facilitators to HIV Prevention, Testing, and Treatment among Young Transgender Women". Journal of Adolescent Health. 58 (2): S81–S82. doi:10.1016/j.jadohealth.2015.10.175.
  10. ↑ Jack, Harrison,; Jaime, Grant,; L., Herman, Jody (2012-04-01). "A Gender Not Listed Here: Genderqueers, Gender Rebels, and OtherWise in the National Transgender Discrimination Survey". LGBTQ Public Policy Journal at the Harvard Kennedy School. 2 (1).
  11. ↑ von Krafft-Ebing, Richard (1894). Psychopathia Sexualis. ISBN 9782357792173.
  12. ↑ Cohen-Kettenis, Peggy T.; Pfäfflin, Friedemann (2009-10-17). "The DSM Diagnostic Criteria for Gender Identity Disorder in Adolescents and Adults". Archives of Sexual Behavior. 39 (2): 499–513. doi:10.1007/s10508-009-9562-y. ISSN 0004-0002.
  13. ↑ Cole, Collier M.; O'Boyle, Michael; Emory, Lee E.; Iii, Walter J. Meyer. "Comorbidity of Gender Dysphoria and Other Major Psychiatric Diagnoses". Archives of Sexual Behavior. 26 (1): 13–26. doi:10.1023/A:1024517302481. ISSN 0004-0002.
  14. 1 2 Budge, Stephanie L.; Adelson, Jill L.; Howard, Kimberly A. S. "Anxiety and depression in transgender individuals: The roles of transition status, loss, social support, and coping.". Journal of Consulting and Clinical Psychology. 81 (3): 545–557. doi:10.1037/a0031774.
  15. 1 2 Department of Health and Human Services, Office of Disease and Health Promotion. (2016, September). Lesbian, Gay, Bisexual, and Transgender Health. Retrieved from HealthyPeople.gov: https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health
  16. ↑ Anastas J.W. (2013) Policy, practice, and people: Current issues affecting clinical practice. Clinical Social Work Journal, 41(3),302-307.
  17. 1 2 Wilson, D.; Marais, A.; de Villiers, A.; Addinall, R.; Campbell, M. M. (2014-06-01). "Transgender issues in South Africa, with particular reference to the Groote Schuur Hospital Transgender Unit". SAMJ: South African Medical Journal. 104 (6): 448–449. ISSN 0256-9574.
  18. 1 2 Gooren, Louis J; Sungkaew, Tanapong; Giltay, Erik J. "Exploration of functional health, mental well-being and cross-sex hormone use in a sample of Thai male-to-female transgendered persons (kathoeys)". Asian Journal of Andrology. 15 (2): 280–285. doi:10.1038/aja.2012.139. PMC 3739151Freely accessible. PMID 23353716.
  19. 1 2 Gooren, Louis J.; Sungkaew, Tanapong; Giltay, Erik J.; Guadamuz, Thomas E. (2015-01-02). "Cross-sex hormone use, functional health and mental well-being among transgender men (Toms) and Transgender Women (Kathoeys) in Thailand". Culture, Health & Sexuality. 17 (1): 92–103. doi:10.1080/13691058.2014.950982. ISSN 1369-1058. PMC 4227918Freely accessible. PMID 25270637.
  20. 1 2 3 Davies, Andrew; Bouman, Walter Pierre; Richards, Christina; Barrett, James; Ahmad, Sheraz; Baker, Karen; Lenihan, Penny; Lorimer, Stuart; Murjan, Sarah (2013-11-01). "Patient satisfaction with gender identity clinic services in the United Kingdom". Sexual and Relationship Therapy. 28 (4): 400–418. doi:10.1080/14681994.2013.834321. ISSN 1468-1994.
  21. 1 2 3 Bianchi, Fernanda T.; Reisen, Carol A.; Zea, Maria Cecilia; Vidal-Ortiz, Salvador; Gonzales, Felisa A.; Betancourt, Fabián; Aguilar, Marcela; Poppen, Paul J. (2014-01-24). "Sex Work Among Men Who Have Sex with Men and Transgender Women in Bogotá". Archives of Sexual Behavior. 43 (8): 1637–1650. doi:10.1007/s10508-014-0260-z. ISSN 0004-0002. PMC 4110190Freely accessible. PMID 24464550.
  22. ↑ Bradford, Judith; Reisner, Sari L.; Honnold, Julie A.; Xavier, Jessica (2012-11-15). "Experiences of Transgender-Related Discrimination and Implications for Health: Results From the Virginia Transgender Health Initiative Study". American Journal of Public Health. 103 (10): 1820–1829. doi:10.2105/AJPH.2012.300796. ISSN 0090-0036. PMC 3780721Freely accessible. PMID 23153142.
  23. ↑ Varny J. (2016). Rainbow Medicine- Supporting the Needs of Lesbian, gay, bisexual, and trans patients. Journal of Clinical Medicine.
  24. 1 2 Chen, Diane; Hidalgo, Marco A.; Leibowitz, Scott; Leininger, Jennifer; Simons, Lisa; Finlayson, Courtney; Garofalo, Robert. "Multidisciplinary Care for Gender-Diverse Youth: A Narrative Review and Unique Model of Gender-Affirming Care". Transgender Health. 1 (1): 117–123. doi:10.1089/trgh.2016.0009.
  25. ↑ Wilson, Erin C.; Chen, Yea-Hung; Arayasirikul, Sean; Raymond, H. Fisher; McFarland, Willi (2016-04-26). "The Impact of Discrimination on the Mental Health of Trans*Female Youth and the Protective Effect of Parental Support". AIDS and Behavior. 20 (10): 2203–2211. doi:10.1007/s10461-016-1409-7. ISSN 1090-7165. PMC 5025345Freely accessible. PMID 27115401.
  26. 1 2 3 Radix, Anita; Silva, Manel. "Beyond the Guidelines: Challenges, Controversies, and Unanswered Questions". Pediatric Annals. 43 (6): e145–e150. doi:10.3928/00904481-20140522-10.
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