Transgender health care

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. While many transgender people do elect to transition physically, every transgender person has different needs and, as such, there is no required transition plan. Preventative health care is a crucial part of transitioning and a primary care physician is recommended for transgender people who are transitioning.

Hormone replacement therapy

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

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. 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.

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. 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.

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.

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. 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.

Gender dysphoria

Gender dysphoria is a well-documented occurrence, with references to it dating back to 1894. 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. Gender dysphoria is a significant motivator in transgender people's decisions to pursue transition.

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.

Rates of depression and anxiety in the transgender community are significantly higher than those found in the general population. 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. A 2003 study concluded that the heightened rate of depression and other mental illness among both transgender men and women may be caused in part due to minority stress.

Access

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

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. 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.

Thailand

Transgender women, known as kathoeys, have access to hormones through non-prescription sources. This kind of access is a result of the low availability and expense of transgender health care clinics. 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. 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.

United Kingdom

A survey of gender identity clinic services provided by the UK 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. 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. 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.

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. 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. As of 2013, over 4000 transgender patients had been treated in Spain, including Spaniards and international patients.

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.

Colombia

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

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. 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.

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

Mexico

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

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.

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. 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. Various factors play a role in creating the limited access to care, such as insurance coverage issues related to their legal gender identity status.

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. 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.

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. 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.

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.

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