Transgender health care

Transgender health care includes the prevention, diagnosis and treatment of physical and mental health conditions, as well as gender-affirming care, 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.

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". ^[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]

Gender-affirming care

Various options are available for transgender people to pursue physical transition. There have been options for transitioning for transgender individuals since 1917. ^[1] Gender-affirming care helps people to change their physical appearance and/or sex characteristics to accord with their gender identity; it includes hormone replacement therapy and gender-affirming 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. ^[14] Preventive health care is a crucial part of transitioning and a primary care physician is recommended for transgender people who are transitioning. ^[14]

Eligibility

In the 11th version of the International Classification of Diseases (ICD-11), the diagnosis is known as gender incongruence. ICD-11 states that "Gender variant behaviour and preferences alone are not a basis for assigning the diagnosis." ^[8]

The US Diagnostic and Statistical Manual of Mental Disorders (DSM) names it gender dysphoria (in version 5 ^[15] ). 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 2023, the most recent version of the standards is Version 8. ^[16] According to the standards of care, "Gender Dysphoria describes a state of distress or discomfort that may be experienced because a person's gender identity differs from that which is physically and/or socially attributed to their sex assigned at birth… Not all transgender and gender diverse people experience gender dysphoria." 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. ^[17] 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. ^[18]

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. ^[16]

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. ^[16]

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. ^[16]

Hormone replacement therapy

Main article: Transgender hormone therapy

A transgender woman before and after two years of hormone replacement therapy.

Hormone replacement therapy (HRT) is primarily concerned with alleviating gender dysphoria in transgender people. ^[14] 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. ^[19] 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. ^[19] 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). ^[19] Regular monitoring by an endocrinologist is a strong recommendation to ensure the safety of individuals as they transition. ^[20]

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. ^[21] 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. ^[22]

Hormone therapy for transgender individuals has been shown in medical literature to be safe, when supervised by a qualified medical professional. ^[23]

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. ^[24]

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. ^[14]

On July 1, 2022, the FDA issued an update that gonadotropin-releasing hormone agonists, drugs that are approved for treating precocious puberty, may be a risk factor for developing pseudotumor cerebri. ^[25]

Reproductive Healthcare

Main article: Transgender pregnancy

There are frequent misconceptions within both patients and doctors about how hormone replacement therapy affects fertility. One common misconception is that starting it automatically leads to infertility. While it may impact the ability to be fertile, it does not mean it leads to a hundred percent infertility rate. ^[26] There have been numerous cases of transgender men experiencing pregnancy and abortion. ^[27] As trans men and doctors can be under this misconception about hormone replacement therapy impacting fertility and serving as a form of contraception, keeping people informed on fertility options remains crucial.

For trans women, it is possible for them to undergo cryopreservation before starting hormone replacement therapy. As evidence has shown that trans women tend to have lower motile sperm compared to their cisgender counterparts, ^[28] fertility preservation can be important for individuals anticipating having biological children in the future. While fertility preservation is important to consider before starting HRT, it is possible in some cases to regain fertility after halting HRT for a period of time. ^[29]

It is also important to educate transgender youth on their fertility preservation options. This is because few adolescents end up doing so, alongside transgender adolescents reporting distress at the prospect of becoming infertile due to medical conditions and treatment relating to their transgender identity. ^[30]

Gender-affirming surgery

Main article: gender-affirming surgery

The goal of gender-affirming surgery is to align the secondary sexual characteristics of transgender people with their gender identity. As hormone replacement therapy, gender-affirming surgery is also employed as a response to diagnosis gender dysphoria ^{[14] [31]}

The World Professional Association for Transgender Health (WPATH) Standards of Care recommend additional requirements for gender-affirming surgery when compared to hormone replacement therapy. Whereas hormone replacement therapy can be obtained through something as simple as an informed consent form, gender-affirming 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.

Effectiveness

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 trans people than in the general population. Many of these problems, in the majority of cases, disappear or decrease significantly after social and/or medical transition. ^{[32] [33] [34] [35] : 2108  [36] : 1570  [37] [38]}

Medical transition in the form of HRT and/or gender-affirming surgery typically results in improved quality of life. ^[39] After treatment, most trans people experience improved psychological, social, and sexual functioning, ^[40] and improved global functioning. ^[41] Less than 1% of post-operative trans patients regret surgery. ^[42]

Gender-affirming surgery alone may not be sufficient treatment in all cases. Dysphoria and thus suicidality may persist, and some trans people may need further health care in addition to surgery. ^[43]

In 2012, the American Psychiatric Association and Royal College of Psychiatrists concluded that certain robust study methods, such as a randomized controlled trial, cannot be carried out on most aspects of transgender health care, especially surgery, due to the nature of the treatment. It was deemed unethical to randomly select study participants for vaginoplasty, for example. ^{[44] [45]}

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. ^[46] 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. ^{[47] [48]} 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. ^[49]

^[50] 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. ^[51]

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. ^[52]

There is limited data regarding the impact of social determinants of health on transgender and gender non-conforming individuals' health outcomes. ^[53] 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. ^[54]

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. ^[55] 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. ^[56]

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. ^[57] 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. ^{[58] [59] [60]}

^[61] 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. ^{[62] [63] [64] [65] [66] [67] [68] [69] [70] [71]}

Those who are transgender are significantly more likely to be diagnosed with anxiety disorders or depression than the general population. ^{[58] [59] [60] [72]} 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. ^{[73] [74]} 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. ^{[73] [74] [75]}

Many studies report extremely high rates of suicide within the transgender community. ^{[58] [72]} 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. ^[76] 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. ^[76] Specifically, transgender males as a group are the most likely to attempt suicide, more so than transgender females. ^{[76] [77]} Later surveys suggest that the rate of suicidal attempts for non-binary individuals is in between the two. ^[77] 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". ^[78]

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. ^[79] The expectation to experience rejection can become an important stressor for transgender and gender non-conforming individuals. ^[80] Mental health problems among trans people are related to higher rates of self-harm, drug usage, and suicidal ideations and attempts. ^[49]

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. ^[81]

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. ^[82]

Clinicians may improperly connect transgender people's symptoms to their gender transition, a phenomenon known as trans broken arm syndrome. ^[83] 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, ^{[84] [85] [86]} or misdiagnosis and prescription of a wrong treatment. ^[87] Misattribution of symptoms to transgender hormone therapy may also cause doctors to erroneously recommend the patient stop taking hormones. ^[88] 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. ^[89] According to The SAGE Encyclopedia of Trans Studies, trans broken arm syndrome is a form of discrimination against transgender people. ^[90] A 2021 survey by TransActual shows that 57% of transgender people in the United Kingdom put off seeing a doctor when they were ill. ^[91] 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". ^[92]

Global access

Global access to healthcare across primary and secondary health settings remains fragmented for transgender people, ^[93] 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. ^{[94] [95]}

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. ^[96] 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. ^[96]

Asia

Thailand

Transgender women, known as kathoeys, have access to hormones through non-prescription sources. ^[97] This kind of access is a result of the low availability and expense of transgender health care clinics. ^[97] 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. ^[98] 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. ^[98]

Mainland China

A 2017 report conducted by Beijing LGBT Center and Peking University showed that out of 1279 of its respondents who wanted to receive hormone treatment, 71% of them felt that it was "difficult", "very difficult", or "virtually impossible" to acquire safe and reliable information about gender affirming medications and receive hormonal replacement therapy with the guidance of a doctor. As a result, 66% of the respondents chose "online" and 51% chose "friends" as one of their sources for hormone replacement therapy medications. Gender reassignment surgeries were reported to be similarly inaccessible, with 89.1% of the respondents who have the needs for such surgeries unable to pursue them. ^[99]

On December 1, 2022, the Chinese National Medical Products Administration banned online sales of cyproterone acetate, estradiol, and testosterone, which are the most common hormones and antiandrogens used in transgender hormone replacement therapy. ^{[100] [101]}

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. ^[102] 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. ^{[102] [103]} As of 2013, over 4000 transgender patients had been treated in Spain, including Spaniards and international patients. ^{[102] [104]}

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. ^[102]

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. ^[105] 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. ^[106]

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, during which they must - without any form of medical transition - successfully live for one full year as their desired gender in all professional, social, and personal matters. Gender clinics are recommended to provide patients with wigs and breast prostheses for the endeavor. Further, those with potential comorbidities are subject to additional long-term scrutiny prior to allowance of any sort of access to medical care. The evaluation additionally involves, if possible, meetings with family members and/or other individuals close to the patient. Patients may be denied care for any number of "psychosocial dimensions", including their choice of job or their marital status. ^{[107] [108] [109]}

Medically transitioning can be very expensive, 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. The fee the individual pays for a doctor's appointment or other care represents only a small fraction of the actual costs. ^[110] 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. ^[109] 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. ^[111]

In Sweden, anyone is allowed to change their name at any time, including for gender transition. ^[112]

Up until January 27, 2017, being transsexual was classed as a disease. Two months earlier, on 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. ^[113]

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 laser hair removal, SRS, facial feminization surgery and hormones. Hormones can be prescribed by licensed endocrinologist in an 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". ^[114] 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. ^[115]

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. ^[116] 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. ^[116] 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. ^[116]

Scotland

There are four NHS Scotland Gender Identity Clinics providing services to adults and a separate service for younger people. ^[117] 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. ^[118] Minister for Public Health Maree Todd has stated that the Scottish Government wants to reduce "unacceptable waits to access gender identity services". ^[119] Research has indicated patient dissatisfaction with long wait times. ^[120] However, overall experience of treatment outcomes was largely positive, particularly for hormone therapy and surgery. ^[121]

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. ^[122] 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. ^[123]

All Canadian provinces fund some sex reassignment surgeries, with New Brunswick being the last of the provinces to start insuring these procedures in 2016. ^[124] 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. ^{[125] [126] [127]} Insurance coverage is not generally provided for the transition-related procedures of facial feminization surgery, tracheal shave, or laser hair removal. ^[128] And in January 2024, The Alberta government of Danielle Smith announced plans to ban gender affirming surgeries for minors under the age of 18 and hormones and puberty blockers for minors under the age of 16. ^{[129] [130]}

Mexico

A July 2016 study in The Lancet Psychiatry reported that nearly half of transgender people surveyed undertook body-altering procedures without medical supervision. ^[131] Transition-related care is not covered under Mexico's national health plan. ^[132] Only one public health institution in Mexico provides free hormones for transgender people. ^[131] Health care for transgender Mexicans focuses on HIV and prevention of other sexually transmitted diseases. ^[131]

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. ^[133]

United States

Main article: Transgender rights in the United States § Healthcare

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. ^[134] 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. ^[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 (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. ^[53] 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. ^[135]

Starting in the early-2020s, as many as 13 U.S. states banned gender affirming health care for transgender youth, ^[136] with several states further restricting treatment for adults as well. ^{[137] [138]} In January 2024, several Republican legislators have expressed their desire to ban gender-affirming healthcare altogether. ^[139]

South America

Colombia

Transgender women sex workers have cited financial difficulties as barriers to accessing physical transition options. ^[140] As a result, they have entered sex work to relieve financial burdens, both those related to transition and those not related to transition. ^[140] 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. ^[140]

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. ^[141] 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. ^[141]

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. ^[142] 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. ^[143]

In a 2018 review, evidence suggested that hormonal treatments for transgender adolescents can achieve their intended physical effects. The mental effects of GnRH modifiers are positive with treatment associated with significant improvements in multiple psychological measures, including global functioning, depression, and overall behavioral and/or emotional problems. ^[144] In a two-year study published in January 2023, Chen et al. found that gender-affirming hormones for transgender and non-binary youth "improved appearance congruence and psychosocial functioning". ^[145] Another study analyzing Dutch transgender youth completed by Catharina van der Loos et al. found that 98% of participants who started gender-affirming hormone treatment in youth continued using said treatment into adulthood. ^[146]

In February 2024, the American Psychological Association approved a policy statement supporting unobstructed access to health care and evidence-based clinical care for transgender, gender-diverse, and nonbinary children, adolescents, and adults, as well as opposing state bans and policies intended to limit access to such care. ^{[147] [148]}

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. ^[149] Trans individuals face the risk of aging with more limited support and in more stigmatizing environments than heteronormative individuals. ^[150] 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. ^[151]

See also

• Medicine portal
• Transgender portal

• Detransition
• Transgender § Healthcare
• Healthcare and the LGBT community
• Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People
• Transgender clinic
• European Network for the Investigation of Gender Incongruence (ENIGI)
• Study of Transition, Outcomes, and Gender (STRONG)

References

1. 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). New York: Oxford University Press.
2. Simons, Lisa K.; Leibowitz, Scott F.; Hidalgo, Marco A. (2014-06-01). "Understanding Gender Variance in Children and Adolescents". Pediatric Annals. 43 (6): e126–e131. doi:10.3928/00904481-20140522-07. ISSN   0090-4481. PMID   24972420.
3. Byne, William; Karasic, Dan H.; Coleman, Eli; Eyler, A. Evan; Kidd, Jeremy D.; Meyer-Bahlburg, Heino F.L.; Pleak, Richard R.; Pula, Jack (May 2018). "Gender Dysphoria in Adults: An Overview and Primer for Psychiatrists". Transgender Health. 3 (1): 57–A3. doi:10.1089/trgh.2017.0053. ISSN   2380-193X. PMC   5944396 . PMID   29756044.
4. von Krafft-Ebing, Richard (1894). Psychopathia Sexualis. Camion blanc. ISBN   9782357792173.
5. Reed, Geoffrey M.; Drescher, Jack; Krueger, Richard B.; Atalla, Elham; Cochran, Susan D.; First, Michael B.; Cohen-Kettenis, Peggy T.; Arango-de Montis, Iván; Parish, Sharon J. (October 2016). "Disorders related to sexuality and gender identity in the ICD-11: revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations". World Psychiatry. 15 (3): 205–221. doi:10.1002/wps.20354. PMC   5032510 . PMID   27717275.
6. Reed, Geoffrey M.; Drescher, Jack; Krueger, Richard B.; Atalla, Elham; Cochran, Susan D.; First, Michael B.; Cohen-Kettenis, Peggy T.; Arango-de Montis, Iván; Parish, Sharon J. (October 2016). "Disorders related to sexuality and gender identity in the ICD-11: revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations". World Psychiatry. 15 (3): 205–221. doi:10.1002/wps.20354. PMC   5032510 . PMID   27717275.
7. 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. hdl: 1871/34512 . ISSN   0004-0002. PMID   19838784. S2CID   16336939.
8. "ICD-11". icd.who.int. Retrieved 2019-03-24.
9. Defreyne, Justine; Kreukels, Baudewijntje; T'Sjoen, Guy; Staphorsius, Annemieke; Den Heijer, Martin; Heylens, Gunter; Elaut, Els (April 2019). "No correlation between serum testosterone levels and state-level anger intensity in transgender people: Results from the European Network for the Investigation of Gender Incongruence". Hormones and Behavior. 110: 29–39. doi:10.1016/j.yhbeh.2019.02.016. PMID   30822410. S2CID   72332772.
10. Castro-Peraza, Maria Elisa; García-Acosta, Jesús Manuel; Delgado, Naira; Perdomo-Hernández, Ana María; Sosa-Alvarez, Maria Inmaculada; Llabrés-Solé, Rosa; Lorenzo-Rocha, Nieves Doria (2019-03-18). "Gender Identity: The Human Right of Depathologization". International Journal of Environmental Research and Public Health. 16 (6): 978. doi: 10.3390/ijerph16060978 . ISSN   1660-4601. PMC   6466167 . PMID   30889934.
11. Latham, J.R. (2017). "Making and Treating Trans Problems The Ontological Politics of Clinical Practices". Studies in Gender and Sexuality. 18 (1): 40–61. doi:10.1080/15240657.2016.1238682. S2CID   152123850.
12. Vargas-Huicochea, Ingrid; Robles, Rebeca; Real, Tania; Fresán, Ana; Cruz-Islas, Jeremy; Vega-Ramírez, Hamid; Medina-Mora, María Elena (November 2018). "A Qualitative Study of the Acceptability of the Proposed ICD-11 Gender Incongruence of Childhood Diagnosis Among Transgender Adults Who Were Labeled Due to Their Gender Identity Since Childhood". Archives of Sexual Behavior. 47 (8): 2363–2374. doi:10.1007/s10508-018-1241-4. ISSN   0004-0002. PMID   29971651. S2CID   49681691.
13. Collin, Lindsay; Reisner, Sari L.; Tangpricha, Vin; Goodman, Michael (2016). "Prevalence of Transgender Depends on the "Case" Definition: A Systematic Review". The Journal of Sexual Medicine. 13 (4): 613–626. doi:10.1016/j.jsxm.2016.02.001. PMC   4823815 . PMID   27045261.
14. 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. S2CID   39664779.
15. "DSM-5". www.psychiatry.org.
16. Coleman, E.; et al. (2022). "Standards of Care for the Health of Transgender and Gender Diverse People, Version 8". International Journal of Transgender Health. 23 (Suppl 1): S1–S259. doi:10.1080/26895269.2022.2100644. PMC   9553112 . PMID   36238954.
17. Ashley, Florence (2019-07-01). "Gatekeeping hormone replacement therapy for transgender patients is dehumanising". Journal of Medical Ethics. 45 (7): 480–482. doi: 10.1136/medethics-2018-105293 . ISSN   0306-6800. PMID   30988174.
18. Lambert, Cei; Hopwood, Ruben; Cavanaugh, Timothy (2016-11-01). "Informed Consent in the Medical Care of Transgender and Gender-Nonconforming Patients". AMA Journal of Ethics. 18 (11): 1147–1155. doi: 10.1001/journalofethics.2016.18.11.sect1-1611 . ISSN   2376-6980. PMID   27883307.
19. Unger, Cécile A. (December 2016). "Hormone therapy for transgender patients". Translational Andrology and Urology. 5 (6): 877–884. doi: 10.21037/tau.2016.09.04 . PMC   5182227 . PMID   28078219.
20. 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. PMID   12915619.
21. 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. CiteSeerX   10.1.1.468.9106 . doi:10.1007/s11136-006-0002-3. ISSN   0962-9343. PMID   16758113. S2CID   12727036.
22. Israel, Gianna (2001). Transgender Care: Recommended Guidelines, Practical Information, and Personal Accounts. Temple University Press. ISBN   978-1-56639-852-7.
23. Weinand, Jamie D.; Safer, Joshua D. (Feb 2015). "Hormone therapy in transgender adults is safe with provider supervision; A review of hormone therapy sequelae for transgender individuals". Journal of Clinical & Translational Endocrinology. 2 (2): 55–60. doi:10.1016/j.jcte.2015.02.003. PMC   5226129 . PMID   28090436.
24. "A guide to hormone therapy for trans people" (PDF). August 2014. p. 10. Retrieved March 2, 2021.
25. url=https://www.fda.gov/media/159663/download]]
26. Moravek, Molly B. (June 2019). "Fertility preservation options for transgender and gender-nonconforming individuals". Current Opinion in Obstetrics & Gynecology. 31 (3): 170–176. doi:10.1097/GCO.0000000000000537. ISSN   1473-656X. PMID   30870185. S2CID   78091839.
27. Light, Alexis; Wang, Lin-Fan; Zeymo, Alexander; Gomez-Lobo, Veronica (2018-10-01). "Family planning and contraception use in transgender men". Contraception. 98 (4): 266–269. doi:10.1016/j.contraception.2018.06.006. ISSN   0010-7824. PMID   29944875. S2CID   49434157.
28. Marsh, Courtney; McCracken, Megan; Gray, Meredith; Nangia, Ajay; Gay, Judy; Roby, Katherine F. (2019-08-01). "Low total motile sperm in transgender women seeking hormone therapy". Journal of Assisted Reproduction and Genetics. 36 (8): 1639–1648. doi:10.1007/s10815-019-01504-y. ISSN   1573-7330. PMC   6708020 . PMID   31250175.
29. Barnard, Emily P.; Dhar, Cherie Priya; Rothenberg, Stephanie S.; Menke, Marie N.; Witchel, Selma F.; Montano, Gerald T.; Orwig, Kyle E.; Valli-Pulaski, Hanna (September 2019). "Fertility Preservation Outcomes in Adolescent and Young Adult Feminizing Transgender Patients". Pediatrics. 144 (3): e20183943. doi: 10.1542/peds.2018-3943 . ISSN   1098-4275. PMID   31383814. S2CID   199451284.
30. Nahata, Leena; Tishelman, Amy C.; Caltabellotta, Nicole M.; Quinn, Gwendolyn P. (July 2017). "Low Fertility Preservation Utilization Among Transgender Youth". The Journal of Adolescent Health. 61 (1): 40–44. doi: 10.1016/j.jadohealth.2016.12.012 . ISSN   1879-1972. PMID   28161526.
31. Choices, NHS. "Gender dysphoria – NHS Choices". www.nhs.uk. Retrieved 9 December 2016.
32. Heylens, Gunter; Verroken, Charlotte; De Cock, Sanne; T'Sjoen, Guy; De Cuypere, Griet (2013). "Effects of Different Steps in Gender Reassignment Therapy on Psychopathology: A Prospective Study of Persons with a Gender Identity Disorder". The Journal of Sexual Medicine. 11 (1): 119–126. doi:10.1111/jsm.12363. ISSN   1743-6095. PMID   24344788.
33. Yolanda L. S. Smith, Stephanie H. M. Van Goozen, Abraham J. Kuiper & Peggy T. Cohen-Kettenis (January 2005). "Sex reassignment: outcomes and predictors of treatment for adolescent and adult transsexuals" (PDF). Psychological Medicine . 35 (1): 89–99. doi:10.1017/S0033291704002776. PMID   15842032. S2CID   6032916.
34. Newfield, E; Hart, S; Dibble, S; Kohler, L (November 2006). "Female-to-male transgender quality of life". Quality of Life Research. 15 (9): 1447–57. CiteSeerX   10.1.1.468.9106 . doi:10.1007/s11136-006-0002-3. PMID   16758113. S2CID   12727036.
35. Richard M. Green, M.D., J.D. (June 8, 2009). "18.3 Gender Identity Disorders". In Benjamin Sadock; Virginia Alcott Sadock; Pedro Ruiz (eds.). Kaplan and Sadock's Comprehensive Textbook of Psychiatry (9th ed.). Lippincott Williams & Wilkins. pp. 2099–2111. ISBN   978-0781768993. Archived from the original on June 6, 2021.
36. George R. Brown, MD (20 July 2011). "Chapter 165 Sexuality and Sexual Disorders". In Robert S. Porter, MD; et al. (eds.). The Merck Manual of Diagnosis and Therapy (19th ed.). Whitehouse Station, NJ, US: Merck & Co., Inc. pp. 1567–1573. ISBN   978-0-911910-19-3.
37. "AMA Resolution 122" (PDF). American Medical Association . May 2008. Archived from the original (PDF) on 2 February 2014. Retrieved 17 January 2014.
38. Drescher, Jack; Haller, Ellen (July 2012). "Position Statement on Access to Care for Transgender and Gender Variant Individuals" (PDF). American Psychiatric Association. Archived from the original (PDF) on 10 August 2015. Retrieved 17 January 2014.
39. Murad, Mohammad Hassan; Elamin, Mohamed B.; Garcia, Magaly Zumaeta; Mullan, Rebecca J.; Murad, Ayman; Erwin, Patricia J.; Montori, Victor M. (2010). "Hormonal therapy and sex reassignment: A systematic review and meta-analysis of quality of life and psychosocial outcomes". Clinical Endocrinology. 72 (2): 214–31. doi:10.1111/j.1365-2265.2009.03625.x. PMID   19473181. S2CID   19590739.
40. Smith, YL; Van Goozen, SH; Kuiper, AJ; Cohen-Kettenis, PT (January 2005). "Sex reassignment: outcomes and predictors of treatment for adolescent and adult transsexuals" (PDF). Psychological Medicine. 35 (1): 89–99. doi:10.1017/S0033291704002776. PMID   15842032. S2CID   6032916.
41. Johansson, Annika; Sundbom, Elisabet; Höjerback, Torvald; Bodlund, Owe (2009). "A Five-Year Follow-Up Study of Swedish Adults with Gender Identity Disorder". Archives of Sexual Behavior. 39 (6): 1429–37. doi:10.1007/s10508-009-9551-1. PMID   19816764. S2CID   22866694.
42. Bustos, Valeria; Bustos, Samyd; Mascaro, Andres; Del Corral, Gabriel; Forte, Antonio; Ciudad, Pedro; Kim, Esther; Langstein, Howard; Manrique, Oscar (March 2021). "Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence". Plastic and Reconstructive Surgery. 9 (3): e3477. doi:10.1097/GOX.0000000000003477. PMC   8099405 . PMID   33968550. Archived from the original on 2022-04-06. Retrieved 2022-04-15.
43. Dhejne, Cecilia; Lichtenstein, Paul; Boman, Marcus; Johansson, Anna L. V.; Långström, Niklas; Landén, Mikael (2011). Scott, James (ed.). "Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden". PLOS ONE. 6 (2): e16885. Bibcode:2011PLoSO...616885D. doi: 10.1371/journal.pone.0016885 . PMC   3043071 . PMID   21364939.
44. William Byne, Susan J. Bradley, Eli Coleman, A. Evan Eyler, Richard Green, Edgardo J. Menvielle, Heino F. L. Meyer-Bahlburg, Richard R. Pleak & D. Andrew Tompkins (August 2012). "Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder" (PDF). Archives of Sexual Behavior . 41 (4): 759–796 (pages cited as pages at link). doi:10.1007/s10508-012-9975-x. PMID   22736225. S2CID   26050161.
45. "Good practice guidelines for the assessment and treatment of adults with gender dysphoria" (PDF). Royal College of Psychiatrists. October 2013. Archived from the original (PDF) on 13 August 2018. Retrieved 17 January 2014.
46. Rood, Brian A.; Reisner, Sari L.; Surace, Francisco I.; Puckett, Jae A.; Maroney, Meredith R.; Pantalone, David W. (2016). "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. PMC   5685272 . PMID   29159306.
47. Budhwani, Henna; Hearld, Kristine R.; Milner, Adrienne N.; Charow, Rebecca; McGlaughlin, Elaine M.; Rodriguez-Lauzurique, Mayra; Rosario, Santo; Paulino-Ramirez, Robert (September 26, 2017). "Transgender Women's Experiences with Stigma, Trauma, and Attempted Suicide in the Dominican Republic". Suicide and Life-Threatening Behavior. 48 (6): 788–796. doi:10.1111/sltb.12400. ISSN   1943-278X. PMID   28950402. S2CID   26033883.
48. Lagos, Danya (December 2018). "Looking at Population Health Beyond "Male" and "Female": Implications of Transgender Identity and Gender Nonconformity for Population Health". Demography. 55 (6): 2097–2117. doi: 10.1007/s13524-018-0714-3 . ISSN   0070-3370. PMID   30255426. S2CID   52822267.
49. Scherer, Bee (2018-12-20). Queering paradigms VII : contested bodies and spaces. Scherer, Burkhard, 1971-, Vries, Patrick de. Oxford, United Kingdom. ISBN   978-1-78874-529-1. OCLC   1080428040.
50. Stieglitz, Kimberly A. (May 2010). "Development, Risk, and Resilience of Transgender Youth". Journal of the Association of Nurses in AIDS Care. 21 (3): 192–206. doi:10.1016/j.jana.2009.08.004. PMID   20347346.
51. Grossman, Arnold H.; D'augelli, Anthony R. (2006-09-25). "Transgender Youth". Journal of Homosexuality. 51 (1): 111–128. doi:10.1300/j082v51n01_06. ISSN   0091-8369. PMID   16893828. S2CID   2939809.
52. Peitzmeier, Sarah M.; Malik, Mannat; Kattari, Shanna K.; Marrow, Elliot; Stephenson, Rob; Agénor, Madina; Reisner, Sari L. (September 2020). "Intimate Partner Violence in Transgender Populations: Systematic Review and Meta-analysis of Prevalence and Correlates". American Journal of Public Health. 110 (9): e1–e14. doi:10.2105/AJPH.2020.305774. ISSN   0090-0036. PMC   7427218 . PMID   32673114.
53. 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
54. Anastas, J.W. (2013). "Policy, practice, and people: Current issues affecting clinical practice". Clinical Social Work Journal. 41 (3): 302–307. doi:10.1007/s10615-013-0454-1. S2CID   143288898.
55. Dowshen, Nadia; Lee, Susan S.; Castillo, Marné; Hawkins, Linda; Barg, Frances K. (February 2016). "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.
56. 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).
57. "What Does Transgender Mean? | Gender Identification Facts". www.plannedparenthood.org. Retrieved 2019-10-23.
58. Connolly, Maureen D.; Zervos, Marcus J.; Barone, Charles J.; Johnson, Christine C.; Joseph, Christine L. M. (2016-11-01). "The Mental Health of Transgender Youth: Advances in Understanding". Journal of Adolescent Health. 59 (5): 489–495. doi:10.1016/j.jadohealth.2016.06.012. ISSN   1054-139X. PMID   27544457.
59. Dhejne, Cecilia; Vlerken, Roy Van; Heylens, Gunter; Arcelus, Jon (2016-01-02). "Mental health and gender dysphoria: A review of the literature". International Review of Psychiatry. 28 (1): 44–57. doi:10.3109/09540261.2015.1115753. ISSN   0954-0261. PMID   26835611. S2CID   207493538.
60. Bouman, Walter Pierre; Claes, Laurence; Brewin, Nicky; Crawford, John R.; Millet, Nessa; Fernandez-Aranda, Fernando; Arcelus, Jon (2017-01-02). "Transgender and anxiety: A comparative study between transgender people and the general population" (PDF). International Journal of Transgenderism. 18 (1): 16–26. doi:10.1080/15532739.2016.1258352. ISSN   1553-2739. S2CID   151463685. Archived from the original (PDF) on 2020-04-23. Retrieved 2019-10-24.
61. Earnshaw, Valerie A.; Bogart, Laura M.; Poteat, V. Paul; Reisner, Sari L.; Schuster, Mark A. (December 2016). "Bullying Among Lesbian, Gay, Bisexual, and Transgender Youth". Pediatric Clinics of North America. 63 (6): 999–1010. doi:10.1016/j.pcl.2016.07.004. PMC   8941671 . PMID   27865341.
62. "School Experiences of Gay, Lesbian, Bisexual, and Transgender Youth", Gay, Lesbian, and Transgender Issues in Education, Routledge, pp. 77–90, 2013-01-11, doi:10.4324/9780203462591-20, ISBN   9780203462591 , retrieved 2023-11-29
63. Bogart, Laura M.; Elliott, Marc N.; Klein, David J.; Tortolero, Susan R.; Mrug, Sylvie; Peskin, Melissa F.; Davies, Susan L.; Schink, Elizabeth T.; Schuster, Mark A. (2014-03-01). "Peer Victimization in Fifth Grade and Health in Tenth Grade". Pediatrics. 133 (3): 440–447. doi: 10.1542/peds.2013-3510 . ISSN   0031-4005. PMC   4530298 . PMID   24534401.
64. Reisner, Sari L.; Greytak, Emily A.; Parsons, Jeffrey T.; Ybarra, Michele L. (2014-04-17). "Gender Minority Social Stress in Adolescence: Disparities in Adolescent Bullying and Substance Use by Gender Identity". The Journal of Sex Research. 52 (3): 243–256. doi:10.1080/00224499.2014.886321. ISSN   0022-4499. PMC   4201643 . PMID   24742006.
65. Russell, Stephen T.; Sinclair, Katerina O.; Poteat, V. Paul; Koenig, Brian W. (March 2012). "Adolescent Health and Harassment Based on Discriminatory Bias". American Journal of Public Health. 102 (3): 493–495. doi:10.2105/ajph.2011.300430. ISSN   0090-0036. PMC   3487669 . PMID   22390513.
66. Díaz, Rafael M.; Ayala, George; Bein, Edward (2004). "Sexual risk as an outcome of social oppression: Data from a probability sample of Latino gay men in three U.S. cities". Cultural Diversity and Ethnic Minority Psychology. 10 (3): 255–267. doi:10.1037/1099-9809.10.3.255. ISSN   1939-0106. PMID   15311978.
67. Li, Michael Jonathan; DiStefano, Anthony; Mouttapa, Michele; Gill, Jasmeet K. (2013-06-25). "Bias-motivated bullying and psychosocial problems: Implications for HIV risk behaviors among young men who have sex with men". AIDS Care. 26 (2): 246–256. doi:10.1080/09540121.2013.811210. ISSN   0954-0121. PMID   23796024. S2CID   28910962.
68. Fekkes, Minne; Pijpers, Frans I.M.; Fredriks, A. Miranda; Vogels, Ton; Verloove-Vanhorick, S. Pauline (2006-05-01). "Do Bullied Children Get Ill, or Do Ill Children Get Bullied? A Prospective Cohort Study on the Relationship Between Bullying and Health-Related Symptoms". Pediatrics. 117 (5): 1568–1574. doi:10.1542/peds.2005-0187. ISSN   0031-4005. PMID   16651310. S2CID   13310867.
69. Rosenthal, Lisa; Earnshaw, Valerie A; Carroll-Scott, Amy; Henderson, Kathryn E; Peters, Susan M; McCaslin, Catherine; Ickovics, Jeannette R (2013-10-22). "Weight- and race-based bullying: Health associations among urban adolescents". Journal of Health Psychology. 20 (4): 401–412. doi:10.1177/1359105313502567. ISSN   1359-1053. PMC   3995896 . PMID   24155192.
70. Gini, Gianluca; Pozzoli, Tiziana (2009-03-01). "Association Between Bullying and Psychosomatic Problems: A Meta-analysis". Pediatrics. 123 (3): 1059–1065. doi:10.1542/peds.2008-1215. ISSN   0031-4005. PMID   19255040. S2CID   32470703.
71. Gini, Gianluca; Pozzoli, Tiziana (2013-10-01). "Bullied Children and Psychosomatic Problems: A Meta-analysis". Pediatrics. 132 (4): 720–729. doi:10.1542/peds.2013-0614. ISSN   0031-4005. PMID   24043275. S2CID   2215195.
72. Zucker, Kenneth J.; Lawrence, Anne A.; Kreukels, Baudewijntje P.C. (2016). "Gender Dysphoria in Adults". Annual Review of Clinical Psychology. 12 (1): 217–247. doi: 10.1146/annurev-clinpsy-021815-093034 . PMID   26788901.
73. Trujillo, Michael A.; Perrin, Paul B.; Sutter, Megan; Tabaac, Ariella; Benotsch, Eric G. (2017-01-02). "The buffering role of social support on the associations among discrimination, mental health, and suicidality in a transgender sample". International Journal of Transgenderism. 18 (1): 39–52. doi:10.1080/15532739.2016.1247405. ISSN   1553-2739. PMC   5996383 . PMID   29904324.
74. McConnell, Elizabeth A.; Birkett, Michelle; Mustanski, Brian (2016-12-01). "Families Matter: Social Support and Mental Health Trajectories Among Lesbian, Gay, Bisexual, and Transgender Youth". Journal of Adolescent Health. 59 (6): 674–680. doi:10.1016/j.jadohealth.2016.07.026. ISSN   1054-139X. PMC   5217458 . PMID   27707515.
75. Durwood, Lily; McLaughlin, Katie A.; Olson, Kristina R. (February 2017). "Mental Health and Self-Worth in Socially Transitioned Transgender Youth". Journal of the American Academy of Child & Adolescent Psychiatry. 56 (2): 116–123.e2. doi:10.1016/j.jaac.2016.10.016. PMC   5302003 . PMID   28117057.
76. Haas, Ann; Rodgers, Philip; Herman, Jody (2017-10-08). "Suicide Attempts among Transgender and Gender Non-Conforming Adults" (PDF). The Williams Institute. Archived (PDF) from the original on 2017-10-08. Retrieved 2019-10-23.
77. Toomey, Russell B.; Syvertsen, Amy K.; Shramko, Maura (2018-10-01). "Transgender Adolescent Suicide Behavior". Pediatrics. 142 (4): e20174218. doi:10.1542/peds.2017-4218. ISSN   0031-4005. PMC   6317573 . PMID   30206149.
78. Herman, Jody L.; Brown, Taylor N.T.; Haas, Ann P. (September 2019). "Suicide Thoughts and Attempts Among Transgender Adults: Findings from the 2015 U.S. Transgender Survey" (PDF). Williams Institute. Retrieved 5 November 2020.
79. Bockting, Walter O.; Miner, Michael H.; Swinburne Romine, Rebecca E.; Hamilton, Autumn; Coleman, Eli (2013). "Stigma, mental health, and resilience in an online sample of the US transgender population". American Journal of Public Health. 103 (5): 943–951. doi:10.2105/ajph.2013.301241. PMC   3698807 . PMID   23488522.
80. Rood, Brian A.; Reisner, Sari L.; Surace, Francisco I.; Puckett, Jae A.; Maroney, Meredith R.; Pantalone, David W. (January 2016). "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. ISSN   2380-193X. PMC   5685272 . PMID   29159306.
81. Heng, Audrey; Heal, Clare; Banks, Jennifer; Preston, Robyn (2018-10-02). "Transgender peoples' experiences and perspectives about general healthcare: A systematic review" (PDF). International Journal of Transgenderism. 19 (4): 359–378. doi:10.1080/15532739.2018.1502711. ISSN   1553-2739. S2CID   150322054.
82. "Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People | Transgender Care". transcare.ucsf.edu. Retrieved 2019-08-06.
83. Ashman, A; Folkers, R; Burns, P. (19 October 2023). "How can surgeons help transgender patients and colleagues feel welcome?". The Bulletin of the Royal College of Surgeons of England. Royal College of Surgeons of England. 105 (8): (epub ahead of print). doi: 10.1308/rcsbull.2023.126 .
84. Pearce, Ruth (2018). Understanding Trans Health: Discourse, Power and Possibility. Policy Press. pp. 111–112.
85. Payton, Naith (9 July 2015). "Feature: The dangers of trans broken arm syndrome". PinkNews .
86. Paradiso, Catherine; Arca-Contreras, Karen; Brillhart, Susan J.; Macchiarola, Jennifer; Curcio, Danna L. (29 July 2022). "Integration of transgender health: A multi-modal approach". Teaching and Learning in Nursing. Elsevier. 17 (4): 425–432. doi:10.1016/j.teln.2022.06.001. S2CID   251204461.
87. Freeman, Lauren; Lopéz, Saray Ayala (September 2018). "Sex Categorization in Medical Contexts: A Cautionary Tale". Kennedy Institute of Ethics Journal . Johns Hopkins University Press. 28 (3): 243–280. doi:10.1353/ken.2018.0017. PMID   30369506. S2CID   53095199 – via Project MUSE.
88. Dietz, Elizabeth; Halem, Jessica (November 2016). "How Should Physicians Refer When Referral Options Are Limited for Transgender Patients?". AMA Journal of Ethics . American Medical Association. 18 (11): 1070–1080. doi: 10.1001/journalofethics.2016.18.11.ecas1-1611 . PMID   27883298.
89. O'Hara, Mary Emily (6 August 2015). "'Trans Broken Arm Syndrome' and the way our healthcare system fails trans people". The Daily Dot .
90. Goldberg, Abbie E.; Beemyn, Genny, eds. (2021). "Health Care, Discrimination". The SAGE Encyclopedia of Trans Studies. SAGE Publishing. p. 356.
91. Vinter, Robyn (10 October 2021). "'GPs fob us off': most trans people avoid the doctor when they're sick". The Observer .
92. Hunt, Jane (2013). "An initial study of transgender people's experiences of seeking and receiving counselling or psychotherapy in the UK". Counselling and Psychotherapy Research. Routledge. 14 (4): 288–296. doi:10.1080/14733145.2013.838597.
93. Arnull, Liam Gary; Kapilashrami, Anuj; Sampson, Margaret (2021-11-30). "Visualizing patterns and gaps in transgender sexual and reproductive health: A bibliometric and content analysis of literature (1990–2020)". International Journal of Transgender Health. 24 (4): 381–396. doi: 10.1080/26895269.2021.1997691 . ISSN   2689-5269. PMC   10601526 . PMID   37901061. S2CID   251942433.
94. Reisner, Sari L; Poteat, Tonia; Keatley, JoAnne; Cabral, Mauro; Mothopeng, Tampose; Dunham, Emilia; Holland, Claire E; Max, Ryan; Baral, Stefan D (2016). "Global health burden and needs of transgender populations: a review". The Lancet. 388 (10042): 412–436. doi:10.1016/S0140-6736(16)00684-X. PMC   7035595 . PMID   27323919.
95. Pillay, Suntosh R; Ntetmen, Joachim M; Nel, Juan A (2022). "Queering global health: an urgent call for LGBT+ affirmative practices". The Lancet Global Health. 10 (4): e574–e578. doi: 10.1016/S2214-109X(22)00001-8 . hdl: 10500/29671 . PMID   35176236. S2CID   246882513.
96. 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". South African Medical Journal. 104 (6): 448–449. doi: 10.7196/SAMJ.8392 . ISSN   0256-9574. PMID   26301294.
97. Gooren, Louis J; Sungkaew, Tanapong; Giltay, Erik J (2013). "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   3739151 . PMID   23353716.
98. 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 and Transgender Women (Kathoeys) in Thailand". Culture, Health & Sexuality. 17 (1): 92–103. doi:10.1080/13691058.2014.950982. ISSN   1369-1058. PMC   4227918 . PMID   25270637.
99. Beijing LGBT Center; Peking University (2017). 2017 Zhong Guo Kua Xing Bie Qun Ti Sheng Cun Xian Zhuang Diao Cha Bao Gao2017中国跨性别群体生存现状调查报告 [2017 Survey Report on Survival Status of Transgender Groups in China](PDF) (in Chinese). Chapter 2.
100. National Medical Products Administration (2022-11-30). "Guo Jia Yao Jian Ju Guan Yu Gui Fan Yao Pin Wang Luo Xiao Shou Bei An He Bao Gao Gong Zuo De Gong Gao (2022 Nian Di 112 Hao)" 国家药监局关于规范药品网络销售备案和报告工作的公告（2022年 第112号） [Announcement of the National Medical Products Administration on Regulating Filing and Reporting of Online Drug Sales (2022 No. 112)]. 国家药品监督管理局 (in Chinese). Retrieved 2022-12-04.
101. "Guo Jia Yao Jian Ju Fa Bu Wang Luo Jin Shou Yao Pin Qing Dan: Bao Kuo Yi Miao, Zhu She Ji Deng" 国家药监局发布网络禁售药品清单：包括疫苗、注射剂等 [The National Medical Products Administration Issued a List of Banned Drugs on the Internet: Including Vaccines, Injections, etc.]. 京报网 (in Chinese). 2022-11-30. Retrieved 2022-12-04.
102. Esteva de Antonio, Isabel; Gómez-Gil, Esther (December 2013). "Coordination of healthcare for transsexual persons". Current Opinion in Endocrinology, Diabetes and Obesity. 20 (6): 585–591. doi:10.1097/01.med.0000436182.42966.31. PMID   24468763. S2CID   36430944.
103. Giraldo, F.; Antonio, I. Esteva de; Miguel, T. Bergero de; Maté, A.; González, C.; Baena, V.; Martín-Morales, A.; Tinoco, I.; Cano, G. (2001-10-01). "Andalusia (Málaga) Gender Team. Surgical experience treating transsexuals in the first and only unit in the Spanish Public Health System". ResearchGate. 27 (4). ISSN   0376-7892.
104. Esteva de Antonio, Isabel; Gómez-Gil, Esther; Almaraz, M. ª Cruz; Martínez-Tudela, Juana; Bergero, Trinidad; Olveira, Gabriel; Soriguer, Federico (2012-06-01). "Organization of healthcare for transsexual persons in the Spanish national health system". Gaceta Sanitaria. 26 (3): 203–209. doi: 10.1016/j.gaceta.2011.10.021 . ISSN   0213-9111. PMID   22402241.
105. "Forced Sterilisation of Trans People". RSFL. 2017-03-25. Archived from the original on 2020-06-13. Retrieved 2018-05-29.
106. Jessica Lundgren (2013-01-10). "Tvångssterilisering vid könskorrigering blir äntligen olagligt". QX.
107. Linander, Ida; Lauri, Marcus (2021). "Two Steps Forward, One Step Back: A Policy Analysis of the Swedish Guidelines for Trans-Specific Healthcare". Sexuality Research and Social Policy. 18 (2): 309–320. doi: 10.1007/s13178-020-00459-5 . S2CID   256073192.
108. "God vård av vuxna med könsdysfori" (PDF).
109. Lundströmmottagningen, Västra Götalandsregionen. (2016-11-28). "Könsdysfori och Utredning". Archived from the original on 2016-08-27. Retrieved 2018-06-04.
110. Ingemar Karlsson Gadea (2016-11-10). "Patient Fees". 1177.
111. RSFL (2015-11-27). "Trans Health Care". Archived from the original on 2019-02-27. Retrieved 2018-05-29.
112. "Namn". Skatteverket (in Swedish). Retrieved March 2, 2021.
113. Richard Ekman and Johannes Kardell (21 November 2016). "Transaktivister har ockuperat Socialstyrelsen". SVT Nyheter. SVT.
114. "LGBT In Britain – Trans Report" (PDF). Stonewall. Retrieved 5 September 2020.
115. "Transgender people face NHS waiting list 'hell'". BBC News. 2020-01-09. Retrieved 2022-11-13.
116. 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. S2CID   145216924.
117. "Scottish Gender Identity Services". Scottish Trans. Retrieved 29 June 2022.
118. "Annual Report 2020/2021" (PDF). National Gender Identity Clinical Network for Scotland. Archived from the original (PDF) on 30 April 2022. Retrieved 29 June 2021.
119. "Supporting NHS gender identity services". Scottish Government. 20 December 2021. Retrieved 29 June 2021.
120. "Health needs assessment of lesbian, gay, bisexual, transgender and non-binary people" (PDF). Traci Leven Research. Retrieved 29 June 2022.
121. "Health Care Needs Assessment of Gender Identity Services" (PDF). Scottish Public Health Network. Retrieved 29 June 2022.
122. "Local access to healthcare for transgender patients lacking, one advocate says". CBS News. January 27, 2016. Retrieved January 3, 2017.
123. "Canadian Transgender Youth Health Survey". Stigma and Resilience Among Vulnerable Youth Centre. The University of British Columbia . Retrieved January 3, 2017.
124. Daniel McHardie (June 3, 2016). "New Brunswick will now cover gender-confirming surgeries". CBS News. Retrieved January 3, 2017.
125. Melissa Fundira (May 3, 2016). "Arson at Montreal clinic concerns trans people awaiting surgery". CBC News. Retrieved January 3, 2017.
126. "Ontario expands referrals for gender reassignment surgery". CBS News. November 6, 2015. Retrieved January 3, 2017.
127. "Canada's health care doesn't meet the needs of transgender patients". CBC Radio. January 15, 2016. Retrieved January 3, 2017.
128. "Publicly Funded Transition-related Medical Care in Canada" (PDF). UFCW Canada. Retrieved January 3, 2017.
130. "Alberta to require parental consent for name, pronoun changes at school". 31 January 2024.
131. Mayela Sánchez (December 18, 2016). "Transgender People in Mexico City Resort to Dangerous Unsupervised Procedures". Global Press Journal. Retrieved January 3, 2017.
132. "Report on Human Rights Conditions of Transgender Women in Mexico" (PDF). Transgender Law Center . May 2016. Retrieved January 3, 2017.
133. Pam Belluck (July 26, 2016). "W.H.O. Weighs Dropping Transgender Identity From List of Mental Disorders". The New York Times . Retrieved January 3, 2017.
134. 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   3780721 . PMID   23153142.
135. Varny J. (2016). Rainbow Medicine- Supporting the Needs of Lesbian, gay, bisexual, and trans patients. Journal of Clinical Medicine.
136. Paris, Francesca (April 15, 2023). "Bans on Transition Care for Young People Spread Across U.S." The New York Times. Archived from the original on May 24, 2023. Retrieved May 24, 2023.
137. "Trans patients being dropped as Florida law bans "Up To 80%"". Los Angeles Blade. May 11, 2023. Archived from the original on May 20, 2023. Retrieved May 24, 2023.
138. "Missouri AG issues emergency order restricting gender-affirming health care". April 13, 2023. Archived from the original on April 21, 2023. Retrieved May 24, 2023.
139. Reed, Erin (27 January 2024). "Ohio, Michigan Republicans In Released Audio: "Endgame" Is To Ban Trans Care "For Everyone"". Erin in the Morning. Archived from the original on 2024-01-30. Retrieved 2024-01-30.
140. 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   4110190 . PMID   24464550.
141. Chen, Diane; Hidalgo, Marco A.; Leibowitz, Scott; Leininger, Jennifer; Simons, Lisa; Finlayson, Courtney; Garofalo, Robert (2016). "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. PMC   5549539 . PMID   28861529.
142. Taylor, Mark. "An Insight into the Life of a Transgender Child". LinkedIn. Retrieved 28 June 2017.
143. 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   5025345 . PMID   27115401.
144. Chew, Denise; Anderson, Jemma; Williams, Katrina; May, Tamara; Pang, Kenneth (2018-04-01). "Hormonal Treatment in Young People With Gender Dysphoria: A Systematic Review". Pediatrics. 141 (4): e20173742. doi: 10.1542/peds.2017-3742 . PMID   29514975.
145. Chen, Diane; Berona, Johnny; Chan, Yee-Ming; Ehrensaft, Diane; Garofalo, Robert; Hidalgo, Marco; Rosenthal, Stephen; Tishelman, Amy; Olson-Kennedy, Johanna (19 January 2023). "Psychosocial Functioning in Transgender Youth after 2 Years of Hormones". The New England Journal of Medicine . 388 (3): 240–250. doi:10.1056/NEJMoa2206297. PMC   10081536 . PMID   36652355. S2CID   255969323.
146. Catharina van der Loos, Maria Anna Theodora (October 20, 2022). "Continuation of gender-affirming hormones in transgender people starting puberty suppression in adolescence: a cohort study in the Netherlands". The Lancet.
147. "APA Policy Statement on Affirming Evidence-Based Inclusive Care for Transgender, Gender Diverse, and Nonbinary Individuals, Addressing Misinformation, and the Role of Psychological Practice and Science". American Psychological Association . February 2024. Retrieved 2024-02-29.
148. Reed, Erin. "World's largest psych association supports trans youth care". www.advocate.com. Retrieved 29 February 2024.
149. "Aging". National Center for Transgender Equality. Retrieved 2019-03-24.
150. de Vries, Brian; Gutman, Gloria; Humble, Áine; Gahagan, Jacqueline; Chamberland, Line; Aubert, Patrick; Fast, Janet; Mock, Steven (2019-03-14). "End-of-Life Preparations Among LGBT Older Canadian Adults: The Missing Conversations" (PDF). The International Journal of Aging and Human Development. 88 (4): 358–379. doi:10.1177/0091415019836738. ISSN   0091-4150. PMID   30871331. S2CID   78094482.
151. Reygan, Finn; Henderson, Neil (2019-03-21). "All Bad? Experiences of Aging Among LGBT Elders in South Africa". The International Journal of Aging and Human Development. 88 (4): 405–421. doi:10.1177/0091415019836929. hdl: 10566/6338 . ISSN   0091-4150. PMID   30897921. S2CID   85446146.