Elsevier

The Lancet

Volume 388, Issue 10042, 23–29 July 2016, Pages 390-400
The Lancet

Series
Transgender people: health at the margins of society

https://doi.org/10.1016/S0140-6736(16)00683-8Get rights and content

Summary

In this paper we examine the social and legal conditions in which many transgender people (often called trans people) live, and the medical perspectives that frame the provision of health care for transgender people across much of the world. Modern research shows much higher numbers of transgender people than were apparent in earlier clinic-based studies, as well as biological factors associated with gender incongruence. We examine research showing that many transgender people live on the margins of society, facing stigma, discrimination, exclusion, violence, and poor health. They often experience difficulties accessing appropriate health care, whether specific to their gender needs or more general in nature. Some governments are taking steps to address human rights issues and provide better legal protection for transgender people, but this action is by no means universal. The mental illness perspective that currently frames health-care provision for transgender people across much of the world is under scrutiny. The WHO diagnostic manual may soon abandon its current classification of transgender people as mentally disordered. Debate exists as to whether there should be a diagnosis of any sort for transgender children below the age of puberty.

Introduction

Transgender people (often called trans people) experience a degree of gender incongruence;1 that is, a discordance between their personal sense of their own gender (their gender identity) and the sex assigned to them at birth.2 Panel 1 defines some key terms related to gender identity.

The terms gender identity and gender incongruence refer to a person's own experience of who they are, and are not the same as sexual orientation, which is about to whom a person is attracted. A transgender man may be attracted to women (including, perhaps, transgender women), in which case he may identify as a heterosexual transgender man. Alternatively, he may be attracted to men (including, perhaps, transgender men), in which case his sexual identity may be as a homosexual or gay man. Furthermore, being transgender is not the same as being intersex. Intersex people develop atypically in regard to some or all aspects of their biological sex, whereas transgender people identify in a way that does not match their assigned sex (panel 2).

In preparing this article we accessed academic papers and documentation published by international agencies, governments and associated institutions, and community-based organisations. We searched various databases, including Google and Google Scholar databases. We also used relevant list serves and journal email alerts to ensure that up-to-date documentation was included. The peer review process, which proceeded by way of several steps, included a consultation meeting in Beijing in November, 2013, attended by, among others, transgender community leaders from several countries.

Section snippets

Gender-affirming health care

Transgender people may seek health-care services for reasons related to their gender incongruence (and accompanying dysphoria). They may seek information and counselling support to help explore identity issues, or to consider difficult decisions about gender transition, and implications for family relationships, employment, and broader social stigma. Children and youth with gender issues, as well as their parents and teachers, may need support and information too.

Key messages

  • Transgender people

The size of the transgender population

We do not know how many transgender people there are, or how many experience a need for health care, which poses a problem for health-care planners. The first task for the researcher in this area is to decide whom to count, and by what means. Transgender people are a very diverse group. Some live with their gender incongruence, but decide not to transition. Some make a social transition only, without accessing any gender-affirming health care. Some buy hormones from non-medical providers (or on

Biological correlations in the development of gender dysphoria

A growing body of scientific evidence is now available to inform debate on the extent to which biological factors (especially hormonal and genetic), rather than factors such as parenting or social environment, contribute to the development of gender identity. Putative contributing factors that are not biological are not within the scope of this section. However, gender outcomes are probably influenced by interactions between underlying biology and cultural norms and mores, which generate social

Rights and health

There remain places (for example, the Caribbean and much of Africa and the Middle East) for which little or no information is available about transgender people, their lived experiences, and their health needs. Nevertheless, across much of the world, transgender people experience stigma on a daily basis, being viewed by others in society as sexually deviant, morally corrupt, unnatural, or mentally disordered.48 They often experience what is called “minority stress”, leading to poor health and

Transgender people: mentally disordered?

Transgender peoples' access to health care is complicated by the fact that, at present, their experiences are conceptualised as a mental disorder. The view that transgender people are mentally disordered has long been criticised by transgender people, clinicians, and researchers, with arguments focused on the way that such diagnoses psychopathologise diversity (turn difference into mental disorder), with consequences for health and wellbeing. In response, in 2010, WPATH issued a public

Conclusions

We have noted that transgender people have a gender identity that is not congruent with their assigned sex, and that they may experience discomfort or distress where opportunities to express that identity are denied them or where that identity is not respected. Some transgender people seek gender-affirming healthcare aimed at bodily changes to match their gender identity. Gender incongruence is more common than clinic-based studies suggest, and may be linked to biological factors. We have seen

References (107)

  • G Rametti et al.

    The microstructure of white matter in male to female transsexuals before cross-sex hormonal treatment. A DTI study

    J Psychiatr Res

    (2011)
  • T Poteat et al.

    HIV risk and preventive interventions in transgender women sex workers

    Lancet

    (2015)
  • R Kakuma et al.

    Human resources for mental health care: current situation and strategies for action

    Lancet

    (2011)
  • P Poompruek et al.

    “For me…it's a miracle”: injecting beauty among kathoeis in a provincial Thai city

    Int J Drug Policy

    (2014)
  • N Drew et al.

    Human rights violations of people with mental and psychosocial disabilities: an unresolved global crisis

    Lancet

    (2011)
  • J Drescher et al.

    Gender incongruence of childhood in the ICD-11: controversies, proposal, and rationale

    Lancet Psychiatry

    (2016)
  • J Drescher et al.

    Minding the body: situating gender identity diagnoses in the ICD-11

    Int Rev Psychiatry

    (2012)
  • Standards of care for the health of transsexual, transgender, and gender nonconforming people

    (2012)
  • M Diamond

    Human intersexuality: difference or disorder?

    Arch Sex Behav

    (2009)
  • C Greenfield

    Should we “fix” intersex children?

    The Atlantic (Washington, DC)

    (July 8, 2014)
  • Gender identity, gender expression and sex characteristics act

  • Gender-confirming surgery grants awarded by Jim Collins Foundation

  • (2011). It's time for reform: trans* health issues in the International Classifications of Diseases. A report on the GATE Experts Meeting, the Hague November 16–18 2011

  • M Murad et al.

    Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes

    Clin Endocrinol

    (2010)
  • C Dhejne et al.

    An analysis of all applications for sex reassignment surgery in Sweden, 1960–2010: prevalence, incidence, and regrets

    Arch Sex Behav

    (2014)
  • C Keo-Meier et al.

    Testosterone treatment and MMPI–2 improvement in transgender men: a prospective controlled study

    J Consult Clin Psychol

    (2015)
  • A De Vries et al.

    Young adult psychological outcome after puberty suppression and gender reassignment

    Pediatrics

    (2014)
  • KJ Conron et al.

    Transgender health in Massachusetts: Results from a household probability sample of adults

    Am J Public Health

    (2012)
  • F Glen et al.

    Technical note: measuring gender identity

    (2012)
  • L Kuyper et al.

    Gender identities and gender dysphoria in the Netherlands

    Arch Sex Behav

    (2014)
  • E Van Caenegem et al.

    Prevalence of gender nonconformity in Flanders, Belgium

    Arch Sex Behav

    (2015)
  • M Diamond

    Transsexuality among twins

    Int J Transgend

    (2013)
  • M Stevens et al.

    Does father absence influence children's gender development? Findings from a general population study of pre-school children

    Parent Sci Pract

    (2002)
  • KJ Zucker et al.

    Gender identity disorder and psychosexual problems in children and adolescents

    (1995)
  • M Diamond et al.

    Sex reassignment at birth. Long term review and clinical implications

    Arch Pediatr Adolesc Med

    (1997)
  • K Kipnis et al.

    Pediatric ethics and the surgical assignment of sex

    J Clin Ethics

    (1998)
  • B Ochoa

    Trauma of the external genitalia in children: amputation of the penis and emasculation

    J Urol

    (1996)
  • SJ Bradley et al.

    Experiment of nurture: ablatio penis at 2 months, sex reassignment at 7 months, and a psychosexual follow-up in young adulthood

    Paediatrics

    (1998)
  • M Hines

    Brain gender

    (2004)
  • AB Dessens et al.

    Gender dysphoria and gender change in chromosomal females with congenital adrenal hyperplasia

    Arch Sex Behav

    (2005)
  • L Hare et al.

    Androgen receptor repeat length polymorphism associated with male to female transsexualism

    Biol Psychiatry

    (2008)
  • AB Dessens et al.

    Prenatal exposure to anticonvulsants and psychosexual development

    Arch Sex Behav

    (1999)
  • R Green

    Family co-occurrence of gender dysphoria: ten sibling or parent-child pairs

    Arch Sex Behav

    (2000)
  • S Burke et al.

    Click-evoked otoacoustic emissions in children and adolescents with gender identity disorder

    Arch Sex Behav

    (2014)
  • E Govier et al.

    Dichotic listening, handedness, brain organisation and transsexuality

    Int J Transgender

    (2010)
  • R Green et al.

    Hand preference, sexual preference, and transsexualism

    Arch Sex Behav

    (2001)
  • KJ Zucker et al.

    Handedness in boys with gender identity disorder

    J Clin Child Psychol Psychiatr

    (2001)
  • H Burglund et al.

    Male-to-female transsexuals show sex-atypical hypothalamus activation when smelling odorous steroids

    Cereb Cortex

    (2008)
  • J-N Zhou et al.

    A sex difference in the human brain and its relation to transsexuality

    Nature

    (1995)
  • FPM Kruijver et al.

    Male to female transsexuals have female neuron numbers in a limbic nucleus

    J Endocrinol Metabol

    (2000)
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