Transgender Health

Description

• Society’s growing acceptance of nontraditional lifestyles has, in recent years, made increased room for transgender individuals, as it has for lesbians, gays, and bisexuals, even as these populations continue to suffer unique health care disparities. Better education of physicians and other providers will improve the health of the transgender population. Such education begins with teaching acceptance of all human beings into health care and ensuring a safe office environment for transgender individuals to speak openly with their clinicians. Once a “safe” space is created, it will be possible to provide appropriate and supportive health care to reduce inequities and the harms and disparities in health outcomes that result.
  • At least 1:11,900 males and 1:30,400 females in the United States define themselves as transgender.
  • Current estimates indicate 0.6% of U.S. adults, or some 1.4 million people, identify themselves as transgender, a 2-fold increase since 2011 (1). Transgender identification is more common among those age 18–24, with a rate of 0.7%, and self-identification occurs at an early age, with 94% of respondents to the 2015 United States Transgender Survey saying that by age 20 they felt that their gender was different from that assigned at birth, with 73% considering themselves transgender by that age (2).
• The terms “transgender” and “gender nonconforming” (GNC), or, more inclusively, TGNB, or transgender and gender non-binary, refer to those whose gender identity or presentation differs from the sex assigned at birth (2,3).
  • Gender identity, the sense of one’s self as male or female, and especially gender presentation, the outward expression of gender, may or may not reflect the self-identification of a TGNB patient.
  • Transgender patients can no more be categorized or thought alike than any other patients. Race, ethnicity, socioeconomic status, age, and other factors all play a role in how transgender patients define themselves.
  • Moreover, a patient’s body may or may not match gender identity or presentation. Although a patient’s anatomy may determine treatment, that treatment must also be sensitive to, and respect, gender identity and/or presentation.
  • Transgender status says nothing about an individual’s sexual orientation. Transgender people may be sexually oriented toward men, women, other transgender people, or any combination of the above.
  • TGNB patients are further defined by those who have undergone surgical procedures and/or medical treatment to better align gender identity, by those who plan such procedures in the future, and by others who do not.
• Accordingly, it is important to ask transgender patients how they would describe themselves and to honor terminology acceptable to each patient, specifically preferred name, preferred pronoun, and preferred gender identity, with those attributes ideally reflected within any electronic medical record (EMR). A two-question approach—first asking current gender, then inquiring after the sex assigned at birth—has been validated and shown to avoid stigmatizing TGNB patients and to encourage provider–patient conversations (2).
• Transgender people have a unique set of mental and physical needs (4).
  • Real or imagined stigma and discrimination are barriers to health care (3).
  • Transgender patients are less likely to have health insurance and more likely to encounter discrimination on the part of health care providers, thereby limiting access to health care services.
  • >50% of transgender patients delay needed care, compared to 20% in the general population (3).
  • 91% of TGNB patients want counseling, hormones, and/or puberty blockers, even though only 65% ever get any of these (2).
• Evidence-based medicine for transgender patients is lacking or limited to case reports and smaller studies aggravated, perhaps, by social stigma, marginalization, and discrimination (4).
• Transgender patients may also suffer from gender dysphoria, recognized in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as the disconnection between gender expression and one’s assigned gender at birth.