Medical problems of transgender people

=Access to health care=

Transgender individuals are often reluctant to seek medical care or are denied access by providers due to transphobia/homophobia or a lack of knowledge or experience with transgender health. Additionally, in some jurisdictions health care related to transgender issues, especially sex reassignment therapy, is not covered by medical insurance. However, Principle 17 of The Yogyakarta Principles affirms that "States shall (g) facilitate access by those seeking body modifications related to gender reassignment to competent, non-discriminatory treatment, care and support. The WPATH's Standards of Care also provide a set of non-binding clinical guidelines for health practitioners who are treating transgender patients.

In 2011, the National Gay and Lesbian Task Force and the National Center for Transgender Equality published the National Transgender Discrimination Survey. Survey results shed light on the discrimination transgender and gender non-conforming people are facing in all aspects of their daily lives, including in medical and health care settings. The survey reported that 19% of respondents had been refused healthcare by a doctor or other provider because they identify as transgender or gender non-conforming and transgender people of color were more likely to have been refused healthcare. 36% of American Indian and 27% of multi-racial respondents reported being refused healthcare, compared to 17% of white respondents. In addition, the survey found that 28% of respondents said they had been verbally harassed in a healthcare setting and 2% of respondents reported being physically attacked in a doctor's office. Transgender people particularly vulnerable to being assaulted in a doctor's office were those who identify as African-Americans (6%), those who engaged in sex work, drug sales or other underground work (6%), those who transitioned before they were 18 (5%), and those who identified as undocumented or non-citizens (4%).

Access to transgender health care is a global issue. In 2004 Venkatesan Chakrapani reported that hijras 'face discrimination in various ways' in the Indian health-care system, and sexual reassignment surgery is unavailable in government hospitals in India. In a report on hijra social exclusion in Bangladesh by Sharful Islam Khan et al., it was said that health facilities sensitive to hijra culture are virtually non-existent in Bangladesh.

In the UK the NHS is legally required to provide treatment for gender dysphoria.

=Insurance Coverage=

Although they are not the only uninsured population in the United States, transgender people are less likely than cisgender people to have access to health insurance and if they do, their insurance plan may not cover medically necessary services The National Transgender Discrimination Survey reported that 19% of survey respondents stated that they had no health insurance compared to 15% of the general population. They were also less likely to be insured by an employer. Undocumented non-citizens had particularly high rates of non-coverage (36%) as well as African-Americans (31%), compared to white respondents (17%).

While a majority of U.S. insurance policies expressly exclude coverage for transgender care, regulations are shifting to expand coverage of transgender and gender non-conforming health care. A number of private insurance carriers cover transgender-related health care under the rubric of “transgender services,” “medical and surgical treatment of gender identity disorder,” and “gender reassignment surgery.” Nine states (California, Colorado, Connecticut, Illinois, Massachusetts, New York, Oregon, Vermont, and Washington) and the District of Colombia require that most private insurance plans cover medically necessary health care for transgender patients.

Depending on where they live, some transgender people are able to access gender-specific health care through public health insurance programs. Medicaid does not have a federal policy on transgender health care and leaves the regulation of the coverage of gender-confirming health care up to each state. While Medicaid does not fund sex reassignment surgery in forty states, several, like New York and Oregon, now require Medicaid to cover (most) transgender care.

=Cancer= Cancers related to hormone use include breast cancer and liver cancer. In addition, transmen who have not had removal of the uterus, ovaries, or breasts remain at risk to develop cancer of these organs, while trans women remain at risk for prostate cancer.

=Mental health=

According to transgender advocate Rebecca A. Allison, trans people are "particularly prone" to depression and anxiety: "In addition to loss of family and friends, they face job stress and the risk of unemployment. Trans people who have not transitioned and remain in their birth gender are very prone to depression and anxiety.  Suicide is a risk, both prior to transition and afterward.  One of the most important aspects of the transgender therapy relationship is management of depression and/or anxiety." Depression is significantly correlated with experienced discrimination. In a study of San Francisco trans women, 62% reported depression. In a 2003 study of 1093 trans men and trans women, there was a prevalence of 44.1% for clinical depression and 33.2% for anxiety.

Suicide attempts are common in transgender people. In some transgender populations the majority have attempted suicide at least once. 41% of the respondents of the National Transgender Discrimination Survey reported having attempted suicide. This statistic was even higher for certain demographics - for example, 56% of American Indian and Alaskan Native transgender respondents had attempted suicide. In contrast, 1.6% of the American population has attempted suicide. In the sample all minority ethnic groups (Asian, Latino, black, American Indian and mixed race) had higher prevalence of suicide attempts than white people. Number of suicide attempts was also correlated with life challenges - 64% of those surveyed who had been sexually assaulted had attempted suicide. 76% who had been assaulted by teachers or other school staff had made an attempt.

In 2012 the Scottish Transgender Alliance conducted the Trans Mental Health Study. 74% of the respondents who had transitioned reported improved mental health after transitioning. 53% had self-harmed at some point, and 11% currently self-harmed. 55% had been diagnosed with or had a current diagnosis of depression. An additional 33% believed that they currently had depression, or had done in the past, but had not been diagnosed. 5% had a current or past eating disorder diagnosis. 19% believed that they had suffered from an eating disorder or currently had one, but had not been diagnosed. 84% of the sample had experienced suicide ideation and 48% had made a suicide attempt. 3% had attempted suicide more than 10 times. 63% of respondents who transitioned thought about and attempted suicide less after transitioning. Other studies have found similar results.

Trans women appear to be at greater risk than trans men and the general population of dying of suicide. However, trans men are more likely to attempt suicide than trans women.

Personality disorders are common in transgender people.

Gender identity disorder is currently classed as a psychiatric condition by the DSM IV-TR. The upcoming DSM-5 removes GID and replaces it with 'gender dysphoria', which is not classified by some authorities as a mental illness. Until the 1970s, psychotherapy was the primary treatment for GID. However, today the treatment protocol involves biomedical interventions, with psychotherapy on its own being unusual. There has been controversy about the inclusion of transsexuality in the DSM, one claim being that Gender Identity Disorder of Childhood was introduced to the DSM-III in 1980 as a 'backdoor-maneuver' to replace homosexuality, which was removed from the DSM-II in 1973.

=Hormones= Transgender individuals frequently take hormones to achieve feminizing or masculinizing effects. Side effects of hormone use include increased risk of blood clotting, high or low blood pressure, elevated blood sugar, water retention, dehydration, electrolyte disturbances, liver damage, increased risk for heart attack and stroke. Use of unprescribed hormones is common, but little is known about the associated risks. One potential hazard is HIV transmission from needle sharing. Cross-sex hormones may reduce fertility.

=Injectable silicone= Some trans women use injectable silicone, sometimes administered by lay persons, to achieve their desired physique. This is most frequently injected into the hip and buttocks. It is associated with considerable medical complications, including morbidity. Such silicone may migrate, causing disfigurement years later. Non-medical grade silicone may contain contaminants, and may be injected using a shared needle. In New York City silicone injection occurs frequently enough to be called 'epidemic', with a NYC survey of trans women finding that 18% were receiving silicone injections from 'black market' providers.

Sexually transmitted infections
Trans people (especially trans women - trans men have actually been found to have a lower rate of HIV than the general US population ) are frequently forced into sex work to make a living, and are subsequently at increased risk for STIs including HIV. According to the National Transgender Discrimination Survey, 2.64% of American transgender people are HIV positive, and transgender sex workers are over 37 times more likely than members of the general American population to be HIV positive. HIV is also more common in trans people of color. For example, in a study by the National Institute of Health more than 56% of African-American trans women were HIV-positive compared to 27% of trans women in general. This has been connected to how trans people of color are more likely to be sex workers.

A 2012 meta analysis of studies assessing rates of HIV infection among transgender women in 15 countries found that trans women are 49 times more likely to have HIV than the general population. HIV positive trans persons are likely to be unaware of their status. In one study, 73% of HIV-positive trans women were unaware of their status.

Latin American trans women have a HIV prevalence of 35%, but most Latin American countries do not recognize transgender people as a population. Therefore, there are no laws catering to their health needs.

Transgender people have higher levels of interaction with the police than the general population. 7% of transgender Americans have been held in prison cell simply due to their gender identity/expression. This rate is 41% for transgender African-Americans. 16% of respondents had been sexually assaulted in prison, a risk factor for HIV. 20% of trans women are sexually assaulted in prison, compared to 6% of trans men. Trans women of color are more likely to be assaulted whilst in prison. 38% of black trans women report having been sexually assaulted in prison compared to 12% of white trans women.

In a San Francisco study, 68% of trans women and 55% of trans men reported having been raped, a risk factor for HIV.

=Substance abuse= Trans people are more likely than the general population to use substances. For example, studies have shown that trans men are 50% more likely, and trans women 200% more likely to smoke cigarettes than other populations. It has been suggested that tobacco use is high among transgender people because many use it to maintain weight loss. In one study of trangender people, the majority had a history of non-injection drug use with the rates being 90% for marijuana, 66% for cocaine, 24% for heroin, and 48% for crack. It has been suggested that transgender people who are more accepted by their families are less likely to develop substance abuse issues.

In the Trans Mental Health Study 2012, 24% of participants had used drugs within the past year. The most commonly used drug was cannabis. 19% currently smoked. A study published in 2013 found that among a sample of transgender adults, 26.5% had abused prescription drugs, most commonly analgesics.

=See also=


 * Medical problems of transgender people in Singapore

=References=