gender reassignment discrimination in health and social care

Gender reassignment discrimination and the NHS

• Using your device

NHS bodies, in their roles as both employer and service provider, increasingly find themselves subject to complaints of discrimination on the grounds of gender reassignment, due to a growing awareness and understanding within the trans community of their rights as employees and patients.

It is therefore important that NHS bodies ensure that they have adequate training and policies in place for the prevention of discrimination against transgender employees or service users.

The two key pieces of legislation that protect transsexual people are the Equality Act 2010 (EqA 2010) and the Gender Recognition Act 2004 (GRA 2004).

The Equality Act 2010

Discrimination under the eqa 2010.

The EqA 2010 provides legal protection from discrimination and harassment. Gender reassignment is one of the nine protected characteristics covered by the Act. A person has the protected characteristic of gender reassignment if that person is proposing to undergo, is undergoing or has undergone a process (or part of a process) for the purpose of reassigning their sex by changing physiological or other attributes of sex.

Under the Act, a reference to a person who has the protected characteristic of gender reassignment is a reference to a transsexual person. Therefore, a woman making the transition to being a man and a man making the transition to being a woman both share the characteristic of gender reassignment.

A key point to note about the definition of gender reassignment under the EqA 2010, is that a person who ‘is proposing to undergo’ the process of changing their sex is protected i.e. they need not have undertaken any actual steps towards the process of transitioning. Further, a person living in the opposite gender without having undergone any medical procedures will be protected. Unlike earlier legislation, there is no requirement to be under medical supervision to qualify for protection under the EqA 2010.

There are five types of prohibited discrimination in respect of gender reassignment:

• Direct discrimination – when a transsexual person is treated less favourably than others because of gender reassignment
• Indirect discrimination – where a transsexual person is particularly disadvantaged by a provision, criterion or practice which applies to everyone
• Harassment – when unwanted conduct related to gender reassignment causes an intimidating, hostile, humiliating or offensive environment for that person
• Victimisation – when a person is subjected to a detriment because they have made or supported a complaint about gender reassignment discrimination
• Absences from work – where an employee is treated less favourably in relation to absences from work because of gender reassignment. This is the only type of prohibited discrimination specific to transsexual people

Case example

One issue that employers are likely to face in relation to transsexual employees is use of single-sex facilities. For example, it is likely, and understandably so, that person will want to use the toilet facilities of the gender to which they are transitioning. In the leading authority on this issue Croft -v- Royal Mail Group plc [2003], the Court of Appeal upheld a decision of an employment tribunal that it was not discrimination to require a pre-operative male to female transsexual employee to use the disabled toilet as opposed to the female toilet facilities during the transition process.

However, the approach in this case should not be regarded as best practice. The recruitment and retention of transgender staff guidance issued by the Government Equalities Office (GEO) Guide states that a trans person should be free to select the facilities appropriate to the gender in which they present and that when a trans person starts to live in their acquired gender role on a full-time basis they should have the right to use the facilities for that gender. Further, the Department of Health Guidance for NHS Trusts sets out that it is not good practice to require a transsexual person to use the disabled facilities and it is not acceptable to require a transsexual person to use the facilities of their assigned gender.

Exceptions: when gender reassignment discrimination may be lawful

Gender reassignment discrimination may be permitted in certain limited circumstances. The EqA 2010 provides for an ‘occupational requirement’ exception that employers can rely on in discrimination claims. This enables employers, in limited circumstances, to require that, having regard to the nature or context of the work, only people who are not transsexuals can do the job. The explanatory notes in the EqA 2010 give the following example of an occupational requirement; ‘a counsellor working with victims of rape might have to be a woman and not a transsexual person, even if she has a gender recognition certificate, in order to avoid causing victims further distress.’ This may also apply to NHS staff employed to help victims of rape or other sexual assault.

Application to the NHS

In addition to NHS employees, patients must not be subjected to discrimination by NHS Trusts. The EqA 2010 prohibits discrimination by a service provider (concerned with the provision of a service to the public) against a person requiring the service. Therefore, NHS trusts must not discriminate against transsexual patients because they have the protected characteristic of gender reassignment.

However, there is an exception in the Act for single-sex only services (for example, a group counselling session provided only for female victims of sexual assault) but NHS trusts must be certain that the provision of separate services is a proportionate means of achieving a legitimate aim.

NHS bodies must also have regard to the Public Sector Equality Duty set out in Section 149 EqA 2010, which sets out that they must have due regard to eliminating discrimination prohibited by the EqA 2010 and advancing equality of opportunity and fostering good relations between those who share a protected characteristic and people who do not share it.

Gender Recognition Act 2004

The Gender Recognition Act 2004 (the Act) allows transsexual people to gain legal recognition of their acquired gender by registering for a Gender Recognition Certificate (GRC). The application is made to the Gender Recognition Panel who will determine whether a GRC should be issued on the basis that the applicant has lived in their acquired gender for two years and intends to live the acquired gender until death. An applicant does not have to have had gender reassignment surgery, but have been diagnosed as gender dysphoric. Where a full GRC has been issued to a person, their gender becomes for all purposes the acquired gender.

Prohibition on disclosure of information

The Act has important implications for NHS trusts, particularly in relation to the provisions on prohibition of disclosure of information relating to a person’s application for a GRC or, if a GRC is issued, their previous gender. Under section 22 of the Act, it is a criminal offence for a person who has acquired, in an official capacity, protected information regarding an individual’s gender identity to disclose that information to any other person. This clearly affects NHS bodies as employers and in the supply of services to the public, as they are likely to acquire such information in relation to their employees or patients.

An example provided by the workplace and gender reassignment: Guide for staff and managers (a:gender Guide) is of someone working in HR with access to an employee’s personal file, disclosing the fact that the employee was born a different gender, without the employee’s prior consent.

Potential defences

There are a number of defences to this prohibition set out in section 22(4) of the Act. These include where the information does not enable that person to be identified and where the person has agreed to the disclosure of the information.

In addition, there is a further defence which will have particular importance to NHS bodies as service providers. The Gender Recognition (Disclosure of Information) (England, Wales and Northern Ireland) (No2) Order 2005 provides a defence in relation to disclosure for medical purposes. It will not be an offence under section 22 of the Act to disclosure protected information if the disclosure is made to a health professional, for medical purposes, and the person making the disclosure reasonably believes that the subject has given consent to the disclosure or cannot give such consent.

Practical considerations for NHS bodies

The a:gender Guide states that ‘it is the antithesis of the intentions of the privacy provision included in the GRA 2004 to ask or expect an individual to evidence they have gender recognition. Given the wider privacy protection applicable to all, it is best practice to assume any transsexual person has gender recognition and treat them accordingly’.

Care should be taken to use appropriate names and terminology in HR and patient records in relation to transsexual people. Where a person is transgender, it is important not to refer to this fact in patient or HR records unless the person has consented to it. In respect of employees, this may involve issuing them with a new set of HR records.

In relation to transgender patients, NHS/Department of Health guidance is that they should be issued with a new set of medical records to reflect their new gender status. NHS trusts may find themselves in a difficult position when there are medical reasons why a transgender patient’s previous gender needs to be referred to. In these circumstances, the medical professionals should seek consent from the patient for their gender history being recorded in their notes and steps should be taken to ensure that access to those notes is limited to those who need to be aware of the patient’s gender history for clinical reasons.

Department of Health guidance recommends that all staff are trained on these issues in relation to transgender patients and employees. Our specialist employment team can provide training on the legislation in this area and its implications for NHS bodies.

• Health litigation bulletin
• Gender reassignment

Related insights

Statutory implementation of medical examiners in england and wales.

18 April 2024

On 15 April 2024 the Department of Health and Social Care (DHSC) confirmed that new regulations governing medical examiners have been laid before parliament and a timeframe mapped out for the...

Procurement Act 2023 Update 4 - What is the role of frameworks and dynamic markets in procurement?

19 April 2024

In this update, we look at the changes to frameworks and the introduction of dynamic markets under the new Procurement Act 2023...

Armageddon clauses – How do these affect your GP practice?

16 April 2024

General Medical Practitioners (GPs) who take a lease of a property normally receive NHS funding to pay the rent reserved under that lease. The GPs would usually continue to receive NHS funding...

AI In healthcare - Opportunities to improve HR processes

12 April 2024

Amidst all the excitement about the potential benefits AI may bring in healthcare, one area that is often overlooked is the opportunity to improve processes in HR to bring about efficiencies...

Article 2 and vulnerable people in the community

03 April 2024

The case of Parkin v HM Assistant Coroner for Inner London (East) was published last week. The family has lost their judicial review of the decision of a coroner that Article 2 did not apply to...

March 2024 Update – Government Response to the Consultation on the Procurement Regulations

On 22nd March 2024, the Government responded to a consultation on the draft regulations that was published by Cabinet Office in two parts in 2023. When the consultations were undertaken and...

Health and social care

With a team of over 250 lawyers, we are one of the leading firms providing legal advice and support to national and international healthcare and life sciences organisations.

From NHS bodies to private providers and practitioners to insurance practices, our multi-disciplinary legal expertise covers the full spectrum of healthcare law including, litigation, commercial, regulatory, employment, investigations and inquests, real estate and disciplinary law. As a full-service international law firm, we take a scalable approach to service delivery, providing immediate access to high-quality legal advice across the full spectrum.

We are committed to working in partnership with our clients, fostering philosophies that are mutually beneficial. Our expertise and experience mean that we understand the issues you face and the clear and practical advice that you require, especially as services and systems become more integrated. We can help you manage risk and obtain better value for money enabling you to improve services and outcomes.

You can also access our  webinar resources  that are designed specifically for our health clients - covering topics that may affect you.

• Introduction
• Conclusions
• Article Information

Outcomes are estimated from bivariate and multivariable generalized estimating equation models. aOR, indicates adjusted odds ratio; GAD-7, Generalized Anxiety Disorder 7-item scale; PHQ-9, Patient Health Questionnaire 9-item scale; whiskers, 95% CIs.

eTable 1. Survey Instruments

eTable 2. Prevalence of Exposure Over Time

eTable 3. Prevalence of Outcomes Over Time by Exposure Group

eTable 4. E-Value Calculation for Association Between Puberty Blockers or Gender-Affirming Hormones and Mental Health Outcomes

eTable 5. Examining Association Between Puberty Blockers or Gender-Affirming Hormones and Mental Health Outcomes Separately

eTable 6. Bivariate Model Restricted to Youths Ages 13 to 17 Years

eTable 7. Multivariable Model Restricted to 90 Youths Ages 13 to 17 Years

eTable 8. Sensitivity Analyses using Patient Health Questionnaire 8-item Scale Score of 10 or Greater for Moderate to Severe Depression

eFigure 1. Schematic of Generalized Estimating Equation Model

eFigure 2. Association Between Receipt of Gender-Affirming Hormones or Puberty Blockers and Mental Health Outcomes

eReferences

• Medical Groups Defend Patient-Physician Relationship and Access to Adolescent Gender-Affirming Care JAMA Medical News & Perspectives April 19, 2022 This Medical News article discusses physicians’ advocacy to protect patients and the patient-physician relationship amid efforts by politicians to limit access or criminalize gender-affirming care. Bridget M. Kuehn, MSJ
• As Laws Restricting Health Care Surge, Some US Physicians Choose Between Fight or Flight JAMA Medical News & Perspectives June 13, 2023 In this Medical News article, 13 physicians and health care experts spoke with JAMA about the increasing efforts to criminalize evidence-based medical care in the US. Melissa Suran, PhD, MSJ
• Data Errors in eTables 2 and 3 JAMA Network Open Correction July 26, 2022
• Improving Mental Health Among Transgender and Gender-Diverse Youth JAMA Network Open Invited Commentary February 25, 2022 Brett Dolotina, BS; Jack L. Turban, MD, MHS

See More About

Sign up for emails based on your interests, select your interests.

Customize your JAMA Network experience by selecting one or more topics from the list below.

• Academic Medicine
• Acid Base, Electrolytes, Fluids
• Allergy and Clinical Immunology
• American Indian or Alaska Natives
• Anesthesiology
• Anticoagulation
• Art and Images in Psychiatry
• Artificial Intelligence
• Assisted Reproduction
• Bleeding and Transfusion
• Caring for the Critically Ill Patient
• Challenges in Clinical Electrocardiography
• Climate and Health
• Climate Change
• Clinical Challenge
• Clinical Decision Support
• Clinical Implications of Basic Neuroscience
• Clinical Pharmacy and Pharmacology
• Complementary and Alternative Medicine
• Consensus Statements
• Coronavirus (COVID-19)
• Critical Care Medicine
• Cultural Competency
• Dental Medicine
• Dermatology
• Diabetes and Endocrinology
• Diagnostic Test Interpretation
• Drug Development
• Electronic Health Records
• Emergency Medicine
• End of Life, Hospice, Palliative Care
• Environmental Health
• Equity, Diversity, and Inclusion
• Facial Plastic Surgery
• Gastroenterology and Hepatology
• Genetics and Genomics
• Genomics and Precision Health
• Global Health
• Guide to Statistics and Methods
• Hair Disorders
• Health Care Delivery Models
• Health Care Economics, Insurance, Payment
• Health Care Quality
• Health Care Reform
• Health Care Safety
• Health Care Workforce
• Health Disparities
• Health Inequities
• Health Policy
• Health Systems Science
• History of Medicine
• Hypertension
• Images in Neurology
• Implementation Science
• Infectious Diseases
• Innovations in Health Care Delivery
• JAMA Infographic
• Law and Medicine
• Leading Change
• Less is More
• LGBTQIA Medicine
• Lifestyle Behaviors
• Medical Coding
• Medical Devices and Equipment
• Medical Education
• Medical Education and Training
• Medical Journals and Publishing
• Mobile Health and Telemedicine
• Narrative Medicine
• Neuroscience and Psychiatry
• Notable Notes
• Nutrition, Obesity, Exercise
• Obstetrics and Gynecology
• Occupational Health
• Ophthalmology
• Orthopedics
• Otolaryngology
• Pain Medicine
• Palliative Care
• Pathology and Laboratory Medicine
• Patient Care
• Patient Information
• Performance Improvement
• Performance Measures
• Perioperative Care and Consultation
• Pharmacoeconomics
• Pharmacoepidemiology
• Pharmacogenetics
• Pharmacy and Clinical Pharmacology
• Physical Medicine and Rehabilitation
• Physical Therapy
• Physician Leadership
• Population Health
• Primary Care
• Professional Well-being
• Professionalism
• Psychiatry and Behavioral Health
• Public Health
• Pulmonary Medicine
• Regulatory Agencies
• Reproductive Health
• Research, Methods, Statistics
• Resuscitation
• Rheumatology
• Risk Management
• Scientific Discovery and the Future of Medicine
• Shared Decision Making and Communication
• Sleep Medicine
• Sports Medicine
• Stem Cell Transplantation
• Substance Use and Addiction Medicine
• Surgical Innovation
• Surgical Pearls
• Teachable Moment
• Technology and Finance
• The Art of JAMA
• The Arts and Medicine
• The Rational Clinical Examination
• Tobacco and e-Cigarettes
• Translational Medicine
• Trauma and Injury
• Treatment Adherence
• Ultrasonography
• Users' Guide to the Medical Literature
• Vaccination
• Venous Thromboembolism
• Veterans Health
• Women's Health
• Workflow and Process
• Wound Care, Infection, Healing

Get the latest research based on your areas of interest.

Others also liked.

• Download PDF
• X Facebook More LinkedIn

Tordoff DM , Wanta JW , Collin A , Stepney C , Inwards-Breland DJ , Ahrens K. Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care. JAMA Netw Open. 2022;5(2):e220978. doi:10.1001/jamanetworkopen.2022.0978

Manage citations:

© 2024

• Permissions

Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care

• 1 Department of Epidemiology, University of Washington, Seattle
• 2 Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
• 3 School of Medicine, University of Washington, Seattle
• 4 Department of Psychiatry and Behavioral Medicine, Department of Adolescent and Young Adult Medicine, Seattle Children’s Hospital, Seattle, Washington
• 5 University of California, San Diego School of Medicine, Rady Children's Hospital
• 6 Division of Adolescent Medicine, Department of Pediatrics, Seattle Children’s Hospital, Seattle, Washington
• Invited Commentary Improving Mental Health Among Transgender and Gender-Diverse Youth Brett Dolotina, BS; Jack L. Turban, MD, MHS JAMA Network Open
• Medical News & Perspectives Medical Groups Defend Patient-Physician Relationship and Access to Adolescent Gender-Affirming Care Bridget M. Kuehn, MSJ JAMA
• Medical News & Perspectives As Laws Restricting Health Care Surge, Some US Physicians Choose Between Fight or Flight Melissa Suran, PhD, MSJ JAMA
• Correction Data Errors in eTables 2 and 3 JAMA Network Open

Question   Is gender-affirming care for transgender and nonbinary (TNB) youths associated with changes in depression, anxiety, and suicidality?

Findings   In this prospective cohort of 104 TNB youths aged 13 to 20 years, receipt of gender-affirming care, including puberty blockers and gender-affirming hormones, was associated with 60% lower odds of moderate or severe depression and 73% lower odds of suicidality over a 12-month follow-up.

Meaning   This study found that access to gender-affirming care was associated with mitigation of mental health disparities among TNB youths over 1 year; given this population's high rates of adverse mental health outcomes, these data suggest that access to pharmacological interventions may be associated with improved mental health among TNB youths over a short period.

Importance   Transgender and nonbinary (TNB) youths are disproportionately burdened by poor mental health outcomes owing to decreased social support and increased stigma and discrimination. Although gender-affirming care is associated with decreased long-term adverse mental health outcomes among these youths, less is known about its association with mental health immediately after initiation of care.

Objective   To investigate changes in mental health over the first year of receiving gender-affirming care and whether initiation of puberty blockers (PBs) and gender-affirming hormones (GAHs) was associated with changes in depression, anxiety, and suicidality.

Design, Setting, and Participants   This prospective observational cohort study was conducted at an urban multidisciplinary gender clinic among TNB adolescents and young adults seeking gender-affirming care from August 2017 to June 2018. Data were analyzed from August 2020 through November 2021.

Exposures   Time since enrollment and receipt of PBs or GAHs.

Main Outcomes and Measures   Mental health outcomes of interest were assessed via the Patient Health Questionnaire 9-item (PHQ-9) and Generalized Anxiety Disorder 7-item (GAD-7) scales, which were dichotomized into measures of moderate or severe depression and anxiety (ie, scores ≥10), respectively. Any self-report of self-harm or suicidal thoughts over the previous 2 weeks was assessed using PHQ-9 question 9. Generalized estimating equations were used to assess change from baseline in each outcome at 3, 6, and 12 months of follow-up. Bivariate and multivariable logistic models were estimated to examine temporal trends and investigate associations between receipt of PBs or GAHs and each outcome.

Results   Among 104 youths aged 13 to 20 years (mean [SD] age, 15.8 [1.6] years) who participated in the study, there were 63 transmasculine individuals (60.6%), 27 transfeminine individuals (26.0%), 10 nonbinary or gender fluid individuals (9.6%), and 4 youths who responded “I don’t know” or did not respond to the gender identity question (3.8%). At baseline, 59 individuals (56.7%) had moderate to severe depression, 52 individuals (50.0%) had moderate to severe anxiety, and 45 individuals (43.3%) reported self-harm or suicidal thoughts. By the end of the study, 69 youths (66.3%) had received PBs, GAHs, or both interventions, while 35 youths had not received either intervention (33.7%). After adjustment for temporal trends and potential confounders, we observed 60% lower odds of depression (adjusted odds ratio [aOR], 0.40; 95% CI, 0.17-0.95) and 73% lower odds of suicidality (aOR, 0.27; 95% CI, 0.11-0.65) among youths who had initiated PBs or GAHs compared with youths who had not. There was no association between PBs or GAHs and anxiety (aOR, 1.01; 95% CI, 0.41, 2.51).

Conclusions and Relevance   This study found that gender-affirming medical interventions were associated with lower odds of depression and suicidality over 12 months. These data add to existing evidence suggesting that gender-affirming care may be associated with improved well-being among TNB youths over a short period, which is important given mental health disparities experienced by this population, particularly the high levels of self-harm and suicide.

Transgender and nonbinary (TNB) youths are disproportionately burdened by poor mental health outcomes, including depression, anxiety, and suicidal ideation and attempts. 1 - 5 These disparities are likely owing to high levels of social rejection, such as a lack of support from parents 6 , 7 and bullying, 6 , 8 , 9 and increased stigma and discrimination experienced by TNB youths. Multidisciplinary care centers have emerged across the country to address the health care needs of TNB youths, which include access to medical gender-affirming interventions, such as puberty blockers (PBs) and gender-affirming hormones (GAHs). 10 These centers coordinate care and help youths and their families address barriers to care, such as lack of insurance coverage 11 and travel times. 12 Gender-affirming care is associated with decreased rates of long-term adverse outcomes among TNB youths. Specifically, PBs, GAHs, and gender-affirming surgeries have all been found to be independently associated with decreased rates of depression, anxiety, and other adverse mental health outcomes. 13 - 16 Access to these interventions is also associated with a decreased lifetime incidence of suicidal ideation among adults who had access to PBs during adolescence. 17 Conversely, TNB youths who present to care later in adolescence or young adulthood experience more adverse mental health outcomes. 18 Despite this robust evidence base, legislation criminalizing and thus limiting access to gender-affirming medical care for minors is increasing. 19 , 20

Less is known about the association of gender-affirming care with mental health outcomes immediately after initiation of care. Several studies published from 2015 to 2020 found that receipt of PBs or GAHs was associated with improved psychological functioning 21 and body satisfaction, 22 as well as decreased depression 23 and suicidality 24 within a 1-year period. Initiation of gender-affirming care may be associated with improved short-term mental health owing to validation of gender identity and clinical staff support. Conversely, prerequisite mental health evaluations, often perceived as pathologizing by TNB youths, and initiation of GAHs may present new stressors that may be associated with exacerbation of mental health symptoms early in care, such as experiences of discrimination associated with more frequent points of engagement in a largely cisnormative health care system (eg, interactions with nonaffirming pharmacists to obtain laboratory tests, syringes, and medications). 25 Given the high risk of suicidality among TNB adolescents, there is a pressing need to better characterize mental health trends for TNB youths early in gender-affirming care. This study aimed to investigate changes in mental health among TNB youths enrolled in an urban multidisciplinary gender clinic over the first 12 months of receiving care. We also sought to investigate whether initiation of PBs or GAHs was associated with depression, anxiety, and suicidality.

This cohort study received approval from the Seattle Children’s Hospital Institutional Review Board. For youths younger than age 18 years, caregiver consent and youth assent was obtained. For youths ages 18 years and older, youth consent alone was obtained. The 12-month assessment was funded via a different mechanism than other survey time points; thus, participants were reconsented for the 12-month survey. The study follows the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We conducted a prospective observational cohort study of TNB youths seeking care at Seattle Children’s Gender Clinic, an urban multidisciplinary gender clinic. After a referral is placed or a patient self-refers, new patients, their caregivers, or patients with their caregivers are scheduled for a 1-hour phone intake with a care navigator who is a licensed clinical social worker. Patients are then scheduled for an appointment at the clinic with a medical provider.

All patients who completed the phone intake and in-person appointment between August 2017 and June 2018 were recruited for this study. Participants completed baseline surveys within 24 hours of their first appointment and were invited to complete follow-up surveys at 3, 6, and 12 months. Youth surveys were used to assess most variables in this study; caregiver surveys were used to assess caregiver income. Participation and completion of study surveys had no bearing on prescribing of PBs or GAHs.

We assessed 3 internalizing mental health outcomes: depression, generalized anxiety, and suicidality. Depression was assessed using the Patient Health Questionnaire 9-item scale (PHQ-9), and anxiety was assessed using the Generalized Anxiety Disorder 7-item scale (GAD-7). We dichotomized PHQ-9 and GAD-7 scores into measures of moderate or severe depression and anxiety (ie, scores ≥10). 26 , 27 Self-harm and suicidal thoughts were assessed using PHQ-9 question 9 (eTable 1 in the Supplement ).

Participants self-reported if they had ever received GAHs, including estrogen or testosterone, or PBs (eg, gonadotropin-releasing hormone analogues) on each survey. We conducted a medical record review to capture prescription of androgen blockers (eg, spironolactone) and medications for menstrual suppression or contraception (ie, medroxyprogesterone acetate or levonorgestrel-releasing intrauterine device) during the study period.

We a priori considered potential confounders hypothesized to be associated with our exposures and outcomes of interest based on theory and prior research. Self-reported gender was ascertained on each survey using a 2-step question that asked participants about their current gender and their sex assigned at birth. If a participant’s self-reported gender changed across surveys, we used the gender reported most frequently by a participant (3 individuals identified as transmasculine at baseline and as nonbinary on all follow-up surveys). We collected data on self-reported race and ethnicity (available response options were Arab or Middle Eastern; Asian; Black or African American; Latinx; Native American, American Indian, or Alaskan Native or Native Hawaiian; Pacific Islander; and White), age, caregiver income, and insurance type. Race and ethnicity were assessed as potential covariates owing to known barriers to accessing gender-affirming care among transgender youth who are members of minority racial and ethnic groups. For descriptive statistics, Asian and Pacific Islander groups were combined owing to small population numbers. We included a baseline variable reflecting receipt of ongoing mental health therapy other than for the purpose of a mental health assessment to receive a gender dysphoria diagnosis. We included a self-report variable reflecting whether youths felt their gender identity or expression was a source of tension with their parents or guardians. Substance use included any alcohol, marijuana, or other drug use in the past year. Resilience was measured by the Connor-Davidson Resilience Scale (CD-RISC) 10-item score developed to measure change in an individual’s state resilience over time. 28 Resilience scores were dichotomized into high (ie, ≥median) and low (ie, <median). Prior studies of young adults in the US reported mean CD-RISC scores ranging from 27.2 to 30.1. 29 , 30

We used generalized estimating equations to assess change in outcomes from baseline at each follow-up point (eFigure 1 in the Supplement ). We used a logit link function to estimate adjusted odds ratio (aOR) for the association between variables and each mental health outcome. We initially estimated bivariate associations between potential confounders and mental health outcomes. Multivariable models included variables that were statistically significant in bivariate models. For all outcomes and models, statistical significance was defined as 95% CIs that did not contain 1.00. Reported P values are based on 2-sided Wald test statistics.

Model 1 examined temporal trends in mental health outcomes, with time (ie, baseline, 3, 6, and 12 months) modeled as a categorical variable. Model 2 estimated the association between receipt of PBs or GAHs and mental health outcomes adjusted for temporal trends and potential confounders. Receipt of PBs or GAHs was modeled as a composite binary time-varying exposure that compared mean outcomes between participants who had initiated PBs or GAHs and those who had not across all time points (eTable 2 in the Supplement ). All models used an independent working correlation structure and robust standard errors to account for the time-varying exposure variable.

We performed several sensitivity analyses. Because our data were from an observational cohort, we first considered the degree to which they were sensitive to unmeasured confounding. To do this, we calculated the E-value for the association between PBs or GAHs and mental health outcomes in model 2. The E-value is defined as the minimum strength of association that a confounder would need to have with both exposure and outcome to completely explain away their association (eTable 4 in the Supplement ). 31 Second, we performed sensitivity analyses on several subsets of youths. We separately examined the association of PBs and GAHs with outcomes of interest, although we a priori did not anticipate being powered to detect statistically significant outcomes owing to our small sample size and the relatively low proportion of youths who accessed PBs. We also conducted sensitivity analyses using the Patient Health Questionnaire 8-item scale (PHQ-8), in which the PHQ-9 question 9 regarding self-harm or suicidal thoughts was removed, given that we analyzed this item as a separate outcome. Lastly, we restricted our analysis to minor youths ages 13 to 17 years because they were subject to different laws and policies related to consent and prerequisite mental health assessments. We used R statistical software version 3.6.2 (R Project for Statistical Computing) to conduct all analyses. Data were analyzed from August 2020 through November 2021.

A total of 169 youths were screened for eligibility during the study period, among whom 161 eligible youths were approached. Nine youths or caregivers declined participation, and 39 youths did not complete consent or assent or did not complete the baseline survey, leaving a sample of 113 youths (70.2% of approached youths). We excluded 9 youths aged younger than 13 years from the analysis because they received different depression and anxiety screeners. Our final sample included 104 youths ages 13 to 20 years (mean [SD] age, 15.8 [1.6] years). Of these individuals, 84 youths (80.8%), 84 youths, and 65 youths (62.5%) completed surveys at 3, 6, and 12 months, respectively.

Our cohort included 63 transmasculine youths (60.6%), 27 transfeminine youths (26.0%), 10 nonbinary or gender fluid youths (9.6%), and 4 youths who responded “I don’t know” or did not respond to the gender identity question on all completed questionnaires (3.8%) ( Table 1 ). There were 4 Asian or Pacific Islander youths (3.8%), 3 Black or African American youths (2.9%); 9 Latinx youths (8.7%); 6 Native American, American Indian, or Alaskan Native or Native Hawaiian youths (5.8%); 67 White youths (64.4%); and 9 youths who reported more than 1 race or ethnicity (8.7%). Race and ethnicity data were missing for 6 youth (5.8%).

At baseline, 7 youths had ever received PBs or GAHs (including 1 youth who received PBs, 4 youths who received GAHs, and 2 youths who received both PBs and GAHs). By the end of the study, 69 youths (66.3%) had received PBs or GAHs (including 50 youths who received GAHs only [48.1%], 5 youths who received PBs only [4.8%], and 14 youths who received PBs and GAHs [13.5%]), while 35 youths had not received either PBs or GAHs (33.7%) (eTable 3 in the Supplement ). Among 33 participants assigned male sex at birth, 17 individuals (51.5%) had received androgen blockers, and among 71 participants assigned female sex at birth, 25 individuals (35.2%) had received menstrual suppression or contraceptives by the end of the study.

A large proportion of youths reported depressive and anxious symptoms at baseline. Specifically, 59 individuals (56.7%) had baseline PHQ-9 scores of 10 or more, suggesting moderate to severe depression; there were 22 participants (21.2%) scoring in the moderate range, 11 participants (10.6%) in the moderately severe range, and 26 participants (25.0%) in the severe range. Similarly, half of participants had a GAD-7 score suggestive of moderate to severe anxiety at baseline (52 individuals [50.0%]), including 20 participants (19.2%) scored in the moderate range, and 32 participants (30.8%) scored in the severe range. There were 45 youths (43.3%) who reported self-harm or suicidal thoughts in the prior 2 weeks. At baseline, 65 youths (62.5%) were receiving ongoing mental health therapy, 36 youths (34.6%) reported tension with their caregivers about their gender identity or expression, and 34 youths (32.7%) reported any substance use in the prior year. Lastly, we observed a wide range of resilience scores (median [range], 22.5 [1-38], with higher scores equaling more resiliency). There were no statistically significant differences in baseline characteristics by gender.

In bivariate models, substance use was associated with all mental health outcomes ( Table 2 ). Youths who reported any substance use were 4-fold as likely to have PHQ-9 scores of moderate to severe depression (aOR, 4.38; 95% CI, 2.10-9.16) and 2-fold as likely to have GAD-7 scores of moderate to severe anxiety (aOR, 2.07; 95% CI, 1.04-4.11) or report thoughts of self-harm or suicide in the prior 2 weeks (aOR, 2.06; 95% CI, 1.08-3.93). High resilience scores (ie, ≥median), compared with low resilience scores (ie, <median), were associated with lower odds of moderate or severe anxiety (aOR, 0.51; 95% CI, 0.26-0.999).

There were no statistically significant temporal trends in the bivariate model or model 1 ( Table 2 and Table 3 ). However, among all participants, odds of moderate to severe depression increased at 3 months of follow-up relative to baseline (aOR, 2.12; 95% CI, 0.98-4.60), which was not a significant increase, and returned to baseline levels at months 6 and 12 ( Figure ) prior to adjusting for receipt of PBs or GAHs.

We also examined the association between receipt of PBs or GAHs and mental health outcomes in bivariate and multivariable models (eFigure 2 in the Supplement ). After adjusting for temporal trends and potential confounders ( Table 4 ), we observed that youths who had initiated PBs or GAHs had 60% lower odds of moderate to severe depression (aOR, 0.40; 95% CI, 0.17-0.95) and 73% lower odds of self-harm or suicidal thoughts (aOR, 0.27; 95% CI, 0.11-0.65) compared with youths who had not yet initiated PBs or GAHs. There was no association between receipt of PBs or GAHs and moderate to severe anxiety (aOR, 1.01; 95% CI, 0.41-2.51). After adjusting for time-varying exposure of PBs or GAHs in model 2 ( Table 4 ), we observed statistically significant increases in moderate to severe depression among youths who had not received PBs or GAHs by 3 months of follow-up (aOR, 3.22; 95% CI, 1.37-7.56). A similar trend was observed for self-harm or suicidal thoughts among youths who had not received PBs or GAHs by 6 months of follow-up (aOR, 2.76; 95% CI, 1.22-6.26). Lastly, we estimated E-values of 2.56 and 3.25 for the association between receiving PGs or GAHs and moderate to severe depression and suicidality, respectively (eTable 4 in the Supplement ). Sensitivity analyses obtained comparable results and are presented in eTables 5 through 8 in the Supplement .

In this prospective clinical cohort study of TNB youths, we observed high rates of moderate to severe depression and anxiety, as well as suicidal thoughts. Receipt of gender-affirming interventions, specifically PBs or GAHs, was associated with 60% lower odds of moderate to severe depressive symptoms and 73% lower odds of self-harm or suicidal thoughts during the first year of multidisciplinary gender care. Among youths who did not initiate PBs or GAHs, we observed that depressive symptoms and suicidality were 2-fold to 3-fold higher than baseline levels at 3 and 6 months of follow-up, respectively. Our study results suggest that risks of depression and suicidality may be mitigated with receipt of gender-affirming medications in the context of a multidisciplinary care clinic over the relatively short time frame of 1 year.

Our findings are consistent with those of prior studies finding that TNB adolescents are at increased risk of depression, anxiety, and suicidality 1 , 11 , 32 and studies finding long-term and short-term improvements in mental health outcomes among TNB individuals who receive gender-affirming medical interventions. 14 , 21 - 24 , 33 , 34 Surprisingly, we observed no association with anxiety scores. A recent cohort study of TNB youths in Dallas, Texas, found that total anxiety symptoms improved over a longer follow-up of 11 to 18 months; however, similar to our study, the authors did not observe statistically significant improvements in generalized anxiety. 22 This suggests that anxiety symptoms may take longer to improve after the initiation of gender-affirming care. In addition, Olson et al 35 found that prepubertal TNB children who socially transitioned did not have increased rates of depression symptoms but did have increased rates of anxiety symptoms compared with children who were cisgender. Although social transition and access to gender-affirming medical care do not always go hand in hand, it is noteworthy that access to gender-affirming medical care and supported social transition appear to be associated with decreased depression and suicidality more than anxiety symptoms.

Time trends were not significant in our study; however, it is important to note that we observed a transient and nonsignificant worsening in mental health outcomes in the first several months of care among all participants and that these outcomes subsequently returned to baseline by 12 months. This is consistent with findings from a 2020 study 36 in an academic medical center in the northwestern US that observed no change in TNB adolescents’ GAD-7 or PHQ-9 scores from intake to first follow-up appointment, which occurred a mean of 4.7 months apart. Given that receipt of PBs or GAHs was associated with protection against depression and suicidality in our study, it could be that delays in receipt of medications is associated with initially exacerbated mental health symptoms that subsequently improve. It is also possible that mental health improvements associated with receiving these interventions may have a delayed onset, given the delay in physical changes after starting GAHs.

Few of our hypothesized confounders were associated with mental health outcomes in this sample, most notably receipt of ongoing mental health therapy and caregiver support; however, this is not surprising given that these variables were colinear with baseline mental health, which we adjusted for in all models. Substance use was the only variable associated with all mental health outcomes. In addition, youths with high baseline resilience scores were half as likely to experience moderate to severe anxiety as those with low scores. This finding suggests that substance use and resilience may be additional modifiable factors that could be addressed through multidisciplinary gender-affirming care. We recommend more granular assessment of substance use and resilience to better understand support needs (for substance use) and effective support strategies (for resilience) for TNB youths in future research.

This study has a number of strengths. This is one of the first studies to quantify a short-term transient increase in depressive symptoms experienced by TNB youths after initiating gender-affirming care, a phenomenon observed clinically by some of the authors and described in qualitative research. 37 Although we are unable to make causal statements owing to the observational design of the study, the strength of associations between gender-affirming medications and depression and suicidality, with large aOR values, and sensitivity analyses that suggest that these findings are robust to moderate levels of unmeasured confounding. Specifically, E-values calculated for this study suggest that the observed associations could be explained away only by an unmeasured confounder that was associated with both PBs and GAHs and the outcomes of interest by a risk ratio of 2-fold to 3-fold each, above and beyond the measured confounders, but that weaker confounding could not do so. 31

Our findings should be interpreted in light of the following limitations. This was a clinical sample of TNB youths, and there was likely selection bias toward youths with supportive caregivers who had resources to access a gender-affirming care clinic. Family support and access to care are associated with protection against poor mental health outcomes, and thus actual rates of depression, anxiety, and suicidality in nonclinical samples of TNB youths may differ. Youths who are unable to access gender-affirming care owing to a lack of family support or resources require particular emphasis in future research and advocacy. Our sample also primarily included White and transmasculine youths, limiting the generalizability of our findings. In addition, the need to reapproach participants for consent and assent for the 12-month survey likely contributed to attrition at this time point. There may also be residual confounding because we were unable to include a variable reflecting receipt of psychotropic medications that could be associated with depression, anxiety, and self-harm and suicidal thought outcomes. Additionally, we used symptom-based measures of depression, anxiety, and suicidality; further studies should include diagnostic evaluations by mental health practitioners to track depression, anxiety, gender dysphoria, suicidal ideation, and suicide attempts during gender care. 2

Our study provides quantitative evidence that access to PBs or GAHs in a multidisciplinary gender-affirming setting was associated with mental health improvements among TNB youths over a relatively short time frame of 1 year. The associations with the highest aORs were with decreased suicidality, which is important given the mental health disparities experienced by this population, particularly the high levels of self-harm and suicide. Our findings have important policy implications, suggesting that the recent wave of legislation restricting access to gender-affirming care 19 may have significant negative outcomes in the well-being of TNB youths. 20 Beyond the need to address antitransgender legislation, there is an additional need for medical systems and insurance providers to decrease barriers and expand access to gender-affirming care.

Accepted for Publication: January 10, 2022.

Published: February 25, 2022. doi:10.1001/jamanetworkopen.2022.0978

Correction: This article was corrected on July 26, 2022, to fix minor errors in the numbers of patients in eTables 2 and 3 in the Supplement.

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2022 Tordoff DM et al. JAMA Network Open .

Corresponding Author: Diana M. Tordoff, MPH, Department of Epidemiology, University of Washington, UW Box 351619, Seattle, WA 98195 ( [email protected] ).

Author Contributions : Diana Tordoff had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Diana Tordoff and Dr Wanta are joint first authors. Drs Inwards-Breland and Ahrens are joint senior authors.

Concept and design: Collin, Stepney, Inwards-Breland, Ahrens.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Tordoff, Wanta, Collin, Stepney, Inwards-Breland.

Critical revision of the manuscript for important intellectual content: Wanta, Collin, Stepney, Inwards-Breland, Ahrens.

Statistical analysis: Tordoff.

Obtained funding: Inwards-Breland, Ahrens.

Administrative, technical, or material support: Ahrens.

Supervision: Wanta, Inwards-Breland, Ahrens.

Conflict of Interest Disclosures: Diana Tordoff reported receiving grants from the National Institutes of Health National Institute of Allergy and Infectious Diseases unrelated to the present work and outside the submitted work. No other disclosures were reported.

Funding/Support: This study was supported Seattle Children’s Center for Diversity and Health Equity and the Pacific Hospital Preservation Development Authority.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

• Register for email alerts with links to free full-text articles
• Access PDFs of free articles
• Manage your interests
• Save searches and receive search alerts

• Open access
• Published: 14 February 2020

Debate: Why should gender-affirming health care be included in health science curricula?

• Elma de Vries   ORCID: orcid.org/0000-0001-6041-5919 1 ,
• Harsha Kathard 2 &
• Alex Müller 3  

BMC Medical Education volume  20 , Article number:  51 ( 2020 ) Cite this article

31k Accesses

46 Citations

41 Altmetric

Metrics details

Every person who seeks health care should be affirmed, respected, understood, and not judged. However, trans and gender diverse people have experienced significant marginalization and discrimination in health care settings. Health professionals are generally not adequately prepared by current curricula to provide appropriate healthcare to trans and gender diverse people. This strongly implies that health care students would benefit from curricula which facilitate learning about gender-affirming health care.

Trans and gender diverse people have been pathologized by the medical profession, through classifications of mental illness in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Disease (ICD). Although this is changing in the new ICD-11, tension remains between depathologization discourses and access to gender-affirming health care.

Trans and gender diverse people experience significant health disparities and an increased burden of disease, specifically in the areas of mental health, Human Immunodeficiency Virus, violence and victimisation. Many of these health disparities originate from discrimination and systemic biases that decrease access to care, as well as from health professional ignorance.

This paper will outline gaps in health science curricula that have been described in different contexts, and specific educational interventions that have attempted to improve awareness, knowledge and skills related to gender-affirming health care. The education of primary care providers is critical, as in much of the world, specialist services for gender-affirming health care are not widely available. The ethics of the gatekeeping model, where service providers decide who can access care, will be discussed and contrasted with the informed-consent model that upholds autonomy by empowering patients to make their own health care decisions.

There is an ethical imperative for health professionals to reduce health care disparities of trans and gender diverse people and practice within the health care values of social justice and cultural humility. As health science educators, we have an ethical duty to include gender-affirming health in health science curricula in order to prevent harm to the trans and gender diverse patients that our students will provide care for in the future.

Peer Review reports

Every person who seeks health care should be affirmed, respected, understood, and not judged. However, trans and gender diverse (TGD) people have experienced significant marginalization and discrimination in health care settings, as will be described further below. Health professionals are generally not adequately prepared by current curricula to provide healthcare to TGD people and have described feeling “completely out-at-sea” [ 1 ]. This strongly implies that healthcare students would benefit from curricula which facilitate learning about gender-affirming health care.

The literature search for this debate started with a key word search of databases including Scopus, Medline, Pubmed and Web of Science during the time period 2017–2018. Search terms included ‘trans’, ‘transgender’, ‘medical education’, ‘health science education’, ‘gender-affirming’, ‘curriculum’ and combinations thereof. A search of article reference lists identified further relevant articles as did personal communication with colleagues. This data informed the main topics for this debate.

Transgender is a term that refers to persons whose gender identity is different to that normatively expected on the basis of assigned sex. Gender diverse is a term to describe “people who do not conform to society’s or culture’s expectations for men and women” [ 2 ]. Nonbinary is a term used for a person who identifies as neither male nor female [ 3 ] and gender nonconforming for a person whose gender identity is different to that normatively expected on the basis of assigned sex, “but may be more complex, fluid, multifaceted, or otherwise less clearly defined than a transgender person” [ 3 ]. Genderqueer is another term used by some with this range of identities [ 3 ]. For this article, trans and gender diverse (TGD) will be used as an umbrella term to include transgender, gender nonconforming, genderqueer and gender diverse people. Cisgender is a term for someone whose gender identity is the same as that normatively expected on the basis of their assigned sex. Gender-affirming health care has been described by Radix, Reisner and Deutch [ 4 ] as “health care that holistically attends to transgender people’s physical, mental, and social health needs and well-being while respectfully affirming their gender identity”. This is more than just transition-related care and refers to an affirming experience in all health care encounters. Gender-affirming care models utilise an approach of depathologisation of human gender diversity (transgender as “identity”), rather than a pathological perspective (transgender as “disorder”) [ 4 ].

Until recently, little gender-affirming research existed, and, in the literature, TGD people have often been included in the broader grouping LGBT. This acronym combines sexual minority people (lesbian, gay, and bisexual people), and gender minority people (TGD people). These sexual and gender minority groups have in common that they often experience social exclusion, stigma, discrimination, violence, as well as ignorance from health professionals [ 5 ]. These experiences are rooted in societal heteronormativity and cisnormativity that generally marginalises non-heteronormative sexual (LGB) and gender (TGD) identities. Heteronormativity is “the assumption that everyone is heterosexual, and that heterosexuality is superior to all other sexualities” [ 6 ]. Cisnormativity is “the assumption all people are cisgender, that those assigned male at birth always grow up to be men and those assigned female at birth always grow up to be women” [ 7 ]. This strong normative facilitates transphobia, which is emotional disgust, fear, hostility, violence, anger or discomfort felt or expressed towards people who do not conform to the gender expectations of society [ 8 ]. Thus, transphobia has been described as a symptom of hetero-cis-normativity [ 9 ]. Müller comments that “though there is a common source of oppression [hetero-cis-normativity], it has to be acknowledged that this oppression acts on different identities (sexual orientation or gender) in different ways” [ 10 ].

Compared to cisgender people, TGD people experience significant health disparities and an increased burden of disease [ 11 ]. Many of these health disparities originate from discrimination and systemic biases that decrease access to care, as well as from health professionals’ ignorance [ 12 ]. It is thus critical to educate health professionals to deliver equitable care for TGD populations, but most health sciences education institutions do not yet provide sufficient education [ 13 ].

Brief history of pathologisation, Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Disease (ICD)

People with diverse gender identities and expressions have been part of society for millennia. With increasing medical interest in providing transition-related care in the 1950’s, the TGD person became a “patient” and with the “medical gaze”, diverse gender identities have often been viewed as pathology [ 14 ]. The history of pathologisation is important to understand in relation to gender-affirming health care, as there is a tension between pathologisation and access to health care [ 15 ].

Historically, medical research produced the “scientific” evidence that pathologized sexualities and gender identities that did not conform to societal expectations, as well as supported treatments such as so-called “conversion therapy” that is now regarded as unethical [ 15 ]. Until 1973, homosexuality was listed as a mental illness in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) [ 16 ]. Sex between people of the same sex or gender still remains criminalised in 68 United Nations member states in 2019 [ 17 ]. The DSM is an influential document that is used internationally to diagnose and classify mental illness. Gender diversity remains listed in the DSM until today. In the DSM-4, the term “Gender identity disorder” was used and in DSM-5 this had been changed to “Gender Dysphoria” [ 18 ]. The intention of the change in the DSM-5 was to reduce stigma, while ensuring that individuals are able to access the care they need [ 14 ]. Proponents for the term “Gender Dysphoria” argued that it was less stigmatizing than “Gender identity disorder” [ 14 ]. However, others have pointed out that gender diversity in itself is not pathological, and have questioned the need to medically classify and diagnose gender diversity [ 19 , 20 ].

The International Classification of Disease (ICD) of the World Health Organisation (WHO) is used to code diagnoses and process payment for health care, especially in the private health care sector. It includes diagnoses for all body systems, whereas the DSM only categorises mental illness. In 1975, a diagnosis of “transsexualism” was introduced in the ICD-9 [ 14 ], and in the ICD-10, published in 1992, the diagnostic term was changed to “Gender Identity Disorder” [ 21 ]. In the ICD–11, this term will be changed to “Gender Incongruence” [ 22 ]. It will be relocated from the chapter on Mental and Behavioural Disorders to a new chapter, Conditions Related to Sexual Health. On 18 June 2018, the WHO published a version of ICD-11, with the press release stating “While evidence is now clear that it is not a mental disorder, and indeed classifying it in this way can cause enormous stigma for people who are transgender, there remain significant health care needs that can best be met if the condition is coded under the ICD” [ 23 ]. The ICD-11 was adopted at the World Health Assembly on 25 May 2019, for implementation in 2022 [ 24 ]. While such a diagnostic classification might be needed in order to access gender-affirming treatment, it is the view of many TGD activists and groups that it can further pathologize and stigmatise TGD identities [ 10 , 25 ]. Although a strong argument has been made towards depathologisation, including in Southern Africa [ 19 ], some in the Southern African TGD community have also raised concerns regarding the depathologisation movement [ 26 ]. McLachlan [ 26 ] argues that “the African context may be more sympathetic towards a person who has a diagnosis and is identified as having a mental condition than a person who diverges from what is seen and/or constructed as the norm”. This remains a controversial topic with many different perspectives, ranging from no diagnostic category at the one end of the spectrum, to the middle ground of a diagnosis of “gender incongruence” in a separate chapter in the ICD-11, to retention as a mental health diagnosis as in the current DSM-V. Tensions continue to exist over how to classify “gender incongruence” to both depathologize gender diversity expressions and identities, while ensuring access to gender-affirming health care [ 15 ]. Regardless of if or how gender incongruence is classified within (or without) medical classification systems, TGD people have the right to receive health care that is affirming, respectful and non-judgmental, for which health professionals play a crucial role.

Do TGD people experience gender-identity related health disparities?

Social determinants of health (SDOHs) are defined by the WHO as “the conditions in which people are born, grow, live, work and age” and that are “shaped by the distribution of money, power and resources.” [ 27 ]. Pega and Veale argue for the recognition of gender identity as a SDOH [ 28 ]. “Prejudice, stigma, transphobia, discrimination, and violence targeted at TGD people produce differential levels of social exclusion for populations defined by gender identity, including in health care settings. These social conditions disadvantage TGD people through social exclusion and privilege cisgender people through social inclusion, resulting in differential health outcomes. So, although gender identity in itself does not determine health, it socially stratifies the population into differential exposures to SDOHs such as transphobia”. This can be compared to other social stratifiers such as race or ethnicity, which are also considered SDOHs [ 28 ].

The health disparities are not inherent to TGD individuals but stem from structural factors such as government policy and hostile health care environments, as well as community and interpersonal factors such as social discrimination and rejection by families [ 12 ]. Such structural, community and interpersonal factors can contribute to a delay in accessing gender-affirming care [ 29 , 30 ]. TGD people who belong to racial and ethnic minority groups face even more challenges [ 31 ]. Intersectionality acknowledges that identity is multidimensional and is impacted on by historical, structural, and cultural factors [ 32 , 33 ]. Ng [ 33 ] eloquently explains that “Practicing medicine through the lens of intersectionality proactively considers patients’ diverse identities and how the sociocultural factors associated with membership in multiple minority groups can affect their health risks and health care experiences, and ultimately health decision making and health outcomes” [ 33 ]. It is thus important to keep in mind that despite a shared marginalised identity, TGD people are not a homogenous group, and that sub-groups and individuals may have different health care needs.

There are specific areas in which gender identity-related health disparities have been researched. In the section that follows, we will discuss mental health, Human Immunodeficiency Virus (HIV), violence and victimisation. This evidence on health disparities shows that there are specific gender identity-related issues that health professionals need to know about and that should be included in health science curricula.

Mental health

A review of the health burden and needs of TGD populations globally reports that there is a significant mental health burden [ 12 ]. For example, estimates of depression prevalence were as high as 63% in a United States of America (USA) sample of 230 TGD women [ 34 ]. An Australian survey of 859 TGD young people found that 74.6% of participants had a diagnosis of depression and 72.2% an anxiety disorder. In this study, the incidence of self-harm was 79.7, and 48.1% of participants reported a suicide attempt in the past [ 35 ]. The authors point out that “the higher frequency of mental health difficulties than the general population is not because an individual identifies as TGD. Rather, these difficulties are largely caused by external factors – in other words, how the world perceives and treats transgender people” [ 35 ]. To make sense of the high rate of attempted suicides by TGD people, experiences of rejection and discrimination need to be considered as a key factor [ 36 ].

Meyer has described the concept of minority stress in LGB persons — explaining that “stigma, prejudice, and discrimination create a hostile and stressful social environment that causes mental health problems” [ 37 ]. Hendricks and Testa framed minority stress as a concept in TGD people [ 38 ], by applying the factors described by Meyer: “prior discrimination or victimization, expectations of future victimization or rejection, internalized transphobia, and resilience” [ 37 , 38 ]. Firstly, the external events that impact on someone’s life as a result of their minority status such as discrimination and threats to their safety can negatively affect their mental health. The second factor is the anticipation and expectation that external stressful events will occur, leading to heightened vigilance. The negative expectations themselves can create distress for the person. The third factor is internalized transphobia, which can negatively affect someone’s ability to cope with external stressful events and ultimately reduces their resilience. This resonates with the description of TGD stigma by White Hughto, Reisner and Pachankis [ 39 ] as operating at structural, interpersonal and individual levels.

Importantly, Meyer [ 37 ] points out that not all of the effects of minority stress are negative, as members of minority groups can develop resilience. Hendricks and Testa [ 38 ] describe “group-level coping” in TGD persons, when they engage with other members of their minority group. Trans-specific social networks can create a supportive community that can buffer the effects of discrimination and violence. Riggs and Treharne (2017) add the theoretical framework of decompensation, described as “[ceasing] being able to compensate, [ceasing] being able to make up for the daily discrimination, [ceasing] being able to prop oneself up in the face of ideologies that render one’s existence unintelligible” [ 40 ]. This framework emphasises the need to challenge ideology and social norms that cause decompensation, as opposed to only focusing on individual resilience [ 40 , 41 ]. Unfortunately, due to the lack of health professionals’ knowledge, and implicit or explicit prejudicial attitudes, the healthcare system often perpetuates the discrimination and marginalisation of TGD people within wider society, and this environment adds to, rather than alleviates, gender identity-related minority stress [ 42 ].

A study that compared the mental health of socially transitioned TGD children who are supported in their gender identity to that of cisgender children, found that depression rates were similar in both groups, and only slightly elevated anxiety rates were found amongst the TGD children [ 43 ]. Social transition can thus be regarded as a buffer against poor mental health. While there is a high prevalence of mental health challenges, there is evidence that gender-affirming hormone treatment can improve mental health [ 44 , 45 , 46 ].

TGD women are disproportionately affected by HIV and other sexually transmitted infections [ 12 ]. A systematic review reported an odds ratio of 48.8 for HIV infection in TGD women compared with all adults of reproductive age across 15 countries [ 47 ]. A study of 230 TGD women in New York found that “gender abuse predicted depressive symptoms, and gender abuse combined with depressive symptoms predicted both high-risk sexual behaviour (unprotected receptive anal intercourse) and HIV” [ 34 ].

Violence and victimisation

A high burden of violence and victimisation experiences in TGD people have been documented in research across the globe [ 12 ]. A WHO review reported that a high proportion of gender minority people experienced physical and sexual violence, motivated by bias or hate based on their gender identity [ 48 ]. This review found that “the prevalence of physical violence in TGD people ranged from 11.8% to 68.2% and sexual violence 7.0% to 49.1%”. A comparative study on being TGD in Europe that included 28 countries, analysed data from 6579 respondents [ 49 ]. While 54% of respondents stated that they had been discriminated against during the last year, 22% felt discriminated against in a health care setting [ 42 ]. A study of the effect of violence on TGD people, with a sample of 179 TGD women and 92 TGD men in Virginia [ 50 ] found that those who had experienced physical and/or sexual violence were significantly more likely to report a history of suicide attempts, alcohol abuse and illicit substance use. TGD individuals who present visibly as gender nonconforming have been shown to face even more discrimination compared to their gender conforming counterparts [ 51 ] and a UK study found that respondents currently undergoing a process of transition were significantly more likely to have reported experiencing physical and sexual harassment, compared to those who were proposing to undergo or had already undergone a process of transition [ 52 ]. In a survey of attitudes towards homosexuality and gender non-conformity in South Africa, 1% of respondents ( n  = 3079) agreed to the statement “I have physically hurt women who dressed and acted like men in public in the past year”, and between 6.2 and 7.4% of South Africans indicated that they might use violence against gender non-conforming people in the future [ 53 ]. Violence towards trans people is not only institutional and societal, but can be experienced within families, as described by Rogers [ 54 ] who found that family perceptions of shame and stigma can lead to transphobic ‘honour-based’ abuse.

Do TGD people experience stigma and discrimination in health care settings?

TGD persons are more likely to face barriers when they try to access appropriate health care, compared to their cisgender peers [ 55 ]. There is evidence in the literature that transphobia in the health sector can lead to experiences of discrimination and stigma. Several USA studies of TGD persons reported negative health care experiences and found that knowledge gaps and discrimination contributed to a disparity in health care delivery [ 56 , 57 , 58 , 59 , 60 ]. A Canadian study of 923 TGD youth found that they described many past negative care encounters, with “uncomfortable and frustrating encounters with doctors” [ 61 ]. Two qualitative Swedish studies [ 62 , 63 ] found that TGD persons experience estrangement in health care settings, due to lack of knowledge among health professionals. Participants described being treated as different, “to be regarded as a monkey in a cage appears to be very strenuous” [ 54 ]. In a UK study, 29 % of respondents ( n  = 411) felt that their gender identity was not validated as genuine in mental health settings and qualitative data indicated that some trans people felt that at gender identity clinics, the clinical sessions “ran counter to the preservation of their dignity and human rights” [ 64 ]. Negative experiences of gender diverse Australians were reported as physical healthcare being “invasive and sometimes abusive” [ 65 ]. There is limited research about TGD people published from the African continent and Asia. Qualitative studies in South Africa have reported that many of the TGD persons interviewed had experienced health workers as being discriminatory and hostile [ 66 , 67 , 68 ].

Negative health care experiences can be the result of subtle, apparently insignificant features of health care spaces and interpersonal interactions called microaggressions [ 69 , 70 ]. Nadal et al. [ 70 ] define microaggressions as “subtle forms of discrimination, often unconscious or unintentional, that communicate hostile or derogatory messages, particularly to and about members of historically marginalized social groups” [ 70 ]. Although originally used to describe racial microaggressions [ 71 ], the theory was expanded to include other marginalised groups, including TGD people [ 70 ]. Health care spaces and providers often convey cisnormative microaggressions, which communicate to TGD people that “their identities, experiences, and relationships are abnormal, pathological, unexpected, unwelcome, or shameful” [ 69 ]. An example would be misgendering, a term meaning patients were misidentified or referred to by the incorrect pronoun [ 72 ].

Gender and sexuality in health science education in relation to sexual and gender minority groups

Much of the negative attitudes of health professionals toward sexual and gender minority groups may originate from wider societal homophobia and transphobia. The paucity of education about LGBTQ health allows these notions to go unchallenged, thereby maintaining the heteronormative and cisnormative culture in health facilities [ 73 ]. In health sciences, the dominant pedagogical approach to sexuality has been biomedical. This emphasis leaves little space to interrogate the constructions of gender and sexuality through social dynamics [ 74 ]. Müller & Crawford-Browne [ 75 ] argue that “biomedical discourse bases its authority on empirical evidence – ‘objective’ scientific facts – and constructs people’s bodies as results of biological processes and determinations”. This biomedical approach makes it difficult to situate these bodies in their social context. Although more emphasis has been placed in recent years on the biopsychosocial approach, the health sciences have traditionally regarded bodies through a positivist lens that limits the extent to which socially constructed identities can be acknowledged [ 75 ].

It is essential for health sciences education to include critical reflection on the historical and contemporary hegemony of heteronormative and cisnormative discourses. This can assist both students and teachers to identify their discomfort with LGBTQ patients and reflect on how this could have originated in oppressive structures [ 76 ]. This can begin to address the root causes of the alienation experienced by TGD persons in health care settings, rather than just treating the symptoms.

What are the gaps in curricula?

Several studies have been published internationally that describe the gaps in medical curricula. In a study of undergraduate medical education in the USA and Canada in 2009–2010, only 30.3% of the 150 medical schools surveyed reported teaching about gender transitioning [ 77 ]. Gaps in residency programs in the USA have been described for Emergency Medicine [ 78 ], Urology [ 79 ] and Plastic surgery [ 80 ]. A survey of 15 Australian and New Zealand medical schools found that teaching about gender and gender identity is varied across schools, with seven respondents (47%) unsure about what is taught [ 81 ]. In a United Kingdom study of medical students, participants were particularly unconfident on TGD health terminology and 72.9% felt “very unconfident” or “unconfident” deciding into which ward TGD patients should be admitted [ 82 ]. Canadian qualitative studies found a reported lack of knowledge regarding TGD health among family physicians [ 83 ] and mental health care providers [ 84 ]. A Canadian qualitative analysis of physician-side barriers to providing health care for TGD patients aptly titled “Completely out-at-sea with two-gender medicine”, found that a lack of knowledge made the clinical management of TGD patients more complicated [ 1 ]. In a survey of emergency medicine physicians in the USA, 82.5% reported that they did not receive formal training on TGD health care although 88% reported caring for this population [ 85 ]. A study of speech-language pathologists in four countries found that although TGD communication is within their scope of practice, 47% of respondents indicated that this was not included in their master’s curriculum [ 86 ]. A study of health professions education in South Africa and Malawi [ 87 ] found that there is little formal inclusion of LGBTQ health topics in nursing and medical curricula, and that educators who do teach LGB health topics reported doing so because “they felt personally compelled to include them”, not because this was supported or mandated institutionally. Topics related to TGD health and differences in sex characteristics were not covered by any of the participating educators [ 87 ].

An ethical discussion by Tomson [ 88 ] that compares the gatekeeping model and the informed-consent model of providing gender-affirming care provides an important perspective of how lack of knowledge of health professionals can lead to unethical care [ 88 ]. In the gatekeeping model, service providers make the assessment of whether or not a patient should be allowed access to gender-affirming care. Tomson [ 88 ] argues that this violates the principle of respect for autonomy. In contrast, the principle of autonomy is upheld by the informed-consent model. In this model, treatment is a cooperative effort between the patient and provider where well informed patients are the primary decision makers about their care [ 89 ]. A patient’s ability to make informed decisions about their health, e.g. starting hormone treatment, is enhanced by thorough education [ 89 ]. Furthermore, Tomson [ 88 ] argues that “since access to medical transition improves outcomes (particularly suicide risk) for TGD patients, limiting access to these interventions can be seen as harmful in and of itself, and as such, is a violation of the principle of non-maleficence”. When patients can decide on their own health care in an informed consent model, without factors such as race, social class or finance creating barriers to access, this promotes equity and fairness and upholds the principle of justice [ 88 ]. Although the informed consent model is used in some clinics [ 90 ], the gatekeeping model is still the mainstream treatment paradigm in many settings [ 91 ], which has implications for the role of health science education to promote an ethical model of care.

What educational interventions have been described?

A recent scoping review of improving medical students’ and residents’ training and awareness of TGD health care found that consensus is lacking on exactly which educational interventions to use to address this topic [ 92 ]. Another review focusing on curricular initiatives that enhance student knowledge and perceptions of sexual and gender minority groups concluded that “multi-modal approaches that encouraged awareness of one’s lens and privilege in conjunction with facilitated communication seemed the most effective” [ 93 ]. The literature supports a shift toward longitudinally integrated and clinical skills based pedagogical interventions [ 92 ]. A 90 min workshop for psychiatry residents at Columbia university, USA, produced significant short-term increases in resident professionalism toward TGD patients [ 94 ]. However, on 90-day follow-up, this study did not find any statistically significant differences in perceived empathy, knowledge, comfort, and motivation for future learning, compared to baseline [ 94 ]. This highlights the limitations of one-time interventions and call for longitudinal programming to produce more durable improvements. Stroumsa et al. [ 95 ] caution that transphobia needs to be addressed specifically as a potential barrier to improved knowledge. Their study did not find any association between increased hours of education and improved knowledge, but found a negative association between transphobia and provider knowledge [ 95 ]. Gamble Blakey and Treharne [ 96 ] emphasize values cultivation as a starting point in educating about TGD healthcare, and argue that simply adding curricular content about gender-affirming care may not result in significant learning as this requires a sensitive and specific pedagogic discourse around values [ 97 ].

The Association of American Medical Colleges published an extensive resource for medical educators in 2014, titled “Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who Are LGBT, Gender Nonconforming, or Born with DSD” [ 98 ]. It discusses the role of medical education and health care professionals in eliminating health disparities, lists professional competency objectives as well as discusses integrating competencies into medical school curricula [ 98 ]. This publication has been described by Donald et al. [ 29 ] as “representing a new frontier in medical education that attempts to redefine health to be inclusive of sexual orientation, gender identity, gender expression, and sex development—four intrinsic components of personhood” [ 29 ]. In the chapter on Trauma and Resilience, the authors emphasize that competence in providing care to diverse individuals requires more than an understanding of the causes of health disparities and to know to avoid microaggressions, making assumptions or discriminatory remarks: “It is imperative that health care providers learn how to promote resilience in the lives and families of individuals who are members of these groups so as to mitigate the effects of real and perceived trauma on risk behaviours and adverse health outcomes” [ 98 ].

There has been a recent proliferation of publications in professional journals to educate medical practitioners already in practice. These include the specialities of Endocrinology [ 99 ], Paediatrics [ 100 , 101 , 102 ]; Family Medicine [ 103 , 104 ], Gynaecology [ 105 ], Psychiatry [ 106 ], Surgery [ 107 , 108 ] and Anaesthesia [ 109 ]. Free e-learning courses have been developed such as “Primary Health Care for Trans, Gender Diverse & Non-binary People” [ 110 ] and “Caring for Gender Nonconforming young people” [ 111 ].

Argument for including TGD health care in curricula

Winter argues that because “primary care is the most common point of contact that TGD people have with the health system, effective training for primary care providers through medical education and continuing professional development, is needed” [ 112 ]. Primary care providers can evaluate gender dysphoria and manage applicable hormone therapy [ 104 ]. In much of the world, specialist services for gender-affirming health care are not widely available, which reinforces the need for the training of primary care providers.

DasGupta and colleagues argue that incorporating social justice into the education of medical professionalism is critical [ 113 ]. A global consensus document on the social accountability of medical schools [ 114 ] includes statements that resonate with the need to include gender-affirming health in curricula, such as: “The medical school recognizes the various social determinants of health – and directs its education, research and service delivery programs accordingly,” and “the medical school recognizes the local community as a primary stakeholder and shares responsibility for a comprehensive set of health services to a defined population in a given geographical area, consistent with values of quality, equity, relevance”. A South African report, “Reconceptualising Health Professions Education in South Africa” [ 115 ] states that “the ultimate goal of health professions education is to produce knowledgeable, competent, relevant, socially accountable health care professionals capable of confidently and collaboratively promoting health and addressing the country’s burden of disease across the continuum of health care in the context of quality universal health coverage”. To be socially accountable, medical educators need to include the health needs of TGD people in medical curricula [ 29 , 116 ]. The ethical imperative of the medical profession to reduce health care disparities and practice within the health care values of social justice, cultural humility and humanism has been highlighted by medical educators and researchers [ 98 ]. The World Medical Association (WMA) adopted a statement on TGD people in 2015 [ 117 ]. In this document, the WMA calls “for the provision of appropriate expert training for physicians at all stages of their career to enable them to recognise and avoid discriminatory practises, and to provide appropriate and sensitive transgender health care” [ 117 ].

Whereas ideally gender should be viewed as a spectrum, and gender diversity as part of the diversity of humanity, in reality TGD persons often have very difficult lives due to not fitting into society’s cisnormative expectations [ 11 , 12 ]. This leads to significant gender identity-related health disparities in the areas of mental health [ 34 , 35 ], HIV risk [ 47 ], as well as violence and discrimination [ 48 ]. TGD people often experience stigma and discrimination in health care settings, which is a barrier to access to care [ 55 ]. Health professional attitudes and knowledge gaps contribute to and exacerbate these health disparities [ 56 , 57 ]. The minority stress model describes how external stressors such as transphobic experiences can lead to anticipation of bad experiences, which can lead to avoidance of accessing health care [ 37 , 38 ]. Several studies have described the gaps in undergraduate medical training [ 77 , 81 , 82 ] as well as residency training [ 78 , 79 , 80 ]. The gatekeeping model, where service providers decide who can access care, violates the ethical principle of respect for autonomy, while the informed-consent model upholds autonomy by empowering patients to make their own health care decisions [ 88 ]. As health science educators, representing a profession that has pathologized [ 10 , 25 ], and continues to pathologize TGD identities [ 15 ], we have an ethical duty to include gender-affirming health in health science curricula [ 98 , 116 , 117 ] in order to prevent harm to TGD patients that our students will provide care for in the future.

Availability of data and materials

All data generated or analysed during this study are included in this published article

Abbreviations

Diagnostic and Statistical Manual of Mental Disorders

Human Immunodeficiency Virus

International Classification of Disease

Lesbian, gay, bisexual

Lesbian, gay, bisexual, transgender

Lesbian, gay, bisexual, transgender, queer

Social determinants of health

• Trans and gender diverse

United States of America

World Health Organisation

World Medical Association

Snelgrove JW, Jasudavisius AM, Rowe BW, Head EM, Bauer GR. “Completely out-at-sea” with “two-gender medicine”: a qualitative analysis of physician-side barriers to providing healthcare for transgender patients. BMC Health Serv Res. 2012;12(1):110.

Article   Google Scholar  

Oliphant J, Veale J, MacDonald J, Carroll R, Johnson R, Harte M, et al. Guidelines for gender affirming healthcare for gender diverse and transgender children, young people and adults in Aotearoa, New Zealand. N Z Med J. 2018;131(1487):86–96.

Google Scholar  

Center of Excellence for Transgender Health. Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people. In: Deutsch MB, editor. University of California, San Francisco. San Francisco: Center of Excellence for Transgender Health; 2016.

Reisner SL, Radix A, Deutsch MB. Integrated and gender-affirming transgender clinical care and research. J Acquir Immune Defic Syndr. 2016;72:S235–42.

Ard KL, Makadon HJ. Improving the health care of lesbian, gay, bisexual and transgender people. Boston: The Fenway Institute; 2012. https://www.lgbtagingcenter.org/resources/pdfs/12-054_LGBTHealtharticle_v3_07-09-12.pdf . Accessed 21 Jan 2018

National LGBT Health Education Center. Glossary of LGBT terms for health care teams. Boston: National LGBT Health Education Center; 2017. p. 1–7. https://www.lgbthealtheducation.org/wp-content/uploads/2018/03/Glossary-2018-English-update-1.pdf . Accessed 26 Mar 2018

Bourns A. Guidelines and protocols for hormone therapy and primary health care for trans clients. 2nd ed. Toronto: Sherbourne Health Centre; 2015. https://www.rainbowhealthontario.ca/wp-content/uploads/woocommerce_uploads/2015/04/SHC-Protocols-for-Hormone-Therapy-Final1.pdf . Accessed 26 Mar 2018

Psychological Society of South Africa. Practice guidelines for psychology professionals working with sexually and gender-diverse people. 1st ed. Victor CJ, Nel JA, editors. Johannesburg: Psychological Society of South Africa; 2017. http://www.psyssa.com . Accessed 22 Apr 2018

Worthen MGF. Hetero-cis–normativity and the gendering of transphobia. Int J Transgenderism. 2016;17(1):31–57.

Müller A. Health for all? Sexual orientation, gender identity, and the implementation of the right to access to health care in South Africa. Heal Hum Rights An Int J. 2016;18(2):195–208.

Noonan EJ, Sawning S, Combs R, Weingartner LA, Martin LJ, Jones VF, et al. Engaging the transgender community to improve medical education and prioritize healthcare initiatives. Teach Learn Med. 2018;30(2):119–32.

Reisner SL, Poteat T, Keatley JA, Cabral M, Mothopeng T, Dunham E, et al. Global health burden and needs of transgender populations: a review. Lancet. 2016;388(10042):412–36.

Holthouser A, Sawning S, Leslie KF, Faye Jones V, Steinbock S, Noonan EJ, et al. eQuality: a process model to develop an integrated, comprehensive medical education curriculum for LGBT, gender nonconforming, and DSD health. Med Sci Educ. 2017;27(2):371–83.

Beek TF, Cohen-kettenis PT, Kreukels BPC. Gender incongruence / gender dysphoria and its classification history. Int Rev Psychiatry. 2016;28(1):5–12.

Polderman TJC, Kreukels BPC, Irwig MS, Beach L, Chan YM, Derks EM, et al. The biological contributions to gender identity and gender diversity: bringing data to the table. Behav Genet. 2018;48(2):95–108.

King M. Treatments of homosexuality in Britain since the 1950s - an oral history: the experience of professionals. BMJ. 2004;328(7437):429–0.

Mendos LR. State-sponsored homophobia. Geneva: Switzerland; 2019. https://ilga.org/state-sponsored-homophobia-report . Accessed 2 May 2019

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Association; 2013.

Kara S. Gender is not an illness. How pathologizing trans people violates international human rights law: GATE; 2017. https://transactivists.org/category/campaigns-advocacy/publications/ . Accessed 3 May 2019

Davy Z, Sørlie A, Schwend AS. Democratising diagnoses? The role of the depathologisation perspective in constructing corporeal trans citizenship. Crit Soc Policy. 2018;38(1):13–34.

World Health Organization (WHO). ICD-10 International statistical classification of diseases and related health problems 10th Revision. Geneva: World Health Organization; 1992.

Beek TF, Cohen-Kettenis PT, Bouman WP, De Vries ALC, Steensma TD, Witcomb GL, et al. Gender incongruence of adolescence and adulthood: acceptability and clinical utility of the world health organization’s proposed ICD-11 criteria. PLoS One. 2016;11(10):1–21.

World Health Organization (WHO). ICD-11: Classifying disease to map the way we live and die. 2018. https://www.who.int/news-room/spotlight/international-classification-of-diseases . Accessed 25 July 2018.

World Health Organisation. World Health Assembly Update, 25 May 2019. 2019. https://www.who.int/news-room/detail/25-05-2019-world-health-assembly-update . Accessed 3 June 2019.

Drescher J, Cohen-Kettenis P, Winter S. Minding the body: situating gender identity diagnoses in the ICD-11. Int Rev Psychiatry. 2012;24(6):568–77.

McLachlan C. Que(e) ring trans and gender diversity. South African J Psychol. 2019;49(1):7–9.

WHO. About social determinants of health: WHO; 2017. http://www.who.int/social_determinants/sdh_definition/en/ . Accessed 22 Apr 2018

Pega F, Veale JF. The case for the world health organization’s commission on social determinants of health to address gender identity. Am J Public Health. 2015;105(3):e58–62.

Donald CA, DasGupta S, Metzl JM, Eckstrand KL. Queer frontiers in medicine. Acad Med. 2017;92(3):345–50.

Seelman KL, Colón-Diaz MJP, LeCroix RH, Xavier-Brier M, Kattari L. Transgender noninclusive healthcare and delaying care because of fear: connections to general health and mental health among transgender adults. Transgender Heal. 2017;2(1):17–28.

Kattari SK, Walls NE, Whitfield DL, Langenderfer-Magruder L. Racial and ethnic differences in experiences of discrimination in accessing health services among transgender people in the United States. Int J Transgenderism. 2015;16(2):68–79.

Eckstrand KL, Eliason J, St Cloud T, Potter J. The priority of intersectionality in academic medicine. Acad Med. 2016;91(7):904–7.

Ng HH. Intersectionality and shared decision making in LGBTQ health. LGBT Heal. 2016;3(5):325–6.

Nuttbrock L, Bockting W, Rosenblum A, Hwahng S, Mason M, Macri M, et al. Gender abuse, depressive symptoms, and HIV and other sexually transmitted infections among male-to-female transgender persons: a three-year prospective study. Am J Public Health. 2013;103(2):300–7.

Strauss P, Cook A, Winter S, Watson V, Wright Toussaint DLA. Trans pathways: the mental health experiences and care pathways of trans young people - summary of results. Perth; 2017. https://www.telethonkids.org.au/transpathways . Accessed 22 Apr 2018

Klein A, Golub SA. Family rejection as a predictor of suicide attempts and substance misuse among transgender and gender nonconforming adults. LGBT Heal. 2016;3(3):193–9.

Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674–97.

Hendricks ML, Testa RJ. A conceptual framework for clinical work with transgender and gender nonconforming clients: an adaptation of the minority stress model. Prof Psychol Res Pract. 2012;43(5):460–7.

White Hughto JM, Reisner SL, Pachankis JE. Transgender stigma and health: a critical review of stigma determinants, mechanisms, and interventions. Soc Sci Med. 2015;147:222–31.

Riggs DW, Treharne GJ. Decompensation: a novel approach to accounting for stress arising from the effects of ideology and social norms. J Homosex. 2017;64(5):592–605.

Riggs DW, Ansara GY, Treharne GJ. An evidence-based model for understanding the mental health experiences of transgender Australians. Aust Psychol. 2015;50(1):32–9.

Jacob M, Cox SR. Examining transgender health through the international classification of functioning, disability, and health’s (ICF) contextual factors. Qual Life Res. 2017;26(12):3177–85.

Olson KR, Durwood L, DeMeules M, McLaughlin KA. Mental health of transgender children who are supported in their identities. Pediatrics. 2015;137(3):e20153223.

Colizzi M, Costa R, Todarello O. Transsexual patients’ psychiatric comorbidity and positive effect of cross-sex hormonal treatment on mental health: results from a longitudinal study. Psychoneuroendocrinology. 2014;39(1):65–73.

Wilson EC, Chen YH, Arayasirikul S, Wenzel C, Raymond HF. Connecting the dots: examining transgender women’s utilization of transition-related medical care and associations with mental health, substance use, and HIV. J Urban Health. 2015;92(1):182–92.

Keo-Meier CL, Herman LI, Reisner SL, Pardo ST, Sharp C, Babcock JC. Testosterone treatment and MMPI-2 improvement in transgender men: a prospective controlled study. J Consult Clin Psychol. 2015;83(1):143–56.

Baral SD, Poteat T, Strömdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis. 2013;13(3):214–22.

Blondeel K, de Vasconcelos S, García-Moreno C, Stephenson R, Temmerman M, Toskin I. Violence motivated by perception of sexual orientation and gender identity: a systematic review. Bull World Health Organ. 2018 ;96(1):29-41L. https://doi.org/10.2471/BLT.17.197251 Accessed 10 Feb 2018.

European Union Agency for Fundamental Rights. Being trans in the EU – comparative analysis of EU LGBT survey data. 2014. papers3://publication/doi/10.2811/92683. Accessed 22 Apr 2018.

Testa RJ, Sciacca LM, Wang F, Hendricks ML, Goldblum P, Bradford J, et al. Effects of violence on transgender people. Prof Psychol Res Pract. 2012;43(5):452–9.

Miller LR, Grollman EA. The social costs of gender nonconformity for transgender adults: implications for discrimination and health. Sociol Forum. 2015;30(3):809–31.

Ellis SJ, Bailey L, McNeil J. Transphobic victimisation and perceptions of future risk: a large-scale study of the experiences of trans people in the UK. Psychol Sex. 2016;7(3):211–24.

Sutherland C, Roberts B, Gabriel N, Struwig JGS. Progressive prudes - a survey of attitudes towards homosexuality & gender non-conformity in South Africa. Pretoria; 2016. http://www.hsrc.ac.za/en/research-data/view/8245 . Accessed 10 Feb 2018

Rogers M. Transphobic ‘honour’-based abuse: a conceptual tool. Sociology. 2017;51(2):225–40.

Müller A. Scrambling for access: availability, accessibility, acceptability and quality of healthcare for lesbian, gay, bisexual and transgender people in South Africa. BMC Int Health Hum Rights. 2017;17(16):1–10.

Grant JM, Mottet L a, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at every turn - a report of the national transgender discrimination survey. Washington; 2011. http://www.thetaskforce.org/static_html/downloads/reports/reports/ntds_summary.pdf . Accessed 11 Feb 2018

Jaffee KD, Shires DA, Stroumsa D. Discrimination and delayed health care among transgender women and men implications for improving medical education and health care delivery. Med Care. 2016;54(11):1010–6.

James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M’a. The report of the 2015 U.S. transgender survey. Washington, DC; 2016. https://www.transequality.org/sites/default/files/docs/USTS-Full-Report-FINAL.PDF . Accessed 18 Mar 2018

Kosenko K, Rintamaki L, Raney S, Maness K. Transgender patient perceptions of stigma in health care contexts. Med Care. 2013;51(9):819.

Samuels EA, Tape C, Garber N, Bowman S, Choo EK. “Sometimes you feel like the freak show”: a qualitative assessment of emergency care experiences among transgender and gender-nonconforming patients. Ann Emerg Med. 2018;71(2):170–182.e1.

Clark BA, Veale JF, Greyson D, Saewyc E. Primary care access and foregone care: a survey of transgender adolescents and young adults. Fam Pract. 2017. https://doi.org/10.1093/fampra/cmx112 .

Lindroth M. ‘Competent persons who can treat you with competence, as simple as that’ - an interview study with transgender people on their experiences of meeting health care professionals. J Clin Nurs. 2016;25(23–24):3511–21.

von Vogelsang AC, Milton C, Ericsson I, Strömberg L. ‘Wouldn’t it be easier if you continued to be a guy?’ – a qualitative interview study of transsexual persons’ experiences of encounters with healthcare professionals. J Clin Nurs. 2016;25(23–24):3577–88.

Ellis SJ, Bailey L, McNeil J. Trans people’s experiences of mental health and gender identity services: a UK study. J Gay Lesbian Ment Heal. 2015;19(1):4–20.

Riggs DW, Coleman K, Due C. Healthcare experiences of gender diverse Australians: a mixed-methods, self-report survey. BMC Public Health. 2014;14(1):1–5.

Sanger N. Young and transgender: understanding the experiences of young transgender persons in educational institutions and the health sector in South Africa A. Cape Town: Gender DynamiX; 2014.

Stevens M. Transgender access to sexual health services in South Africa : findings from a key informant survey. Cape Town; 2012. https://genderdynamix.org.za/wp-content/uploads/2012/10/Transgender-access-to-sexual-health-services-in-South-Africa.pdf?x91330 . Accessed 10 Feb 2018

Newman-Valentine D, Duma S. Injustice to transsexual women in a hetero-normative healthcare system. Afr J Prim Heal Care Fam Med. 2014;6(1):1–5.

Dean MA, Victor E, Guidry-Grimes L. Inhospitable healthcare spaces: why diversity training on LGBTQIA issues is not enough. J Bioeth Inq. 2016;13(1):557–70.

Nadal KL, Whitman CN, Davis LS, Erazo T, Davidoff KC. Microaggressions toward lesbian, gay, bisexual, transgender, queer, and genderqueer people: a review of the literature. J Sex Res. 2016;53(4–5):488–508.

Sue DW, Capodilupo CM, Torino GC, Bucceri JM, Holder AMB, Nadal KL, et al. Racial microaggressions in everyday life: implications for clinical practice. Am Psychol. 2007;62(4):271–86.

Nadal KL, Skolnik A, Wong Y. Interpersonal and systemic microaggressions toward transgender people: implications for counseling. J LGBT Issues Couns. 2012 Jan;6(1):55–82.

Meer T, Müller A. “They treat us like we’re not there”: queer bodies and the social production of healthcare spaces. Health Place. 2017;45(March):92–8.

Bennett J, Reddy V. “Feeling the disconnect”: teaching sexualities and gender in South African higher education. Fem Africa. 2007:43–62.

Müller A, Crawford-Browne S. Challenging medical knowledge at the source – attempting critical teaching in the health sciences briefing challenging medical knowledge at the source – attempting critical teaching in the health sciences. Agenda. 2013;27(4):25–34.

Harbin A, Beagan B, Goldberg L. Discomfort, judgment, and health care for queers. J Bioeth Inq. 2012;9(2):149–60.

Obedin-Maliver J, Goldsmith ES, Stewart L, White W, Tran E, Brenman S, et al. Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. Jama. 2011;306(9):971–7.

Moll J, Krieger P, Moreno-Walton L, Lee B, Slaven E, James T, et al. The prevalence of lesbian, gay, bisexual, and transgender health education and training in emergency medicine residency programs: what do we know? Acad Emerg Med. 2014;21(5):608–11.

Dy GW, Osbun NC, Morrison SD, Grant DW, Merguerian PA. Exposure to and attitudes regarding transgender education among urology residents. J Sex Med. 2016 Oct;13(10):1466–72.

Morrison SD, Dy GW, Chong HJ, Holt SK, Vedder NB, Sorensen MD, et al. Transgender-related education in plastic surgery and urology residency programs. J Grad Med Educ. 2017;9(2):178–83.

Sanchez AA, Southgate E, Rogers G, Duvivier RJ. Inclusion of lesbian, gay, bisexual, transgender, queer, and intersex health in Australian and New Zealand Medical Education. LGBT Heal. 2017;4(4):lgbt.2016.0209.

Parameshwaran V, Cockbain BC, Hillyard M, Price JR. Is the lack of specific lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) health care education in medical school a cause for concern? Evidence from a survey of knowledge and practice among UK medical students. J Homosex. 2017;64(3):367–81.

Beagan B, Fredericks E, Bryson M. Family physician perceptions of working with LGBTQ patients: physician training needs. Can Med Educ J. 2015;6(1):e14–22.

Rutherford K, Mcintyre J, Daley A, Ross LE. Development of expertise in mental health service provision for lesbian, gay, bisexual and transgender communities. Med Educ. 2012;46(9):903–13.

Chisolm-Straker M, Willging C, Daul AD, Mcnamara S, Cham SS, Shattuck DG, et al. Transgender and gender-nonconforming patients in the emergency department: what physicians know, think, and do. Ann Emerg Med. 2018;71(2):183–188.e1.

Hancock A, Haskin G. Speech-language pathologists’ knowledge and attitudes regarding lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations. Am J Speech-Language Pathol. 2015;24(2):206–21.

Müller A, Daskilewicz K, Langen B, Odumosu O. These are the topics cannot run away from. Amsterdam: COC Netherlands; 2017.

Tomson A. Gender-affirming care in the context of medical ethics – gatekeeping v . informed consent. S Afr J Bioeth Law. 2018;11(1):24–8.

Cundill P, Wiggins J. Protocols for the initiation of hormone therapy for trans and gender diverse patients. Melbourne: Equinox Gender Diverse Health Centre; 2017. https://thorneharbour.org/documents/108/b3e096c2-equinox-informed-consent-guidelines.pdf . Accessed 10 Oct 2019

Deutsch MB. Use of the informed consent model in the provision of cross-sex hormone therapy: a survey of the practices of selected clinics. Int J Transgenderism. 2012;13:140–6.91.

Schulz SL. The informed consent model of transgender care: an alternative to the diagnosis of gender dysphoria. J Humanist Psychol. 2018;58(1):72–92.

Dubin SN, Nolan IT, Greene RE, Radix AE, Morrison SD. Transgender health care: improving medical students’ and residents’ training and awareness. Adv Med Educ Pract. 2018;9:377–91.

Desrosiers J, Wilkinson T, Abel G, Pitama S. Curricular initiatives that enhance student knowledge and perceptions of sexual and gender minority groups: a critical interpretive synthesis. Can Med Educ J. 2016;7(2):e121–38.

Kidd JD, Bockting W, Cabaniss DL, Blumenshine P. Special-“T” training: extended follow-up results from a residency-wide professionalism workshop on transgender health. Acad Psychiatry. 2016;40(5):802–6.

Stroumsa D, Shires DA, Richardson CR, Jaffee KD, Woodford MR. Transphobia rather than education predicts provider knowledge of transgender health care. Med Educ. 2019;53:398–407.

Gamble Blakey A, Treharne GJ. Overcoming barriers to transgender healthcare education in Aotearoa New Zealand. New Zeal J Educ Stud. 2019;54(2):357–66.

Gamble Blakey A, Treharne GJ. Advancing transgender healthcare teaching in Aotearoa/New Zealand. N Z Med J. 2019;132(1491):104–6.

Association of American Medical Colleges. Implementing curricular and institutional climate changes to improve health care for individuals who are LGBT, gender nonconforming, or born with DSD, vol. 2. Washington, DC: Association of American Medical Colleges; 2014. https://members.aamc.org/eweb/upload/Executive%20LGBT%20FINAL.pdf . Accessed 11 Feb 2018

Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2017;102(11):3869–903.

Rafferty J. Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Pediatrics. 2018;142(4):e20182162. w.

Lopez X, Marinkovic M, Eimicke T, Rosenthal SM, Olshan JS. Statement on gender-affirmative approach to care from the pediatric endocrine society special interest group on transgender health. Curr Opin Pediatr. 2017;29(4):475–80.

de Vries ALC, Klink D, Cohen-Kettenis PT. What the primary care pediatrician needs to know about gender incongruence and gender dysphoria in children and adolescents. Pediatr Clin N Am. 2016;63(6):1121–35.103.

Stumbar S. The responsibility of family physicians to our transgender patients. Am Fam Physician. 2018;98(11):635.

Klein DA, Paradise SL, Goodwin ET. Caring for transgender and gender-diverse persons: what clinicians should know. Am Fam Physician. 2018;98(11):645–53.

Unger CA. Care of the transgender patient: the role of the gynecologist. Am J Obstet Gynecol. 2014;44(0):8371.

Wylie K, Barrett J, Besser M, Bouman WP, Bridgman M, Clayton A, et al. Good practice guidelines for the assessment and treatment of adults with gender dysphoria. Sex Relatsh Ther. 2014;29(2):154–214.

Berli JU, Knudson G, Fraser L, Tangpricha V, Ettner R, Ettner FM, et al. What surgeons need to know about gender confirmation surgery when providing care for transgender individuals. JAMA Surg. 2017;152(4):394.

Salibian AA, Levitt N, Zhao LC, Bluebond-Langner R. Preoperative and postoperative considerations in gender-affirming surgery. Curr Sex Heal Reports. 2018;10(3):186–95.

Etienne Tollinche L, Burrows Walters C, Radix A, Long M, Galante L, Garner Goldstein Z, et al. The perioperative care of the transgender patient. Anesth Analg. 2018;127(2):359–66.

McNair R, Andrews C. Primary health care for gender diverse young people. https://aelp.smartsparrow.com/v/open/f3xc2ipc . Accessed 7 Oct 2019.

GIRES. Caring for gender nonconforming young people – gender identity research & education society. https://www.gires.org.uk/e-learning/caring-for-gender-nonconforming-young-people/ . Accessed 7 Oct 2019.

Winter S, Settle E, Wylie K, Reisner S, Cabral M, Knudson G, et al. Synergies in health and human rights: a call to action to improve transgender health. Lancet. 2016;388(10042):318–21.

DasGupta S, Fornari A, Geer K, Hahn L, Kumar V, Lee HJ, et al. Medical education for social justice: Paulo Freire revisited. J Med Humanit. 2006;27(4):245–51.

Boelen C. Global consensus on social accountability of medical schools, vol. 23; 2010. http://healthsocialaccountability.org/ . Accessed 11 Feb 2018

Academy of Science of South Africa. Reconceptualising health professions education in south Africa. Pretoria. 2018; https://doi.org/10.17159/assaf.2018/0021 . Accessed 23 July 2018.

Bonvicini KA. LGBT healthcare disparities: what progress have we made? Patient Educ Couns. 2017;100(12):2357–61.

World Medical Association. WMA statement on transgender people - adopted by the 66th WMA general assembly. Moscow; 2015. http://www.wma.net/en/30publications/10policies/t13/index.html . Accessed 20 Mar 2018

Download references

Acknowledgements

We would like to thank all reviewers for helpful suggestions and literature, especially reviewers 1 and 3 for pointing out our own unconscious normativities, which prompted us to reword our definitions related to transgender and cisgender people.

Not applicable

Author information

Authors and affiliations.

School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa

Elma de Vries

Department of Health and Rehabilitation Sciences, University of Cape Town, Cape Town, South Africa

Harsha Kathard

Gender, Health and Justice Research Unit, University of Cape Town, Cape Town, South Africa

Alex Müller

You can also search for this author in PubMed   Google Scholar

Contributions

All authors conceptualised the topic and outline of the work together and had lively debates around the key concepts. EDV wrote the initial draft, AM and HK made substantial contributions to the draft and the manuscript in subsequent revisions. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Elma de Vries .

Ethics declarations

Ethics approval and consent to participate, consent for publication, competing interests.

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Cite this article.

de Vries, E., Kathard, H. & Müller, A. Debate: Why should gender-affirming health care be included in health science curricula?. BMC Med Educ 20 , 51 (2020). https://doi.org/10.1186/s12909-020-1963-6

Download citation

Received : 13 May 2019

Accepted : 07 February 2020

Published : 14 February 2020

DOI : https://doi.org/10.1186/s12909-020-1963-6

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Transgender
• Health disparities
• Pathologisation
• Gender-affirming health care
• Social justice
• Health science education

BMC Medical Education

ISSN: 1472-6920

• Submission enquiries: [email protected]
• General enquiries: [email protected]

Recognizing, Addressing Unintended Gender Bias in Patient Care

How can you improve care for female patients.

Despite good intentions, gender bias persists in health care. A survey conducted in early 2019 by TODAY found that more than one-half of women, compared with one-third of men, believe gender discrimination in patient care is a serious problem. One in five women say they have felt that a health care provider has ignored or dismissed their symptoms, and 17% say they feel they have been treated differently because of their gender—compared with 14% and 6% of men, respectively.

Studies show that women’s perceptions of gender bias are correct. Compared with male patients, women who present with the same condition may not receive the same evidence-based care. In several key areas, such as cardiac care and pain management, women may get different treatment, leading to poorer outcomes.

Few physicians think intentional discrimination is at play here. Instead, it’s a result of the vestiges of disproved beliefs and outdated conventions. “The origins of this situation go back many years,” explains Janine Clayton, MD, director of the Office of Research on Women’s Health (ORWH) at the NIH. Much of medical science is based on the belief that male and female physiology differ only in terms of sex and reproductive organs, she says. Because of this, most research has been conducted on male animals and male cells, Clayton explains. “This is a major root of this issue.”

In addition, women—especially those in child-bearing years—were excluded from clinical trials for many years, in part to protect them and their fetuses from potential adverse effects. Researchers also felt that they could not adequately control for women’s variable hormonal status.

“Because we have studied women less, we know less about them,” Clayton says. “The result is that women may not have always received the most optimal care.”

Increasing the Knowledge Base

Women now constitute approximately one-half of participants in NIH-supported clinical research, which has increased the knowledge base about sex and gender differences.

“We now know that sex affects cell physiology, metabolism, and many other biological functions; symptoms and manifestations of disease; and responses to treatment,” says Clayton, pointing out that this research has led to a better understanding of both male and female physiology—knowledge that is critical as we move further into an era of precision/personalized medicine. The ORWH website ( www.nih.gov/women ) provides free courses on sex and gender differences in medicine that are open to the public. It also contains an A-to-Z guide on sex and gender influences on health and disease.

“It is important for everyone who works in a medical practice to know how sex and gender—as well as age and race/ethnicity—affect health,” says Clayton.

Recognizing and Addressing the Problem

Office-based physicians may face challenges when trying to recognize and address the effects of unintended gender bias in their practices, says Calvin Chou, MD, a primary care physician at the San Francisco Veterans Affairs Medical Center and a senior faculty adviser for external education for the Academy of Communication in Healthcare. “We interact with our patients one by one, without much [outside] observation.” Additionally, time constraints in a medical practice can encourage some clinicians to inadvertently cut corners or jump to conclusions during patient visits.

“I don’t think there are any practitioners who imagine that they are delivering different care based on gender,” says Chou. “The first step is awareness. You can’t change your practices without awareness.”

“Biases are not moral failings; they are habits of mind,” adds Denise Davis, MD, clinical professor of medicine at the University of California, San Francisco, and faculty physician at the San Francisco Veterans Affairs Medical Center. With effort, habits can be changed. The following tips can help clinicians identify and combat gender bias.

Diverse health care teams. Explicitly encouraging discussion of gender or other bias during team huddles can help team members feel comfortable speaking up about any concerns.

Open-ended questions. Questions that elicit a limited range of responses from patients are more easily “contaminated by bias,” Davis says. However, open-ended questions pave the way to optimal patient care. For example, clinicians can ask, “What are your concerns today? What am I missing that is important for us to talk about?”

Substitution. If Davis thinks bias may be slipping into her patient interaction, she asks herself what questions she would ask if the patient was a different gender. For example, she might be more likely to ask a young male patient about substance use or risky behavior, such as having guns at home. Additionally, she might assume a female patient has an ample social support system. Any of these assumptions can lead to missed opportunities for more comprehensive patient care.

Data collection and analysis. Collecting and analyzing data can illuminate differences in care that would otherwise go undetected. Davis suggests first examining areas where disparities have been documented, such as in rates of cardiology consultations.

Checklists and guidelines. Using computerized checklists that prompt providers to ask patients about risk factors, for example, can help ensure all patients undergo the same evaluation. Similarly, clinical guidelines for patient care can ensure that clinicians follow evidence-based methods for all patients.

Training opportunities. Bringing in practice coaches or attending training opportunities on patient experience or patient communication can also help clinicians become aware of their own biases.

“Awareness of the problem is growing, as is an appreciation of the fact that women can have different diagnostic and treatment needs. I am hopeful that gender bias in health care will decrease over time,” Clayton says.

Check out recent practice management articles: 

Top Five Questions About MACRA

Four Key Issues That PAs and NPs Want Physicians to Understand

Related Articles

The adult trans care pathway

The adult trans care pathway focuses on the care of people with:

• variations of sex characteristics (VSC)
• trans people aged 17 years and older and transitioning their gender
• non-binary people aged 17 years and older and transitioning their gender

The trans care pathway refers mainly to patients transitioning gender medically, rather than socially or legally.

People with VSC, trans and non-binary people may be particularly vulnerable to receiving poor care. This may be for reasons such as a lack of training for staff, inefficient monitoring of trans status, and potential transphobia.

The General Medical Council (GMC) has produced guidance on trans care . It states that trans and non-binary people experience the same health problems as everyone else and that healthcare professionals must assess, provide treatment for and refer trans patients in the same way as other patients.

Terminology

• Transgender is usually shortened to ‘trans’. It describes people whose felt sense of gender (gender identity) is not the same as the gender assigned at birth on the basis of genital appearance
• Non-binary is an umbrella term to describe gender identities that are not only masculine or only feminine. They are outside the ‘gender binary’ of male and female. Not all non-binary people identify as trans.
• Gender affirmation is the process a transgender person goes through to change their physical sexual characteristics to match their gender identity. This typically involves a combination of surgical procedures and hormone treatment.
• Gender reassignment (wording of the Act to mean trans status) is one of the nine protected characteristics under the Equality Act 2010. The Act recognises prejudice and discrimination that trans and non-binary people may face in receiving both services and employment.
• Gender variance is an umbrella term to describe gender identity, expression, or behaviour that falls outside culturally defined norms associated with a specific assigned gender.
• Cisgender relates to a person whose sense of gender identity corresponds with their sex assigned at birth.

When we assess health and care services, we consider equality and whether services are providing high-quality care for all people, including people on the trans care pathway. We judge whether services are meeting the equality aspects of the Health and Social Care Act regulations, particularly:

• Regulation 9 (Person centred care)
• Regulation 10 (Dignity and Respect)

When we assess services, we will look at how they provide care for people who are on the trans care pathway, where this is relevant. This will take into account the local access arrangements to gender services.

Adult trans care pathway: what CQC expects from GP practices

Adult trans care pathway: what CQC expects from maternity and gynaecology services

Adult trans care pathway: what CQC expects from speech and language services

Further information

• How to find a gender identity clinic (NHS England)
• Inclusive language (NHS Digital Service Manual)
• Transgender issues in later life (Age UK)
• Trans healthcare (General Medical Council)
• Support for GPs and trans patients (LGBT Foundation/NHS in Greater Manchester)
• Gender Dysphoria Clinical Programme (NHS England)
• The role of the GP in caring for gender-questioning and transgender patients (Royal College of General Practitioners)
• Fair care for trans and non-binary people (Royal College of Nursing)
• The Royal College of Psychiatrists position statement Supporting transgender and gender diverse people
• LGBT in Britain: Trans report (Stonewall and YouGov)
• Standards of care for the Health of Transsexual, Transgender, and Gender Nonconforming People: Version 7 (World Professional Association for Transgender Health)

Find out more

Advertisement

The Role of Mental Health Professionals in Gender Reassignment Surgeries: Unjust Discrimination or Responsible Care?

• Letter to the Editor
• Experimental/Special Topics
• Published: 25 October 2014
• Volume 38 , pages 1177–1183, ( 2014 )

Cite this article

• Gennaro Selvaggi 1 &
• Simona Giordano 2  

1998 Accesses

27 Citations

16 Altmetric

Explore all metrics

Recent literature has raised an important ethical concern relating to the way in which surgeons approach people with gender dysphoria (GD): it has been suggested that referring transsexual patients to mental assessment can constitute a form of unjust discrimination. The aim of this paper is to examine some of the ethical issues concerning the role of the mental health professional in gender reassignment surgeries (GRS).

The role of the mental health professional in GRS is analyzed by presenting the Standards of Care by the World Professional Association of Transgender Health, and discussing the principles of autonomy and non-discrimination.

Purposes of psychotherapy are exploring gender identity; addressing the negative impact of GD on mental health; alleviating internalized transphobia; enhancing social and peer support; improving body image; promoting resilience; and assisting the surgeons with the preparation prior to the surgery and the patient’s follow-up. Offering or requesting psychological assistance is in no way a form of negative discrimination or an attack to the patient’s autonomy. Contrarily, it might improve transsexual patients’ care, and thus at the most may represent a form of positive discrimination. To treat people as equal does not mean that they should be treated in the same way, but with the same concern and respect, so that their unique needs and goals can be achieved.

Conclusions

Offering or requesting psychological assistance to individuals with GD is a form of responsible care, and not unjust discrimination.

Level of Evidence V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price includes VAT (Russian Federation)

Instant access to the full article PDF.

Rent this article via DeepDyve

Institutional subscriptions

There are various other ways of referring to similar procedures: “gender reaffirming” surgery, “gender confirming” surgery, “sex reassignment surgery,” and “gender realignment” surgery are the most common. Some terms, such as “confirming” or “realignment,” seem to suggest that perceived gender is innate, and surgery is meant to re-align the body to the “real” gender of the person. We will not examine in great detail the terminological issues; partly, people’s preference for one term rather than the other depends on views relating to how gender identity develops. For theories on gender identity development, see Giordano S, Children with Gender Identity Disorder, Routledge, 2012, Chapter 2. For ease, in this paper, we opt for “gender reassignment surgery.” We opt for “gender” rather than “sex,” because the latter refers to the genital area only.

Wherever possible, we shall privilege the terms “medical interventions” and “medical procedures” over the terms “medical treatments” or “therapies”, in that they might imply a difference between these and “cosmetic” procedures. The terms “procedures” or “interventions,” in fact, would apply to all areas of medical care. We shall also refer particularly to surgery, but what is said is also relevant to other areas of healthcare for people with GD.

Latham J (2013) Ethical issues in considering transsexual surgery as aesthetic plastic surgery. Aesthetic Plast Surg 35:648–649

Article   Google Scholar  

Salle A (2013) Transsexuals face surgery “double standard”. ABC news in science. http://www.abc.net.au/science/articles/2013/05/24/3759117.htm?site=science/tricks&topic=latest . Last accessed 31 August 2014

Mahowald MB (1992) To be or not be a woman: anorexia nervosa, normative gender roles, and feminism. J Med Philos 17:233–251

Article   CAS   PubMed   Google Scholar  

Nasser M (1997) Culture and weight consciousness. Routledge, London and New York

Book   Google Scholar  

Giordano S, Harris J (2005) What is gender equality in sports? In: Tamburrini CM, Tännsjö T (eds) Genetic technology and sport: ethical questions. Routledge, London and New York, pp 209–217

Google Scholar  

Sterodimas A, Radwanski HN, Pitanguy I (2011) Ethical issues in plastic and reconstructive surgery. Aesthetic Plast Surg 35:262–267

Article   PubMed   Google Scholar  

Edmonds A (2013) Can medicine be aesthetic? Med Anthropol Quart 27(2):233–252

Kitzinger C (2001) Sexualities. In: Unger Rhoda K (ed) Handbook of the psychology of women and gender. Wiley, New Jersey, pp 272–288

Giordano S (2014) Where should gender identity disorder go? reflections on the ICD-11. In: Gender identity: disorders, developmental perspectives and social implications. Nova Publishers (in press)

Cummings K (1992) Katherine’s Diary: The Story of a Transsexual. Heinemann, Melbourne

Di Ceglie D (2000) Gender identity disorder in young people. Adv Psychiatr Treat 6:456–466

GLSEN (2011) The 2011 national school climate survey. http://www.glsen.org/sites/default/files/2011%20National%20School%20Climate%20Survey%20Full%20Report.pdf . Last accessed 9 June 2014

Rivers I (2011) Homophobic bullying: research and theoretical perspectives. Oxford University Press, Oxford

D. Di Ceglie (1998) Management and therapeutic aims in working with children and adolescents with gender identity disorders, and their families. In: Di Ceglie D, Freedman D (eds). A stranger in my own body—atypical gender identity development and mental health, chap 12. Karnac Books, London, pp 185–197

Haas AP, Rodgers PL, Herman JL (2014) Suicide attempts among transgender and gender non-conforming adults, finding of the national transgender discrimination survey, american foundation for suicide prevention and the williams institute, January 2014. http://williamsinstitute.law.ucla.edu/wp-content/uploads/AFSP-Williams-Suicide-Report-Final.pdf . Last accessed 9 June 2014

Giordano S (2010) Sliding doors: gender identity disorder, epistemological and ethical issues. Med Healthc Philos 15(1):1–10

Selvaggi G, Elander A (2008) Penile reconstruction/formation. Curr Opin Urol 18(6):589–597

Selvaggi G, Bellringer J (2011) Gender reassignment surgery: an overview. Nat Rev Urol 8(5):274–282

Wroblewski P, Gustafsson J, Selvaggi G (2013) Sex reassignment surgery for transsexuals. Curr Opin Endocrinol Diabetes Obes 20(6):570–574

Selvaggi G, Dhejne C, Landen, M, Elander A (2012) The 2011 WPATH standards of care and penile reconstruction in female-to-male transsexual individuals. Adv Urol. doi: 10.1155/2012/581712

The World Professional Association for Transgender Health, Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 2011

Monstrey S, Vercruysse HJ, De Cuypere G (2009) Is gender reassignment evidence-based? recommendation for the seventh version of the WPATH Standards of care. Internat J Transgenderism 11:206–214

Winter S (2009) Cultural considerations for the world professional association for transgender health’s standards of care: the asian perspective. Internat J Transgenderism 11(1):19–41

Dixen J, Maddever H, Van Maasdam J, Edwards PW (1984) Psychosocial characteristics of applicant calculated for surgical gender reassignment. Arch Sex Behav 13:269–276

Pfäfflin F, Junge A (1992) Nach untersuchungen nach geslechtumwandlung: eine kommentierte literature Ubersicht 1961-1991. Schattauer, Stuttgart

Layton A, Moss F, Morgan G (1998) Mapping out the patient’s journey: experiences of developing pathways of care. Qual Healthc 7(suppl):30–36

Lillrank P (2012) Integration and operations in healthcare: an operations management view. J Integr Care 20(1):6–12

Monstrey S, Hoebeke P, Dhont M, De Cuypere G, Rubens R, Moerman M, Hamdi M, Van Landuyt K, Blondeel P (2011) Surgical therapy in transsexual patients: a multi-disciplinary approach. Acta Chir Belg 101(5):200–209

Esteva de Antonio I, Gomez-Gil E, Cruz-Almaraz M, Martinez-Tudela J, Begero T, Olveira G, Soriguer F, Grupo GIDSEEN (2012) Organizacion de la asistencia a la transexualidad en el sistema sanitario publico espanol. Gac Sanit 26(3):203–210

Hembree WC, Cohen-Kettenis P, Delemarre-van den Waal HA, Gooren LJ, Meyer WJ 3rd, Spack NP, Tangpricha V, Montori VM (2009) Endocrine Society. J Clin Endocrinol Metab 94(9):3132–3154

Bockting WO, Knudson G, Goldberg JM (2007) Counseling and mental health care for transgender adults and loved ones. Int J Transgenderism 9(3/4):36–82

Carroll L (2010) Counseling sexual and gender minorities. Merrill/Pearson, Upper Saddle River, NJ

Fassinger RE, Arsenau JR (2007) I’d rather get wet than be under that umbrella: differentiating the experiences and identities of lesbian, gay, bisexual, and transgender people. In: Bieschke KJ, Perez RM, Debord KA (eds) Handbook of counseling and psychotherapy with lesbian, gay, bisexual and transgender clients, 2nd edn. American Psychological Association, Washington DC, pp 19–50

Chapter   Google Scholar  

Korell SC, Lorah P (2007) An overview of affirmative psychotherapy and counseling with transgender clients. In: Bieschke KJ, Perez RM, DeBord KA (eds) Handbook of counseling and psychotherapy with lesbian, gay, bisexual, and transgender clients. American Psychological Association, Washington DC, pp 271–288

Download references

Conflict of interest

The authors declare that they have no conflict of interest.

Author information

Authors and affiliations.

Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gröna Stråket 8, 41345, Gothenburg, Sweden

Gennaro Selvaggi

Reader in Bioethics, CSEP/iSEI, The School of Law, The University of Manchester, Williamson Building, Oxford Road, Manchester, M13 9PL, UK

Simona Giordano

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Gennaro Selvaggi .

Rights and permissions

Reprints and permissions

About this article

Selvaggi, G., Giordano, S. The Role of Mental Health Professionals in Gender Reassignment Surgeries: Unjust Discrimination or Responsible Care?. Aesth Plast Surg 38 , 1177–1183 (2014). https://doi.org/10.1007/s00266-014-0409-0

Download citation

Received : 25 March 2014

Accepted : 29 September 2014

Published : 25 October 2014

Issue Date : December 2014

DOI : https://doi.org/10.1007/s00266-014-0409-0

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Gender dysphoria
• Gender reassignment surgeries
• Transsexualism
• Medical ethics
• Mental health professional
• Find a journal
• Publish with us
• Track your research

• Type 2 Diabetes
• Heart Disease
• Digestive Health
• Multiple Sclerosis
• COVID-19 Vaccines
• Occupational Therapy
• Healthy Aging
• Health Insurance
• Public Health
• Patient Rights
• Caregivers & Loved Ones
• End of Life Concerns
• Health News
• Thyroid Test Analyzer
• Doctor Discussion Guides
• Hemoglobin A1c Test Analyzer
• Lipid Test Analyzer
• Complete Blood Count (CBC) Analyzer
• What to Buy
• Editorial Process
• Meet Our Medical Expert Board

What Is Transgender?

Diverse gender identities fall under the transgender umbrella

• Gender Affirmation
• Terminology
• Discrimination

How to Be an Ally

Transgender is a term used to describe people whose gender identity does not conform with the gender they were assigned at birth. A person designated male at birth who identifies as female is a transgender woman, while a person designated female at birth who identifies as male is a transgender man.

In recent years, transgender has become an umbrella term that includes not only people who are binary (male or female) but also those who are non-binary or gender-non-conforming .

Gender affirmation , or the process of aligning one's outward expression of gender with one's inward sense of gender, is central to the transgender identity. Medical treatments or surgery may be involved, but not always.

This article explains what it means to be transgender, including the terminology used and how to use it correctly. It also describes the process of gender affirmation and some of the serious challenges faced by transgender people today.

What It Means to Be Transgender

Transgender traditionally means to identify as male if you were assigned female at birth or to identify as female if you were assigned male at birth. And, to many, that remains the definition of "transgender," described on the male-female binary.

But not everyone sees gender in the same way.

Those who are non-binary view gender on a spectrum where roles and expectations aren't automatically assigned based on what genitals a person is born with. As such, a non-binary person may identify as male and female, as neither male nor female, or as their own unique gender (described by some as the "third gender").

In the current vernacular, non-binary people may fall under the "transgender umbrella" when they consciously move away from expected gender roles and align themselves, their presentation, and sometimes their bodies with their own gender identity .

In the end, gender identity is one's internal sense of gender even if that means no gender at all. Examples include:

• Agender : Identifying with no gender
• Bigender: Identifying with both male and female gender characteristics
• Cisgender : Identifying with the sex you were assigned at birth
• Genderfluid or genderqueer : Shifting between genders or outside of society's expectations of gender
• Pangender or polygender: Displaying or experiencing parts of all genders
• Third Spirit: An umbrella term that describes different sexualities and genders in Indigenous Native American people

Gender Identity vs. Sexual Orientation

Gender and sex are not the same thing, and neither are gender identity and sexual orientation.

Gender identity is the personal sense of one's own gender, which can correspond to a person's assigned sex or differ from it. Sexual orientation is a person's identity in relation to the gender or genders they are sexually attracted to.

Gender Affirmation and Gender Expression

Whether binary or non-binary, the one characteristic that connects all transgender people is that the gender assigned to them at birth does not match their own internal sense of gender identity.

This mismatch can be felt from as early as three to five years in some transgender children. Others may not recognize it until puberty when changes in their bodies create a palpable sense of unease about their gender and all that implies. Others still may not recognize this until later in life.

This uneasiness is referred to as gender dysphoria . Gender dysphoria is not a psychological illness. It simply describes distress caused by the misalignment of a person's assigned gender and gender identity.

In response to gender dysphoria, a transgender person may pursue gender affirmation in its different forms to align their gender identity (their inward sense of gender) with their gender expression (their outward expression of their gender).

Gender affirmation (formerly known as gender transitioning ) can include one or all of the following:

• Social affirmation , which may involve changing your name and pronouns, your manner (such as the way you sit and talk), your appearance (such as your clothing and hair), and the washroom you use
• Legal affirmation , which may involve changing your name and gender on your driver's license, birth certificate, bank accounts, passport, medical records, and other governmental and non-governmental records
• Medical affirmation , which may involve gender-affirming hormone therapy and gender-affirming surgeries (such as breast augmentation , vaginoplasty , phalloplasty , orchiectomy , or  facial feminization )

Do All Transgender People Have Surgery?

Despite what many people think, a person does not have to undergo medical treatments to be transgender. Social and/or legal affirmation may be far more important to some people.

While many transgender people will take hormones to align their physical expression with their gender identity, there are many who don't and have no desire to.

Terminology and Appropriate Usage

Transgender is an adjective (as in "he is a transgender man"). It is not used as a noun (such as "he is a transgender")" or a verb ("he is transgendered").

"Trans" is often used as a shorthand for transgender, so it is usually acceptable to describe a transgender man as a trans man and a transgender woman as a trans woman.

If someone identifies as transgender, you would typically use the pronouns "he" and "him" for a transgender man and "she" and "her" for a transgender woman. Even so, non-binary or gender-non-conforms people may prefer "them" and "they" or other pronouns, so ask first if you are unsure.

If in doubt, err on the side of caution by offering your pronouns first and then asking the person what pronouns they use.

Mistakes can occur, but to intentionally or repeatedly use the wrong pronouns is a disrespectful act known as misgendering .

Equally disrespectful is calling someone by their "dead name" (their name prior to gender affirmation) rather than their "affirmed name." This is true even if you're a family member or have grown up with that person.

Terms to Avoid

There are other terms that have been displaced because they mischaracterize was being transgender is about. Others still are considered offensive and should never be used.

These include:

• Biological sex : "Biological" is often construed to mean authentic as in "biologically male" or "biologically female." It also suggests that genitals are physical and gender identity is somehow psychological.
• Gender-confirming : A transgender person does not need to confirm or "prove" their gender. A transgender person affirms their gender by asserting their authentic self. Gender-affirming surgery is preferred, for example, over gender-confirming surgery.
• Gender reassignment : In the same vein, a transgender person's gender is not changed or reassigned. This is especially true if you are non-binary and identify as neither male nor female.
• Sex change : This is an outdated and largely offensive term that suggests that being transgender is about changing one's genitals.
• Transsexual : This is another outdated and offensive term that equates transgender identity with surgery, such as when describing a "pre-op transsexual" and "post-op transsexual."
• Tranny, She-Male, or She-He : These are defamatory terms used to dehumanize transgender people.
• Transgenderism : This is a term used by anti-trans activists that suggests that there is a movement to "recruit" or "push" people toward becoming transgender.

Discrimination and Transphobia

It is estimated that about 0.5% of adults in the United States (1.3 million) and 1.4% of youth between the ages of 13 and 17 years (or 300,000) identify as transgender.

Studies have shown that being transgender in the United States is fraught with challenges, including transphobia and discrimination in all realms of employment, education, healthcare, safety, and daily living.

The National Transgender Discrimination Survey is the largest survey to assess the experiences of transgender people in the United States. It has been performed twice—first in 2008 with 6,450 respondents and then in 2013 with more than 27,000

Both reports described high rates of discrimination across every facet of life. Discrimination took the form of everything from verbal harassment to sexual assault, and many individuals were forced to leave school or jobs as a result of those experiences.

Transgender individuals also reported many experiences of discrimination in health care. Many individuals were denied access to gender-affirming medical and surgical care.

Perhaps even more disturbing, numerous people reported being denied access to emergency care and general medical care as well as verbal and physical harassment in healthcare spaces.

Because of this, many transgender people report avoiding medical care, for fear of experiencing additional discrimination or abuse. Others report avoiding care because they lacked financial or other resources.

Among the key statistics:

• One in six trans children has had to leave or change schools due to mistreatment.
• One in four trans children has been physically attacked.
• One in eight trans children has been sexually assaulted.
• Nearly half of all trans people were sexually assaulted over the course of their lifetime.
• One in three trans adults has been fired, denied a promotion, or experienced mistreatment in the workplace due to their gender expression.
• One in three trans people has experienced mistreatment in healthcare, ranging from the refusal of service to verbal, physical, or sexual abuse.

Discrimination is even worse for transgender people of color, who may experience bias based on both their skin color and their gender identity.

The survey found that Latinx, American Indian, multiracial, and Black respondents were more than three times as likely as the general U.S. population to be living in poverty.

Gender diversity is a normal part of a functioning society and has been reported throughout history. Although transgender individuals have an increased risk of certain negative health outcomes, research suggests that this does not reflect any inherent issue with being transgender. Instead, it reflects the minority stress related to being part of a society that may not be accepting.

Indeed, research suggests that one of the most important factors associated with the health of transgender people is access to an affirming environment and desired medical care. This is particularly true for transgender children and adolescents, who have been shown to do as well as their cisgender peers when their families are supportive and accepting.

While not all transgender individuals are interested in medical or surgical affirmation, all people need health care at some point during their lives. Therefore, it is important to make all healthcare facilities safe and affirming for people of diverse genders. Lack of access to affirming health care is a risk factor for health concerns for transgender people of all ages.

Fast AA, Olson KR. Gender Development in Transgender Preschool Children . Child Dev. 2018;89(2):620-637. doi:10.1111/cdev.12758

Kaltiala-Heino R, Työläjärvi M, Lindberg N.  Gender dysphoria in adolescent population: a 5-year replication study .  Clin Child Psychol Psychiat . 2019;24(2):379-87. doi:10.1177/1359104519838593

Sevelius JM.  Gender affirmation: a framework for conceptualizing risk behavior among transgender women of color .  Sex Roles . 2013 Jun 1;68(11-12):675-89. doi: 10.1007/s11199-012-0216-5

World Professional Association for Transgender Health.  Standards of care for the health of transsexual, transgender, and gender-nonconforming people .

Williams Institute/University of California, Los Angeles. How many adults and youth identify as transgender in the United States?

Grant JM, Mottet L A , Tanis J, Harrison J, Herman JL, Keisling M. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey . National Center for Transgender Equality and National Gay and Lesbian Task Force. 2011.

James SE, Herman JL, Rankin S, Keisling M, Mottet M, Anafi M. The Report of the 2015 U.S. Transgender Survey . National Center for Transgender Equality. 2016.

Department of Health and Human Services Departmental Appeals Board, Appellate Division. NCD 140.3, Transsexual Surgery, Docket No. A-13-87, Decision No. 2576 . 2014.

Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: An Endocrine Society clinical practice guideline . J Clin Endocrinol Metab . 2017;102(11):3869-3903. doi:10.1210/jc.2017-01658

Mahfouda S, Moore JK, Siafarikas A, et al. Gender-affirming hormones and surgery in transgender children and adolescents. Lancet Diabetes Endocrinol . 2019;7(6):484-498. doi:10.1016/S2213-8587(18)30305-X

Rafferty J, Committee on Psychosocial Aspects of Child and Family Health; Committee on Adolescence; Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness. Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents . Pediatrics . 2018;142(4):e20182162. doi:10.1542/peds.2018-2162

Stotzer RL. Data sources hinder our understanding of transgender murders . Am J Public Health . 2017;107(9):1362-1363.

By Elizabeth Boskey, PhD Boskey has a doctorate in biophysics and master's degrees in public health and social work, with expertise in transgender and sexual health.

Europe PMC requires Javascript to function effectively.

Either your web browser doesn't support Javascript or it is currently turned off. In the latter case, please turn on Javascript support in your web browser and reload this page.

Search life-sciences literature (43,954,836 articles, preprints and more)

• Available from publisher site using DOI. A subscription may be required. Full text
• Citations & impact
• Similar Articles

The role of mental health professionals in gender reassignment surgeries: unjust discrimination or responsible care?

Author information, affiliations.

• Selvaggi G 1

ORCIDs linked to this article

• | 0000-0002-3608-0263

Aesthetic Plastic Surgery , 25 Oct 2014 , 38(6): 1177-1183 https://doi.org/10.1007/s00266-014-0409-0   PMID: 25344469 

Abstract 

Conclusions, level of evidence v, full text links .

Read article at publisher's site: https://doi.org/10.1007/s00266-014-0409-0

References 

Articles referenced by this article (34)

Latham J (2013) Ethical issues in considering transsexual surgery as aesthetic plastic surgery. Aesthetic Plast Surg 35:648–649

Salle a (2013) transsexuals face surgery “double standard”. abc news in science. http://www.abc.net.au/science/articles/2013/05/24/3759117.htmsite=science/tricks&topic=latest . last accessed 31 august 2014, to be or not be a woman: anorexia nervosa, normative gender roles, and feminism..

Mahowald MB

J Med Philos, (2):233-251 1992

MED: 1588246

Nasser M (1997) Culture and weight consciousness. Routledge, London and New York

Giordano s, harris j (2005) what is gender equality in sports in: tamburrini cm, tännsjö t (eds) genetic technology and sport: ethical questions. routledge, london and new york, pp 209–217, ethical issues in plastic and reconstructive surgery..

Sterodimas A , Radwanski HN , Pitanguy I

Aesthetic Plast Surg, (2):262-267 2011

MED: 21336881

Edmonds A (2013) Can medicine be aesthetic? Med Anthropol Quart 27(2):233–252

Kitzinger c (2001) sexualities. in: unger rhoda k (ed) handbook of the psychology of women and gender. wiley, new jersey, pp 272–288, giordano s (2014) where should gender identity disorder go reflections on the icd-11. in: gender identity: disorders, developmental perspectives and social implications. nova publishers (in press), cummings k (1992) katherine’s diary: the story of a transsexual. heinemann, melbourne, citations & impact , impact metrics, citations of article over time, alternative metrics.

Smart citations by scite.ai Smart citations by scite.ai include citation statements extracted from the full text of the citing article. The number of the statements may be higher than the number of citations provided by EuropePMC if one paper cites another multiple times or lower if scite has not yet processed some of the citing articles. Explore citation contexts and check if this article has been supported or disputed. https://scite.ai/reports/10.1007/s00266-014-0409-0

Article citations, transgender women's perspectives on mental health care related to vaginoplasty for gender affirmation..

Marra EE , Mabel H , Feldman S , Mercer MB , Altinay M , Ferrando CA

BMC Womens Health , 24(1):14, 03 Jan 2024

Cited by: 0 articles | PMID: 38172910 | PMCID: PMC10765568

Interdisciplinary, internet-based trans health care (i²TransHealth): study protocol for a randomised controlled trial.

Nieder TO , Renner J , Zapf A , Sehner S , Hot A , König HH , Dams J , Grochtdreis T , Briken P , Dekker A

BMJ Open , 12(2):e045980, 01 Feb 2022

Cited by: 1 article | PMID: 35105559 | PMCID: PMC8808412

Decision-making approaches in transgender healthcare: conceptual analysis and ethical implications.

Gerritse K , Hartman LA , Bremmer MA , Kreukels BPC , Molewijk BC

Med Health Care Philos , 24(4):687-699, 18 May 2021

Cited by: 3 articles | PMID: 34008081 | PMCID: PMC8557156

Experiences of surgery readiness assessments in British Columbia.

Frohard-Dourlent H , MacAulay M , Shannon M

Int J Transgend Health , 21(2):147-162, 02 Apr 2020

Cited by: 7 articles | PMID: 33015666 | PMCID: PMC7430474

Free full text in Europe PMC

Gender Dysphoria: Bioethical Aspects of Medical Treatment.

Bizic MR , Jeftovic M , Pusica S , Stojanovic B , Duisin D , Vujovic S , Rakic V , Djordjevic ML

Biomed Res Int , 2018:9652305, 13 Jun 2018

Cited by: 10 articles | PMID: 30009180 | PMCID: PMC6020665

Similar Articles 

To arrive at the top five similar articles we use a word-weighted algorithm to compare words from the Title and Abstract of each citation.

Young adult psychological outcome after puberty suppression and gender reassignment.

de Vries AL , McGuire JK , Steensma TD , Wagenaar EC , Doreleijers TA , Cohen-Kettenis PT

Pediatrics , 134(4):696-704, 08 Sep 2014

Cited by: 262 articles | PMID: 25201798

Care of the transgender patient: the role of the gynecologist.

Am J Obstet Gynecol , 210(1):16-26, 23 May 2013

Cited by: 34 articles | PMID: 23707806

Psychological and medical care of gender nonconforming youth.

Vance SR , Ehrensaft D , Rosenthal SM

Pediatrics , 134(6):1184-1192, 17 Nov 2014

Cited by: 34 articles | PMID: 25404716

Informed Consent in the Medical Care of Transgender and Gender-Nonconforming Patients.

Cavanaugh T , Hopwood R , Lambert C

AMA J Ethics , 18(11):1147-1155, 01 Nov 2016

Cited by: 47 articles | PMID: 27883307

Should Mental Health Screening and Psychotherapy Be Required Prior to Body Modification for Gender Expression?

AMA J Ethics , 18(11):1079-1085, 01 Nov 2016

Cited by: 7 articles | PMID: 27883299

Europe PMC is part of the ELIXIR infrastructure

The role of mental health professionals in gender reassignment surgeries: unjust discrimination or responsible care?

Affiliation.

• 1 Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gröna Stråket 8, 41345, Gothenburg, Sweden, [email protected].
• PMID: 25344469
• DOI: 10.1007/s00266-014-0409-0

Objective: Recent literature has raised an important ethical concern relating to the way in which surgeons approach people with gender dysphoria (GD): it has been suggested that referring transsexual patients to mental assessment can constitute a form of unjust discrimination. The aim of this paper is to examine some of the ethical issues concerning the role of the mental health professional in gender reassignment surgeries (GRS).

Method: The role of the mental health professional in GRS is analyzed by presenting the Standards of Care by the World Professional Association of Transgender Health, and discussing the principles of autonomy and non-discrimination.

Results: Purposes of psychotherapy are exploring gender identity; addressing the negative impact of GD on mental health; alleviating internalized transphobia; enhancing social and peer support; improving body image; promoting resilience; and assisting the surgeons with the preparation prior to the surgery and the patient's follow-up. Offering or requesting psychological assistance is in no way a form of negative discrimination or an attack to the patient's autonomy. Contrarily, it might improve transsexual patients' care, and thus at the most may represent a form of positive discrimination. To treat people as equal does not mean that they should be treated in the same way, but with the same concern and respect, so that their unique needs and goals can be achieved.

Conclusions: Offering or requesting psychological assistance to individuals with GD is a form of responsible care, and not unjust discrimination.

Level of evidence v: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Publication types

• Attitude of Health Personnel
• Ethics, Clinical
• Health Services for Transgender Persons / organization & administration*
• Mental Health*
• Physician's Role / psychology*
• Physician-Patient Relations*
• Sex Reassignment Procedures / psychology*
• Sex Reassignment Procedures / statistics & numerical data
• Transgender Persons
• Transsexualism / psychology*

EDITORIAL article

This article is part of the research topic.

Health Inequities and Reproductive Justice in the Modern Era

Editorial: Health Inequities and Reproductive Justice in the Modern Era Provisionally Accepted

• 1 Fairfield University, United States

The final, formatted version of the article will be published soon.

Chiziba and Hangoma highlight the influence of power imbalance between sexual partners on contraceptive usage among married and partnered women in Zambia. Even when contraceptives are available, women are not always given shared decisionmaking in their use with their male partners. The modeling in this study sheds light on the variables that influence these partner dynamics and usage of contraception that may limit a woman's autonomy in these decisions. As Chiziba and Hangoma concluded in their study, increased education did not always reflect equitable reproductive choice.Likewise, this theme of equitable access of reproductive care to meet sexual health needs was portrayed in a differing geographical context in Maharashtra, India in an article by Shewale and Sahay. These authors closely examined the needs and behaviors of female sex workers in this high HIV prevalent region, illustrating the inadequacy of condom-focused interventions to protect against HIV/STI transmission as well as unintended pregnancies. Stigma, violence, discrimination, and gender inequity often disempower female sex workers from contraceptive use and reproductive choice. Although condoms can protect against HIV/STI transmission and unintended pregnancy, within contexts of sexual power imbalances, adherence is inconsistent and the need for non-barrier modes of contraceptives to prevent unintended pregnancy are an option to be further explored.The role of social mobility and racial disparities were highlighted in the article by Hawkins, Mallapareddi and Misra who analyzed high levels of perinatal depression among Black women in Detroit, Michigan. They illustrate that while economic status can be protective against depression, there is a surprising connection between upward (in addition to downward) social mobility over the life course with increased depression, contributing to a burgeoning literature on diminished returns to education and financial security experienced by historically marginalized groups in the United States. Rising incomes are not necessarily manifesting in the expected improved health outcomes when coupled with racism, discrimination and bias. The authors underscore the importance of improving equitable outcomes in clinical settings through medical training that emphasizes evidence-based screening, identification and support for depressive symptoms in pregnancy. In line with the implications highlighted above, education gaps among health care providers ranging from cultural insensitivity to clinical knowledge about abortion care, amplify inequities in health and reproductive outcomes. Janusonyte, Fetters, Flores and Espinoza surveyed medical students across 85 countries and identified a gap in medical school preparation for abortion care specifically, and limited instruction on gynecology more generally. Given the broad willingness of those surveyed to provide abortion care, the authors attribute the training gap to a global lack of institutional support. A lack of skilled services can lead to less compassionate and effective care and can place women who are already in vulnerable positions at greater risk of adverse health outcomes. We see this in the experiences of the female sex workers in Maharashtra, India, interviewed by Shewale and Sahay, who face discrimination from healthcare providers when accessing antenatal care and abortion services, particularly in rural areas. Among these women, stigma, discrimination, violence and lack of knowledge and misinformation around pregnancy detection and contraceptive methods and efficacy were identified as barriers to access and effective usage of contraceptives.Finally, in addition to social determinants of health, there are clear environmental injustices that limit maternal and child health. Outdated water infrastructure exposes large swathes of the US population to lead-contaminated water, with children and those in-utero most vulnerable to the potential consequences. The water crises of Flint Michigan and Washington DC were associated with reduced fertility rates and low birthweight outcomes. Kodjebacheva et al. surveyed women of reproductive age from the University of Michigan -Flint and found their knowledge of proper mitigation to be lacking, despite the vast media attention on the city's ongoing water crisis. They highlight improved interventions to protect pregnant women and children from lead exposure. This research also necessitates work to protect environments and conditions for women and children to thrive so that individuals do not need to take extraneous measures to receive basic needs, like water, safely.Together this series spans international contexts to highlight the themes of reproductive injustice and health inequity for women and children, imploring clinicians, public health workers, and all those who interact with and support individuals during the critical reproductive years to reduce harmful practices that adversely impact their health and limit their rights.

Keywords: reproductive justice, Gender equity, healthcare provider bias, sexual and reproductive autonomy, Prenatal health

Received: 08 Apr 2024; Accepted: 22 Apr 2024.

Copyright: © 2024 Aksan and Schindler-Ruwisch. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Dr. Anna-Maria Aksan, Fairfield University, Fairfield, United States

People also looked at

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• HHS Author Manuscripts

The impact of discrimination on the mental health of trans*female youth and the protective effect of parental support

Erin c. wilson.

1 Center for Public Health Research, San Francisco Department of Public Health, San Francisco, CA

Yea-Hung Chen

Sean arayasirikul, h. fisher raymond, willi mcfarland.

Significant health disparities exist for transgender female (trans*female) youth. We assessed differences in mental health outcomes based on exposure to discrimination among transgender female youth in the San Francisco Bay Area aged 16–24 years. Youth were recruited using a combination of respondent driven sampling with online and social media methods. Logistic regression models were used to estimate odds ratios for the mental health outcomes, comparing levels of discrimination and levels of resiliency promoting protective factors among sexually active youth in the sample (N=216). High transgender-based discrimination was significantly associated with greater odds of PTSD (AOR, 2.6; 95% CI, 1.4–5.0), depression (AOR, 2.6; 95% CI, 1.2–5.9), and stress related to suicidal thoughts (AOR 7.7, 95% CI 2.3–35.2). High racial discrimination was significantly associated with greater odds of psychological stress (AOR 3.6; 95% CI 1.2–10.8), PTSD (AOR 2.1; 95% CI 1.1–4.2) and stress related to suicidal thoughts (AOR 4.3, 95% CI 1.5–13.3). Parental closeness was related to significantly lower odds of all four mental health outcomes measured, and intrinsic resiliency positively reduced risk for psychological stress, PTSD, and stress related to suicidal thoughts. Transgender and racial discrimination may have deleterious effects on the mental health of trans*female youth. Interventions that address individual and intersectional discrimination and build resources for resiliency and parental closeness may have success in preventing mental health disorders in this underserved population.

Introduction

High prevalence and significant disparities in mental health exist for transgender youth assigned a male sex at birth who identify as a different gender (trans*female youth) 1 – 3 . Studies assert that prejudice towards transwomen occurs because they are perceived to transgress societal gender norms 4 . Prejudice is enacted in numerous forms of discrimination resulting in everything from discrimination in education, employment and health care to unpunished violence and murder of transwomen, especially transwomen of color 5 , 6 . Discrimination and rejection due to gender nonconformity often starts at an early age and puts trans*female youth at risk of isolation, school dropout and academic performance issues 7 . From a systems perspective, discrimination based on transgender identity leads to unequal access to education, employment, and other economic resources 6 , 8 , which then create economic insecurity impacting safe housing and income. Economic hardship due to transphobia may be a primary reason why transwomen turn to sex work, which raises their risk for HIV, other sexually transmitted diseases and violence 9 – 11 .

An important and understudied area of research is the link between discrimination and mental health outcomes for trans* female youth. Discrimination has been linked to poor mental health outcomes among adult transgender people. Prevalence of suicide attempts in the transgender population range from 18–41%, which is 15–38 percentage points higher than in the overall U.S. population 5 . Compared with cisgender females, transwomen have reported lower overall mental health and quality of life 12 . A study of transwomen and transmen in Australia recently found that almost half of the sample experienced psychological distress; psychological distress was associated with younger age, lack of family social support and greater number of victimization experiences, pointing to heightened need for research with youth in the trans population 13 . Recent research found that transgender youth had significantly higher risk for depression, anxiety, and suicide when compared to cisgender youth matched controls 3 . In a study of transmen and transwomen, factors associated with substance use disorder and a history of substance use treatment included being a transwoman, lifetime PTSD, current depression, and current mental health treatment 14 In a previous analysis of this dataset we found that transgender-related discrimination is associated with increased odds of alcohol and drug use in our sample of trans*female youth 15 . Stress related to transgender-based discrimination may similarly affect mental health outcomes in this population.

Racial discrimination on top of gender-based stigma may exert a profound effect on mental health. Racism has been linked to poor mental health among racial/ethnic minority populations 16 , 17 . New research has investigated the pathways to poor health outcomes and identified stress as a primary mechanism affecting the mental health of racial/ethnic minority individuals 18 . For racial/ethnic minority trans*female youth who manage multiple marginalized social identities (i.e., racial minorities who are gender minorities), extreme heightened stress and fewer coping mechanisms may result in poorer mental health 19 . In the transgender literature, there are major gaps in how intersections of race and transgender identity impact mental health outcomes among transgender people. Such research is needed to determine if there are disparities in mental health risks within the trans community and to properly target prevention and care interventions.

Resiliency factors that protect from risks related to discrimination are also needed. Positive parental relationships may be a critical protective factor for transgender youth as has been found with gay, lesbian and bisexual youth 20 . Though the literature is limited, one study found that trans*female youth who reported having support from at least one parent were more likely to report consistent safe sex compared to youth who were rejected by family 21 . Intrinsic resiliency, or the ability, assets, and skills of youth to overcome adversity and have positive health and social outcomes, may also be protective of various forms of discrimination 22 . There may also be resiliency promoting factors that are specific to trans*female youth, such as open access to transition-related care. A study by Rotundi found that transgender people ready but not able to medically transition were more likely to have depressive symptoms than peers who began the transition process 23 . Conversely, in a study comparing quality of life between transwomen on and off hormones, utilization of hormonal therapy was associated with higher quality of life scores in general and better mental health overall 24 . Having friends who are transgender or supportive of one’s gender identity may also be a unique and important resiliency-promoting factor. Such friends may be protective from bullying and could serve as positive forms of social support and information about transitioning 25 , 26 .

The current study was conducted to determine the prevalence of transgender-based, racial and trans-racial discrimination experienced by participants in a large cohort of trans*female youth aged 16–24 years. We also examined the relationship between discrimination and mental health to determine if high exposure to discrimination is associated with poor mental health outcomes. To do so, we assessed three different types of discrimination–transgender-based, racial, and combined transgender-based and racial (trans-racial) discrimination–on the mental health of trans*female youth. We also sought to test the protective effect of important youth resiliency promoting factors to give providers and interventionists directions for supporting trans*female youth who face discrimination that negatively impacts their mental health.

Participants

SHINE is a study of HIV risk and resiliency among trans*female youth in the San Francisco Bay Area; the present analysis uses data from enrollment visits between August 2012 and December 2013 as a cross-sectional sample. The target sample size for the study was 300. Study participants were initially recruited using a peer-referral method to obtain a diverse sample of this hard-to-reach population. Slow recruitment chains resulted in adaptations to the sampling methodology including allowance of e-referrals and expanding the number of referrals that successful recruiters could have 27 . In total, 79 participants were recruited through peer referral only, while 221 participants were recruited using respondent driven sampling (RDS) in combination with social networking outreach 28 . In addition to peer referral, participants were recruited through outreach on social networking sites (e.g. Facebook, Tumblr), in person at events attended by trans*female youth (e.g. Trans March, Queer Prom), and with referrals from both community-based organizations that provide social services to transgender women and youth and gender-specific health clinics (additional details provided in a manuscript outlining the recruitment methods 28 ). Individuals were eligible for the study if they: [1] self-identified as any gender other than that associated with their assigned male sex at birth, [2] were 16–24 years of age, and [3] lived in the San Francisco Bay Area. Data for this analysis only included participants who were HIV-negative. Informed consent was obtained before starting the behavioral survey, which was administered via hand-held tablet computers and took about 1 hour on average to complete, and conducting a rapid HIV test. Youth were given a $50 incentive for participation in the study. All study procedures were approved by the Institutional Review Board at the University of California, San Francisco. Written consent was obtained from all youths. For those who were under 18 years of age, written consent was provided in accordance with a review board waiver of parental consent.

Socio-demographic factors

Basic demographic factors assessed were age, gender, race/ethnicity, whether youth were born in the U.S. or abroad, sexual orientation (straight/heterosexual, lesbian/gay, queer, bisexual, pansexual, questioning, no p1.00), HIV status, education (in school/GED/HS graduate; highest grade attained); income (inclusive of all sources of income and dichotomized to those above and below the federal poverty level); unstable housing currently (defined as a hotel, rooming house, transitional housing, or homeless shelter) and as a child between the kindergarten and age 16 (Y/N responses); and living situation as a child (i.e. with parents of origin, family caregiver, were adopted or lived in foster care).

Discrimination ever based on transgender identity, race or both were the primary exposures to predict risk for mental health disorders as measured by brief mental health screeners conducted as part of this study. Racial discrimination measures were drawn from the discrimination items in Nancy Krieger’s standardized “experiences of discrimination measure” 29 that all begin with the preface, “Have you ever experienced discrimination, been prevented from doing something, or been hassled or made to feel inferior in any of the following situations because of your race, ethnicity or color?” Experiences of transgender-based discrimination were measured as yes/no responses to various types of discrimination due to youths’ gender identity or gender presentation. We measured transgender and racial discrimination based on five items - (1) discrimination in trying to get a job, (2) discrimination at school (race) / having to change schools or drop out (gender), (3) discrimination at work (race) / losing a job or career opportunity (gender), (4) discrimination in obtaining housing (race) / having to move from family or friends (gender), and (5) discrimination in medical care (race) / getting health care services (gender). Youth who responded yes to 2 or more items for each type of discrimination were categorized as having high exposure to racial, and/or transgender-related discrimination. Youth who reported high exposure to both transgender-based and racial discrimination were categorized as experiencing high trans-racial discrimination.

Psychological distress was measured with the 18 item version of the Brief Symptom Inventory (BSI-18), converting the BSI-18 Global Severity Index (GSI) to T-scores and using a validated clinical cutoff of T > 62 for symptomatic psychological distress in the last seven days 30 – 32 . The BSI-18 assesses symptoms in the last 12 months. We rescaled the BSI and our cutoff for psychological stress was a score of 62 or greater. The BSI-18 T-scores calculated in this study had high internal consistency (Cronbach’s alpha=0.92). We assessed depressive symptoms in the past week using the short version of the Center for Epidemiologic Studies Depression Scale 33 . Based off of 4 items measured, each with possible values of 0, 1, 2, or 3, we required that at least 3 of the 4 items have responses of 2 or greater to be categorized as having symptoms of depression. We used the primary care posttraumatic stress disorder screen items from the brief New York PTSD Risk Score 34 to assess trauma symptoms in the past year. Based off of 4 yes/no items, we required that at least 3 of the 4 items have a response of yes. PTSD scores calculated in this study had high internal consistency (Cronbach’s alpha=0.70) . Stress related to thoughts of suicide was measured with the item, “How much were you distressed by thoughts of ending your life?”. Responses we measured on a 5-point Likert scale ranging from “not at all” to “extremely”. Any response other than “not at all” was coded as positive. This item was asked about stress related to thoughts of suicide over the last year.

Resiliency Promoting Protective Factors

For this study, we utilized the Connor Davidson Resilience Scale (CD-RS) 35 of intrinsic resiliency for trans*female youth. The CD-RISC contains 25 items, all of which carry a 5-point range of responses with a maximum score of 100 for each participant. The CD-RS scores calculated in this study had high internal consistency (Cronbach’s alpha=0.89). To measure support from transgender peers, we used our transgender community connectedness measure, which is an 11-item scale that was adapted from the gay community connectedness measure and has been previously validated in minority populations 36 . To measure social support, we used an adapted social support measure developed based on the 12-item Multidimensional Scale of Perceived Social Support (MSPSS) 37 that first asked youth from whom they get the most support (parents, chosen family, mentor). The participant’s chosen support was then inserted in place of the word “family” for four of the items assessed in the MSPSS. Youth were asked questions like “I can talk about my problems with my [person(s) listed above].” A scaled global social support value was then computed as the sum of the responses to the individual questions; the alpha coefficient for this sample was .9 in a prior study with this population 36 . Parental acceptance was measured by developing 10 questions based on research from the Family Acceptance Project 38 . Parental closeness was measured with 5 items: (a) warmth and love from parents while growing up, (b) parents encouraging independence, (c) teaching right from wrong, (d) satisfaction with mother-child communication, and (e) satisfaction with closest parent relationship. The absence of barriers to transgender-specific care was assessed with the question, “Have you ever had any problems getting health care because of your gender identity or presentation?”

The original study was conducted to identify risk and resiliency promoting factors related to HIV. To inform HIV prevention efforts, this analysis was conducted with youth in the sample who self-reported being HIV-negative. The first step of the analysis was to assess exposure to racial and transgender-related discrimination overall for youth in the sample, separately and combined. Next we assessed differences in mental health outcomes (i.e. BSI, PTSD, Depression and stress related to suicidal thoughts) between those with high vs. low exposure to racial, transgender-related and trans-racial discrimination. To do so, we fit logistic regression models to estimate odds ratios for the mental health outcomes, comparing levels of discrimination types and adjusting for age and race. Age and race covariates were chosen a priori. Youth who reported high exposure to both racial and transgender-related discrimination were part of a separate group for analysis having high exposure to trans-racial discrimination. We then assessed whether protective factors were related to mental health outcomes. First, we conducted analyses to determine if there were significant differences in reporting of the protective factors of resiliency, community connectedness, social support, parental acceptance and parental closeness by age and race. We then fit logistic regression models to estimate odds ratios for mental health outcomes, comparing levels of protective factor and adjusting for age and race. We used cubic spline adjustment for age, with knots at the quartiles. We used a 95% level for all confidence intervals. We conducted all analysis in R (Revolution Analytics, Palo Alto, CA).

Demographics and exposure to discrimination

There were a total of 216 sexually active HIV-negative trans*female youth in this sample ( Table 1 ). Nearly half (44%) were aged 21 years and under, while 56% were aged 22–24. Most youth in the sample (81.9%) were aged 20–24 years. Most youth identified as female (44.4%), followed by transgender (31.9%), and genderqueer (i.e., identify as neither woman nor man) (16.7%). The sample was 34.3% White, 23.1% Latina, 15.3% mixed race, 13.4% African American, and 5.6% Asian; 8.3% identified as other. Almost half of youth had some college or more education (46.8%). Almost three quarters lived on $1000 or less month (71%) and 21.8% were unstably housed. Almost half of youth moved two or more times during their childhood (43.5%), and 81.5% lived with their family of origin as a child.

Demographics of trans*female youth aged 16–24 with and without exposure to racial, transgender or both types of discrimination, SHINE study, San Francisco, 2014.

More than one quarter of youth (26.2%) reported high racial discrimination, almost half (45.9%) reported high transgender-based discrimination, 15.9% reported high transgender-based and high racial discrimination ( Table 1 ). Only 37% reported low exposure to discrimination. Racial discrimination as trans-racial discrimination (30.3%) was disproportionately higher among African Americans (28.3%) relative to the composition of the overall sample (only 13.4% were African American). The same was true for heterosexuals. Racial (42.3%) and trans-racial discrimination (48.5%) were elevated among heterosexuals who only made up 32.3% of those comparing sexual orientation groups. Racial (28.3%) and trans-racial discrimination (39.4%) was also disproportionately higher for those who were unstably housed (21.8% were unstably housed). Racial discrimination and trans-racial discrimination were disproportionately higher among those who had moved 2 or more times as a child (65.4% and 66.7%, respectively compared to 43.5% overall who had moved 2 or more times as a child). Disproportionately high rates of racial and trans-racial discrimination were reported by youths who were in foster care as children (11.3% and 12.1%, respectively vs. 5.1% of the overall population).

Discrimination and mental health disorders/psychological stress

Discrimination has differential impacts on mental health depending on the type of discrimination. Those with higher exposure to transgender-based discrimination had almost three times the odds of PTSD compared to those with lower exposure (AOR, 2.6; 95% CI, 1.4–5.0) ( Table 2 ). Those with higher exposure to transgender-based discrimination had more than 2 times the odds of depression than those with lower exposure (AOR, 2.6; 95% CI, 1.2–5.9). High exposure to transgender-based discrimination had the most significant impact on stress related to thoughts of suicide. Those reporting higher exposure to transgender-based discrimination reporting almost 8 times higher odds of stress compared to those with lower exposure (AOR 7.7, 95% CI 2.3–35.2), though the confidence intervals were wide. Those with higher exposure to racial discrimination had significantly higher odds for psychological distress (i.e. as measured by the BSI) (AOR 3.6; 95% CI 1.2–10.8) and PTSD symptoms (AOR 2.1; 95% CI 1.1–4.2) than those with lower exposure. Those with higher exposure to racial discrimination had significantly higher odds for stress related to thoughts of suicide than those with lower exposure (AOR 4.3, 95% CI 1.5–13.3). Those with higher exposure to both transgender-based and racial discrimination had higher odds of PTSD symptoms (AOR 2.5, 95% CI 1.0–6.7) and stress related to thoughts of suicide (AOR 3.4, 95% CI 1.1–10.8) compared to those with lower exposure to both types of discrimination.

The impact of high exposure to racial, transgender and both types of discrimination on mental health/psychological stress among trans * female youth,

Protective Factors for mental health disorders/psychological stress

Parental Closeness was the most consistently protective resiliency promoting factor for mental health disorders and psychological distress ( Table 3 ). Youth with higher parental closeness had significantly lower odds of psychological distress (AOR 0.3, 95% CI 0.1–0.9), PTSD symptoms (AOR 0.4, 95% CI 0.2–0.7), depression (AOR 0.4, 95% CI 0.2–0.9), and stressful thoughts regarding suicide (AOR 0.2, 95% CI 0.0–0.9) compared to those with lower parental closeness. Youth who reported higher resiliency had significantly lower odds of psychological distress (AOR 0.3, 95% CI 0.1–0.8), PTSD symptoms (AOR 0.4, 95% CI 0.2–0.7), and stressful thoughts regarding suicide (AOR 0.1, 95% CI 0.0–0.3) compared to those with lower resiliency. Youth with higher parental acceptance of their transgender identity reported significantly lower odds of PTSD compared to those with lower parental acceptance (AOR 0.4, 95% CI 0.2–0.7).

Protective effect of resiliency promoting protective factors on mental health/psychological stress among trans * female youth in the San Francisco Bay Area aged 16–24 years

BSI = Brief Symptom Index

PTSD = Post Traumatic Stress Disorder

Results suggest that transgender-based discrimination is the most pervasive type of discrimination experienced by trans*female youth with the greatest impact on mental health. More than 40% of the sample reported experiencing transgender-based discrimination, which was in turn was related to threefold higher odds of PTSD, double the odds of depression and an eightfold increase in odds for stress related to suicidal thoughts. Fewer youth reported experiencing racial discrimination; however, racial discrimination was significantly related to an almost fourfold higher odds of psychological stress and double the odds of PTSD.

The most notable mental health impact of discrimination was on stress related to suicidal thoughts. All three types of discrimination measured significantly increased the odds of stress related to suicidal thoughts. The National Transgender Discrimination Survey found that those who were bullied, harassed, assaulted, or expelled because they were transgender or gender non-conforming in school had elevated levels of suicide attempts (51%) 5 . Clements-Nolle found in 2006 that discrimination related to being transgender was an independent predictor of suicide 39 . In 2012, Testa et al 40 found that transwomen who experienced physical violence, of which 97% was related to being transgender, had an almost 4 times greater odds of suicidal ideation and more than 5 times greater odds of suicide attempts.

Findings regarding the impact of transgender-based discrimination on depression were echoed in the literature with adults. A recent prospective study of transwomen found that psychological and physical gender abuse was a cause of major depression 41 . Consistent with the research among adult transwomen, levels of depression were also higher than that found in the general youth population 42 . Findings regarding psychological distress are unique and point to the important intersection of racial and gender minority status. Racial discrimination was the only type of discrimination that impacted psychological distress, which aligns with current research efforts showing adult sexual minority populations are negatively impacted by racial discrimination 43 . Given the great impact of transgender-based discrimination in relation to racial discrimination in this study, future efforts to address mental health among racial minority trans*female youth may need to consider strengthening assets to address transgender-based discrimination specifically at the intersection of gender, racial and sexual minority identities.

The overall impact of all transgender and racial discrimination on mental health for trans*female youth may have important implications for the future health and wellbeing of this population. Prior analyses of this data already found a link between psychological distress and substance use as well as sex while under the influence 15 . Victimized lesbian, gay and bisexual youth have exhibited higher engagement in sexual risk behavior due to feelings of isolation, psychological distress 44 . Similarly, Nuttbrock et al. recently found that gender-related abuse caused depressive symptoms that predicted HIV and STIs for young transwomen 41 . Victimization also impedes learning and other school based outcomes for youth, which then impacts youths’ ability to succeed in school and the job market 45 .

The primary limitation to this study is that it was not population-based and therefore cannot be generalized to the entire trans*female youth population. However, this is the largest sample of trans*female youth in a geographical area known to be a draw to gender non-conforming people of all ages, and may represent a large portion of all trans*female youth in the San Francisco Bay Area. Also, temporal issues may have arisen in the findings about resiliency. For example, youth with higher parental acceptance may have had lower odds of PTSD because they were not abused by their parents and not because accepting parents protected from the effect of other types of trauma.

Despite these limitations, these data provide an important starting point for interventions and programs to address risk for mental health disorders that impact substance use and HIV risk. Data from this study clearly demonstrate the impact of discrimination on mental health and behaviors. Interestingly, different types of discrimination were associated with different mental health symptoms, suggesting the need for interventions that address discrimination-related stressors specific to both gender identity and race/ethnicity. Interventions seeking to address stigma need to pay particular attention to intersectional identities. This study also documents the importance of parental support. Of the six resiliency promoting protective factors, parents emerged as two of the three significant protective factors from poor mental health outcomes among trans*female youth in this study. Once again, we find that parents and caregivers are central to the health and wellbeing of our young people. Interventions that can foster understanding between youth and their parents would go far in promoting the health of this important population.

Acknowledgments

The grant was completed with funding from the National Institutes of Mental Health, grant # R01MH095598. Most importantly, we want to acknowledge and thank the trans*female youth community in the San Francisco Bay Area who contributed their time and expertise to provide a better understanding of factors affecting health in this important community.

Medindia » News » Research News » A Global Comparison: Best Countries for Gender Reassignment Surgery

A Global Comparison: Best Countries for Gender Reassignment Surgery

Purpose and Procedures

Chest surgery (top surgery) for ftm transitions:, phalloplasty for ftm transitions:, breast augmentation for mtf transitions:, facial feminization surgery (ffs) for mtf transitions:, vaginoplasty for mtf transitions:.

Turkey Emerges as a Budget-Friendly Destination

Latin america offers competitive prices.

Belgium: Affordable and Progressive in Europe

The u.s.: highest costs and legal challenges.

• Expert Q&A: Gender Dysphoria - (https://www.psychiatry.org/patients-families/gender-dysphoria/expert-q-and-a)

• Consult Online Doctor
• Take Telemedicine course
• Health Centers
• Health Tools
• Health info by Speciality
• Know Your Body
• Health and Wellness
• Web Stories
• Health Tips
• Nutrition Facts
• Lifestyle & Wellness
• Beauty Tips
• Diet & Nutrition
• Home Remedies
• Obesity & Weight Loss
• Complementary Medicine
• Special Reports
• Press Releases
• Health Guide
• Health articles
• Health Quiz
• Health Facts
• Travel Health
• Medicine and Movies
• Symptom Articles
• Diabetes Tools
• Pediatric Calculators
• Men's Health
• Women's Health
• Height Weight Tools
• Cardiac Tools
• Pharma Tools
• Wellness Interactive Tools
• Drug Information
• Drugs by Condition
• Drug Price List - Brand Names
• Drug Interaction with Food
• Drug Price List - Generic Names
• Drugs - Side Effects
• Drug Videos
• Drug Database
• Doctor Directory
• Diagnostic Lab Directory
• Hospital Directory
• Pharmacy or Chemist
• Medical Equipment Suppliers
• Pharma Directory
• Emergency Services
• PG Education
• Family Medicine
• Other Resources
• Medical Aphorism
• Health Acts in India
• Health Quotations
• Medical Conference
• Amazing Body Facts
• Health poll

• Editorial Team
• Exclusive Interviews
• In the News
• Partners & Affiliates
• Advertise With Us
• हिन्दी
• français
• Español
• 中文