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Transgender health care, also known as gender-affirming care,[1] includes the prevention, diagnosis and treatment of physical and mental health conditions, as well as sex reassignment therapies, for transgender individuals.[2] Questions implicated in transgender health care include gender variance, sex reassignment therapy, health risks (in relation to violence and mental health), and access to healthcare for trans people in different countries around the world.

Sex reassignment therapy or medical transition is the medical aspect of gender transitioning, that is, modifying one's sex characteristics to better suit one's gender identity. It can consist of hormone therapy to modify secondary sex characteristics, sex reassignment surgery to alter primary sex characteristics, and other procedures altering appearance, such as permanent hair removal for trans women.

In appropriately evaluated cases of severe gender dysphoria, sex reassignment therapy is often the best when standards of care are followed.[3]: 1570 [4]: 2108  There is academic concern over the low quality of the evidence supporting the efficacy of sex reassignment therapy as treatment for gender dysphoria, but more robust studies are impractical to carry out;[5]: 22  as well, there exists a broad clinical consensus, supplementing the academic research, that supports the effectiveness in terms of subjective improvement of sex reassignment therapy in appropriately selected patients.[5]: 2–3  Treatment of gender dysphoria does not involve attempting to correct the patient's gender identity, but to help the patient adapt.[3]: 1568 

Major health organizations in the United States and UK have issued affirmative statements supporting sex reassignment therapy as comprising medically necessary treatments in certain appropriately evaluated cases.[6][7][8][9][10]

Eligibility

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In the International Classification of Diseases, the diagnosis is known as transsexualism.[11] The US Diagnostic and Statistical Manual of Mental Disorders (DSM) names it gender dysphoria (in version 5[12]). Some people who are validly diagnosed have no desire for all or some parts of sex reassignment therapy, particularly genital reassignment surgery, and/or are not appropriate candidates for such treatment.

The general standard for diagnosing, as well as treating, gender dysphoria is outlined in the WPATH Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. As of February 2014, the most recent version of the standards is Version 7.[13] According to the standards of care, "gender dysphoria refers to discomfort or distress that is caused by a discrepancy between a person's gender identity and that person's sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics). Only some gender-nonconforming people experience gender dysphoria at some point in their lives". Gender nonconformity is not the same as gender dysphoria; nonconformity, according to the standards of care, is not a pathology and does not require medical treatment.

The informed consent model is an alternative to the standard WPATH approach which does not require a person seeking transition related medical treatment to undergo formal assessment of their mental health or gender dysphoria. Arguments in favor of this model describe required assessments as gatekeeping, dehumanizing, pathologizing, and reinforcing a reductive perception of transgender experiences.[14] Informed consent approaches include conversations between the medical provider and person seeking care on the details of risks and outcomes, current understandings of scientific research, and how the provider can best assist the person in making decisions.[15]

Local standards of care exist in many countries.

Eligibility for different stages of treatment

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While a mental health assessment is required by the standards of care, psychotherapy is not an absolute requirement but is highly recommended.[13]

Hormone replacement therapy is to be initiated from a qualified health professional. The general requirements, according to the WPATH standards, include:

  1. Persistent, well-documented gender dysphoria;
  2. Capacity to make a fully informed decision and to consent for treatment;
  3. Age of majority in a given country (however, the WPATH standards of care provide separate discussion of children and adolescents);
  4. If significant medical or mental health concerns are present, they must be reasonably well-controlled.

Often, at least a certain period of psychological counseling is required before initiating hormone replacement therapy, as is a period of living in the desired gender role, if possible, to ensure that they can psychologically function in that life-role. On the other hand, some clinics provide hormone therapy based on informed consent alone.[13]

Eligibility of minors

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While the WPATH standards of care generally require the patient to have reached the age of majority, they include a separate section devoted to children and adolescents.[13]

Psychological treatment

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According to the WPATH SOC v7, "Psychotherapy (individual, couple, family, or group) for purposes such as exploring gender identity, role, and expression; addressing the negative impact of gender dysphoria and stigma on mental health; alleviating internalized transphobia; enhancing social and peer support; improving body image; or promoting resilience" is a treatment option.[13]

Some transsexual people may suffer from co-morbid psychiatric conditions unrelated to their gender dysphoria. In cases of comorbid psychopathology, the standards are to manage the psychopathology "prior to, or concurrent with, treatment of gender dysphoria".[13] Treatment may still be appropriate and necessary in cases of significant comorbid psychopathology, as cases have been reported in which the individual was both suffering from severe co-occurring psychopathology, and was a 'late-onset, gynephilic' trans woman, and yet experienced a long-term, positive outcome with hormonal and surgical gender transition.[5]: 22  The DSM-IV itself states that in rare instances, gender dysphoria may co-exist with schizophrenia, and that psychiatric disorders are not generally considered contraindications to sex reassignment therapy unless they are the primary cause of the patient's gender dysphoria.[16]: 108 

Hormone therapy

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For trans people, hormone therapy causes the development of many of the secondary sexual characteristics of their desired sex. However, many of the existing primary and secondary sexual characteristics cannot be reversed by hormone therapy. For example, hormone therapy can induce breast growth for trans women but can only minimally reduce breasts for trans men. HRT can prompt facial hair growth for transgender men, but cannot regress facial hair for transgender women. Hormone therapy may, however, reverse some characteristics, such as distribution of body fat and muscle, as well as menstruation in trans men.

Generally, those traits that are easily reversible will revert upon cessation of hormonal treatment, unless chemical or surgical castration has occurred, though for many trans people, surgery is required to obtain satisfactory physical characteristics. But in trans men, some hormonally-induced changes may become virtually irreversible within weeks, whereas trans women usually have to take hormones for many months before any irreversible changes will result.

As with all medical activities, health risks are associated with hormone replacement therapy, especially when high hormone doses are taken as is common for pre-operative or no-operative trans patients. It is always advised that all changes in therapeutic hormonal treatment should be supervised by a physician because starting, stopping or even changing dosage rates and levels can have physical and psychological health risks.

Although some trans women use herbal phytoestrogens as alternatives to pharmaceutical estrogens, little research has been performed with regards to the safety or effectiveness of such products. Anecdotal evidence suggests that the results of herbal treatments are minimal and very subtle, if at all noticeable, when compared to conventional hormone therapy.

Some trans people are able to avoid the medical community's requirements for hormone therapy altogether by either obtaining hormones from black market sources, such as internet pharmacies which ship from overseas, or more rarely, by synthesizing hormones themselves.

Medications

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Testosterone therapy is typically used for masculinizing treatments. Effects can include thicker vocal cords, increased muscle mass, hair loss, and thicker skin.[17][18] Intramuscular, subcutaneous, and transdermal options are available.[19] These include cypionate (Depo-Testosterone®), and the longer acting testosterone undecanoate (Aveed®). Oral formulations are available in Europe, Andriol®, but are not available in the U.S. due to their pharmacokinetic properties.[20]

Estrogen and anti-androgen therapy are typically used for feminizing treatments.[21][22] Estrogen is available in oral, parenteral, and transdermal formulations. Often, estrogen alone is insufficient for androgen suppression, and appropriate therapy will call for additional anti-androgen medications.[23] Anti-androgen medications include progesterone, medroxyprogesterone acetate, spironolactone, and finasteride.[20]

Sex reassignment surgery

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Sex reassignment surgery (SRS) refers to the surgical and medical procedures undertaken to align intersex and transsexual individuals' physical appearance and genital anatomy with their gender identity. SRS may encompass any surgical procedures which will reshape a male body into a body with a female appearance or vice versa, or more specifically refer to the procedures used to make male genitals into female genitals and vice versa.

Other terms used for SRS include "gender confirmation surgery", "gender realignment surgery", and "transsexual surgery". These terms may also specifically refer to genital surgeries like vaginoplasty, metoidioplasty, and phalloplasty, even though more specific terms exist to refer exclusively to genital surgery, the most common of which is genital reassignment surgery (GRS). The term "genital reconstruction surgery" may also be used.

Chest surgery

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Many trans men seek mastectomy and male chest reconstruction.

Breast augmentations for trans women are done in a similar manner to those for cisgender women.

Effectiveness

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The Merck Manual states, in regard to trans women, "In follow-up studies, genital surgery has helped some transsexual people live happier and more productive lives and so is justified in highly motivated, appropriately assessed and treated transsexual people, who have completed a 1- to 2-year real-life experience in a different gender role. Before surgery, transsexual people often need assistance with passing in public, including help with gestures and voice modulation. Participation in support groups, available in most large cities, is usually helpful."[3]: 1570  With regards to trans men, it states, "Surgery may help certain [trans men] patients achieve greater adaptation and life satisfaction. Similar to trans women, trans men should live in the male gender role for at least 1 yr before surgery. Anatomic results of neophallus surgical procedures are often less satisfactory in terms of function and appearance than neovaginal procedures for trans women. Complications are common, especially in procedures that involve extending the urethra into the neophallus."[3]: 1570 

Kaplan and Sadock's Comprehensive Textbook of Psychiatry states, with regards to adults, "When patient gender dysphoria is severe and intractable, sex reassignment is often the best solution."[4]: 2108  Regret tends to occur in cases of misdiagnosis, no Real Life Experience, and poor surgical results. Risk factors for return to original gender role include history of transvestic fetishism, psychological instability, and social isolation. In adolescents, careful diagnosis and following strict criteria can ensure good post-operative outcomes. Many prepubescent children with cross-gender identities do not persist with gender dysphoria.[4]: 2109–2110  With regards to follow-up, it states that "Clinicians are less likely to report poor outcomes in their patients, thus shifting the reporting bias to positive results. However, some successful patients who wish to blend into the community as men or women do not make themselves available for follow-up. Also, some patients who are not happy with their reassignment may be more known to clinicians as they continue clinical contact."[4]: 2109 

A 2009 systematic review looking at individual surgical procedures found that "[t]he evidence concerning gender reassignment surgery has several limitations in terms of: (a) lack of controlled studies, (b) evidence has not collected data prospectively, (c) high loss to follow up and (d) lack of validated assessment measures. Some satisfactory outcomes were reported, but the magnitude of benefit and harm for individual surgical procedures cannot be estimated accurately using the current available evidence."[24]

A 2010 meta-analysis of follow-up studies reported "Pooling across studies shows that after sex reassignment, 80% of individuals with GID reported significant improvement in gender dysphoria (95% CI = 68–89%; 8 studies; I2 = 82%); 78% reported significant improvement in psychological symptoms (95% CI = 56–94%; 7 studies; I2 = 86%); 80% reported significant improvement in quality of life (95% CI = 72–88%; 16 studies; I2 = 78%); and 72% reported significant improvement in sexual function (95% CI = 60–81%; 15 studies; I2 = 78%)." The study concluded "Very low quality evidence suggests that sex reassignment that includes hormonal interventions in individuals with GID likely improves gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life."[25]

A study evaluating quality of life in female-to-male transgender individuals found "statistically significant (p<0.01) diminished quality of life among the FTM transgender participants as compared to the US male and female population, particularly in regard to mental health. FTM transgender participants who received testosterone (67%) reported statistically significant higher quality of life scores (p<0.01) than those who had not received hormone therapy."[26]

A recent Swedish study (2010) found that “almost all patients were satisfied with sex reassignment at 5 years, and 86% were assessed by clinicians at follow-up as stable or improved in global functioning”[27] A prospective study in the Netherlands that looked at the psychological and sexual functioning of 162 adult applicants of adult sex reassignment applicants before and after hormonal and surgical treatment found, "After treatment the group was no longer gender dysphoric. The vast majority functioned quite well psychologically, socially and sexually. Two non-homosexual male-to-female transsexuals expressed regrets."[28]

A long-term follow-up study performed in Sweden over a long period of time (1973–2003) found that morbidity, suicidality, and mortality in post-operative trans people were still significantly higher than in the general population, suggesting that sex reassignment therapy is not enough to treat gender dysphoria, highlighting the need for improved health care following sex reassignment surgery. 10 controls were selected for each post-operative trans person, matched by birth year and sex; two control groups were used: one matching sex at birth, the other matching reassigned sex. The study states that "no inferences can be drawn [from this study] as to the effectiveness of sex reassignment as a treatment for transsexualism," citing studies showing the effectiveness of sex reassignment therapy, though noting their poor quality. The authors noted that the results suggested that those who received sex reassignment surgery before 1989 had worse mortality, suicidality, and crime rates than those who received surgery on or after 1989: mortality, suicidality, and crime rates for the 1989-2003 cohort were not statistically significant compared to healthy controls (though psychiatric morbidity was); it is not clear if this is because these negative factors tended to increase a decade after surgery or because in the 1990s and later improved treatment and social attitudes may have led to better outcomes.[29]

The abstract of the American Psychiatric Association Task Force on GID's report from 2012 states, "The quality of evidence pertaining to most aspects of treatment in all subgroups was determined to be low; however, areas of broad clinical consensus were identified and were deemed sufficient to support recommendations for treatment in all subgroups."[5] The APA Task Force states, with regard to the quality of studies, "For some important aspects of transgender care, it would be impossible or unwise to engage in more robust study designs due to ethical concerns and lack of volunteer enrollment. For example, it would be extremely problematic to include a 'long-term placebo treated control group' in an RCT of hormone therapy efficacy among gender variant adults desiring to use hormonal treatments."[5]: 22  The Royal College of Psychiatrists concurs with regards to SRS in trans women, stating, "There is no level 1 or 2 evidence (Oxford levels) supporting the use of feminising vaginoplasty in women but this is to be expected since a randomised controlled study for this scenario would be impossible to carry out."[9]

Following up on the APA Task Force's report, the APA issued a statement stating that the APA recognizes that in "appropriately evaluated" cases, hormonal and surgical interventions may be medically necessary and opposes "categorical exclusions" of such treatment by third-party payers.[6] The American Medical Association's Resolution 122 states, "An established body of medical research demonstrates the effectiveness and medical necessity of mental health care, hormone therapy and sex reassignment surgery as forms of therapeutic treatment for many people diagnosed with GID".[7]

The need for treatment is emphasized by the higher rate of mental health problems, including depression, anxiety, and various addictions, as well as a higher suicide rate among untreated transsexual people than in the general population. Many of these problems, in the majority of cases, disappear or decrease significantly after a change of gender role and/or physical characteristics.[30][31]

In 2021, a review published in Plastic And Reconstructive Surgery found that less than 1% of people who undergo gender-affirming surgery regret the decision, although the authors said more research was needed, as the pool of sources was heterogeneous and many were viewed at "medium-to-high" risk of bias.[32]

Ethical, cultural, and political considerations

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Sex reassignment therapy is a controversial ethical subject. Notably, the Roman Catholic church, according to an unpublished Vatican document, holds that changing sex is not possible and, while in some cases treatment might be necessary, it does not change the person's sex in the eyes of the church.[33] Some Catholic ethicists go further, proclaiming that a "sex change operation" is "mutilation" and therefore immoral.[34]

Paul R. McHugh is a well-known opponent of sex reassignment therapy. According to his own article,[35] when he joined Johns Hopkins University as director of the Department of Psychiatry and Behavioral Science, it was part of his intention to end sex reassignment surgery there. McHugh succeeded in ending it at the university during his time.[36] However, a new gender clinic at Johns Hopkins has been opened in 2017.[37]

Opposition was also expressed by several writers identifying as feminist, most famously Janice Raymond. Her paper was allegedly instrumental in removing Medicaid and Medicare support for sex reassignment therapy in the US.[38]

Sex reassignment therapy, especially surgery, tends to be expensive and is not always covered by public or private health insurance. In many areas with comprehensive nationalized health care, such as some Canadian provinces and most European countries, SRT is covered under these plans. However, requirements for obtaining SRS and other transsexual services under these plans are sometimes more stringent than the requirements laid out in the WPATH Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, and in Europe, many local Standards of Care exist. In other countries, such as the United States, no national health plan exists and the majority of private insurance companies do not cover SRS. The government of Iran, however, pays for such surgery because it is believed to be valid under Shi'ite Belief.[39]

A significant and growing political movement exists, pushing to redefine the standards of care, asserting that they do not acknowledge the rights of self-determination and control over one's body, and that they expect (and even in many ways require) a monolithic transsexual experience. In opposition to this movement is a group of transsexual persons and caregivers who assert that the SOC are in place to protect others from "making a mistake" and causing irreversible changes to their bodies that will later be regretted – though few post-operative transsexuals believe that sexual reassignment surgery was a mistake for them.[40]

The United States

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From 1981 until 2014, the Centers for Medicare and Medicaid Services (CMS) categorically excluded coverage of sex reassignment surgery by Medicare in its National Coverage Determination (NCD) "140.3 Transsexual Surgery," but that categorical exclusion came under challenge by an "aggrieved party" in an Acceptable NCD Complaint in 2013 and was subsequently struck down the following year by the Departmental Appeals Board (DAB), the administrative court of the U.S. Department of Health and Human Services (HHS).[41][42] In late 2013, the DAB issued a ruling finding the evidence on record was "not complete and adequate to support the validity of the NCD" and then moved on to discovery to determine if the exclusion was valid.[43] CMS did not defend its exclusion throughout the entire process. On May 30, 2014, HHS announced that the categorical exclusion was found by the DAB to not be valid "under the 'reasonableness standard,'" allowing for Medicare coverage of sex reassignment surgery to be decided on a case-by-case basis. HHS says it will move to implement the ruling. As Medicaid and private insurers often take their cues from Medicare on what to cover, this may lead to coverage of sex reassignment therapy by Medicaid and private insurers.[41][42] The evidence in the case "outweighs the NCD record and demonstrates that transsexual surgery is safe and effective and not experimental," according to the DAB in its 2014 ruling.[44]

A 2014 article published in American Journal of Public Health called on third-party payers to cover sex reassignment therapy in appropriately selected cases.[45]

Mandatory sterilization

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In Sweden until 2012, sterilization was mandatory before sex reassignment in Sweden.[46]

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In 2011, Christiane Völling won the first successful case brought by an intersex person against a surgeon for non-consensual surgical intervention described by the International Commission of Jurists as "an example of an individual who was subjected to sex reassignment surgery without full knowledge or consent".[47]

In 2015, the Council of Europe recognized, for the first time, a right for intersex persons to not undergo sex assignment treatment.[48] In April 2015, Malta became the first country to recognize a right to bodily integrity and physical autonomy, and outlaw non-consensual modifications to sex characteristics. The Act was widely welcomed by civil society organizations.[49][50][51][52][53]

Gender variance and medicine

Gender variance is defined in medical literature as "gender identity, expression, or behavior that falls outside of culturally defined norms associated with a specific gender".[54] For centuries, gender variance was seen by medicine as a pathology.[55][56] The World Health Organization identified gender dysphoria as a mental disorder in the International Classification of Diseases (ICD) until 2018.[57] Gender dysphoria was also listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) of the American Psychiatric Association, where it was previously called "transsexualism" and "gender identity disorder".[58][59]

In 2018, the ICD-11 included the term "gender incongruence" as "marked and persistent incongruence between an individual’s experienced gender and the assigned sex", where gender variant behaviour and preferences do not necessarily imply a medical diagnosis.[60] However, the difference between "gender dysphoria" and "gender incongruence" is not always clear in the medical literature.[61]

Some studies posit that treating gender variance as a medical condition has negative effects on the health of transgender people and claim that assumptions of coexisting psychiatric symptoms should be avoided.[55][62][63] Other studies argue that gender incongruence diagnosis may be important and even positive for transgender people at the individual and social level.[64]

As there are various ways of classifying or characterizing those who are either diagnosed or self-affirm as transgender individuals, the literature cannot clearly estimate how prevalent these experiences are within the total population. The results of a recent systematic review highlight the need to standardize the scope and methodology related to data collection of those presenting as transgender.[65]

Sex reassignment therapy

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Various options are available for transgender people to pursue physical transition. There have been options for transitioning for transgender individuals since 1917.[2] Sex reassignment therapy helps people to change their physical appearance and/or sex characteristics to accord with their gender identity; it includes hormone replacement therapy and sex reassignment surgery. While many transgender people do elect to transition physically, every transgender person has different needs and, as such, there is no required transition plan.[66] Preventive health care is a crucial part of transitioning and a primary care physician is recommended for transgender people who are transitioning.[66]

Hormone replacement therapy

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

Hormone replacement therapy is primarily concerned with alleviating gender dysphoria in transgender people.[66] Trans women are usually treated with estrogen and complementary anti-androgenic therapy. This therapy induces breast formation, reduces male hair pattern growth, and changes fat distribution, also leading to a decreased testicular size and erectile function.[20] Trans men are normally treated with exogenous testosterone, which is expected to cease menses, to increase facial and body hair, to cause changes in skin and in fat distribution, and to increase muscle mass and libido.[20] After at least three months, other effects are expected, such as the deepening of the voice and changes in sexual organs (such as atrophy of vaginal tissues, and increased clitoral size).[20] Regular monitoring by an endocrinologist is a strong recommendation to ensure the safety of individuals as they transition.[67]

Access to hormone replacement therapy has been shown to improve quality of life for people in the female-to-male community when compared to female-to-male people who do not have access to hormone replacement therapy.[68] Despite the improvement in quality of life, there are still dangers with hormone replacement therapy, in particular with self-medication. An examination of the use of self-medication found that people who self-medicated were more likely to experience adverse health effects from preexisting conditions such as high blood pressure as well as slower development of desired secondary sex characteristics.[69]

Hormone therapy for transgender individuals has been shown in medical literature to be safe, when supervised by a qualified medical professional.[70]

Transgender people seeking surgery may be informed they will need to take hormones for the rest of their life if they want to maintain the feminizing effects of oestrogen or the masculinizing effects of testosterone. Their dose of hormones will usually be reduced, but it should still be enough to produce the effects that they need and to keep them well, and to protect them against osteoporosis (thinning of the bones) as they get older. If they are still on hormone blockers, they will stop taking them altogether.[71]

Monitoring of risk factors associated with hormone replacement therapy, such as prolactin levels in transgender women and polycythemia levels in transgender men, are crucial for the preventive health care of transgender people taking these treatments.[66]

Sex reassignment surgery

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The goal of sex reassignment surgery, also known as gender reassignment surgery, is to align the secondary sexual characteristics of transgender people with their gender identity. As hormone replacement therapy, sex reassignment surgery was also employed as a response to diagnosis gender dysphoria[66][72]

The World Professional Association for Transgender Health (WPATH) Standards of Care recommend additional requirements for sex reassignment surgery when compared to hormone replacement therapy. Whereas hormone replacement therapy can be obtained through something as simple as an informed consent form, sex reassignment surgery can require a supporting letter from a licensed therapist (two letters for genital surgery such as vaginoplasty or phalloplasty), hormonal treatment, and (for genital surgery) completion of a 12-month period in which the person lives full-time as their gender. WPATH standards, while commonly used in gender clinics, are non-binding; many trans patients undergoing surgery do not meet all of the eligibility criteria.

Issues affecting transgender patients

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Violence

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The heightened levels of violence and abuse that transgender people experience result in unique adverse effects on bodily and mental health.[73] Specifically, in resource-constrained settings where non-discriminatory policies may be limited or not enforced, transgender people may encounter high rates of stigma and violence which are associated with poor health outcomes.[74][75] Studies in countries of the Global North show higher levels of discrimination and harassment in school, workplace, healthcare services and the family when compared with cisgender populations, situating transphobia as a key health risk factor for the physical and mental health of transgender people.[76]

There is limited data regarding the impact of social determinants of health on transgender and gender non-conforming individuals health outcomes.[77] However, despite the limited data available, transgender and gender non-conforming individuals have been found to be at higher risk of experiencing poor health outcomes and restricted access to health care due to increased risk for violence, isolation, and other types of discrimination both inside and outside the health care setting.[78]

Despite its importance, access to preventive care is also limited by several factors, including discrimination and erasure. A study on young transgender women's access to HIV treatment found that one of the main contributors to not accessing care was the use of incorrect name and pronouns.[79] A meta analysis of the National Transgender Discrimination Survey examined respondents who used the "gender not listed here" option on the survey and their experiences with accessing health care. Over a third of the people who chose that option said that they had avoided accessing general care due to bias and fears of social repercussions.[80]

Mental health

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Transgender individuals may experience distress and sadness as a result of their gender identity being inconsistent with their biological sex. This distress is referred to as gender dysphoria.[81] Gender dysphoria is typically most upsetting for the individual prior to transitioning, and once the individual begins to transition into their desired gender, whether the transition be socially, medically, or both, the distress frequently lessens.[82][83][84]

Those who are transgender are significantly more likely to be diagnosed with anxiety disorders or depression than the general population.[82][83][84][85] A number of studies suggest that the inflated rates of depression and anxiety in transgender individuals may partially be because of systematic discrimination or a lack of support.[86][87] Evidence suggests that these increased rates begin to normalize when transgender individuals are accepted as their identified gender and when they live within a supportive household.[86][87][88]

Many studies report extremely high rates of suicide within the transgender community.[82][85] A United States study of 6,450 transgender individuals found that 41% of them had attempted suicide, as differing from the national average of 4.6%. The very same survey found that these rates were the most high for certain demographics, with transgender youth between the ages of 18 and 24 having the highest percent.[89] Individuals in the survey who were multiracial, had lower levels of education, and those with a lower annual income were all more likely to have attempted.[89] Specifically, transgender males as a group are the most likely to attempt suicide, more so than transgender females.[89][90] Later surveys suggest that the rate of suicidal attempts for non-binary individuals is in between the two.[90] Transgender adults who have "de-transitioned", meaning having gone back to living as their sex assigned at birth, are significantly more likely to attempt suicide than transgender adults who have never "de-transitioned".[91]

Several studies have shown the relation between minority stress and the heightened rate of depression and other mental illness among both transgender men and women.[92] The expectation to experience rejection can become an important stressor for transgender and gender non-conforming individuals.[93] Mental health problems among trans people are related to higher rates of self-harm, drug usage, and suicidal ideations and attempts.[76]

Health experiences

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Trans people are a vulnerable population of patients with negative experiences in health care contributing to stigmatization of their gender identity. As noted by a systematic review conducted by researchers at James Cook University, evidence reports that 75.3% of respondents have negative experiences during physician visits when seeking gender identity-based care.[94]

Clinic environment

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Guidelines from the UCSF Transgender Care Center state the importance of visibility in chosen gender identity for transgender or non-binary patients. Safe environments include a two-step process in collecting gender identity data by differentiating between personal identity and assignments at birth for medical histories. Common techniques recommended are asking patients their preferred name, pronouns, and other names they may go by in legal documents. In addition, visibility of non-cisgender identities is defined by the work environment of the clinic. Front-desk staff and medical assistants will interact with patients, which these guidelines recommend appropriate training. The existence of at least one gender-neutral bathroom shows consideration of patients with non-binary gender identities.[95]

Clinicians may improperly connect transgender people's symptoms to their gender transition, a phenomenon known as trans broken arm syndrome. Trans broken arm syndrome is particularly prevalent among mental health practicioners, but it exists in all fields of medicine. Misguided investigation of transition-related causes can frustrate patients and cause delay in or refusal of treatment,[96][97][98] or misdiagnosis and prescription of a wrong treatment.[99] Misattribution of symptoms to transgender hormone therapy may also cause doctors to erroneously recommend the patient stop taking hormones.[100] Trans broken arm syndrome may also manifest as health insurance companies refusing to pay for treatments, claiming the treated condition is caused by the patient's transgender status, and thus is a pre-existing condition.[101] According to The SAGE Encyclopedia of Trans Studies, trans broken arm syndrome is a form of discrimination against transgender people.[102] A 2021 survey by TransActual shows that 57% of transgender people in the United Kingdom put off seeing a doctor when they were ill.[103] In 2014, 43% of transgender counselling clients in the UK said their counsellor "wanted to explore transgender issues in therapy even when this wasn't the reason they had sought help".[104]

Global access to transgender health care

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Global access to healthcare across primary and secondary health settings remains fragmented for transgender people,[105] with access and services highly dependent on a political administration's support for trans health in policy as well as globally-engrained health inequalities largely shaped by financial wealth inequalities such as the Global North and Global South divide.[106][107]

Africa

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South Africa

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Access to transition care, mental care, and other issues affecting transgender people is very limited; there is only one comprehensive transgender health care clinic available in South Africa.[108] Additionally, the typical lack of access to transition options that comes as a result of gatekeeping is compounded by the relatively limited knowledge of transgender topics among psychiatrists and psychologists in South Africa.[108]

Asia

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Thailand

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Transgender women, known as kathoeys, have access to hormones through non-prescription sources.[109] This kind of access is a result of the low availability and expense of transgender health care clinics.[109] However, transgender men have difficulty gaining access to hormones such as testosterone in Thailand because it is not as readily available as hormones for kathoeys.[110] As a result, just a third of all trans men surveyed are taking hormones to transition whereas almost three quarters of kathoeys surveyed are taking hormones.[110]

Mainland China

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In Mainland China access to resources and HRT prescriptions are rare, and as a result most people resort to hormones through non-prescription resources. The resources of accessing hormone including Peking University Third Hospital, Dr.Liu(刘烨)and Dr. Pan(潘柏林), Zhongshan Hospital, Dr. Li (李小英), And Shanghai Ninth People's Hospital, Dr. Cheng (程辰). In Changhai Hospital of Shanghai (Hongkou division), Dr. Zhao (赵烨德) can do both HRT prescriptions and SRS.[111]

Europe

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Spain

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Public health care services are available for transgender individuals in Spain, although there has been debate over whether certain procedures should be covered under the public system.[112] The region of Andalusia was the first to approve sex reassignment procedures, including sex reassignment surgery and mastectomies, in 1999, and several other regions have followed their lead in the following years. Multiple interdisciplinary clinics exist in Spain to cater specifically to diagnosing and treating transgender patients, including the Andalusian Gender Team.[112][113] As of 2013, over 4000 transgender patients had been treated in Spain, including Spaniards and international patients.[112][114]

Beginning in 2007, Spain has begun allowing transgender individuals who are eighteen years or older to change their name and gender identity on public records and documents if they have been receiving hormone replacement therapy for at least two years.[112]

Sweden

[edit]

In 1972, Sweden introduced a law that made it possible to change a person's legal gender, but in order to do that, transgender individuals were required to be sterilized and were not allowed to save any sperm or eggs. Apart from this, there were no other mandatory surgeries required for legal gender change.[115] In 1999, people who had been forcibly sterilized in Sweden were entitled to compensation. However, the sterilization requirement remained for people who changed their legal gender. In January 2013, forced sterilization was banned in Sweden.[116]

Depending on the persons health and wishes there are a number of different treatments and surgeries available. Today, no form of treatment is mandatory. An individual with a transsexual or gender dysphoria diagnosis can, together with the assessment team and other doctors, decide what suits them. Although, in order to access medical and legal transitional treatment (e.g. hormone replacement therapy, and top surgery to enhance or remove breast tissue), the person will need to be diagnosed with transexualism or gender dysphoria, which requires at least one year of therapy.[117] To medically transition can cost a lot of money, but in Sweden, the whole treatment is covered by the high-cost protection for medications and doctor's visits and there is no surgery fee.[118] The fee the individual pays for a doctor's appointment or other care represents only a small fraction of the actual costs.[119] If a person would like to change their legal gender marker and personal identity number they will have to seek permission from the National Board of Health and Welfare.[117] For non-binary persons younger than 18 years, the healthcare is very limited. These individuals do not have access to a legal gender marker change or bottom surgery.[120]

In Sweden, anyone is allowed to change their name at any time, including for gender transition.[121]

Up until January 27, 2017, being transsexual was classed as a disease. Two months earlier, in November 21, 2016, around 50 trans activists broke into and occupied the Swedish National Board of Health and Welfare (Swedish: Socialstyrelsen) premises in Rålambsvägen in Stockholm. The activists demanded that their voices be heard regarding the way the country, healthcare, and the National Board of Health and Welfare mistreat transgender and intersex individuals.[122]

Netherlands

[edit]
A sign at a rally calling for equal access to health care for transgender people

Gender care in the Netherlands is insured under the national health care of third part insurer’s, including lazer hair removal, SRS, facial feminization surgery and hormones. Hormones can be prescribed by licensed endocrinologist in a academic hospital from the age 16 and older. Blockers can be prescribed from age 12 when puberty usually starts.

United Kingdom

[edit]

In 2018 Stonewall described UK transgender healthcare as having "significant barriers to accessing treatment, including waiting times that stretch into years, far exceeding the maximums set by law for NHS patients".[123] Patients have the legal right to begin treatment within 18 weeks of referral by their GP, however the average wait for patients to gender identity clinics was 18 months in 2020 with over 13,000 people on the waiting list for appointments at gender identity clinics. .[124]

A 2013 survey of gender identity clinic services provided by the UK National Health Service (NHS) found that 94% of transgender people using the gender identity clinics were satisfied with their care and would recommend the clinics to a friend or family member.[125] This study focused on transgender people using the NHS clinics and so was prone to survivorship bias, as those unhappy with the NHS service are less likely to use it. Despite this positive response, however, other National Health Service programs are lacking; almost a third of respondents reported inadequate psychiatric care in their local area.[125] The options available from the National Health Service also vary with location; slightly differing protocols are used in England, Scotland, Wales and Northern Ireland. Protocols and available options differ widely outside of the UK.[125]

Scotland
[edit]

There are four NHS Scotland Gender Identity Clinics providing services to adults and a separate service for younger people.[126] The National Gender Identity Clinical Network for Scotland reported in 2021 that some patients had waited in excess of two years from referral for their first appointment.[127] Minister for Public Health Maree Todd has stated that the Scottish Government wants to reduce "unacceptable waits to access gender identity services".[128] Research has indicated patient dissatisfaction with long wait times.[129] However, overall experience of treatment outcomes was largely positive, particularly for hormone therapy and surgery.[130]

North America

[edit]

Canada

[edit]

A study of transgender Ontario residents aged 16 and over, published in 2016, found that half of them were reluctant to discuss transgender issues with their family doctor.[131] A 2013–2014 nationwide study of young transgender and genderqueer Canadians found that a third of younger (ages 14–18) and half of the older (ages 19–25) respondents missed needed physical health care. Only 15 percent of respondents with a family doctor felt very comfortable discussing transgender issues with them.[132]

All Canadian provinces fund some sex reassignment surgeries, with New Brunswick being the last of the provinces to start insuring these procedures in 2016.[133] Waiting times for surgeries can be lengthy, as few surgeons in the country provide them; a clinic in Montreal is the only one providing a full range of procedures.[134][135][136] Insurance coverage is not generally provided for the transition-related procedures of facial feminization surgery, tracheal shave, or laser hair removal.[137]

Blood donation
[edit]

Canada's blood collection organization Canadian Blood Services has eligibility criteria for transgender people, which came into effect on August 15, 2016. This criteria states that transgender donors who have not had lower gender affirming surgery will be asked questions based on their sex assigned at birth. They will be eligible to donate or be deferred based on these criteria. For example, trans women will be asked if they have had sex with a man in the last 3 months. If the response is yes, they will be deferred for 3 months after their last sexual contact with a man. Donors who have had lower gender affirming surgery will be deferred from donating blood for 3 months after their surgery. After those months, these donors will be screened in their affirmed gender.[138][139][140]

Mexico

[edit]

A July 2016 study in The Lancet Psychiatry reported that nearly half of transgender people surveyed undertook body-altering procedures without medical supervision.[141] Transition-related care is not covered under Mexico's national health plan.[142] Only one public health institution in Mexico provides free hormones for transgender people.[141] Health care for transgender Mexicans focuses on HIV and prevention of other sexually transmitted diseases.[141]

The Lancet study also found that many transgender Mexicans have physical health problems due to living on the margins of society. The authors of the study recommended that the World Health Organization declassify transgender identity as a mental disorder, to reduce stigma against this population.[143]

United States

[edit]

Transgender people face various kinds of discrimination, especially in health care situations. An assessment of transgender needs in Philadelphia found that 26% of respondents had been denied health care because they were transgender and 52% of respondents had difficulty accessing health services.[144] Aside from transition related care, transgender and gender non-conforming individuals need preventive care such as vaccines, gynecological care, prostate exams, and other annual preventive health measures.[2] Various factors play a role in creating the limited access to care, such as insurance coverage issues related to their legal gender identity status.[2]

The Affordable Care Act (commonly known as Obamacare) marketplace has improved access to insurance for the LGBT community through anti-discriminatory measures, such as not allowing insurance companies to reject consumers for being transgender.[77] However, insurance sold outside of the ACA marketplace does not have to follow these requirements. This means that preventive care, such as gynecological exams for transgender men, may not be covered.[145]

South America

[edit]

Colombia

[edit]

Transgender women sex workers have cited financial difficulties as barriers to accessing physical transition options.[146] As a result, they have entered sex work to relieve financial burdens, both those related to transition and those not related to transition.[146] However, despite working in the sex trade, the transgender women are at low risk for HIV transmission as the Colombian government requires education about sexual health and human rights for sex workers to work in so-called tolerance zones, areas where sex work is legal.[146]

Health care for transgender youth

[edit]

Transition options for transgender adolescents and youth are significantly limited compared to those for transgender adults. Prepubescent transgender youth can go through various social changes, such as presenting as their gender and asking to be called by a different name or different pronouns.[147] Medical options for transition become available once the child begins to enter puberty. Under close supervision by a team of doctors, puberty blockers may be used to limit the effects of puberty.[147]

Discrimination has a significant effect on the mental health of young transgender people. The lack of family acceptance, rejection in schools and abuse from peers can be powerful stressors, leading to poor mental health and substance abuse.[148] A study done on transgender youth in San Francisco found that higher rates of both transgender-based and racial bias are associated with increased rates of depression, post-traumatic stress disorder, and suicidal ideation.[149]

The use of puberty blockers as a form of treatment for transgender youth is in question. While the World Professional Association for Transgender Health recommends their use, the likelihood of issues of gender dysphoria resolving before adolescence and before the use of puberty blockers are quite high.[66][150] Concerns regarding the impact of puberty blockers on physical health, such as bone density, have also been raised.[150] Long-term use of puberty blockers has also gone relatively unstudied, bringing up questions about harmful long-term side effects.[150] While there is concern about the physical effects of puberty blockers, the mental effects are positive with treatment associated with significant improvements in multiple psychological measures, including global functioning, depression, and overall behavioral and/or emotional problems.[151]

Health care for transgender older adults

[edit]

Transgender older adults can encounter challenges in the access and quality of care received in health care systems and nursing homes, where providers may be ill-prepared to provide culturally sensitive care to trans people.[152] Trans individuals face the risk of aging with more limited support and in more stigmatizing environments than heteronormative individuals.[153] Despite the rather negative picture portrayed by medical literature in relation to the depression and isolation that many transgender people encounter at earlier stages of life, some studies found testimonies of older LGBT adults relating feelings of inclusion, comfort and community support.[154]

See also

[edit]

Bibliography

[edit]
  • Brown, Mildred L.; Chloe Ann Rounsley (1996). True Selves: Understanding Transsexualism – For Families, Friends, Coworkers, and Helping Professionals. Jossey-Bass. ISBN 978-0-7879-6702-4.
  • Dallas, Denny (2006). Transgender Rights: Transgender Communities of the United States in the Late Twentieth Century. University of Minnesota Press. ISBN 978-0-8166-4312-7.
  • Feinberg, Leslie (1999). Trans Liberation : Beyond Pink or Blue. Beacon Press. ISBN 978-0-8070-7951-5.
  • Kruijver, F. P. M. (2000). "Male-to-Female Transsexuals Have Female Neuron Numbers in a Limbic Nucleus". Journal of Clinical Endocrinology & Metabolism. 85 (5): 2034–41. doi:10.1210/jcem.85.5.6564. PMID 10843193.
  • Coleman, E.; Bockting, W.; Botzer, M.; Cohen-Kettenis, P.; DeCuypere, G.; Feldman, J.; Fraser, L.; Green, J.; Knudson, G.; Meyer, W. J.; Monstrey, S.; Adler, R. K.; Brown, G. R.; Devor, A.H.; Ehrbar, R.; Ettner, R.; Eyler, E.; Garofalo, R.; Karasic, D. H.; Lev, A. I.; Mayer, G.; Meyer Bahlburg, H.; Hall, B.P.; Pfaefflin, F.; Rachlin, K.; Robinson, B.; Schechter, L. S.; Tangpricha, V.; van Trotsenburg, M.; Vitale, A.; Winter, S.; Whittle, S.; Wylie, K. R.; Zucker, K. (2012). "Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7" (PDF). International Journal of Transgenderism. 13 (4): 165–232. doi:10.1080/15532739.2011.700873. ISSN 1553-2739. S2CID 39664779. Archived from the original (PDF) on 2014-08-02.
  • Pfäfflin, Friedemann & Astrid Junge -Sex Reassignment. Thirty Years of International Follow-up Studies After Sex Reassignment Surgery: A Comprehensive Review, 1961–1991 (translated from German into American English by Roberta B. Jacobson and Alf B. Meier)
  • Rathus, Spencer A.; Jeffery S. Nevid; Lois Fichner-Rathus (2002). Human Sexuality in a World of Diversity. Allyn & Bacon. ISBN 978-0-205-40615-9.
  • Schneider, H; Pickel, J; Stalla, G (2006). "Typical female 2nd–4th finger length (2D:4D) ratios in male-to-female transsexuals—possible implications for prenatal androgen exposure". Psychoneuroendocrinology. 31 (2): 265–9. doi:10.1016/j.psyneuen.2005.07.005. PMID 16140461. S2CID 33927715.
  • Xavier, J., Simmons, R. (2000) – The Washington transgender needs assessment survey, Washington, DC: The Administration for HIV and AIDS of the District of Columbia Government

References

[edit]
  1. ^ "What is gender-affirming care? Your questions answered". AAMC. Retrieved 2022-05-22.
  2. ^ a b c d Gorton N, Grubb HM (2014). General, Sexual, and Reproductive health. In L. Erickson-Schroth. Trans Bodies, Trans Selves: A Resource for the transgender community (pp. 215-240). New York: Oxford University Press.
  3. ^ a b c d George R. Brown, MD (20 July 2011). "Chapter 165 Sexuality and Sexual Disorders". In Robert S. Porter, MD; et al. (eds.). The Merck Manual of Diagnosis and Therapy (19th ed.). Whitehouse Station, NJ, USA: Merck & Co., Inc. pp. 1567–1573. ISBN 978-0-911910-19-3.
  4. ^ a b c d Richard M. Green, M.D., J.D. (June 8, 2009). "18.3 Gender Identity Disorders". In Benjamin Sadock; Virginia Alcott Sadock; Pedro Ruiz (eds.). Kaplan and Sadock's Comprehensive Textbook of Psychiatry (9th ed.). Lippincott Williams & Wilkins. pp. 2099–2111. ISBN 978-0781768993. Archived from the original on June 6, 2021. {{cite book}}: |editor3= has generic name (help)CS1 maint: multiple names: authors list (link)
  5. ^ a b c d e William Byne, Susan J. Bradley, Eli Coleman, A. Evan Eyler, Richard Green, Edgardo J. Menvielle, Heino F. L. Meyer-Bahlburg, Richard R. Pleak & D. Andrew Tompkins (August 2012). "Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder" (PDF). Archives of Sexual Behavior. 41 (4): 759–796 (pages cited as pages at link). doi:10.1007/s10508-012-9975-x. PMID 22736225. S2CID 26050161.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  6. ^ a b Drescher, Jack; Haller, Ellen (July 2012). "Position Statement on Access to Care for Transgender and Gender Variant Individuals" (PDF). American Psychiatric Association. Retrieved 17 January 2014.
  7. ^ a b "AMA Resolution 122" (PDF). American Medical Association. May 2008. Retrieved 17 January 2014.
  8. ^ "APA Policy Statement: Transgender, Gender Identity, & Gender Expression Non-Discrimination". American Psychological Association]. American Psychological Association. August 2008. Retrieved 17 January 2014.
  9. ^ a b "Good practice guidelines for the assessment and treatment of adults with gender dysphoria" (PDF). Royal College of Psychiatrists]. Royal College of Psychiatrists. October 2013. Retrieved 17 January 2014.
  10. ^ Whittle, Stephen; Bockting, Walter; Monstrey, Stan; Brown, George; Brownstein, Michael; DeCuypere, Griet; Ettner, Randi; Fraser, Lin; Green, Jamison; Rachlin, Katherine; Robinson, Beatrice. "WPATH Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage for Transgender and Transsexual People Worldwide". WPATH. Archived from the original on 14 August 2015. Retrieved 27 August 2015.
  11. ^ F64.0"Excerpt from ICD 10".
  12. ^ "DSM-5". www.psychiatry.org.
  13. ^ a b c d e f "Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7" (PDF). Archived from the original (PDF) on 2016-01-06.
  14. ^ Ashley, Florence (2019-07-01). "Gatekeeping hormone replacement therapy for transgender patients is dehumanising". Journal of Medical Ethics. 45 (7): 480–482. doi:10.1136/medethics-2018-105293. ISSN 0306-6800. PMID 30988174.
  15. ^ Lambert, Cei; Hopwood, Ruben; Cavanaugh, Timothy (2016-11-01). "Informed Consent in the Medical Care of Transgender and Gender-Nonconforming Patients". AMA Journal of Ethics. 18 (11): 1147–1155. doi:10.1001/journalofethics.2016.18.11.sect1-1611. ISSN 2376-6980. PMID 27883307.
  16. ^ Brown, Mildred (2003). True selves : understanding transsexualism-- for families, friends, coworkers, and helping professionals. San Francisco: Jossey-Bass. ISBN 978-0-7879-6702-4.
  17. ^ "Transgender Health & Transitioning | Revel & Riot". www.revelandriot.com. Retrieved 2019-08-07.
  18. ^ "Information on Testosterone Hormone Therapy | Transgender Care". transcare.ucsf.edu. Retrieved 2019-08-07.
  19. ^ Hashemi, Leila; Weinreb, Jane; Weimer, Amy K.; Weiss, Rebecca Loren (July 2018). "Transgender Care in the Primary Care Setting: A Review of Guidelines and Literature". Federal Practitioner. 35 (7): 30–37. ISSN 1945-337X. PMC 6368014. PMID 30766372.
  20. ^ a b c d e Unger, Cécile A. (December 2016). "Hormone therapy for transgender patients". Translational Andrology and Urology. 5 (6): 877–884. doi:10.21037/tau.2016.09.04. ISSN 2223-4691. PMC 5182227. PMID 28078219.{{cite journal}}: CS1 maint: unflagged free DOI (link) Cite error: The named reference "Unger 877–884" was defined multiple times with different content (see the help page).
  21. ^ Deutsch, Madeline B.; Bhakri, Vipra; Kubicek, Katrina (March 2015). "Effects of cross-sex hormone treatment on transgender women and men". Obstetrics and Gynecology. 125 (3): 605–610. doi:10.1097/AOG.0000000000000692. ISSN 1873-233X. PMC 4442681. PMID 25730222.
  22. ^ Hashemi, Leila; Weinreb, Jane; Weimer, Amy K.; Weiss, Rebecca Loren (July 2018). "Transgender Care in the Primary Care Setting: A Review of Guidelines and Literature". Federal Practitioner. 35 (7): 30–37. ISSN 1078-4497. PMC 6368014. PMID 30766372.
  23. ^ Hembree, Wylie C.; Cohen-Kettenis, Peggy; Delemarre-van de Waal, Henriette A.; Gooren, Louis J.; Meyer, Walter J.; Spack, Norman P.; Tangpricha, Vin; Montori, Victor M. (2009-09-01). "Endocrine Treatment of Transsexual Persons:An Endocrine Society Clinical Practice Guideline". The Journal of Clinical Endocrinology & Metabolism. 94 (9): 3132–3154. doi:10.1210/jc.2009-0345. ISSN 0021-972X. PMID 19509099.
  24. ^ P. A. Sutcliffe, S. Dixon, R. L. Akehurst, A. Wilkinson, A. Shippam, S. White, R. Richards & C. M. Caddy (March 2009). "Evaluation of surgical procedures for sex reassignment: a systematic review". Journal of Plastic, Reconstructive & Aesthetic Surgery. 62 (3): 294–306. doi:10.1016/j.bjps.2007.12.009. PMID 18222742.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  25. ^ Murad, Mohammad Hassan; Elamin, Mohamed B.; Garcia, Magaly Zumaeta; Mullan, Rebecca J.; Murad, Ayman; Erwin, Patricia J.; Montori, Victor M. (2010). "Hormonal therapy and sex reassignment: A systematic review and meta-analysis of quality of life and psychosocial outcomes". Clinical Endocrinology. 72 (2): 214–31. doi:10.1111/j.1365-2265.2009.03625.x. PMID 19473181. S2CID 19590739.
  26. ^ Newfield, E; Hart, S; Dibble, S; Kohler, L (November 2006). "Female-to-male transgender quality of life". Quality of Life Research. 15 (9): 1447–57. CiteSeerX 10.1.1.468.9106. doi:10.1007/s11136-006-0002-3. PMID 16758113. S2CID 12727036.
  27. ^ Johansson, Annika; Sundbom, Elisabet; Höjerback, Torvald; Bodlund, Owe (2009). "A Five-Year Follow-Up Study of Swedish Adults with Gender Identity Disorder". Archives of Sexual Behavior. 39 (6): 1429–37. doi:10.1007/s10508-009-9551-1. PMID 19816764. S2CID 22866694.
  28. ^ Smith, YL; Van Goozen, SH; Kuiper, AJ; Cohen-Kettenis, PT (January 2005). "Sex reassignment: outcomes and predictors of treatment for adolescent and adult transsexuals" (PDF). Psychological Medicine. 35 (1): 89–99. doi:10.1017/S0033291704002776. PMID 15842032. S2CID 6032916.
  29. ^ Dhejne, Cecilia; Lichtenstein, Paul; Boman, Marcus; Johansson, Anna L. V.; Långström, Niklas; Landén, Mikael (2011). Scott, James (ed.). "Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden". PLOS ONE. 6 (2): e16885. Bibcode:2011PLoSO...616885D. doi:10.1371/journal.pone.0016885. PMC 3043071. PMID 21364939.
  30. ^ Heylens, Gunter; Verroken, Charlotte; De Cock, Sanne; T'Sjoen, Guy; De Cuypere, Griet (2013). "Effects of Different Steps in Gender Reassignment Therapy on Psychopathology: A Prospective Study of Persons with a Gender Identity Disorder". The Journal of Sexual Medicine. 11 (1): 119–126. doi:10.1111/jsm.12363. ISSN 1743-6095. PMID 24344788.
  31. ^ Yolanda L. S. Smith, Stephanie H. M. Van Goozen, Abraham J. Kuiper & Peggy T. Cohen-Kettenis (January 2005). "Sex reassignment: outcomes and predictors of treatment for adolescent and adult transsexuals" (PDF). Psychological Medicine. 35 (1): 89–99. doi:10.1017/S0033291704002776. PMID 15842032. S2CID 6032916.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  32. ^ Bustos, Valeria; Bustos, Samyd; Mascaro, Andres; Del Corral, Gabriel; Forte, Antonio; Ciudad, Pedro; Kim, Esther; Langstein, Howard; Manrique, Oscar (March 2021). "Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence". Plastic and Reconstructive Surgery. 9 (3): e3477. doi:10.1097/GOX.0000000000003477. PMC 8099405. PMID 33968550. Archived from the original on 2022-04-06. Retrieved 2022-04-15.
  33. ^ "Vatican says 'sex-change' operation does not change person's gender". National Catholic Reporter. 2011-09-19.
  34. ^ "FAQ on Gender Identity Disorder and "Sex Change" Operations". National Catholic Bioethics Center. Archived from the original on 2014-02-22.
  35. ^ Paul McHugh. "Psychiatric misadventures".
  36. ^ Richard P. Fitzgibbons, M.D., Philip M. Sutton, and Dale O’Leary, The Psychopathology of "Sex Reassignment" Surgery, Assessing Its Medical, Psychological, and Ethical Appropriateness, The National Catholic Bioethics Quarterly, Spring 2009, p. 100. Archived 2014-08-09 at the Wayback Machine
  37. ^ Allen, Samantha (12 April 2017). "Can Trans People Trust Johns Hopkins's New Clinic?". The Daily Beast.
  38. ^ "Why The Trans Community Hates Dr. Janice G. Raymond". TransGRiot. 2010-09-20.
  39. ^ Iran's gay plan, Matthew Hays, Canadian Broadcasting Corporation, August 26, 2008; accessed August 13, 2009.
  40. ^ Kuiper, A.J; P.T. Cohen-Kettenis (September 1998). "Gender Role Reversal among Postoperative Transsexuals". International Journal of Transgenderism. 2 (3). Archived from the original on 2007-02-04. Retrieved 2007-02-25.
  41. ^ a b Wayne, Alex (30 May 2014). "Medicare Ordered to Consider Covering Sex-Change Surgery". Bloomberg.com. Bloomberg. Retrieved 30 May 2014.
  42. ^ a b McMorris-Santoro, Evan (30 May 2014). "Obama Administration Opens The Door To Medicare-Funded Sex Reassignment Surgery". BuzzFeed Politics. Retrieved 30 May 2014.
  43. ^ Leslie A. Sussan; Constance B. Tobias; Sheila Ann Hegy (presiding) (2 Dec 2013). "NCD 140.3 Transsexual Surgery: NCD Ruling No. 2" (PDF). Acceptable National Coverage Determination Complaints (DAB). HHS.gov. Docket No. A-13-47. Retrieved 7 Feb 2014.
  44. ^ Leslie A. Sussan; Constance B. Tobias; Sheila Ann Hegy (presiding) (30 May 2014). "NCD 140.3 Transsexual Surgery: Decision No. 2576" (PDF). Acceptable National Coverage Determination Complaints (DAB). HHS.gov. Docket No. A-13-87. Retrieved 4 Jul 2014.
  45. ^ Daphna Stroumsa (January 2014). "The State of Transgender Health Care: Policy, Law, and Medical Frameworks". American Journal of Public Health. 104 (3): e31–8. doi:10.2105/AJPH.2013.301789. PMC 3953767. PMID 24432926.
  46. ^ Sweden keeps sex-change sterilisation law, The Local, January 12, 2012
  47. ^ International Commission of Jurists. "SOGI Casebook Introduction, Chapter six: Intersex". Retrieved 2015-12-27.
  48. ^ Council of Europe; Commissioner for Human Rights (April 2015), Human rights and intersex people, Issue Paper
  49. ^ Cabral, Mauro (April 8, 2015). "Making depathologization a matter of law. A comment from GATE on the Maltese Act on Gender Identity, Gender Expression and Sex Characteristics". Global Action for Trans Equality. Archived from the original on July 4, 2015. Retrieved 2015-07-03.
  50. ^ OII Europe (April 1, 2015). "OII-Europe applauds Malta's Gender Identity, Gender Expression and Sex Characteristics Act. This is a landmark case for intersex rights within European law reform". Retrieved 2015-07-03.
  51. ^ Carpenter, Morgan (April 2, 2015). "We celebrate Maltese protections for intersex people". Organisation Intersex International Australia. Retrieved 2015-07-03.
  52. ^ Star Observer (2 April 2015). "Malta passes law outlawing forced surgical intervention on intersex minors". Star Observer.
  53. ^ Reuters (1 April 2015). "Surgery and Sterilization Scrapped in Malta's Benchmark LGBTI Law". The New York Times. {{cite news}}: |last= has generic name (help)
  54. ^ Simons, Lisa K.; Leibowitz, Scott F.; Hidalgo, Marco A. (2014-06-01). "Understanding Gender Variance in Children and Adolescents". Pediatric Annals. 43 (6): e126–e131. doi:10.3928/00904481-20140522-07. ISSN 0090-4481. PMID 24972420.
  55. ^ a b Byne, William; Karasic, Dan H.; Coleman, Eli; Eyler, A. Evan; Kidd, Jeremy D.; Meyer-Bahlburg, Heino F.L.; Pleak, Richard R.; Pula, Jack (May 2018). "Gender Dysphoria in Adults: An Overview and Primer for Psychiatrists". Transgender Health. 3 (1): 57–A3. doi:10.1089/trgh.2017.0053. ISSN 2380-193X. PMC 5944396. PMID 29756044.
  56. ^ von Krafft-Ebing, Richard (1894). Psychopathia Sexualis. ISBN 9782357792173.
  57. ^ Reed, Geoffrey M.; Drescher, Jack; Krueger, Richard B.; Atalla, Elham; Cochran, Susan D.; First, Michael B.; Cohen-Kettenis, Peggy T.; Arango-de Montis, Iván; Parish, Sharon J. (October 2016). "Disorders related to sexuality and gender identity in the ICD-11: revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations". World Psychiatry. 15 (3): 205–221. doi:10.1002/wps.20354. PMC 5032510. PMID 27717275.
  58. ^ Reed, Geoffrey M.; Drescher, Jack; Krueger, Richard B.; Atalla, Elham; Cochran, Susan D.; First, Michael B.; Cohen-Kettenis, Peggy T.; Arango-de Montis, Iván; Parish, Sharon J. (October 2016). "Disorders related to sexuality and gender identity in the ICD-11: revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations". World Psychiatry. 15 (3): 205–221. doi:10.1002/wps.20354. PMC 5032510. PMID 27717275.
  59. ^ Cohen-Kettenis, Peggy T.; Pfäfflin, Friedemann (2009-10-17). "The DSM Diagnostic Criteria for Gender Identity Disorder in Adolescents and Adults". Archives of Sexual Behavior. 39 (2): 499–513. doi:10.1007/s10508-009-9562-y. hdl:1871/34512. ISSN 0004-0002. PMID 19838784. S2CID 16336939.
  60. ^ "ICD-11". icd.who.int. Retrieved 2019-03-24.
  61. ^ Defreyne, Justine; Kreukels, Baudewijntje; T'Sjoen, Guy; Staphorsius, Annemieke; Den Heijer, Martin; Heylens, Gunter; Elaut, Els (April 2019). "No correlation between serum testosterone levels and state-level anger intensity in transgender people: Results from the European Network for the Investigation of Gender Incongruence". Hormones and Behavior. 110: 29–39. doi:10.1016/j.yhbeh.2019.02.016. PMID 30822410. S2CID 72332772.
  62. ^ Castro-Peraza, Maria Elisa; García-Acosta, Jesús Manuel; Delgado, Naira; Perdomo-Hernández, Ana María; Sosa-Alvarez, Maria Inmaculada; Llabrés-Solé, Rosa; Lorenzo-Rocha, Nieves Doria (2019-03-18). "Gender Identity: The Human Right of Depathologization". International Journal of Environmental Research and Public Health. 16 (6): 978. doi:10.3390/ijerph16060978. ISSN 1660-4601. PMC 6466167. PMID 30889934.
  63. ^ Latham, J.R. (2017). "Making and Treating Trans Problems The Ontological Politics of Clinical Practices". Studies in Gender and Sexuality. 18 (1): 40–61. doi:10.1080/15240657.2016.1238682. S2CID 152123850.
  64. ^ Vargas-Huicochea, Ingrid; Robles, Rebeca; Real, Tania; Fresán, Ana; Cruz-Islas, Jeremy; Vega-Ramírez, Hamid; Medina-Mora, María Elena (November 2018). "A Qualitative Study of the Acceptability of the Proposed ICD-11 Gender Incongruence of Childhood Diagnosis Among Transgender Adults Who Were Labeled Due to Their Gender Identity Since Childhood". Archives of Sexual Behavior. 47 (8): 2363–2374. doi:10.1007/s10508-018-1241-4. ISSN 0004-0002. PMID 29971651. S2CID 49681691.
  65. ^ Collin, Lindsay; Reisner, Sari L.; Tangpricha, Vin; Goodman, Michael (2016). "Prevalence of Transgender Depends on the "Case" Definition: A Systematic Review". The Journal of Sexual Medicine. 13 (4): 613–626. doi:10.1016/j.jsxm.2016.02.001. PMC 4823815. PMID 27045261.
  66. ^ a b c d e f Coleman, E.; Bockting, W.; Botzer, M.; Cohen-Kettenis, P.; DeCuypere, G.; Feldman, J.; Fraser, L.; Green, J.; Knudson, G. (2012-08-01). "Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7". International Journal of Transgenderism. 13 (4): 165–232. doi:10.1080/15532739.2011.700873. ISSN 1553-2739. S2CID 39664779.
  67. ^ Moore, Eva; Wisniewski, Amy; Dobs, Adrian (2003-08-01). "Endocrine Treatment of Transsexual People: A Review of Treatment Regimens, Outcomes, and Adverse Effects". The Journal of Clinical Endocrinology & Metabolism. 88 (8): 3467–3473. doi:10.1210/jc.2002-021967. ISSN 0021-972X. PMID 12915619.
  68. ^ Newfield, Emily; Hart, Stacey; Dibble, Suzanne; Kohler, Lori (2006-06-07). "Female-to-male transgender quality of life". Quality of Life Research. 15 (9): 1447–1457. CiteSeerX 10.1.1.468.9106. doi:10.1007/s11136-006-0002-3. ISSN 0962-9343. PMID 16758113. S2CID 12727036.
  69. ^ Israel, Gianna (2001). Transgender Care: Recommended Guidelines, Practical Information, and Personal Accounts. Temple University Press. ISBN 978-1-56639-852-7.
  70. ^ Weinand, Jamie D.; Safer, Joshua D. (Feb 2015). "Hormone therapy in transgender adults is safe with provider supervision; A review of hormone therapy sequelae for transgender individuals". Journal of Clinical & Translational Endocrinology. 2 (2): 55–60. doi:10.1016/j.jcte.2015.02.003. PMC 5226129. PMID 28090436.
  71. ^ "A guide to hormone therapy for trans people" (PDF). August 2014. p. 10. Retrieved March 2, 2021.
  72. ^ Choices, NHS. "Gender dysphoria – NHS Choices". www.nhs.uk. Retrieved 9 December 2016.
  73. ^ Rood, Brian A.; Reisner, Sari L.; Surace, Francisco I.; Puckett, Jae A.; Maroney, Meredith R.; Pantalone, David W. (2016). "Expecting Rejection: Understanding the Minority Stress Experiences of Transgender and Gender-Nonconforming Individuals". Transgender Health. 1 (1): 151–164. doi:10.1089/trgh.2016.0012. PMC 5685272. PMID 29159306.
  74. ^ Budhwani, Henna; Hearld, Kristine R.; Milner, Adrienne N.; Charow, Rebecca; McGlaughlin, Elaine M.; Rodriguez-Lauzurique, Mayra; Rosario, Santo; Paulino-Ramirez, Robert (September 26, 2017). "Transgender Women's Experiences with Stigma, Trauma, and Attempted Suicide in the Dominican Republic". Suicide and Life-Threatening Behavior. 48 (6): 788–796. doi:10.1111/sltb.12400. ISSN 1943-278X. PMID 28950402. S2CID 26033883.
  75. ^ Lagos, Danya (December 2018). "Looking at Population Health Beyond "Male" and "Female": Implications of Transgender Identity and Gender Nonconformity for Population Health". Demography. 55 (6): 2097–2117. doi:10.1007/s13524-018-0714-3. ISSN 0070-3370. PMID 30255426. S2CID 52822267.
  76. ^ a b Scherer, Bee (2018-12-20). Queering paradigms VII : contested bodies and spaces. Scherer, Burkhard, 1971-, Vries, Patrick de. Oxford, United Kingdom. ISBN 978-1-78874-529-1. OCLC 1080428040.{{cite book}}: CS1 maint: location missing publisher (link)
  77. ^ a b Department of Health and Human Services, Office of Disease and Health Promotion. (2016, September). Lesbian, Gay, Bisexual, and Transgender Health. Retrieved from HealthyPeople.gov: https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health
  78. ^ Anastas, J.W. (2013). "Policy, practice, and people: Current issues affecting clinical practice". Clinical Social Work Journal. 41 (3): 302–307. doi:10.1007/s10615-013-0454-1. S2CID 143288898.
  79. ^ Dowshen, Nadia; Lee, Susan S.; Castillo, Marné; Hawkins, Linda; Barg, Frances K. (February 2016). "Barriers and Facilitators to HIV Prevention, Testing, and Treatment among Young Transgender Women". Journal of Adolescent Health. 58 (2): S81–S82. doi:10.1016/j.jadohealth.2015.10.175.
  80. ^ Jack, Harrison; Jaime, Grant; L., Herman, Jody (2012-04-01). "A Gender Not Listed Here: Genderqueers, Gender Rebels, and OtherWise in the National Transgender Discrimination Survey". LGBTQ Public Policy Journal at the Harvard Kennedy School. 2 (1).{{cite journal}}: CS1 maint: multiple names: authors list (link)
  81. ^ "What Does Transgender Mean? | Gender Identification Facts". www.plannedparenthood.org. Retrieved 2019-10-23.
  82. ^ a b c Connolly, Maureen D.; Zervos, Marcus J.; Barone, Charles J.; Johnson, Christine C.; Joseph, Christine L. M. (2016-11-01). "The Mental Health of Transgender Youth: Advances in Understanding". Journal of Adolescent Health. 59 (5): 489–495. doi:10.1016/j.jadohealth.2016.06.012. ISSN 1054-139X. PMID 27544457.
  83. ^ a b Dhejne, Cecilia; Vlerken, Roy Van; Heylens, Gunter; Arcelus, Jon (2016-01-02). "Mental health and gender dysphoria: A review of the literature". International Review of Psychiatry. 28 (1): 44–57. doi:10.3109/09540261.2015.1115753. ISSN 0954-0261. PMID 26835611. S2CID 207493538.
  84. ^ a b Bouman, Walter Pierre; Claes, Laurence; Brewin, Nicky; Crawford, John R.; Millet, Nessa; Fernandez-Aranda, Fernando; Arcelus, Jon (2017-01-02). "Transgender and anxiety: A comparative study between transgender people and the general population" (PDF). International Journal of Transgenderism. 18 (1): 16–26. doi:10.1080/15532739.2016.1258352. ISSN 1553-2739. S2CID 151463685.
  85. ^ a b Zucker, Kenneth J.; Lawrence, Anne A.; Kreukels, Baudewijntje P.C. (2016). "Gender Dysphoria in Adults". Annual Review of Clinical Psychology. 12 (1): 217–247. doi:10.1146/annurev-clinpsy-021815-093034. PMID 26788901.
  86. ^ a b Trujillo, Michael A.; Perrin, Paul B.; Sutter, Megan; Tabaac, Ariella; Benotsch, Eric G. (2017-01-02). "The buffering role of social support on the associations among discrimination, mental health, and suicidality in a transgender sample". International Journal of Transgenderism. 18 (1): 39–52. doi:10.1080/15532739.2016.1247405. ISSN 1553-2739. PMC 5996383. PMID 29904324.
  87. ^ a b McConnell, Elizabeth A.; Birkett, Michelle; Mustanski, Brian (2016-12-01). "Families Matter: Social Support and Mental Health Trajectories Among Lesbian, Gay, Bisexual, and Transgender Youth". Journal of Adolescent Health. 59 (6): 674–680. doi:10.1016/j.jadohealth.2016.07.026. ISSN 1054-139X. PMC 5217458. PMID 27707515.
  88. ^ Durwood, Lily; McLaughlin, Katie A.; Olson, Kristina R. (February 2017). "Mental Health and Self-Worth in Socially Transitioned Transgender Youth". Journal of the American Academy of Child & Adolescent Psychiatry. 56 (2): 116–123.e2. doi:10.1016/j.jaac.2016.10.016. PMC 5302003. PMID 28117057.
  89. ^ a b c Haas, Ann; Rodgers, Philip; Herman, Jody (2017-10-08). "Suicide Attempts among Transgender and Gender Non-Conforming Adults" (PDF). The Williams Institute. Archived (PDF) from the original on 2017-10-08. Retrieved 2019-10-23.
  90. ^ a b Toomey, Russell B.; Syvertsen, Amy K.; Shramko, Maura (2018-10-01). "Transgender Adolescent Suicide Behavior". Pediatrics. 142 (4): e20174218. doi:10.1542/peds.2017-4218. ISSN 0031-4005. PMC 6317573. PMID 30206149.
  91. ^ Herman, Jody L.; Brown, Taylor N.T.; Haas, Ann P. (September 2019). "Suicide Thoughts and Attempts Among Transgender Adults: Findings from the 2015 U.S. Transgender Survey" (PDF). Williams Institute. Retrieved 5 November 2020.
  92. ^ Bockting, Walter O.; Miner, Michael H.; Swinburne Romine, Rebecca E.; Hamilton, Autumn; Coleman, Eli (2013). "Stigma, mental health, and resilience in an online sample of the US transgender population". American Journal of Public Health. 103 (5): 943–951. doi:10.2105/ajph.2013.301241. PMC 3698807. PMID 23488522.
  93. ^ Rood, Brian A.; Reisner, Sari L.; Surace, Francisco I.; Puckett, Jae A.; Maroney, Meredith R.; Pantalone, David W. (January 2016). "Expecting Rejection: Understanding the Minority Stress Experiences of Transgender and Gender-Nonconforming Individuals". Transgender Health. 1 (1): 151–164. doi:10.1089/trgh.2016.0012. ISSN 2380-193X. PMC 5685272. PMID 29159306.
  94. ^ Heng, Audrey; Heal, Clare; Banks, Jennifer; Preston, Robyn (2018-10-02). "Transgender peoples' experiences and perspectives about general healthcare: A systematic review" (PDF). International Journal of Transgenderism. 19 (4): 359–378. doi:10.1080/15532739.2018.1502711. ISSN 1553-2739. S2CID 150322054.
  95. ^ "Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People | Transgender Care". transcare.ucsf.edu. Retrieved 2019-08-06.
  96. ^ Pearce, Ruth (2018). Understanding Trans Health: Discourse, Power and Possibility. Policy Press. pp. 111–112.
  97. ^ Payton, Naith (9 July 2015). "Feature: The dangers of trans broken arm syndrome". PinkNews.
  98. ^ Paradiso, Catherine; Arca-Contreras, Karen; Brillhart, Susan J.; Macchiarola, Jennifer; Curcio, Danna L. (29 July 2022). "Integration of transgender health: A multi-modal approach". Teaching and Learning in Nursing. 17 (4). Elsevier: 425–432. doi:10.1016/j.teln.2022.06.001. S2CID 251204461.
  99. ^ Freeman, Lauren; Lopéz, Saray Ayala (September 2018). "Sex Categorization in Medical Contexts: A Cautionary Tale". Kennedy Institute of Ethics Journal. 28 (3). Johns Hopkins University Press: 243–280. doi:10.1353/ken.2018.0017. PMID 30369506. S2CID 53095199 – via Project MUSE.
  100. ^ Dietz, Elizabeth; Halem, Jessica (November 2016). "How Should Physicians Refer When Referral Options Are Limited for Transgender Patients?". AMA Journal of Ethics. 18 (11). American Medical Association: 1070–1080. doi:10.1001/journalofethics.2016.18.11.ecas1-1611. PMID 27883298.
  101. ^ O'Hara, Mary Emily (6 August 2015). "'Trans Broken Arm Syndrome' and the way our healthcare system fails trans people". The Daily Dot.
  102. ^ Goldberg, Abbie E.; Beemyn, Genny, eds. (2021). "Health Care, Discrimination". The SAGE Encyclopedia of Trans Studies. SAGE Publishing. p. 356.
  103. ^ Vinter, Robyn (10 October 2021). "'GPs fob us off': most trans people avoid the doctor when they're sick". The Observer.
  104. ^ Hunt, Jane (2013). "An initial study of transgender people's experiences of seeking and receiving counselling or psychotherapy in the UK". Counselling and Psychotherapy Research. 14 (4). Routledge: 288–296. doi:10.1080/14733145.2013.838597.
  105. ^ Arnull, Liam Gary; Kapilashrami, Anuj; Sampson, Margaret (2021-11-30). "Visualizing patterns and gaps in transgender sexual and reproductive health: A bibliometric and content analysis of literature (1990–2020)". International Journal of Transgender Health: 1–16. doi:10.1080/26895269.2021.1997691. ISSN 2689-5269. S2CID 251942433.
  106. ^ Reisner, Sari L; Poteat, Tonia; Keatley, JoAnne; Cabral, Mauro; Mothopeng, Tampose; Dunham, Emilia; Holland, Claire E; Max, Ryan; Baral, Stefan D (2016). "Global health burden and needs of transgender populations: a review". The Lancet. 388 (10042): 412–436. doi:10.1016/S0140-6736(16)00684-X. PMC 7035595. PMID 27323919.
  107. ^ Pillay, Suntosh R; Ntetmen, Joachim M; Nel, Juan A (2022). "Queering global health: an urgent call for LGBT+ affirmative practices". The Lancet Global Health. 10 (4): e574–e578. doi:10.1016/S2214-109X(22)00001-8. PMID 35176236. S2CID 246882513.
  108. ^ a b Wilson, D.; Marais, A.; de Villiers, A.; Addinall, R.; Campbell, M. M. (2014-06-01). "Transgender issues in South Africa, with particular reference to the Groote Schuur Hospital Transgender Unit". South African Medical Journal. 104 (6): 448–449. doi:10.7196/SAMJ.8392. ISSN 0256-9574. PMID 26301294.
  109. ^ a b Gooren, Louis J; Sungkaew, Tanapong; Giltay, Erik J (2013). "Exploration of functional health, mental well-being and cross-sex hormone use in a sample of Thai male-to-female transgendered persons (kathoeys)". Asian Journal of Andrology. 15 (2): 280–285. doi:10.1038/aja.2012.139. PMC 3739151. PMID 23353716.
  110. ^ a b Gooren, Louis J.; Sungkaew, Tanapong; Giltay, Erik J.; Guadamuz, Thomas E. (2015-01-02). "Cross-sex hormone use, functional health and mental well-being among transgender men and Transgender Women (Kathoeys) in Thailand". Culture, Health & Sexuality. 17 (1): 92–103. doi:10.1080/13691058.2014.950982. ISSN 1369-1058. PMC 4227918. PMID 25270637.
  111. ^ "目前已知与性别认同相关的医疗资源列表" [List of currently known medical resources related to gender identity] (in Chinese). Retrieved March 2, 2021.
  112. ^ a b c d Esteva de Antonio, Isabel; Gómez-Gil, Esther (December 2013). "Coordination of healthcare for transsexual persons". Current Opinion in Endocrinology, Diabetes and Obesity. 20 (6): 585–591. doi:10.1097/01.med.0000436182.42966.31. PMID 24468763. S2CID 36430944.
  113. ^ Giraldo, F.; Antonio, I. Esteva de; Miguel, T. Bergero de; Maté, A.; González, C.; Baena, V.; Martín-Morales, A.; Tinoco, I.; Cano, G. (2001-10-01). "Andalusia (Málaga) Gender Team. Surgical experience treating transsexuals in the first and only unit in the Spanish Public Health System". ResearchGate. 27 (4). ISSN 0376-7892.
  114. ^ Esteva de Antonio, Isabel; Gómez-Gil, Esther; Almaraz, M. ª Cruz; Martínez-Tudela, Juana; Bergero, Trinidad; Olveira, Gabriel; Soriguer, Federico (2012-06-01). "Organization of healthcare for transsexual persons in the Spanish national health system". Gaceta Sanitaria. 26 (3): 203–209. doi:10.1016/j.gaceta.2011.10.021. ISSN 0213-9111. PMID 22402241.
  115. ^ "Forced Sterilisation of Trans People". RSFL. 2017-03-25.
  116. ^ Jessica Lundgren (2013-01-10). "Tvångssterilisering vid könskorrigering blir äntligen olagligt". QX.
  117. ^ a b Lundströmmottagningen, Västra Götalandsregionen. (2016-11-28). "Könsdysfori och Utredning".
  118. ^ Transgender Medical That Fits Your Budget: "One of the best decisions I've ever made." (Website), GenderGP Transgender Services, March 16, 2022, retrieved 2 April 2022{{citation}}: CS1 maint: location missing publisher (link)
  119. ^ Ingemar Karlsson Gadea (2016-11-10). "Patient Fees". 1177.
  120. ^ RSFL (2015-11-27). "Trans Health Care". Archived from the original on 2019-02-27. Retrieved 2018-05-29.
  121. ^ "Namn". Skatteverket (in Swedish). Retrieved March 2, 2021.
  122. ^ Richard Ekman and Johannes Kardell (21 November 2016). "Transaktivister har ockuperat Socialstyrelsen". SVT Nyheter. SVT.
  123. ^ "LGBT In Britain – Trans Report" (PDF). Stonewall. Retrieved 5 September 2020.
  124. ^ "Transgender people face NHS waiting list 'hell'". BBC News. 2020-01-09. Retrieved 2022-11-13.
  125. ^ a b c Davies, Andrew; Bouman, Walter Pierre; Richards, Christina; Barrett, James; Ahmad, Sheraz; Baker, Karen; Lenihan, Penny; Lorimer, Stuart; Murjan, Sarah (2013-11-01). "Patient satisfaction with gender identity clinic services in the United Kingdom". Sexual and Relationship Therapy. 28 (4): 400–418. doi:10.1080/14681994.2013.834321. ISSN 1468-1994. S2CID 145216924.
  126. ^ "Scottish Gender Identity Services". Scottish Trans. Retrieved 29 June 2022.
  127. ^ "Annual Report 2020/2021" (PDF). National Gender Identity Clinical Network for Scotland. Retrieved 29 June 2021.
  128. ^ "Supporting NHS gender identity services". Scottish Government. 20 December 2021. Retrieved 29 June 2021.
  129. ^ "Health needs assessment of lesbian, gay, bisexual, transgender and non-binary people" (PDF). Traci Leven Research. Retrieved 29 June 2022.
  130. ^ "Health Care Needs Assessment of Gender Identity Services" (PDF). Scottish Public Health Network. Retrieved 29 June 2022.
  131. ^ "Local access to healthcare for transgender patients lacking, one advocate says". CBS News. January 27, 2016. Retrieved January 3, 2017.
  132. ^ "Canadian Transgender Youth Health Survey". Stigma and Resilience Among Vulnerable Youth Centre. The University of British Columbia. Retrieved January 3, 2017.
  133. ^ Daniel McHardie (June 3, 2016). "New Brunswick will now cover gender-confirming surgeries". CBS News. Retrieved January 3, 2017.
  134. ^ Melissa Fundira (May 3, 2016). "Arson at Montreal clinic concerns trans people awaiting surgery". CBC News. Retrieved January 3, 2017.
  135. ^ "Ontario expands referrals for gender reassignment surgery". CBS News. November 6, 2015. Retrieved January 3, 2017.
  136. ^ "Canada's health care doesn't meet the needs of transgender patients". CBC Radio. January 15, 2016. Retrieved January 3, 2017.
  137. ^ "Publicly Funded Transition-related Medical Care in Canada" (PDF). UFCW Canada. Retrieved January 3, 2017.
  138. ^ "Eligibility criteria for trans individuals". blood.ca. Retrieved 30 June 2017.
  139. ^ "Canadian Blood Services places restrictions on transgender donors". cbc.ca. Retrieved 30 June 2017.
  140. ^ "Canadian Blood Services Annual Report 2018–2019" (PDF). Retrieved 2 February 2021.
  141. ^ a b c Mayela Sánchez (December 18, 2016). "Transgender People in Mexico City Resort to Dangerous Unsupervised Procedures". Global Press Journal. Retrieved January 3, 2017.
  142. ^ "Report on Human Rights Conditions of Transgender Women in Mexico" (PDF). Transgender Law Center. May 2016. Retrieved January 3, 2017.
  143. ^ Pam Belluck (July 26, 2016). "W.H.O. Weighs Dropping Transgender Identity From List of Mental Disorders". The New York Times. Retrieved January 3, 2017.
  144. ^ Bradford, Judith; Reisner, Sari L.; Honnold, Julie A.; Xavier, Jessica (2012-11-15). "Experiences of Transgender-Related Discrimination and Implications for Health: Results From the Virginia Transgender Health Initiative Study". American Journal of Public Health. 103 (10): 1820–1829. doi:10.2105/AJPH.2012.300796. ISSN 0090-0036. PMC 3780721. PMID 23153142.
  145. ^ Varny J. (2016). Rainbow Medicine- Supporting the Needs of Lesbian, gay, bisexual, and trans patients. Journal of Clinical Medicine.
  146. ^ a b c Bianchi, Fernanda T.; Reisen, Carol A.; Zea, Maria Cecilia; Vidal-Ortiz, Salvador; Gonzales, Felisa A.; Betancourt, Fabián; Aguilar, Marcela; Poppen, Paul J. (2014-01-24). "Sex Work Among Men Who Have Sex with Men and Transgender Women in Bogotá". Archives of Sexual Behavior. 43 (8): 1637–1650. doi:10.1007/s10508-014-0260-z. ISSN 0004-0002. PMC 4110190. PMID 24464550.
  147. ^ a b Chen, Diane; Hidalgo, Marco A.; Leibowitz, Scott; Leininger, Jennifer; Simons, Lisa; Finlayson, Courtney; Garofalo, Robert (2016). "Multidisciplinary Care for Gender-Diverse Youth: A Narrative Review and Unique Model of Gender-Affirming Care". Transgender Health. 1 (1): 117–123. doi:10.1089/trgh.2016.0009. PMC 5549539. PMID 28861529.
  148. ^ Taylor, Mark. "An Insight into the Life of a Transgender Child". LinkedIn. Retrieved 28 June 2017.
  149. ^ Wilson, Erin C.; Chen, Yea-Hung; Arayasirikul, Sean; Raymond, H. Fisher; McFarland, Willi (2016-04-26). "The Impact of Discrimination on the Mental Health of Trans*Female Youth and the Protective Effect of Parental Support". AIDS and Behavior. 20 (10): 2203–2211. doi:10.1007/s10461-016-1409-7. ISSN 1090-7165. PMC 5025345. PMID 27115401.
  150. ^ a b c Radix, Anita; Silva, Manel (2014). "Beyond the Guidelines: Challenges, Controversies, and Unanswered Questions". Pediatric Annals. 43 (6): e145–e150. doi:10.3928/00904481-20140522-10. PMID 24972423.
  151. ^ Chew, Denise; Anderson, Jemma; Williams, Katrina; May, Tamara; Pang, Kenneth (2018-04-01). "Hormonal Treatment in Young People With Gender Dysphoria: A Systematic Review". Pediatrics. 141 (4): e20173742. doi:10.1542/peds.2017-3742. PMID 29514975.
  152. ^ "Aging". National Center for Transgender Equality. Retrieved 2019-03-24.
  153. ^ de Vries, Brian; Gutman, Gloria; Humble, Áine; Gahagan, Jacqueline; Chamberland, Line; Aubert, Patrick; Fast, Janet; Mock, Steven (2019-03-14). "End-of-Life Preparations Among LGBT Older Canadian Adults: The Missing Conversations" (PDF). The International Journal of Aging and Human Development. 88 (4): 358–379. doi:10.1177/0091415019836738. ISSN 0091-4150. PMID 30871331. S2CID 78094482.
  154. ^ Reygan, Finn; Henderson, Neil (2019-03-21). "All Bad? Experiences of Aging Among LGBT Elders in South Africa". The International Journal of Aging and Human Development. 88 (4): 405–421. doi:10.1177/0091415019836929. hdl:10566/6338. ISSN 0091-4150. PMID 30897921. S2CID 85446146.