Why is transgenders’ health a human rights issue?
Transgenders are individuals who may not identify with, or behave, per the sex assigned at birth. Their biological characteristics (i.e. anatomy, genetics and hormonal composition), which comprise determinants of sex, may differ from how they choose to express themselves, and how they are traditionally perceived in society (i.e., gender identity and roles). This could result in lack of understanding and sensitivity within the health-care system, and exposes many transgenders to abuse, stigmatization and exclusion from support and treatment.[1,2] Meanwhile, many transgenders require personalized health care additional to health requirements shared with the general population.
What are the relevant global sources?
At present, there are no human rights treaties that specifically recognize the health rights of transgenders. However, experts from 25 countries unanimously adopted the Yogyakarta Principles on the Application of International Human Rights Law in relation to Sexual Orientation and Gender Identity. These include clear recommendations for international organizations, national governments, non-state actors and the media on promoting the rights of transgenders by eliminating stereotypes, improving policies and providing technical and financial support to organisations committed to this cause.[3]
What are relevant issues related to transgenders’ health?
- Lack of awareness. There is little awareness on transgender health in present day society, even though historical references to transgenders exist amongst cultures worldwide, including the Americas, Europe, Asia and Africa. Fear of stigmatization or social exclusion prevent transgenders from publicly revealing or discussing their gender identities. Other factors, such as insufficient/derogatory media coverage and no legal protection also contribute towards lack of awareness on transgender health needs.[4] Terminology and sub-categories well recognized within the transgender and related communities may be uncommon for health staff, which could drive misunderstanding and intentional or unintentional discrimination towards transgenders.
- Specialized health-care needs. Transgenders may have specialized health-care needs that differ from other groups. Examples include:[4]
– Safe, quality assured and consensual gender re-affirming surgery or hormone therapy.
– Specific medical examinations that may not relate to the gender identity or biological characteristics of the transgender; for example, prostate cancer screening for individuals with male anatomy, self-identifying as female.
– Guidance on reproductive health and related decisions.
– Protection against sexually transmitted diseases including HIV (i.e., diagnosis, treatment & prevention strategies).
– Protection against HIV-status related discrimination.
– Psychosocial support for depression, anxiety disorders and suicidal ideation.
– Protection from coerced surgical or hormonal intervention for gender affirming purposes.
Access to treatment. Basic or specialized health care may not be available or affordable for transgenders. This could result from geographical limitations, discriminatory practices or lack of insurance coverage on services such as surgery or hormonal therapy. For example, health-care providers may withhold treatment by not recognizing transgenders’ rights or wishes.
Gender reaffirming surgery or hormonal treatment may not be considered medically justified.[4] In the absence of gender reaffirmation surgery, transgenders could resort to self-mutilation, as recorded in some countries.[5] A health-care system that fails to meet transgender requirements increases the risk that services are obtained illegally, and may not be subject to formal quality control.
How can this situation be improved?
International organisations are encouraged to include transgender priorities in policy dialogue, global standards and health-care programmes. The United Nations Sustainable Development Goals (SDGs) emphasize “individuals furthest behind” from developmental progress, or restricted from health care or medicines due to discrimination or exclusion, which take transgenders into consideration.[6]
The World Health Organization (WHO) is committed to enable transgenders and other gender minorities to realise their right to health. On-going transgender related initiatives include: extending evidence on health-care status, needs and preferences, promoting health rights and equitable quality and coverage of services by eliminating barriers to health (i.e., social exclusion, inadequate legal protection).[7] The WHO has developed tailored guidance, monitoring and programme implementation tools for policy makers and health practitioners. Guidance extends towards sexual health and HIV prevention, diagnostics, treatment and care and addressing general health-care needs (i.e., accessibility of quality health information for transgenders).[7]
Attempting to improve societal perceptions of transgenders and reduce discrimination, the 11th International Statistical Classification of Diseases and related health problems (ICD-11) will be revised to reclassify gender identity disorders as “gender incongruence”; a more neutral classification compared to “mental and behavioral disorders”.[5,7]
Legal recognition and political commitment by constitutionally acknowledging non-binary (male/female) gender identities helps secure social status and inclusion for transgenders in health systems. For example, the governments of several countries including Argentina, Australia, Bangladesh, India, Nepal, New Zealand, Pakistan, Portugal and Thailand have some legal provisions for transgender rights.[5]
Implementing best practices for informed consent for transgenders supports autonomous decision making and could prevent medical abuse such as involuntary sterilization.
Incorporating transgender health in medical curricula helps inform upcoming and existing health-care professionals about specialized care needs. For example, multiple provinces in Canada now offer transgender-related sex and medical education.[5] And South African and United States based universities have systematically evaluated medical education curricula to identify and document gaps related to transgender health and rights.[8,9]
Enabling consensual gender-reaffirmation surgery through legal and financial provisions – It is possible to modify one’s gender identity and name without judicial approval or surgery in Argentina since 2012.[5] The socialized health-care system also offers transitionary medical treatment (including surgery) free of cost.[10] Gender-reaffirmation surgery is free in India as of 2009. However, access remains a challenge.[5]
What can health workers do?
Individual health professionals and their professional organizations can support transgender people in realising their right to health by respecting their autonomy, delivering specialized services and eliminating systemic bias.
Practical tips to consider when interacting with transgender patients include:
- Assuring confidentiality during treatment and gender related discussions.
- Creating a safe environment for transgender patients to express themselves.
- Treating transgender patients with the utmost respect and sensitivity.
- Politely clarifying gender identity related matters if these are not clear.
- Developing and implementing checklists/guidance documents tailored to transgender health issues during treatment and follow-up sessions.
- Ensuring that transgender patients make informed health-care decisions by providing adequate information and support.
- Protecting transgender people from coercive gender reaffirming medical interventions.
- Recognising that transgender patients may need psychosocial counselling in relation to other medical interventions.
- Advocating in favour of specialised care for transgender patients.
- Engaging with the wider medical community to share best practices related to transgender care.
Deconstructing the determinants of health status for transgender people, and helping them attain the highest standards of health promises improved outcomes, well-being and productivity for those particularly vulnerable to systemic discrimination and exclusion.
This page was written by Gauri Deoras in February 2018.
References
[1] Human Rights Campaign (HRC)
[2] Office of the High Commissioner for Human Rights (2011). Discriminatory laws and practices and acts of violence against individuals based on their sexual orientation and gender identity, A/HRC/19/41.
[3] Yogyakarta Principles (YP+10) (2017). Additional principles and state obligations on the application of human rights law in relation to sexual orientation, gender identity, gender expression, and sex characteristics to complement the Yogyakarta Principles.
[4] United Nations Development Program (UNDP) (2013). Discussion Paper: Transgenders, Health and Human Rights.
[5] World Health Organization (WHO). Growing Recognition of Transgender Health
[6] United Nations (UN) (2015). Transforming Our World: The 2030 Agenda for Sustainable Development.
[7] Thomas, R., Pega, F., Khosla, R. et al. Ensuring an inclusive global health agenda for transgender people. Bulletin of the World Health Organization 2017;95:154-156.
[8] Online.liebertpub.com. (2018). Assessing Residency Program Approaches to the Transgender Health CREOG Objective.
[9] Müller, A. (2013). Teaching lesbian, gay, bisexual and transgender health in a South African health sciences faculty: Addressing the gap. BMC Medical Education, 13(1).
[10] Transgender Europe (2013). Argentina Gender Identity Law.