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Intro to Transgendered Health Issues

"Five years ago, while battling an undiagnosed case of bacterial endocarditis, I was refused care at a Jersey City emergency room. After the physician who examined me discovered that I am female-bodied, he ordered me out of the emergency room despite the fact that my temperature was above 104° F (40° C). He said I had a fever "because you are a very troubled person."

Weeks later I was hospitalized with the same illness in New York City in a Catholic hospital where management insists patients be put in wards on the basis of birth sex. They place transsexual women who have completed sex reassignment surgery in male wards. Putting me in a female ward created a furor. I awoke in the night to find staff standing around my bed ridiculing my body and referring to me as a "Martian." The next day the staff refused to work unless "it" was removed from the floor. These and other experiences of hatred forced me to leave.

Had I died from this illness, the real pathogen would have been bigotry."[1]

Transgendered individuals include transsexuals, cross-dressers, biologically intersexed, or those who otherwise challenge strict gender norms. Standard definitions of sexual orientation that relate to absolute and exclusive gender identities do not necessarily make sense for transgendered individuals who have a more fluid and evolving concept of sex and gender. Transgendered people may have any combination of natal sex, gender identity and sexual orientation[2].

Gender dysphoria is a state of emotional distress associated with an awareness of incongruity between one’s biological sex and gender identity. Often, as a person gets older, the sense of incongruity between natal sex and gender identity increases and causes increasing gender dysphoria and depression. The American Psychiatric Association’s DSMIV contains a diagnosis for Gender Identity Disorder that is applied to individuals with clinically significant distress or functional impairment due to their gender dysphoria. This diagnosis being a part of the DSMIV stigmatizes transgendered individuals as mentally ill and pathologizes their gender identity[2].

Transgendered individuals are even more of a minority than the lesbian, gay and bisexual population. There is little data available, but transgendered people may be at an increased risk for depression, suicide, substance abuse and antigay violence. Many transgendered individuals are either un- or under-employed due to discrimination. In a study of 47 HIV positive men in Vancouver, all of the transsexual men worked in the sex trade industry, which has serious health implications[3]. The rate of HIV infection in transsexual women is high and may even exceed rates in gay and bisexual men[2] [4] [3] [5].

Transgendered individuals face numerous barriers to obtaining health care. Fear of discrimination, insensitivity of providers, for example, by using the pronoun "he" for transsexual women, and financial reasons all may prevent transgendered individuals from accessing health care[2] [5]. In Ontario, sex reassignment surgery is not a service covered by OHIP[6].

Transgendered individuals may experience shame and anxiety over their bodies and, when seen clinically, should not be asked to disrobe unless absolutely necessary. Another important point to remember is that the stereotypical maleness or femaleness of a person’s body is not an indication of the gender dysphoria suffered by the individual[2] [5].

In the United Kingdom, the sex on your birth certificate is your sex for life, even if you undergo sex reassignment surgery[7].

Transsexuals live as the opposite sex and will seek to change their outward appearance to correspond with their inner identity through the use of hormones and possibly sex reassignment surgery[8]. There are several treatment protocols for hormonal and surgical therapy for transsexual individuals[9] [10]. The global standards of care are the Harry Benjamin International Gender Dysphoria Association’s standards, however, they are regarded by some in the transsexual community as being restrictive[2] [5]. The Health Law Standards of Care[9] for transsexuals were developed by transgendered activists and lawyers. One of the guiding principles of the Standards is that transsexualism itself is not a mental disorder or a medical illness, and the emphasis is on accessibility and patient control over decision-making[2]. In their book, Transgender Care, Isreal and Tarver[11], present in-depth guidelines and recommendations for consumer preparedness for hormonal therapy, aesthetic surgery and gonadal reassignment surgery as well as a commentary on the guidelines.

Despite the fact that side effects may occur, the vast majority of transsexuals will transition without suffering any serious side effects[8]. Hormonal therapy also causes physical and psychological changes that make the patient feel more like their gender identity, limit the psychiatric morbidity and increases the patients’ quality of life[2]. In contrast, refusing to administer hormone therapy to a patient is a risk factor for self-treatment with illegally obtained hormones and sharing needles for hormone treatment[2].

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1. Feinberg L. Trans health crisis: for us it's life or death. American Journal of Public Health. 2001;91(6):897-900.

2. Kaiser Permanente National Diversity Council. A Provider's Handbook on Culturally Competent Care: Lesbian, Gay, Bisexual and Transgendered Population. Oakland, CA. Kaiser Permanente; 2000.

3. Schilder AJ, Kennedy C, Goldstone IL, Ogden RD, Hogg RS, O'Shaughnessy MV. "Being dealth with as a whole person." Care seeking and adherence: the benefits of culturally competent care. Social Science & Medicine. 2001;52:1643-1659.

4. Lee R. Health care problems of lesbian, gay, bisexual, and transgender patients. Western Journal of Medicine. 2000;172:403-408.

5. Lombardi E. Enhancing transgender health care. American Journal of Public Health. 2001;91(6):869-872.

6. Government of Ontario. Schedule of Benefits: Physician Services Under the Health Insurance Act. Section 24 of Regulation 552 of Revised Regulations of Ontario, 1990. Amended September 1, 2003. http://www.health.gov.on.ca/english/providers/program/ohip/sob/physserv/physserv_mn.html. Accessed on December 23, 2003.

7. Woodward K, Editor. Questioning Identity: Gender, Class, Nation. New York, NY. Routledge; 2000.

8. Oriel KA. Medical care of transsexual patients. Journal of the Gay and Lesbian Medical Association. 2000;4(4):185-194.

9. Health Law Project. Health Law Standards of Care for Transsexualism. 2nd International Conference on Transgender Law and Employment Policy, August 1993. 1996. Alternative Sexuality Resources. Accessed October 17, 2003 at http://www.altsex.org/transgender/healthlaw.html#soc.

10. Harry Benjamin International Gender Dysphoria Association. The Standards of Care for Gender Identity Disorders, Version 6. 2001. http://www.hbigda.org/soc.html. Accessed January 18, 2004.

11. Isreal GE, Tarver DE. Transgender Care: Recommended Guidelines, Practical Information, and Personal Accounts. Philedelphia, PA. Temple University Press; 1997.

All references for this section