Ensuring an inclusive global health agenda for transgender people

There is a growing commitment in public health to understand and improve the health and well-being of transgender people and other gender minorities, who comprise an estimated 0.3-0.5% (25 million) of the global population. (1) The adoption of The 2030 agenda for sustainable development and its pledge to "leave no one behind" has given renewed impetus to this movement. (2) Transgender is an umbrella term used to describe people with a wide range of gender identities, which are different from the sex assigned at birth. The term is increasing in familiarity globally, although other culturally-specific terms may be used to describe people who have non-gender binary identities, such as hijra (India), waria (Indonesia), muxe (Mexico), fa'afafine (Samoa), kathoey (Thailand) and Two-Spirit (indigenous North Americans). Many cultures and countries--including Australia, Bangladesh, Germany, India, Ireland, Nepal and Pakistan--recognize a third gender both in laws and in cultural traditions. Transgender people share many of the same health needs as the general population, but may have other specialist health-care needs, such as gender-affirming hormone therapy and surgery. However, evidence suggests that transgender people often experience a disproportionately high burden of disease, including in the domains of mental, sexual and reproductive health. Exposure to violence, victimization, stigma and discrimination are also higher in this population. In addition, they experience barriers to accessing health care and health-determining resources, such as education, employment and housing. (3) These barriers are largely attributable to legal, economic and social deprivation, marginalization, stigmatization and discrimination, including non-recognition of a gender identity that is different from the sex assigned at birth. Recent debates have highlighted three challenges to the health and well-being of transgender populations. First, there are gaps in documenting evidence on the determinants and status of transgender people's health. Second, transgender-specific health care and preferences must be better understood and barriers to access, including social and legal drivers of ill-health, tackled. Third, the underlying social exclusion mechanisms that undermine the right to health in health settings and broader society must be addressed. Although the political debate on transgender people continues to be highly polarized, three major shifts are underway at the World Health Organization (WHO) that should contribute to tackling these challenges. These shifts are the proposed changes to relevant sections of the 11th edition of the International statistical classification of diseases and related health problems (ICD-11); the adoption of a person-centred approach to transgender people's health; and a shift towards an equity- and rights-based approach to the health of transgender people. The first shift is the proposed revision of the ICD. Countries use the ICD to define eligibility and access to health services and as a basis for conceptualizing health conditions, treatments and outcomes. Health officials also use the ICD to facilitate the collection of data that guides policy and programme decisions. Under current proposals to the ICD-11 working group, transgender identities would no longer be classified as "Transsexualism" under the category of "Mental health and disorders" but would be classified as "Gender incongruence of adolescence and adulthood" under the category of "Conditions related to sexual health". The proposed reclassification is expected to reduce the perception of illness and stigmatization of transgender people, and to lead the way for improvements in such course that transgender health can be understood, measured and addressed. The reclassification is also likely to positively affect how gender identity is viewed by society more broadly. (4) Concerns have been expressed about the focus on sexual health in the new proposal and there have been calls for the total removal of gender identity from the ICD-11. …