Elsevier

The Lancet

Volume 388, Issue 10042, 23–29 July 2016, Pages 412-436
The Lancet

Series
Global health burden and needs of transgender populations: a review

https://doi.org/10.1016/S0140-6736(16)00684-XGet rights and content

Summary

Transgender people are a diverse population affected by a range of negative health indicators across high-income, middle-income, and low-income settings. Studies consistently document a high prevalence of adverse health outcomes in this population, including HIV and other sexually transmitted infections, mental health distress, and substance use and abuse. However, many other health areas remain understudied, population-based representative samples and longitudinal studies are few, and routine surveillance efforts for transgender population health are scarce. The absence of survey items with which to identify transgender respondents in general surveys often restricts the availability of data with which to estimate the magnitude of health inequities and characterise the population-level health of transgender people globally. Despite the limitations, there are sufficient data highlighting the unique biological, behavioural, social, and structural contextual factors surrounding health risks and resiliencies for transgender people. To mitigate these risks and foster resilience, a comprehensive approach is needed that includes gender affirmation as a public health framework, improved health systems and access to health care informed by high quality data, and effective partnerships with local transgender communities to ensure responsiveness of and cultural specificity in programming. Consideration of transgender health underscores the need to explicitly consider sex and gender pathways in epidemiological research and public health surveillance more broadly.

Introduction

Transgender people are those whose assigned sex at birth differs from their current gender identity or expression, and they represent a diverse population across regions and within countries worldwide (panel 1).1, 2 Although accurate data about the size of the transgender population globally are absent and numbers depend on the definition of transgender used, estimates suggest a prevalence of 0·3–0·5% for people who identify as transgender3 (see also paper 1 of this Series4). Despite their small numbers, transgender people are a population burdened by substantial adverse health indicators across high-income, middle-income, and low-income settings.5, 6 Health inequities for transgender people are hypothesised to be multifactorial, with risks including systematic social and economic marginalisation, pathologisation, stigma, discrimination, and violence, including in health-care systems and settings.7 The purpose of the data synthesis we present here is to characterise the global health burden facing transgender populations, including the specific contexts and multiple determinants of health affecting them. We reviewed data from the peer-reviewed scientific literature to characterise the burden and distribution of disease in transgender populations globally. This synthesis of information describes transgender population health and leverages data from different regions of the world to highlight the unique sex and gender-related biological, behavioural, social, legal, and structural factors surrounding health risks and resiliencies for this underserved population. We further seek to inform future advocacy, funding, health surveillance, public health policy, monitoring, reporting processes, and research initiatives not only to address and improve health, but also to promote health equity, social justice, and human rights, including the right of all people to self-determination.

Section snippets

Search, selection criteria, and data synthesis

We undertook a review and synthesis of peer-reviewed recent literature (2008–14) about transgender health. We searched for “transgender” and associated terms (eg, hijra, waria, travesti, trans masculine, MTF) alongside health terms (eg, HIV, disease, illness, mental health), related concepts (eg, wellbeing), and social factors (eg, discrimination, stigma). Search databases included PubMed, Embase, OVID, PsycINFO, Web of Science, and ProQuest. The appendix includes a full list of search terms

Overall research trends

We identified 116 studies in 30 countries. Table 1 presents the health outcome studies and key data extracted from each study by region, country, and author. Table 2 presents health-related data on stigma, discrimination, violence and victimisation, and sex work. Figure 1 shows the geographic distribution of current studies in transgender health. Most of the available research was from the USA. Several countries had a single study (eg, Mexico) or between two and five studies (eg, Canada,

Distribution of studies by sex and gender

The distribution of studies by natal sex (sex assigned at birth) is depicted in figure 3. The majority of studies focused on natal males. Because operationalisation of “transgender” was inconsistent, generalisation of scientific findings by gender identity was difficult. Specifically, we found 95 distinct operationalisations of “transgender” across the 116 studies. These can be summarised into two approaches to measuring transgender populations: by identity-based measures (ie, identify as

Current gaps and opportunities

For transgender people, health inequities are hypothesised to arise from systematic exposure to multiple, intersecting social stressors, including legal and other structural factors that are a result of being part of a socially marginalised group.140 Social and economic exclusion are therefore conceptualised as causal pathways to adverse health—however, we found very few studies actually linking these social stressors to health indicators. Furthermore, study designs were largely

The way forward: recommendations

We now offer recommendations based on our research synthesis to guide future health research focused on transgender populations.

Conclusions

The global disease and health burden of transgender people remain understudied, particularly in relation to the effects of stigma, discrimination, social, and structural factors that affect the health of this underserved population.48 Unavailability of standardised survey items to identify transgender respondents limits existing health surveillance efforts. Lack of consistent operationalisation of transgender status across studies limits generalisability of findings. Use of a two-step approach

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