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Growing recognition of health Stigma, discrimination and lack of legal recognition remain major barriers for transgender people to access the health services they need. Vijay Shankar Balakrishnan reports.

Olga Aaron was registered male at birth, from the they were assigned at birth,” “Transgender women may also be sub- but always felt that she was a . says Annette Verster, a technical officer in ject to punitive laws and discriminatory Following a mental health assessment the HIV Department at the World Health policies affecting men who have sex and with the support of her family, at Organization (WHO) in Geneva. with men.” 18 years Aaron underwent surgery and A person’s identity is their WHO’s Member States have com- hormone therapy (and a name change) own sense of whether they are male or mitted themselves to providing univer- to become a woman. , or neither. Some transgender sal coverage of health services in their Two decades later, Aaron is cam- people identify themselves with their efforts to achieve the sustainable devel- paigning for the social acceptance and changed gender: from male to female or opment goals by 2030. “Reaching mar- recognition of transgender women, like female to male. Others see themselves as ginalized groups, such as transgender herself, and to raise awareness about members of a third sex. people, will be essential,” Verster says. their specific health issues in India. Transgender people are one of five “Transgender women are margin- groups that are disproportionately af- alized and denied basic human rights,” Transgender fected by HIV globally, according to says Aaron, who lives in the city of WHO’s Guidelines on HIV prevention, women are Chennai. “ diagnosis, treatment and care for key “I was lucky to have an understand- marginalized and populations released in 2014. The oth- ing family who supported me while I denied basic human ers are: people who inject drugs, men studied at university,” says Aaron, who rights. who have sex with men, sex workers managed to obtain a bachelor’s degree in Olga Aaron and prisoners. English literature and a master’s degree ” “These groups are defined as key in public administration from Madras populations for the HIV response be- University by distance learning. In Thailand transgender people are cause they are at increased risk of HIV Aaron is one of an estimated 25 mil- known as , in Indonesia waria, infection. In addition, they are often lion people, or 0.3 to 0.5% of the global in Mexico muxe and in Bangladesh and marginalized, stigmatized and criminal- population, who are transgender. This Pakistan , (in India the term refers ized which affects their ability to access first global estimate of their numbers to transgender women). health services, including HIV preven- was published in a study in the Lancet “Identity documents that do not tion, testing and treatment,” Verster says. in June. match a person’s gender can hinder “It is estimated that in low- and “Transgender is an umbrella term for access to health services, social protec- middle-income countries transgender people whose is different tion and employment,” Verster says. women are around 49 times more likely to be living with HIV than other adults of reproductive age,” says Verster, citing a 2013 study published in The Lancet infectious diseases – the first to estimate the HIV burden among transgender women outside the United States of America (USA). The authors found that data on HIV prevalence in transgender women were only available for 15 countries and, of those, India had the highest prevalence with 43.7% of the 135 study participants living with HIV. Transgender people in India are considered to be of low status according to Hindu mythology. “Many transgender women are rejected by their families in India. Even if they have an education, they struggle to find employment and often end up as sex workers and beg- gars,” Aaron says. Courtesy of Olga Aaron Following the WHO key popula- tions guideline released in 2014, WHO Olga Aaron providing education and raising awareness about transgender issues in India published a technical brief with its

790 Bull World Health Organ 2016;94:790–791 | doi: http://dx.doi.org/10.2471/BLT.16.021116 News

partners, in 2015 entitled HIV and young Indeed, this is what Reisner and in 2009, although this is still not acces- transgender people on how best to pro- his fellow researchers discovered when sible everywhere in the vast country of vide health services, programmes and they reviewed the scientific literature 1.2 billion people. support for young transgender people. on transgender people’s health over the In Argentina, a 2012 law – the first of In the same year a WHO Policy Brief last five years. its kind according to Reisner – allows trans- on Transgender people and HIV was In their findings published in a gender people to change their legal gender published summarizing relevant WHO Lancet series on the subject in June, identity from male to female or vice versa recommendations. Reisner and his colleagues found that through a simple administrative process. In addition, WHO and its partners most health research divides the hu- In Canada, gender affirmation sur- developed a guide on how to use the population into male and female, gery and treatment are covered by the technical guidance, entitled Implement- although recently studies started to publicly-funded health insurance system ing comprehensive HIV and STI pro- include a third category for transgender and some universities are integrating grammes with transgender people, which people. transgender health into the medical was published this year by the United Most of the health data they found curricula. Nations Development Programme. on transgender people were on HIV “There is a broader acceptance and a While preparing the WHO guid- infection, mental health, sexual and re- desire on the part of health-care provid- ance, Verster and her colleagues did productive health, substance use disor- ers to learn about , , bisexual, a qualitative survey with transgender ders, violence and victimization, and on transgender and (LGBTQ) health people from around the world. the effects of stigma and discrimination issues,” says Dr Ed Kucharski, who is re- “We found that transgender people such as mental health issues. sponsible for incorporating these issues tend to have health priorities other than into the curriculum at the University of HIV,” Verster says, adding: “Unless health Toronto. services are designed in accordance with “Few textbooks include LGBTQ the needs of transgender people and in con- Unless health health issues, so we use materials from sultation with them, it may be difficult to services“ are designed LGBTQ community centres and from reach them with HIV prevention and care.” in accordance the web,” says Kucharski. Not all transgender people seek with the needs of The university is developing tradi- gender affirming treatment. For those transgender people tional and online content that medical who do, hormone therapy is the main and in consultation students can use to learn how to care medical intervention to acquire sex appropriately for transgender patients. characteristics aligned with the indi- with them, it may be Kucharski explains: “In the next year or vidual’s gender identity, according to difficult to reach them so we will be developing a virtual patient the Center of Excellence for Transgender with HIV prevention that students can interact with.” Health at the University of California in and care. Another key development in gain- San Francisco. Annette Verster ing wider recognition for transgender Transgender people may seek a ” health issues is the revision of the range of gender affirming surgeries, International statistical classification including procedures that are also per- The data revealed major health in- of diseases and related health problems formed in non-transgender populations. equities between transgender people and (ICD), the standard diagnostic reference “Not everyone who wants gender many other members of society and that book for epidemiology, health manage- affirming surgery in India can access it. transgender people were often unable ment and clinical practice. Some transgender people remove their to access the health services they need In the original version of the current genitals by self-mutilation, others go to because of their social and economic edition, ICD-10, “gender identity disor- ‘quacks’,” says Aaron, who campaigns marginalization. ders” were classified under “mental and to raise awareness about transgender Reisner and his colleagues proposed behavioural disorders”. But in the next issues in India. four ways forward: count the transgen- edition, ICD–11, which was released “HIV is not the only health issue that der population globally; address stigma for Member State comments last month transgender people face,” says Aaron, and other issues that make transgender and is due to be published in 2018, adding that they face mental health issues people vulnerable to health risks; recog- transgender health issues appear in a including depression, mood and anxiety nize their human and legal rights so that new category of “gender incongruence”. disorders and suicidal ideation. Studies they can be covered by health services; For Reisner this classification shift from the Islamic Republic of Iran and and do health research with transgender reflects the struggle for transgender Nepal highlight the prevalence of mental people rather than on them. health issues to find their place. “There health issues in transgender people. Several countries – including Ar- are many opinions from many sides on Dr Sari Reisner, an epidemiologist gentina, Australia, Bangladesh, India, this,” Reisner says, welcoming the shift: at the Boston Children’s Hospital in the Nepal, New Zealand, Pakistan, Portugal “I don’t think transgender issues need to USA and a transgender man himself, and Thailand – have legislation recog- be seen as a mental disorder.” ■ agrees that there are many health issues nizing the rights of transgender people that transgender people face other than in some way. HIV infection, but that there is very little In India, the government started research on these other health issues. offering free gender affirming surgery

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