This document discusses enhancing health care for transgender individuals. It begins by outlining some of the health issues transgender people face, such as discrimination, lack of access to care, and high HIV rates. It then discusses challenges to care like insensitivity from providers and lack of coverage for transition-related needs. Finally, it proposes strategies to improve care, such as acknowledging transgender identities, advocating for research and innovation, and limiting unnecessary surgeries on intersex infants. The overall goal is to make health care more culturally sensitive and address the actual needs of transgender communities.

1. Enhancing Transgender Health Care
A B S T R A C T Emilia Lombardi, PhD
As awareness of transgender men Transgender health issues are beginning the sake of uniformity within this commen-
and women grows among health care to come to the attention of many health prac- tary, however, the label transgender is used
educators, researchers, policymakers, titioners and researchers. In fact, the desire in a global sense, encompassing transvestites,
and clinicians of all types, the need to to improve the treatment experienced by transsexuals, and self-identified transgender
create more inclusive settings also transgender individuals led the American individuals.
grows. Public Health Association to pass a resolu- Generally, people can be categorized
Greater sensitivity and relevant in- tion on transgender health issues during its across 4 characteristics: biological sex, legal–
formation and services are required in 1999 annual meeting.1 Acknowledging health institutional sex, social gender, and psycho-
dealing with transgender men and care discrepancies is only a start, however. To logic gender. Biological sex is usually deter-
women. These individuals need their provide much-needed services to this popu- mined by people’s genitals but can encom-
identities to be recognized as authentic, lation, researchers, educators, and health care pass other factors such as chromosomes,
they need better access to health care professionals of all types need concrete, com- hormonal makeup, secondary sex character-
resources, and they need education and prehensible information about transgender istics, and other physiologic variations. Fur-
prevention material appropriate to their individuals. thermore, there are intersexed conditions that
experience. Gender variations have been documented can create problems in regard to categorizing
In addition, a need exists for ac- for many years. Generally, female-to-male infants as male or female (e.g., children born
tivities designed to enhance under- gender transgression has been described as with ambiguous genitalia, androgen sensitiv-
standing of transgender health issues resulting from the inequality found between ity syndrome). These children may undergo
and to spur innovation. (Am J Public women and men and women’s desire for sta- surgical intervention so that their genitals
Health. 2001;91:869–872) tus and resources, whereas male-to-female more clearly resemble those found on tradi-
transgression has been explained as resulting tionally male or female children.
from the need to express an inner desire or Legal–institutional sex refers to people’s
has been eroticized.2 More recent explana- designation on identification, forms, and even
tions have been based on the medical model. questionnaires. There may be ways for people
The term transvestite was used early in to change their legal–institutional sex; fre-
the 20th century to describe people (prima- quently this requires some sort of professional
rily men) who dress in women’s clothing for intervention (i.e., needing to submit a letter
their own interests (usually erotic).3 Later, from one’s surgeon to change one’s birth cer-
transsexualism (listed as gender identity dis- tificate). However, different areas of the coun-
order in the fourth edition of the American try (and across the world) have different reg-
Psychiatric Association’s Diagnostic and Sta- ulations allowing for such changes.
tistical Manual of Mental Disorders4) was Social gender refers to how people pre-
used to describe a population of individuals sent themselves in public: the clothing they
whose feelings concerning their gender in- wear, their hairstyle, their physical character-
volved more than a desire to dress in a par- istics, even how they act and talk. Different
ticular set of clothes and a stronger identifi- cultures have different ways of explaining and
cation with gender values contrary to societal dealing with gender variance; some Native
expectations.5 American cultures refer to two-spirit people
Transgender was originally used to dif- (aspects of both genders), and Hindu cultures
ferentiate those who seek medical intervention include hidras (neither man nor woman). So-
in changing their gender from those who do cial gender can also be influenced by med-
not; however, this term later changed to en- ical interventions used to change aspects of
compass a range of possible identities and be- people’s appearance. Many people go to great
haviors, including transvestitism and trans- lengths to change aspects of their appearance
sexualism (the way in which transgender (some of which is necessary to change their
evolved in usage has not been examined fully). legal sex). In addition, individuals may be
Currently, transgender, transvestite, and trans- consistent or inconsistent in their gender pre-
sexual are at times used interchangeably to sentation. People may have an inconsistent
describe individuals whose identities and so- social gender because one aspect of their gen-
cial lives are very similar. It is likely, how- der is used for performances, fun, or even sex-
ever, that many people will not fit into tradi- ual behavior.
tional conceptions of transvestite, transsexual,
or transgender. The author is with the Drug Abuse Research Cen-
The use of terminology has not been con- ter, University of California, Los Angeles.
sistent across time and among writers. The Requests for reprints should be sent to Emilia
Lombardi, PhD, UCLA–DARC, 11075 Santa Mon-
meaning of such terms varies among indi-
ica Blvd, Suite 200, Los Angeles, CA 90025 (e-mail:
viduals as well, and as a result there is little un- redemmie@earthlink.net).
derstanding of what people mean when they This commentary was accepted February 14,
say they are transgender or transsexual. For 2001.
June 2001, Vol. 91, No. 6 American Journal of Public Health 869

2. Psychologic gender refers to a person’s during the injection of hormones or drugs is are regarded as authoritative by providers but
self-indentification as a man or a woman. How- also a risk factor.8–11 These individuals may be as restrictive by many clients.21,22 In addition,
ever, these may not be the only options. Again, difficult to target through traditional preven- these guidelines have given rise to small
different cultures may allow for other alterna- tion campaigns, and they may fear discrimi- groups of “experts” within specific areas
tives in the way people identify themselves. In nation should they seek services such as HIV/ whose services are sought by all transgender
addition, individuals may create alternative AIDS education and testing.13,14 Insensitivity persons wishing to medically change their
identities. Some people who are part of a of health care professionals has been cited as gender; those living in isolated areas may not
“queer” or “alternative” subculture may use a reason that these and other services are not have ready access to such “experts” and may
identities other than simply man or woman.6 accessed.15 Indeed, reports of insensitive be- have to find other ways to go about their tran-
The preceding is only a short summary havior among health care providers (e.g., re- sition. Current constraints on access to med-
of the factors that can be used to describe sex ferring to transgender women as “he” and ical care related to gender changes may place
and gender and to understand the ways in “him” and not acknowledging or respecting people at risk by forcing them to seek unsafe
which they can vary. There are many other their identity) suggest that services are se- methods of making these changes (e.g., using
factors that can influence people, some of verely lacking in terms of provision of cul- hormones bought off the street, sharing nee-
which have already been mentioned. Race, turally sensitive interventions and, potentially, dles while injecting hormones).
ethnicity, or culture can influence how people provision of HIV-related health care.13,14 The constraints for transgender youths
identify themselves and the social roles that Health care service providers have found are even greater; often, such youths are de-
they desire or have access to. Similarly, a per- that helping transgender individuals obtain the nied the ability to change their social gender
son’s area of residence can involve variations services they need (e.g., substance use treat- in any way within institutional settings, which
in how sex is institutionalized and how legal ment, housing, health care) is difficult because may force them back into situations that can
sex can be changed. other service providers may not want to work place them at great risk. There is some support
Finally, the resources available to peo- with transgender clients.15 Furthermore, lack for allowing transgender youths to begin the
ple can influence their ability to pay for med- of sensitivity on the part of health care pro- process of changing their gender; many do so
ical interventions in addition to other strate- viders who do not respect the expressed gen- without trouble.21,23
gies used to change their social gender or legal der identity of transgender persons can ad-
sex (or both). It is not enough to know the versely influence whether these individuals
definitions of labels (e.g., What is a cross- will access and stay in treatment.14,16,17 Cultural Relevancy
dresser? What is a transsexual?); it is more Transgender persons may be resistant to
important to know that aspects of a person’s seeking help because other transgender indi- Finally, health-related research, policies,
gender and physical form can vary widely and viduals have reported past discriminatory treat- and materials do not (except for rare excep-
be influenced by different factors. Health care ment on the part of service providers. Focus tions at the expense of local agencies) men-
educators, researchers, policymakers, and cli- group research conducted in San Francisco tion or deal with the actual lives of transgen-
nicians need to know that transgender indi- and Minneapolis has shown evidence of dis- der persons.13,14,21 Simply adding transgender
viduals can vary widely but that, in general, crimination against transgender men and materials to existing materials is not enough,
all are still at risk for problems in accessing women within HIV/AIDS programs.13,14 Many nor is using materials or programs originally
and receiving health care. programs are not sensitive to the needs of created for other populations. Research, poli-
transgender individuals.13,14 Furthermore, stud- cies, and materials need to be culturally rele-
ies have shown that doctors have somewhat vant and specific. The differences in identities,
Health Care Issues negative opinions of transsexual women.18,19 experiences, and physical form among trans-
Overall, individuals who do not conform to gender individuals relative to nontransgender
Transgender individuals are likely to ex- traditional conceptions of sex and gender are populations create very different needs and
perience some form of discrimination or vi- likely to be at risk for many health-related strategies, and efforts must be directed toward
olence sometime in their lives. A study of problems, including, unfortunately, discrimi- the actual experiences of transgender people.
transgender individuals within the United nation within the treatment setting. An example of a culturally relevant educa-
States showed that approximately 60% had tional tool with regard to prevention of HIV
experienced some form of harassment or vi- and other sexually transmitted diseases among
olence and that 37% had experienced some Access to Care transgender women is shown in Figure 1.
form of economic discrimination.7 In addi-
tion, focus group research conducted in San Often, transgender people have 2 differ-
Francisco showed that among transgender ent sets of health care providers: one involved Intersexed Issues
persons, a street lifestyle, lack of education with gender transition and one involved with
and job opportunities, and low self-esteem all regular health care visits. In addition to the The term intersexed refers to people born
contributed to drug and alcohol abuse.8 problems experienced by transgender men with physical differences that will result in
Increasing evidence demonstrates that and women within health care settings, tradi- their being difficult to classify as either bio-
the rate of HIV infection among transgender tional health care plans (public and private) logically male or biologically female. This
women is high and that in California the risk do not cover the costs related to changing condition can assume various forms and in-
of infection may even surpass that for bisex- one’s gender, leaving people to find other volve the structure of one’s genitals, the exis-
ual and homosexual men.9–12 Reported sero- ways to fund their transition from one gender tence or nonexistence of specific reproduc-
prevalence rates exceed 20% and have been to another.20 tive organs, and chromosomes other than XX
shown to be as high as 60% among African Individuals both within and allied to the and XY. Sometimes these physical differences
Americans. Many transgender women (i.e., transgender community believe that the stan- are life threatening (e.g., affecting the ability
male to female) are at risk primarily because dards of care imposed by the Harry Benjamin to pass urine from the body) and require sur-
of risky sexual behaviors, but sharing needles International Gender Dysphoria Association gical intervention. Other times, however, the
870 American Journal of Public Health June 2001, Vol. 91, No. 6

3. differences are aesthetic, and surgery is done 6. Advocate for more and better promo-
so that the child can be more readily identified tion of transgender-related research and for
as either male or female.24 more innovation within transgender health
Today, such aesthetically motivated sur- care practices.
geries are the focus of criticism from many 7. Advocate for greater awareness of
intersexed individuals. The Intersexed Society intersexed individuals and against the prac-
of North America (http://www.isna.org) was tice of surgically altering children and infants
formed in response to the individual cases of for solely aesthetic reasons. This would in-
trauma caused by many of these surgeries. clude conducting more research on the effects
The goals of this organization are to reform (both short- and long-term) of medical in-
the treatment of intersexed individuals, to limit terventions on intersexed infants and children
the practice of surgical interventions to those and taking a critical stand against surgically
that are medically necessary, and to limit sur- altering children and infants purely for aes-
geries performed on children purely for the thetic reasons.
sake of aesthetics.
Acknowledgments
Suggestions for Improving the I wish to thank Rosalyne Blumenstein, MSW, of
Health of Transgender the Gender Identity Project, Lesbian and Gay Com-
munity Services Center, New York City, for the use
Individuals of the phallic woman figure and the Lesbian, Gay,
Bisexual, and Transgender Caucus of Public Health
The American Public Health Associa- Workers, American Public Health Association.
tion’s 1999 resolution concluded by stating
the need for health care providers and re-
searchers of all types to provide transgender References
individuals with culturally relevant and sen- 1. APHA policy statement 9933: the need for ac-
sitive treatment and resources1; however, it knowledging transgendered individuals within
does not provide much specific guidance. In research and clinical practice. Am J Public
addition to the books and articles available to Health. 2000;90:483–484.
increase people’s knowledge of transgender 2. Bullough VL, Bullough B. Crossdressing, Sex,
and Gender. Philadelphia: University of Penn-
men and women, the following strategies can sylvania Press; 1993.
be used to begin improving the health of trans- 3. Hirschfeld M. Transvestites: An Investigation of
gender individuals.25–27 the Erotic Drive to Cross-Dress. New York,
NY: Prometheus Books; 1993.
1. Acknowledge the authenticity of trans- 4. Diagnostic and Statistical Manual of Mental
gender individuals’ identities and lives in all Disorders, Fourth Edition. Washington, DC:
areas (policy, research, and clinical practice). American Psychiatric Association; 1994.
When in doubt, inquire in a respectful man- 5. Benjamin H. Transsexualism and transvestism
ner. Allow for complexities; people may not as psychosomatic somato-psychic syndromes.
Am J Psychother. 1954;8:219–230.
fall into neat categories. Do not become overly 6. Butler J. Bodies That Matter: On the Discursive
fixated upon the technical–medical aspects Limits of Sex. New York, NY: Routledge; 1993.
found in the Diagnostic and Statistical Man- 7. Lombardi EL, Wilchins RA, Priesing D, Mal-
ual of Mental Disorders or the Harry Ben- ouf D. Gender violence: transgender experi-
jamin International Gender Dysphoria As- ences with violence and discrimination. J Ho-
sociation standards of care. mosex. In press.
FIGURE 1—Phallic woman putting 8. HIV Prevention and Health Service Needs of
on a condom, an 2. Promote the view that discrimination
the Transgender Community in San Francisco:
illustration from HIV and denial of services to transgender men and Results From Eleven Focus Groups. San Fran-
prevention education women will not be tolerated. cisco, Calif: San Francisco Dept of Public
material produced for 3. Allow young people some flexibility Health, AIDS Office; 1997.
distribution in New in questioning their gender identity. 9. Simon PA, Reback CJ. Baseline characteristics
York City. This 4. Advocate for increased and better ac- of a cohort of male-to-female transgenders re-
cess to health care resources. This includes ceiving services at four community-based pre-
illustration was
vention programs in Los Angeles County. Paper
produced in-house, public and private third-party coverage of hor- presented at: 16th Annual AIDS Investigators’
because such mones and surgeries needed for people to Meeting and Second Annual Conference on
transgender-sensitive change their legal sex, greater input of trans- AIDS Research in California; February 1999;
education tools are gender individuals in their own care, and more San Diego, Calif.
unavailable from other education on transgender health care issues. 10. The Transgender Community Health Project:
HIV prevention 5. Advocate for cultural relevancy within Descriptive Results. San Francisco, Calif: San
sources. (Reprinted research, policy, education and prevention Francisco Dept of Public Health; 1999.
with permission from 11. Nemoto T, Luke D, Mamo L, Ching A, Patria J.
programs, and direct care contexts. One strat- HIV risk behaviors among male-to-female
the Gender Identity egy is to contact and develop partnerships
Project, New York, NY.) transgenders in comparison with homosexual
with individuals and organizations within the or bisexual males and heterosexual females.
local transgender community. AIDS Care. 1999;11:297–312.
June 2001, Vol. 91, No. 6 American Journal of Public Health 871

4. 12. Sykes DL. Transgendered people: an “invisi- Providers. San Francisco, Calif: Transgender al. The standards of care for gender identity dis-
ble” population. California HIV/AIDS Update. Substance Abuse Treatment Policy Group, San orders. 6th version. Int J Transgenderism [serial
1999;12:80–85. Francisco Lesbian, Gay, Bisexual, Transgen- on-line]. February 2001;5(1).
13. Bockting WO, Robinson B, Rosser B. Trans- der Substance Abuse Task Force; 1995. 23. Cohen-Kettenis PT, van Goozen SH. Pubertal
gender HIV prevention: a qualitative needs as- 18. Green R, Stoller RJ, MacAndrew C. Attitudes delay as an aid in diagnosis and treatment of a
sessment. AIDS Care. 1998;10:505–526. toward sex transformation procedures. Arch transsexual adolescent. Eur Child Adolesc Psy-
14. Clements K, Wilkinson W, Kitano K, Marx R. Gen Psychiatry. 1966;15:178–182. chiatr. 1998;7:246–248.
HIV prevention and health service needs of the 19. Franzini LR, Casinelli DL. Health profession- 24. Kessler SJ. Lessons From the Intersexed. New
transgender community in San Francisco. Int J als’ factual knowledge and changing attitudes Brunswick, NJ: Rutgers University Press; 1998.
Transgenderism [serial on-line]. 1999;3(1 + 2). toward transsexuals. Soc Sci Med. 1986;22: 25. Israel GE, Tarver DE II. Transgender Care:
15. JSI Research and Training Institute Inc. Access 535–539. Recommended Guidelines, Practical Informa-
to Health Care for Transgendered Persons in 20. Middleton L. Insurance and the reimbursement tion and Personal Accounts. Philadelphia, Pa:
Greater Boston. Boston, Mass: Gay, Lesbian, of transgender health care. In: Bullough B, Temple University Press; 1997.
Bisexual, and Transgender Health Access Proj- Bullough VL, Elias J, eds. Gender Blending. 26. Lombardi EL, van Servellen G. Correcting de-
ect; 2000. Amherst, Mass: Prometheus Books; 1997: ficiencies in HIV/AIDS care to transgendered
16. Moriarty HJ, Thiagalingam A, Hill PD. Audit of 455–465. individuals. J Assoc Nurses AIDS Care. 2000;
service to a minority client group: male to fe- 21. Dean L, Meyer IH, Robinson K, et al. Lesbian, 11:61–69.
male transsexuals. Int J STD AIDS. 1998;9: gay, bisexual, and transgender health: findings 27. Lombardi EL, van Servellen G. Building cul-
238–240. and concerns. J Gay Lesbian Med Assoc. 2000; turally sensitive substance use programs for
17. Transgender Protocol: Treatment Services 4:102–151. transgendered populations. J Subst Abuse Treat.
Guidelines for Substance Abuse Treatment 22. Meyer III W, Bockting W, Cohen-Kettenis P et 2000;19:291–296.
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