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Review shows significant research gaps in transgender health

As part of a new series from Lancet, a review of research on transgender health indicated areas of need, particularly highlighting the lack of research regarding general health in transgender individuals.

“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,” Sari L. Reisner, ScD, of Boston Children’s Hospital and Harvard Medical School, and colleagues wrote. “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.”

Sari L. Reisner

To assess the global health burden and needs of transgender populations, researchers conducted a review and synthesis of peer-reviewed literature published between 2008 and 2014 about transgender health. Analysis included 116 studies in 30 countries.

Overall, researchers identified 981 unique health-related datapoints among the reviewed studies.

Mental health was the most commonly studied area of transgender health, accounting for 303 datapoints or 31% of studies. The majority of data focused on mood disorders (n = 96; 32%), suicidal and non-suicidal self-injury (n = 50; 17%) and anxiety disorders (n = 44; 15%).

Most mental health research reported prevalence data only (n = 161; 53%).

“Measures of association between risk factors and mental health conditions are an important area for future research efforts. Additional gaps in mental health research included a scarcity of studies examining post-traumatic stress disorder or traumatic stress (n = 3), which is surprising,” according to the researchers.

Sexual and reproductive health was the second most commonly studied area of transgender health, accounting for 219 datapoints or 22%. Seventy-five percent of sexual and reproductive health outcomes reported included HIV or sexually transmitted infection (STI) prevalence.

When data were examined by assigned sex at birth, analysis indicated the focus on HIV and STI prevalence was directed at transgender individuals assigned male sex at birth.

Substance use was the third most frequently studied area of transgender health, accounting for 193 datapoints. Data focused on alcohol (n = 35; 18%), marijuana (n = 25; 13%), any unspecified illicit drug use (n = 16; 8%), and tobacco (n = 14; 7%).

Research on substance abuse, dependence or disorder only accounted for 5% of substance use data.

Research on violence and victimization accounted for 105 datapoints, of which 76% (n = 80) reported prevalence data only. Types of violence or victimization datapoints included sexual (34%), physical (17%), psychological or emotional (7%), verbal (4%) or unspecified (38%).

General health of transgender individuals was the least researched area, accounting for 68 datapoints. The majority of research in this area reported unadjusted prevalence estimates only (n = 52; 77%).

In response to these findings, researchers recommended the following:

• Revisions to WHO’s diagnostic manual move the diagnoses for transgender individuals from the “mental and behavioral disorders” chapter to the “conditions related to sexual health” chapter;
• WHO should reconsider the diagnosis of “gender incongruence in childhood” for children below puberty age;
• Health care for transgender individuals, including access to feminizing and masculinizing hormones, should be funded similar to other health care;
• Physicians should be trained to understand health needs of transgender individuals, particularly general, mental and reproductive health;
• Governments should abolish gender reparative therapies for children;
• Anti-discrimination laws include transgender individuals; and
• Further research of transgender health needs in unstudied geographic areas, such as Africa, the Middle East, and central Asia.

“Despite substantial gaps in empirical research, there are sufficient actionable data highlighting unique biological, behavioral, social, and structural contextual factors surrounding health risks and resiliencies for transgender people that need interventions,” Reisner and colleagues wrote. “Studies are needed that conceptually integrate and examine transgender-specific social determinants of health, including incorporating a framework of gendered situated vulnerabilities. An important next step will be a comprehensive public health approach that includes access to gender affirmation (in a social, psychological, medical, and legal context), improved health systems informed by high quality data, and effective partnerships with local transgender communities to ensure responsiveness of and cultural specificity of programming.” – by Amanda Oldt

Disclosure: The researchers report no relevant financial disclosures.