“In transition: ensuring the sexual and reproductive health and rights of transgender populations.” A roundtable discussion

Abstract

This roundtable discussion is the result of a research symposium entitled In Transition: Gender [Identity], Law & Global Health where participants took up the challenge to engage with the question: What will it take to ensure the sexual and reproductive health and rights (SRHR) of transgender populations across the globe? The barriers to overcome are fierce, and include not only lack of access to health services and insurance but also stigma and discrimination, harassment, violence, and violations of rights at every turn. Transgender people must of course lead any sort of initiatives to improve their lives, even as partnerships are needed to build capacity, translate lived experience into usable data, and to make strategic decisions. The SRHR of transgender people can only be addressed with attention to the social, cultural, legal, historical, and political contexts in which people are situated, with social, psychological, medical, and legal gender affirmation as a key priority shaping any intervention. Bringing together nine diverse yet complementary perspectives, our intent is to jumpstart a global and multigenerational conversation among transgender activists, lawyers, policy-makers, programmers, epidemiologists, economists, social workers, clinicians and all other stakeholders to help think through priority areas of focus that will support the needs, rights, and health of transgender populations. Making the changes envisioned here is possible but it will require not only the advocacy, policy, programmatic and research directions presented here but also struggle and action locally, nationally, and globally.

Résumé

Cette table ronde est l’aboutissement d’un symposium de recherche, intitulé En transition : genre [identité], droit et santé mondiale, où les participants ont relevé le défi de s’attaquer à la question : Que faudra-t-il pour garantir la santé et les droits sexuels et reproductifs des populations transgenres autour du monde ? Les obstacles à surmonter sont virulents et comprennent non seulement le manque d’accès aux services de santé et à l’assurance maladie, mais aussi la stigmatisation et la discrimination, le harcèlement, la violence et les violations des droits de tous les instants. Les personnes transgenres doivent bien sûr diriger toutes les initiatives destinées à améliorer leur vie, même si des partenariats sont nécessaires pour renforcer les capacités, traduire les expériences vécues en données utilisables et prendre des décisions stratégiques. La santé et les droits sexuels et reproductifs des personnes transgenres ne peuvent être abordés qu’en prêtant attention aux contextes sociaux, culturels, juridiques, historiques et politiques dans lesquels ces personnes se situent, avec l’affirmation de genre social, psychologique, médical et juridique comme priorité clé pour façonner toute intervention. Rassemblant neuf perspectives diverses mais néanmoins complémentaires, nous nous efforçons de lancer un dialogue mondial et multigénérationnel parmi les militants transgenres, les juristes, les décideurs, les responsables de programmes, les épidémiologistes, les économistes, les travailleurs sociaux, les cliniciens et tous les autres acteurs afin d’aider à penser par le biais des domaines prioritaires qui étayeront les besoins, les droits et la santé des populations transgenres. Il est possible de faire le type de changements envisagés ici, mais cela nécessitera non seulement les orientations de plaidoyer, de politique, de programme et de recherche présentées dans l’article, mais aussi une lutte et une action aux niveaux local, national et mondial.

Resumen

Esta mesa redonda es el resultado de un simposio de investigaciones titulado “En transición: género [identidad], ley y salud mundial”, en el cual los participantes aceptaron el reto de contestar la pregunta: ¿qué se necesita para garantizar la salud y los derechos sexuales y reproductivos de las poblaciones transgénero en todo el mundo? Para ello es necesario superar barreras tremendas, no solo la falta de acceso a servicios de salud y seguro médico sino también barreras como estigma, discriminación, acoso, violencia y violaciones de derechos a cada paso. Por supuesto, las personas transgénero deben liderar todo tipo de iniciativa para mejorar su vida, ya que se necesitan alianzas para desarrollar capacidad, traducir experiencias vividas a datos utilizables y tomar decisiones estratégicas. La salud y los derechos sexuales y reproductivos de personas transgénero solo pueden abordarse si se presta atención a los contextos sociales, culturales, legislativos, históricos y políticos en los cuales las personas están situadas, con la afirmación social, psicológica, médica y jurídica de género como prioridad clave para definir toda intervención. Al reunir nueve perspectivas diversas pero complementarias, nuestra intención es iniciar una conversación mundial multigeneracional entre activistas, abogados, formuladores de políticas, programadores, epidemiólogos, economistas, trabajadores sociales, profesionales clínicos y todas las demás partes interesadas transgénero, para facilitar la reflexión sobre lás áreas de enfoque prioritarias que apoyarán las necesidades, los derechos y la salud de las poblaciones transgénero. Es posible hacer los cambios aquí previstos, pero se necesitarán no solo las direcciones de promoción y defensa, políticas, programas e investigaciones presentadas aquí, sino también lucha y acción a nivel local, nacional y mundial.

Keywords:

• transgender
• human rights
• sexual and reproductive health
• key populations
• gender affirmation
• multidisciplinary perspectives

Introduction

Sofia Gruskin

What will it take to ensure the sexual and reproductive health and rights (SRHR) of transgender populations, whether they live in Los Angeles or Ouagadougou? The purpose of this roundtable discussion is not to argue the case for why doing so is important. We are well past this point. Instead, we hope that by bringing together different disciplinary perspectives, it will be possible to jumpstart a global and multigenerational conversation among transgender activists, lawyers, policy-makers, programmers, epidemiologists, economists, social workers, clinicians, and all other stakeholders on what is needed to get us there. To begin this process, we have convened this roundtable, to help think through priority areas of focus that will support the needs, rights, and health of transgender populations, all with the ultimate aim of identifying advocacy, policy, programmatic, and research needs moving forward.

We take seriously as our starting point the need for any such effort not just to include but in large part to be driven by the voices and priorities of people from transgender communities. Key to the diversity of perspectives presented here is that no one comes to the table as THE expert and that lived experience, diverse disciplines, and debate are all needed. All voices presented here believe in the need to come together not only to overcome the stigma and discrimination that continues to impact the well-being of people’s lives but also to address the enormous gaps in research, policy, programming, and advocacy needed to truly support the SRHR of transgender people across the globe.

This roundtable is the result of a research symposium held in April 2017 at the University of Southern California entitled In Transition: Gender [Identity], Law & Global Health where participants were willing to take up the challenge of not only presenting to one another but also truly listening and engaging with one another. Building on this experience, each contributor presented here was asked to respond to the following questions:

“What are the key issues that must be addressed to ensure the SRHR of transgender populations in the United States and around the globe?”

“What do you believe are the drivers for change and why?”

We anticipate that this journal article will be read primarily by sexual and reproductive health specialists, but it is our hope that the brevity of this format will help to make the diversity of approaches presented here accessible to a wider audience.

Research and advocacy on trans people’s SRHR should not begin and end with sexual health

Avery Everhart

First and foremost, trans people must be the leaders for any sort of initiatives to improve our lives in the US and around the world. We are not merely research subjects; we are also researchers and knowledge producers. We carry embodied knowledge and lived experience that our advocates, allies, and co-conspirators must recognise and can help us to translate into specific actions for change. Purposeful interdisciplinarity is heartening because it presents an opportunity to consider the state of affairs for trans populations on a global scale and recognise that trans people the world over know what we need in our respective geographic and social contexts. What is needed is the opportunity for those who wish to work with us to meet us where we are and help us to build our own capacities, generate research priorities, follow through with that research, and make strategic decisions about how to navigate our global and local socio-legal landscapes.

Of primary concern to me when thinking about SRHR is the utter lack of comprehensive and culturally competent reproductive care for trans people. The World Professional Association for Transgender Health (WPATH) Standards of Care chapter on “Reproductive Health” cites only a 1979 publication related to the effects that long-term oestrogen intake has on sperm production and a 1998 publication on trans men and pregnancy.¹ Addressing this dearth of research is a key avenue for the progressive realisation of SRHR for trans people.

Importantly, in April 2017, the EU Court of Human Rights found that the requirement that trans people be sterilised in order to have their gender legally recognised violates human rights.² This decision offers hope that legal institutions may have a newfound understanding of trans people’s reproductive health needs. Relatedly, as proposed changes to the International Classification of Diseases are moving diagnoses related to transgender populations from the mental health chapter to a new chapter on sexual health, it has become clear that a global movement for trans equality has made headway. But more work needs to be done. Protections like these, and others such as the 2012 Gender Identity Law in Argentina, may be landmark wins for trans people in certain countries.³ The progressive realisation of rights and protections, however, is only half the battle toward the full realisation of SRHR for trans people globally.

I ask us to consider what it would mean to simultaneously articulate transgender people’s legal recognition as our true genders and the realisation of our right to choose how we reproduce. How would this necessitate an interrogation of the operative assumptions about gender and sexuality within our health systems? What would reproductive justice look like for trans people? And how might we coordinate with existing movements for trans health and rights at national levels to push for more adaptable policies and standards on a global scale?

Addressing transgender health and transgender healthcare

Diana Feliz Olivia

This moment in time is often heralded as the transgender tipping point. Across the world, discussions about transgender people are entering mainstream discourse.⁴

Despite the surge in media attention regarding the transgender community and growing acceptance of transgender identities, even in Los Angeles where I live and work, systemic and societal barriers remain. These include lack of access to health insurance, stigma, lack of sensitivity and cultural competency, employment discrimination, homelessness, harassment, and violence at alarmingly high rates. All these contribute to persistent, unmet health needs for transgender individuals. In a 2013 Los Angeles County study,⁵ it was found that transgender communities, particularly transgender people of colour and those of low socio-economic status, experienced significant barriers to accessing healthcare and a disproportionate burden of preventable morbidity and mortality.

Transgender individuals experience anxiety, depression, and suicidality at significantly high rates compared to the general population as documented in different parts of the world, for example in the 2015 US Transgender Survey and a 2012 Survey in Ireland and England.^6,7 Lack of access to sexual and reproductive healthcare has a significant, deleterious impact on health outcomes. Numerous studies show that for transgender people, inaccessibility to healthcare can have notably harmful impacts. Due in part to stigma and inability to access healthcare, high rates of mental distress due to harassment and discrimination, and a lack of cultural competency and sensitivity regarding gender identity and pertinent health issues in the medical care system, transgender individuals experience significant disparities in access and use of these services. Although the WPATH Standards of Care provide an entry point for adaptation, around the world, few medical curricula or training programmes provide systematic integration of transgender health and rights in public health and medical education.^8,9

The inclusion of transgender-specific healthcare and gender-affirming education in medical schools would increase the number of primary care providers who are able to provide competent transgender healthcare services. Not only would this expand access to care for transgender patients by increasing the number of competent and trained practitioners, but this would also normalise transgender health as an important component of all healthcare providers’ knowledge base.

Ultimately, we need to develop more transgender sexual and reproductive healthcare programmes that utilise patient-centred models of care, and address the physical and social determinants of health of transgender individuals. To develop low-barrier/no-barrier programmes involves consideration, critique, and deconstruction of traditional models of healthcare delivery that have created barriers in access to care for transgender patients.

We must continue to challenge the view that transgender healthcare is difficult or significantly different from traditional primary care, a view that has impeded access to care and contributed to the marginalisation of transgender individuals inside and outside the healthcare system. We need to establish programmes that incorporate acceptance, respect, and preservation of dignity, with acknowledgement of the diverse identities and lived experiences of transgender communities.

Leveraging data to challenge assumptions of gender binaries in low- and middle-income countries

Stefan Baral

There is no evidence to suggest that the prevalence of those that do not identify with the gender assigned to them at birth varies significantly around the world. Moreover, pre-colonial history in many settings around the world celebrated transgender communities.^10,11 The social dynamics, including stigma and even criminalisation of transgender communities, that we observe today in many lower- and middle-income settings can largely be understood as consequences of colonial era laws and religious customs.¹² Of note is that these laws now remain intact or enforced in the countries that were colonised and to a large degree no longer in the colonial countries. The laws, enforcement of those laws, and the social dynamics that those laws engender create dynamics challenging the natural expression of one’s gender and the collective emergence of transgender communities.^13,14

There has been a historical assumption that heteronormative sexual identities and gender binaries are relevant across much of the world. However, using sub-Saharan Africa as an example, the study of historical documents challenges this assumption.^10,15 As noted above, this may in part be due to the sustained influence of colonial era powers and neo-colonial religious entities.¹⁶ The outcome is significant violence affecting transgender women and men, including the most severe crimes of rape and murder.¹⁷ This facilitates environments where enacted healthcare and community-level stigmas are the norms, and many people experience, perceive, and anticipate stigmas limiting their engagement with sexual and reproductive health services.^18–20

Notably, even in such challenging contexts, transgender people and communities are asserting their rights and serving their peers with healthcare services – sometimes at great personal risk.²¹ The drivers of change have to emerge from within each country, but external support can ensure that communities are resourced to provide these services and engage in needed advocacy. The resource requirements are not exclusively financial and include capacity-building to manage organisations and skills-building for research, advocacy, and service delivery. While early and sustained exposure to negative messages has likely engendered sustained community stigma, positive messaging which includes and is about transgender people in general and in health education curricula may facilitate improved social contexts over time.¹⁵ Ultimately, collaborative efforts leveraging local communities, academia including social and epidemiologic scientists, clinicians, governments and local champions may collectively turn the tide and improve the health and human rights of transgender communities.¹¹

Gender affirmation: a critical component of SRHR of transgender people

Sari L. Reisner

SRHR of transgender people can only be understood by considering the social, cultural, legal, historical, and political contexts in which people are situated. It is therefore necessary to address the situated vulnerabilities and resiliencies surrounding health risks and rights for transgender people, including the pervasive stigma, discrimination, violence, and social and economic marginalisation that transgender people face. One key issue that must be addressed to ensure the SRHR of transgender people is gender affirmation. Gender affirmation refers to the process of being affirmed and recognised in one’s identified gender identity or expression. Four dimensions of gender affirmation have been conceptualised: social (e.g. name, pronoun, dressing,), psychological (e.g. internalised transphobia), medical (e.g. hormones, surgery), and legal (e.g. change of name and gender marker on identity documents).²² There is no “one-size-fits-all” approach to gender affirmation. Some transgender people socially but not medically affirm their gender; others medically but not legally gender affirm; and sometimes gender affirmation is fluid and occurs in one context (e.g. home) but not in another (e.g. employment). Many transgender people do not have access to, or are denied, gender affirmation, including hormones monitored by a healthcare provider in accordance with international standards of care, trained medical providers, insurance coverage for surgeries and other medical interventions, and legal recognition of gender identity before the law.^12,23 Additionally, gender-affirming healthcare that appropriately and respectfully attends to the sexual and reproductive health needs of transgender people is uncommon. The right of transgender people to high-quality healthcare includes access to gender-affirming primary care, such as preventive screening for mammograms or colonoscopies. It also means access to gender-affirming medical interventions, such as pubertal blockers for youth, hormones, and/or surgical procedures, using informed consent models of care without unnecessary and unjust hurdles effectively barring access to such services. Sexual health and reproductive healthcare services for transgender people, such as HIV counselling and testing, biobehavioural prevention (e.g. pre-exposure prophylaxis, PrEP) and treatment for HIV infection, and screening and treatment for sexually transmitted infections (STIs), must be gender-affirming. This means that services do not make assumptions about the bodies transgender people have, the kinds of sex they engage in, or the gender of their sexual partners. Transgender people may use all body parts, whether or not these are “concordant” with self-identified gender. Transgender people may have sex with cisgender males, cisgender females, and/or other transgender people; they may self-identify their sexual orientation as gay/lesbian, bisexual, queer, pansexual, or straight. Sexual healthcare that is gender-affirming situates sexual risk behaviours within the context of gender affirmation, recognising that gender validation from a sexual partner may be prioritised over sexual safety, and that earning more money for a condomless sex act may mean fewer encounters are needed to fund a surgical procedure. Gender-affirming sexual and reproductive healthcare is also sex-positive and not shaming, empowering transgender people to have safe and pleasurable sex, that is consensual and free from coercion and violence. Some transgender people may want to biologically have children, either contributing gametes or actually bearing or birthing children. Transgender people have the right to have a family if they choose to and being transgender does not threaten this right. Offering transgender people reproductive options should be standard practice in the provision of gender-affirming care.

The historical pathologisation of transgender people by medicine has resulted in transgender communities being highly mistrustful of medical establishments and healthcare settings and contexts, including those which deliver sexual and reproductive healthcare. Transgender people have often had to be resourceful in going outside a medical system which has traditionally excluded them to get their needs met, such as procuring street hormones, consulting peers for dosing, and other advice about health issues; however, these practices are not without risk. Investing in transgender communities through funding and capacity-building represents a critical component of ensuring sexual and reproductive justice for this historically underserved and stigmatised population. Drawing on the lived experiences of transgender people and cultivating strong partnerships with transgender community allies will ensure that public health efforts are culturally responsive to the sexual and reproductive health needs and rights of transgender people, garner trust of the community, acknowledge and celebrate gender and sexual diversity, and leverage population strengths and resiliencies to maximise impact.

Legal gender affirmation for improved health and well-being (including in relation to sexual and reproductive health)

Eszter Kismödi

Increasing documentation and research shows that trans people’s dignity, security, equality, privacy, health, and well-being, including their sexual and reproductive well-being, are severely compromised if their gender identity and expression are not recognised through legal and administrative processes.²⁴ These include the possibility of changing name details and gender markers on identification documents and administrative records, such as birth certificates, identity cards, passports, ration cards, and health, educational, and employment-related documents and records. Stigma, discrimination, and violence associated with the lack of legal gender recognition can impact all areas of life, including the ability to stay at school and to graduate, as well as to gain and keep a job. All can have knock-on effects that can result in economic and social exclusion, including in relation to health and social benefits.²⁵ In 2018, for example, a study clearly demonstrates how transgender people in Thailand suffer numerous forms of rights violations and discrimination as a result of a lack of legal gender recognition.²⁵

Stigma and discrimination associated with the lack of legal gender recognition can also influence access to health services and health-seeking behaviour, including in relation to HIV- and STI-related services, access to contraception and abortion, pregnancy, and prevention of reproductive morbidities such as cervical, ovarian, or prostate cancer. This is often exacerbated by the behaviours of healthcare providers who may be judgmental, dismissive, or abusive towards transgender people: for example, refusing to provide access to gender-segregated hospital wards, when a transgender person’s legal sex on hospital records does not match their gender identity or expression.²⁶

In addition, there is a paradoxical relationship between the ability to gain legal gender recognition and to access transition-related health services. In some countries, undergoing transition-related services is a precondition of legal gender recognition, and in other countries, accessing transition-related services is only possible if a person undergoes certain procedures, such as hormonal treatment or what is called gender-affirming surgery. In many countries, there is limited or no understanding by legal and healthcare professionals that some transgender people may not wish to undergo such surgeries or may wish to have some forms of medical intervention, but not others, in order to express their gender and to be legally recognised.²⁷

Human rights standards are increasingly calling for the establishment of rights-based legal gender recognition; however, across the world, most national levels laws are not yet in compliance.²⁸ These include regulations that impose abusive requirements as a precondition of legal gender recognition – for example by requiring that applicants be unmarried and undergo forced sterilisation, forced gender reassignment, and other medical procedures.²⁹ They also include those laws that are narrow in their understanding of gender diversity, for example those that only provide protection against sexual violence against women, based on a narrow understanding of what it means to be a woman, by which they exclude many transgender persons from accessing legal protection and health services for violence.³⁰

Documenting the nature and impact of the lack of legal gender recognition is necessary to support legal reform, but it can also help to create standards of care and training for providers that are prerequisites to providing quality health services for transgender people, based on their needs and their rights.³¹

Education as a foundation for transgender rights and health

David Cruz

Anyone who wishes to ensure the SRHR of transgender populations must pay attention to the need to educate the public about the lived realities of transgender persons. In many parts of the world, violence and legally tolerated discrimination are significant risk factors for members of transgender populations. People cannot enjoy health if they are assaulted or murdered for being transgender; lack of gainful employment can, without a nationalised health system, lead people to ignore health problems to which they cannot afford to attend as they struggle to feed, shelter, and clothe themselves, at times by participating in sex work that itself can expose them to additional risks and harms.

Attitudes that drive anti-transgender discrimination and violence are exacerbated by unfamiliarity with transgender people. It is all too easy to “other” those with whom we are unfamiliar, people whose lives may challenge what we have been taught about the human sexes, or what we have assumed and taken for granted in light of cultural reflections of a binary sex paradigm. Coming out has been a powerful tactic for the gay and lesbian and then bisexual movements across the world, and social science has shown that heterosexual people who know that they know gay people – their friends, relatives, co-workers – are more supportive of sexual orientation equality. With this in mind, numerous transgender leaders have urged transgender people who are in a position to do so to come out as trans. Trans persons around the world have thrived and succeeded, in education, in business, in the military, and other professions, often without this key aspect of their identity being largely known. Knowing, and arguably even knowing about, transgender people as real humans and not as clinical abstractions can help move systems toward more just and compassionate responses. Within the United States,

“[t]here is broad public support for laws protecting gay, lesbian, bisexual and transgender people against discrimination in jobs, public accommodations and housing. Seven in ten (70%) Americans favor laws that would provide these protections to LGBT people, compared to roughly one-quarter (26%) who oppose such laws.”³²

It is hard to imagine that the current majority US support for non-discrimination in the workplace for transgender persons would have come about without the heightened visibility trans people have enjoyed in popular culture in recent years. Not every place in the world is in a position to mount massive public education efforts like the Transform California campaign, led by the Transgender Law Center and Equality California (on whose Institute board I sit), to promote respect, understanding, and safety for transgender and gender nonconforming persons. But in all parts of the world, local analogues of whatever scale, informed and led by people on the ground, can help transform public understanding and opinion, which are the surest foundation for enduring social change and needed legal rights.

Social workers: key allies in amplifying the voice of transgender communities

Cary Klemmer

The exclusion of transgender and gender non-binary (trans/NB) people in the research process is a fundamental, historical problem.³³ Research with this population has often lacked oversight, or even input, by community members. Consequently, trans/NB people have generally been allocated little agency to direct the creation and provision of social and other services that address their needs. The idea that there can be nothing for us without us must be fully taken on board if gains are to be made towards positive health and meaningful rights for trans/NB people. Without adequate funding and implementation of research that fully takes into account the voice of trans/NB people, the projects and social policy initiatives that follow will continue to fail to adequately address their needs.

Social workers are uniquely situated to connect trans/NB populations with institutional power structures within and outside research universities. As social workers, we are committed by a professional code of ethics to advocate for disenfranchised and vulnerable populations.³⁴ Furthermore, social work training is unique, and the multidisciplinary biopsychosocial and ecological perspectives of our profession have us placed within communities, working directly with individuals, families, and groups to address their problems of living. This gives us great potential to ensure that the voices of trans/NB populations are heard. For example, social workers can bridge trans/NB clients with researchers for community-based participatory research, or other community–university partnerships from within the health clinics, community centres, neighbourhoods, and other contexts where we work. These projects can serve to situate trans/NB groups as experts in decision-making institutions so that they are able to guide the direction of services and policies intended to affect them.³⁵ For this ground-up model to function, the social work profession and each individual worker will have to confront any lack of understanding and deeply held biases regarding gender identity, expression, and sexuality.

Often social workers and other health professionals have lacked the knowledge and skills to respectfully engage trans/NB clients seeking services.³⁶ Also, social service settings themselves have been the source of transphobic harassment and victimisation in part due to a history of medicine labelling non-cisgender, non-heterosexual individuals as ill, and social workers acting as agents of that medical model.^37,38 Social workers able and ready to act with trans/NB people to ensure their rights are respected can become drivers of change. To meet this end, social work, as is true for other professions, must continue to advance its educational requirements and include competencies for work with trans/NB populations.^30,37,39,40 The inclusion of explicit content in social work curricula on trans/NB populations and human gender diversity are essential.^36,40 A guiding value of the social work profession is the “dignity and worth of the person,”³⁴ which in the case of trans/NB populations is yet to be adequately achieved.

A health systems perspective on responding to transgender populations

Michael R. Reich

The title for this roundtable “In Transition: Ensuring the SRHR of Transgender Populations” is appropriate in many ways. We are all “in transition” with regard to health, even if we are not fully aware of how. Systems, on the other hand, are “sticky” and tend to resist transitions. As a political scientist interested in health systems and reform, let me offer three comments that may be helpful to addressing health system “stickiness” as it impacts the SRHR of transgender populations.

First, every system is biased and resists reform. Every system has what E.E. Schattschneider called a “mobilisation of bias”⁴¹ in both explicit and implicit ways, with both intended and unintended consequences. He wrote about this in a book concerned with a “realist’s view of democracy” about the “semi-sovereign people.” (This view is needed even more today with the current president and his administration in Washington, where we seem to have lost a lot of our collective sovereignty along with our collective sanity.) The implication of this systemic resistance to reform is that changing the bias built into a system is not easy. This resistance, no matter how needed the reform, is related to the concept of “path dependency,” where, once a system adopts a particular policy, it is difficult to change that policy as the system and its stakeholders become accustomed to the existing approach. In short, most systems, and in all parts of the world, will resist efforts to make them more responsive and appropriate to the health of transgender populations.

Second, even if there is interest in doing so, changing the bias in a health system requires multiple policy changes. The overarching question must therefore be: What can be done to change the performance of a health system to better serve transgender populations? My approach to assessing and working to improve health systems uses a model developed with colleagues in the book Getting Health Reform Right,⁴² which engages five policy levers: financing, payment, organisation, regulation, and persuasion. Each of these policy arenas has implications for moving a health system towards better addressing the SRHR of transgender populations. For example, for low- and middle-income countries, for financing, one might ask which international donors provide transgender-sensitive support for health projects. On payment, debate arises over which health services are covered for transgender populations by health insurance and which are not, thereby creating incentives for hospitals and health providers. For the organisation, how, for example, are transgender issues addressed in the curricula for physicians and nurses, and in continuing education programmes? On regulation, what are the insurance rules for services and medicines that can be covered and provided to transgender populations? And for persuasion, how are the attitudes and behaviours and language (such as pronouns) being changed so that transgender-affirming care can be provided at health facilities? These examples illustrate that multiple kinds of policy considerations will be required to transform the care provided in current health systems in countries around the world.

Finally, making these kinds of changes in health systems requires political struggle. “Evidence” alone rarely produces changes in systems. These struggles will need to occur at the local level, in national health agencies, and in global organisations. Examples of cases where positive changes in health systems have occurred for transgender populations around the world (such as Argentina’s landmark Gender Identity Law),⁴³ and understanding how those changes were achieved politically, will be important for the research agenda necessary to create transgender-sensitive systems for the future.

Research on transgender health and rights: promoting relevance, participation, and interdisciplinarity

Laura Ferguson

Recent data showing very high prevalence in transgender women across a range of countries has received a great deal of attention.⁴⁴ The high HIV prevalence is an obvious concern, but often not the top priority of transgender populations even within the realm of SRHR; it is but one part of life. Transgender health has been chronically under-funded and under-prioritised. However, if harnessed effectively, this attention to HIV among transgender women might constitute a useful entry point for broader action on transgender health that might also encompass health issues transgender people consider more important. But (how) can donor priorities be broadened to match the population’s priorities and what role should the research community play in this?

“Nothing about us without us” as noted above is a well-recognised refrain. It resonates particularly in the context of global research on the SRHR of transgender populations, and attention to participant safety is key. The heterogeneity of the transgender community – gender identities and expressions as well as intersections with other categories of difference – creates challenges for researchers, even those who are well-intentioned, around who can talk for whom within the community. Gradients of power and privilege need to be understood and taken into account. Furthermore, recent research across 10 countries in sub-Saharan Africa found limited participation by transgender populations in national policy fora, due to their lack of legal recognition, and relatively low levels of community cohesion and organisation.⁴⁵ Demand for capacity-building by transgender communities, as well as health workers and policy-makers, was high across many of these settings to create safe spaces for open and informed dialogue. Only with such meaningful participation can the needs and priorities of transgender communities, whether in research or services, be understood and appropriately addressed.

Compelling research findings highlighting the need for action to support the SRHR of transgender people exist from a range of different disciplines.^26,46 However, multidisciplinary work on the health and rights of transgender populations that concurrently draw on the respective strengths of, for example, law, epidemiology, social science and public policy, is still under-explored.

Intervention studies, interventions with rigorous evaluation attached, are also few and far between; yet, there is much to learn about how best to take action to promote transgender health and rights. These studies must be appropriately situated within broader political, legal, policy, social, and cultural environments to understand which of these spheres might constitute appropriate points of action on transgender health and rights in different contexts. Yet, determining attribution for changes in outcomes related to transgender health or human rights deriving from such macro-level change remains methodologically challenging. Strong theories of change are needed alongside innovative combinations of methods.

A few critical questions can constitute a starting point for moving forward research related to the SRHR of transgender populations:

1. How do we build appropriate partnerships and coalitions to ensure that transgender communities are centrally involved throughout alongside a multidisciplinary research team and the policy-makers and practitioners who are in a position to effect change?

2. What are the processes that are creating or exacerbating social or other exclusions that negatively impact the health, well-being, and rights of different groups of transgender people?

3. What levers of change might be effective?

4. How do we engage in the social and political processes we need to be involved with in order to change people’s lives?

The urgency of the situation requires that learning be oriented towards practical actions to improve transgender SRHR. Researchers tend to convey messages in numbers (quantitative) and words (qualitative) but the key issue is that underlying these data are people, and it is critical that the focus be maintained on understanding their lived experience so as to improve it.

Conclusion

This roundtable highlights a range of opportunities to help ensure the SRHR of transgender populations around the world. While much of the experience described here focused on the United States; a good amount of discussion was given to similarities and differences with other settings, primarily sub-Saharan Africa and Asia, with respect to work carried out in partnership with local organisations. Unsurprisingly, all of the experiences described underscore the need for sensitivity to local laws, policies, cultures, health systems, and social structures. There is no “one-size-fits-all” approach; there are lessons to be learned from the experience of the transgender community in every country, and within every country around the world.

All of us have a role to play, or perhaps multiple roles: as community members, family members, allies, researchers, service providers, policy-makers, law enforcers, and more. By drawing attention to the range of issues discussed here, we hope to stimulate action – research, activism, education, service provision, policy change – to improve and support the SRHR of transgender populations in all parts of the world.

Disclosure statement

No potential conflict of interest was reported by the authors.

ORCID

Sofia Gruskin http://orcid.org/0000-0002-2418-011X

Avery Everhart http://orcid.org/0000-0001-6146-0180

Stefan Baral http://orcid.org/0000-0002-5482-2419

Cary Klemmer http://orcid.org/0000-0003-1591-8239

Michael R Reich http://orcid.org/0000-0003-3338-0612

Laura Ferguson http://orcid.org/0000-0002-1340-793X