Tonia Poteat, PhD, PA-C, MPH Assistant Professor, Center for Public Health and Human Rights Trans Nations: A Global Review

Paper 3 in the Lancet Transgender Health Series: Global health burden and needs of transgender populations Reisner SL, Poteat T, Keatley J, Cabral M, Mothopeng T, Dunham E, Holland CE, Max R, Baral SD. The Lancet Jun 16.

Terminology and framing Sex: Anatomy, chromosomes, hormones, genes Gender: Psychosocial and cultural dimensions Transgender: Gender identity/expression differ from assigned sex at birth Male-to-Female (MTF), transgender women, transgender girls Female-to-Male (FTM), transgender men, transgender boys Other diverse genders (genderqueer, non-binary, bigender) Cultural variations (hijra, waria, travesti, trans) 25 million transgender people worldwide

Gender affirmation

Background “Situated vulnerabilities” affect the health and wellbeing of transgender populations Need to characterize the global health burden facing transgender populations Effectively prioritize the geography and content of transgender health research

Methods Data from peer-reviewed scientific literature (PRISMA) Inclusion criteria Published Jan 1, 2008 to Dec 20, 2014 inclusive Any study design, quantitative data, disease burden Pubmed, Embase, OVID, PsychInfo, Web of Science, ProQuest Search terms: - “transgender” (e.g., hijra, waria, travesti, female-to-male) - health terms (e.g., HIV, disease, illness, mental health) Title search, abstract review, full-text review, data abstraction Completed by two reviewers, third reviewer as a tie-breaker Duplicates removed and excluding non-scientific journals

Distribution of studies about transgender health (n=116)

Number of studies about transgender health published per year (n=116)

Distribution of studies about transgender health by assigned sex at birth (n=116)

Distribution of data points from research about transgender health grouped by six health-related outcome categories (n=981)

Sexual and reproductive health data points in transgender health research (n=219) Studies that reported HIV and STI data were coded in the “HIV” category. “STI-related” indicates studies reporting only on STIs.

Limitations Excluded qualitative studies, a rich source of information Limited to peer-reviewed literature Many non-peer reviewed sources provide invaluable data Partnerships between community members and researchers to collect data will improve transgender health research and dissemination worldwide Complex set of search terms and keywords to accurately identify current health research “Transgender” added to PubMED as MeSH term in 2013

Gaps and Opportunities No data or limited data in the majority of the world Understudied health conditions (e.g., non-communicable diseases) Need for shared lexicon and population definitions Address the “situated vulnerabilities” surrounding health risks Increase the rigor and reach of transgender public health research, programming, practice, and policy

Recommendations: The way forward Count transgender populations Put gender back into transgender health Integrate health and human rights in a multi-sectoral perspective Engage transgender people: participatory population perspective

Participatory population perspective

“Despite substantial gaps in empirical research, there are sufficient actionable data … surrounding health risks and resiliencies for transgender people that need interventions.”

Acknowledgements ◦ We thank the transgender community members worldwide who participate in these studies given substantial risks and limited personal benefits ◦ The community groups that make great personal and professional sacrifices to serve the unmet health and advocacy needs of those most marginalized in the HIV response. ◦ Johns Hopkins Center for AIDS Research ◦ The United Nations Development Program

“A comprehensive public health approach to address the health of transgender people requires access to gender affirmation services, evidence-based healthcare delivery systems, and effective partnerships with local transgender communities.” Transgender health