Transgender Health Care in Europe

In recent years, in Eastern Europe and Central Asia (EECA) region, Trans*gender public health, clinical epidemiology, and medicine have begun to garner increasing interest, attention, and support as “legitimate” areas of scientific inquiry and domains for Trans*gender clinical care innovation thanks to the #SoS_project funded by GFTAM through Alliance for Public Health (#APH) and implemented by Eurasian Key Populations Coalition (#EKPC). Accompanying this growth, and perhaps non-bi-directionally influencing it, has been a paradigmatic shift in the field of Trans*gender health moving away from conceptualizing Trans*gender as a “disorder” and toward conceptualizing Trans*gender as an “identity.” Indeed, as gender diversity is becoming increasingly depathologized in EECA region, there is beginning to be greater recognition of the proliferation of gender identities and heterogeneous gender presentations that exist for Trans*gender people.

Based on #EKPC available research and empirical data review, Trans*gender people in EECA region differ from Cisgender people on demographics (younger age, more male assigned sex at birth, more sexual minority identified, lower educational engagement, less privately insured), gender affirmation (higher levels of internalized transphobia, less current medical gender affirmation, higher visual gender nonconformity), healthcare utilization (less routine engagement in healthcare, more teaching of healthcare providers to obtain appropriate care), mental health (more depression and anxiety, more unmet need for mental health services), substance use (greater alcohol  and drug misuse), and violence victimization (more experiences of victimization).

Through its strategic Trans* funding instrument in the region, EKPC continues to operate in about 16 countries in the EECA region, changing the lives of Trans*gender people and making a difference in their lives and wellbeing both in health and rights aspects.

Transgender health care in Iceland began in the 90´s with very few transgender people asking for treatment. The service has grown and more health care professionals joined in the following years, as the demand for transgender health care grew. The National Hospital developed a multidisciplinary team providing services to an increasing numer of people asking for trans health care. A new and rather progressive law was set in 2019 that stated all people had the right to define their own gender identity. The transgender health care team has through the years cooperated with other national multidisciplinary teams for example in Denmark, Sweden and The Netherlands with the aim of providing high quality care according to best practice at the time and has therefore developed the working guidelines according to best practice and the national law. In these turbulent times the team is working towards new working methods at the same time it is facing difficulties in several areas, both within the hospital as well as globally.

Adolescent gender identity services in England are undergoing major changes under the direction of the National Health Service specialist services commission. Two new centres are being established in the North of England and in London, and another agency to manage the ever increasing waiting list. Transition pathways to adult gender identity clinics are being consolidated. New initiatives for gender services in community care are being piloted. Wales and Scotland have their own gender services.

From the perspective of a provider of the trans specific healthcare in the Czech Republic, I would like to address the issues associated with the system of medical transition and the quality of trans specific medical care in Czechia.

In 2018 and 2020, the Czech trans-led organization Transparent compiled two publications of research findings entitled The Hopes and Fears of Trans Persons (396 respondents) and Trans People’s Experience with Medical and Therapy Services (212 respondents) that unveil the perspective of transgender and gender diverse clients with medical services in Czechia. One of the most striking outcomes is the fact that those who reported negative, humiliating and discriminating treatment mostly stated that they have experienced this treatment from care professionals and in medical and care environments.

One of the problematic aspects related to the quality of care in Czechia that often manifests itself as pathologizing and dehumanizing methods applied by experts providing trans-specific healthcare (sexologists) consists in the clash between the old view and the modern approach to gender incongruence. The majority of sexologists still implement outdated diagnostic methods which are underpinned by the belief that the need for and surgery and sterilization is naturally an integral part of the transgender identity of their clients. That is also why the desire for surgical treatment is often taken as one of the key diagnostic criteria. Despite the international progress including the ICD-11 and Standards of Care 8, outdated terminology incl. the terms disorder, transsexualism is still used, and a “cure narrative” is followed that is based on the conviction that medical treatment and interventions such as hormones and surgeries will cure patients suffering from a sex identity disorder to become healthy men or women.

The prevalent approach also fails to cater to the individual needs of the clients and a standardized process for all is promoted: diagnostics, consisting of hormonal treatment and surgery, followed by legal change of the gender marker, birth number and name in documents. Nevertheless, what the clients need most – i.e. psychotherapy, sensitive and respectful support and guidance in the process of transition, is usually neglected.

One of the reasons of such a highly impersonal and objectivising approach seems to be the need to have tangible diagnostic data, therefore employing humiliating instruments such as the falo- or vulvo-pletysmograph as well as prolonged real life experience.
In contrast and in order to cater to the needs of the clients I based my medical practice on trust and respect to the experience of the clients and the model I follow is the informed consent model that represents an agreement between the provider and the client. This approach naturally leads to the improvement in overall health and wellbeing of trans and non-binary clients who seek medical support.