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Policy Statement Adopted by the Governing Council of the American Public Health Association, November 10, 1999

9933: The Need for Acknowledging Transgendered Individuals within Research and Clinical Practice The American Public Health Association,

Realizing that transgender refers to a population of individuals who do not and/or cannot conform to traditional norms of gender,for example:

Transgender: Transgender is an umbrella term used to describe the full range of individuals who do not necessarily conform to society’s standards of gender and sex; and incorporate one or more aspects, traits, social roles or characteristics of the other gender.

FTM: Common abbreviation denoting a female-to-male transgendered/transsexual. This term can cover many forms of gender expression of the individual.

MTF: Common abbreviation denoting a male-to-female transgendered/transsexual. This term can cover many forms of gender expressions of the individual.

Transsexual: An individual who actively seeks to change or has changed his/her body through hormonal reassignment and/or various surgical procedures.

Transvestite/Cross-dresser: One who wears the clothing and cultivates the appearance of the other gender. This word has a few different meanings. In its purest form, transvestitism means Cross-dressing.

Intersexed: Anatomic sex differentiation occurs on a male/female continuum, and there are several dimensions. Genetic sex, or the organization of the sex chromosomes, is commonly thought to be isomorphic to some idea of true sex. The sex chromosomes determine the differentiation of the gonads into ovaries, testes, ovo-testes, or non functioning streaks. The hormones produced by the fetal gonads determine the differentiation of the external genitalia into male, female, or intermediate (intersexual) morphology; * and

Understanding that transgendered individuals vary by age, race, culture, income, education, residence, sexual orientation, marital status, religion, ability/disability, immigration status, and interest in medical interventions; and

Noting that studies generally either do not identify the existence of transgendered individuals, or combine them into a single transgender category and/or misconceptualized under other labels; and

Acknowledging that little is known about the long term health risks associated with the hormonal and/or surgical reassignment, some of which is conducted without a health care provider’s participation, and that studies that do exist have small sample sizes and little generalizability; and

Noting that medical procedures are conducted upon many children and adolescents with little understanding of their long-term outcome often resulting in pain and distress, and examples of this are that

(a) Gender Identity Disorder within the DSM-IV is misused by some health care professionals to treat pre-homosexual and pre-transsexual childrenand adolescents so as to promote their development into nontranssexual, heterosexual adults, and

(b) genital surgery or sex reassignment surgery are sometimes conducted upon intersexed infants so that their external genitalia resembles that of normal infants; and

Noting a growing body of literature that finds many transgendered individuals within the United States are at risk of experiencing violence, HIV infections, and many sexually transmitted diseases; and

Concluding that transgendered individualsare not receiving adequate health care, information, or inclusion within researchstudies because of discrimination by and/or lack of training of health care providers and researchers; therefore

1. Urges the National Institutes of Health and the Centers for Disease Control and Prevention (as well as individuals researchers and health care workers) to categorize MtF and FtM transgendered individuals as such and not conflate them with gay men or lesbians (unless as appropriate to an individual’s sexual orientation in their preferred gender) as well as acknowledging the variation that exists among transgendered individuals;

2. Urges researchers and health care workers to be sensitive to the lives of trans-gendered individuals and treat them with dignity and respect, and not to force them to fit within rigid gender norms. This includes referring to them as the gender with which they identify;

3. Urges researchers, health care workers, the National Institutes of Health, and the Centers for Disease Control and Prevention to be aware of the distinct health care needs of transgendered individuals; and

4. Urges the National Institutes of Health and the Centers for Disease Control and Prevention to make available resources, including funding for research, that will enable a better understanding of the health risks of transgendered individuals, especially the barriers they experience within health care settings.

References

1. Bolin A. Transforming Transvestism and Transsexualism: Polarity, Politics, and Gender.
In: Gender Blending. Bullough B. Bullough VL, Elias J (eds.) Amherst: Prometheus Books, 1997:25-32.

2. Devor, H. FTM: Female to Male Trans-sexuals in Society.
IN: Indiana Universi-ty Press, 1997.

3. Levine SB, Brown G, Coleman E, Cohen-Kettenis P, Hage JJ, Van Maas-dam J, Petersen M, Pfafflin F, Schaefer LC.
The standards of care for gender identity disorders. International Journal of Transgenderism 1998; 2. http://www.symposion.com/ijt/ijtc0405.htm.

4. Pettiway LE. Honey, Honey, Miss Thang: Being Black, Gay, and On the Streets.
Philadelphia, PA: Temple University Press, 1996.

5. The FTM Newsletter, issues 1-45, FTM International, Inc., 1360 Mission St., Ste. 200, San Francisco, CA 94103, 1987- 1999.

6. Boles J, Elifson KW. The social organi-zation of transvestite prostitution and AIDS. Social Science and Medicine. 1994;39:85-93.

7. US Department of Health and Human Services. The Northwest Regional Work-shop: HIV Prevention Approaches for Alcohol and Drug Use Among Men who have Sex with Men. Atlanta, GA: Cen-ters for Disease Control and Prevention: 1997.

8. Asscheman H, Gooren LJG, Eklund PLE. Mortality and morbidity in trans-sexual patients with cross-gender hor-mone treatment. Metabolism. 1989;38: 869-873. 9. Bodlund O, Kullgren G. Transsexualism-general outcome and prognostic factors: a five-year follow-up study of nineteen transsexuals in the process of changing sex. Archives of Sexual Behavior. 1996; 25:303-317.

10. Bodsworth NJ, Price R, Davies SC. Gonococcal infection of the neovagina in a male-to-female transsexual. Sexually Transmitted Diseases. 1994;21:211-212.

11. Cohen-Kettenis PT, Gooren LJG. Trans-sexualism: A review of etiology, Diagno-sis, and treatment. Journal of Psychoso-matic Research. 1999;46:315-333.

12. Futterweit W. Endocrine therapy of transsexualism and potential complica-tions of long-term treatment. Archives of Sexual Behavior. 1998;27:227.

13. Gishel N, Timmins KL, Duffy SJ, Tran BT, O’Brien RC, Harper RW, Meredith IT. Long-term estrogen therapy improves vascular function in male to female transsexuals. J Am College Cardiology. 1997;29:1437-1444.

14. Midence K, Hargreaves I. Psychosocial adjustment in male-to-female transsexu-als: An overview of the research evi-dence. J Psych. 1997;131:602-615.

15. Rehman J, Lazer S, Benet AE, Schaefer LC, Melman A. The reported sex and surgery satisfactions of 28 postoperative male-to-female transsexual patients. Archives of Sexual Behavior. 1999;28:71.

16. Schlatterer K, Yassouridis A, Werder K, Poland D, Kemper J, Stalla GK. A fol-low- up study for estimating the effective-ness of a cross-gender hormone substitu-tion therapy on transsexual patients. Archives of Sexual Behavior. 1998;27: 475-494.

17. Burke, P. Gender Shock: Exploding the Myths of Male and Female. New York: First Anchor Books 1996.

18. Diamond M, Sigmundson HK. Management of intersexuality: Guidelines for dealing with persons with ambiguous genitalia. Arch Ped Adoles Med. 1997;151:1046-1050.

19. Diamond M, Sigmundson HK. Sex reas- signment at birth: A long-term review and clinical implications. Arch Ped Adoles Med. 1997;150:298-304.

20. Dreger A D. Ambiguous Sex or Ambivalent Medicine? Ethical Issues in the Medical Treatment of Intersexuality. Hastings Center Report. 1998;28:24-35.

21. Kessler SJ. Lessons from the Intersexed. New York: Rutgers University Press, 1998.

22. National Gay, Lesbian Task Force. NGLTF Statement on gender identity disorder and transgender people. http://www.ngltf.org/press/gid.html, 1996.

23. Zucker KJ, Bradley SJ. Gender Identity Disorder and Psychosexual Problems in Children and Adolescents. New York: Guilford Press, 1995.

24. Alan DL, Guinan J, Mccallum L. HIV Seroprevalence and Its Implications for a Transsexual Population. International Conference on AIDS, Montreal, June 4- 9, 1989.

25. Chew S, Tham KF, Ratman SS. Sexual behavior and prevalence of HIV antibod-ies in transsexuals. J Obstet Gynecol Res. 1997;23:33-36.

26. Elifson KW, Boles J, Sweat M, Posey E, Darrow W. HIV-1 and STD Infection among Male Transvestite Prostitutes. International Conference on AIDS, San Francisco, June 20-23, 1990.

27. Moden B, Goldschmidt R, Rubinstein E, Vonsover A, Zinn M, Golan R, Chetrit A, Gottlieb-Stematzky T. Prevalence of HIV antibodies in transsexual and female prostitutes. Am J Publ Health. 1992;82:590-592.

28. Reback CJ, Lombardi EL. HIV risk behaviors of male-to-female transgen-ders in a community-based harm reduc-tion program. Intl J Transgenderism. (on-line serial) 1999;3. http://www.symposion. com/ijt/ hiv_risk/reback.htm. 29. Rekart ML, Manzon LM, Tucker P. Transsexuals and AIDS. International Conference on AIDS, Berlin, June 6-11, 1993.

30. Bockting WO, Robinson BE, Rosser BRS. Transgender HIV prevention: A qualitiative needs assessment. AIDS Care. 1988;10:505-526.

31. Clement K. Transgender and HIV: Risks, prevention, and care. Intl J Transgen-derism (on-line serial) 1999;3: http://www.symposion.com/ijt/hiv_risk/clements.htm.

32. Gagne P, Tewksbury R. Conformity pressures and gender resistance among trans-gendered individuals. Social Problems. 1998;45:81-101.

33. Green J. Report on Discrimination Against Transgendered People. San Francisco Human Rights Commission, 1994.

34. Kammerer N, Mason T, Connors M. Transgender health and social service needs in the context of HIV risk. Intl J Transgenderism (on-line serial) 1999;3. http://www.symposion.com/ijt/hiv_risk/kammerer.htm.

35. Lombardi EL, Wilchins RA, Priesing D, Malouf D. Gender violence: Transgender experiences with violence and discrimi-nation.
(In review, Journal of Homosexuality) 1998.

36. Moriarty HJ, Thiagalingam A, Hill PD. Audit of service to a minority client group: Male to female transsexuals. Intl J STD and AIDS. 1998;9:238-240.

37. Rodgers LL. Transgendered youth fact sheet. Transgender Protocol: Treatment Services Guidelines for Substance Abuse Treatment Providers Edited by The Transgender Protocol Team, pp 7-8. San Francisco, CA: Lesbian, Gay, Bisexual, Transgender Substance Abuse Task Force, 1995.

38. San Francisco Department Of Public Health, AIDS Office. HIV Prevention and Health Service Needs of the Trans-gender Community in San Francisco: Results from Eleven Focus Groups.San Francisco, CA: San Francisco Depart-ment of Public Health, AIDS Office, 1997.

39. The Transgender Protocol Team. Transgender Protocol: Treatment Services Guidelines For Substance Abuse Treat-ment Providers. San Francisco, CA: Les-bian, Gay, Bisexual, Transgender Sub-stance Abuse Task Force, 1995.

40. Ettner R. Gender Loving Care. New York and London: W. W. Norton & Company, 1999.

Footnote

* The Intersex Society of North America (ISNA) is a peer support, education, and advocacy group founded and operated by and for intersexuals: individuals born with anatomy or physiology which dif-fers from cultural ideals of male and female. http://www.isna.org