Hacia una salud pública con orgullo: equidad en la salud en las personas lesbianas, gais, bisexuales y trans en España / Towards a public health system with pride: equity in health in the lesbian, gay, bisexual and trans community in Spain

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Atención psicomédica a personas transexuales en España en la era de la despatologización de la transexualidad como trastorno mental. Una revisión global / Psycho-medical care of transsexuals in Spain in the era of depathologization of transsexualism as a mental disorder. An overall review

Objetivo Identificar fortalezas y debilidades en los protocolos españoles de atención sanitaria a personas transexuales y compararlos con los estándares internacionales actuales. Revisar el estado actual de la etiología y prevalencia de la transexualidad. Sugerir medidas para optimizar esta atención en vistas a una mejora significativa, incluyendo opciones de ahorro de recursos financieros. Métodos Comparación entre los contenidos relacionados con la transexualidad incluidos en la CIE-10, el DSM- IV y los protocolos españoles de las unidades de (trastornos de) identidad de género, los estándares internacionales para el cuidado de personas transgénero y el último borrador del DSM-5. Revisión sistemática de la literatura relacionada con la etiología y la prevalencia de la transexualidad. Resultados Se han identificado discrepancias significativas respecto al periodo mínimo de diagnóstico, el acceso a la terapia sustitutiva hormonal y el acceso a las cirugías genitales, así como a la exigencia de la experiencia de vida real. Se ha comprobado el impacto hormonal sobre la etiología de la transexualidad, y la infraestimación de su prevalencia. Se desestima la exigencia del tratamiento exclusivamente en unidades funcionales por carecer de justificación médica. Conclusiones El acceso al tratamiento endocrinológico y quirúrgico requiere una revisión profunda y se recomienda la descentralización de la atención a personas transexuales, ya que todos los hospitales universitarios disponen de psiquiatras, psicólogos clínicos y endocrinólogos. Aunque las cirugías de reasignación de género precisan además de cirujanos plásticos, su formación actual ya incluye esta especialidad (AU)

Objective To identify the strengths and weaknesses of Spanish healthcare protocols for transsexual persons and to compare them to current international protocols. To review the current status as regards transsexuality etiology and prevalence. To suggest measures to optimize care to achieve a significant improvement, including options for saving financial resources. Methods A comparison of the contents of texts related to transsexualism in the ICD-10, DSM- IV , and guidelines of the Spanish gender units with international standards of care for transgender persons and the last draft version of the DSM-5. Systematic revision of the literature related to the etiology and prevalence of transsexualism.Results Significant discrepancies have been found as regards the minimum time period for diagnosis, access to hormone replacement therapy and to genital surgery, and the requirement of the so-called real-life experience. Impact of sex hormones on the etiology of transsexualism and underestimation of its prevalence was confirmed. Conclusions The access to hormonal and surgical treatment requires a profound review, and decentralization of transsexual care is recommended, because all university hospitals haves psychiatrists, clinical psychologists, and endocrinologists available. Although gender reassignment surgery also requires plastic surgery specialists, plastic surgeons currently receive training in this field (AU)

Progress on the road to better medical care for transgender patients.

PURPOSE OF REVIEW: In order to improve transgender individuals' access to healthcare, primary care physicians and specialists alike should be knowledgeable about transgender medicine. This review is intended to provide concise transgender hormone treatment guidelines. RECENT FINDINGS: Transgender individuals report that the lack of knowledgeable providers represents the greatest barrier to transgender medical care. Hormone treatments are generally well tolerated and greatly benefit transgender patients. After physicians recognize that gender identity is stable, hormone treatments for transgender patients are often straightforward. A practical target for hormone therapy for transgender men (female to male) is to increase testosterone levels to the normal male physiological range (300-1000 ng/dl) by administering testosterone. A practical target for hormone therapy for transgender women (male to female) is to decrease testosterone levels to the normal female range (30-100 ng/dl) without supra-physiological levels of estradiol (<200 pg/ml) by administering an antiandrogen and estrogen. Patients should be monitored every 3 months for the first year and then every 6-12 months for hormonal effects. SUMMARY: Although more studies are required, recently published transgender medical treatment guidelines provide a good start toward making care of transgender patients more generalized and accessible to healthcare providers.

Safety of hormonal treatment in transgenders.

PURPOSE OF REVIEW: Discussion of short and long-term issues of cross-hormone treatment of transgender individuals in the light of recent literature. RECENT FINDINGS: Gender nonconformity has been depathologized and replaced by gender dysphoria in the Diagnostic and Statistical Manual of Mental Disorders version V.Safety of cross-sex hormone treatment is still a matter of debate, but the latest findings in literature are quite reassuring about short-term and long-term effects. No dramatic changes in recommendations for treatment have emerged in the past years, and for the most part, clinical work is based on Endocrine Society Clinical Guidelines published in 2009. SUMMARY: Most recent findings agreed on the importance of maintaining cross-sex hormone serum concentration within the physiological range, avoiding or limiting maximum peaks and troughs.Treatment must be highly individualized and transitioning patients need to be engaged in a 'clinical contract' with the physician in order to ensure compliance with prescribed treatments.Although overall mortality appears to be higher among transgender individuals, this in not attributed to hormonal treatment but to other causes mostly related to lifestyle habits.

Care of the elderly transgender patient.

PURPOSE OF REVIEW: This review examines recent developments regarding the care of the elderly transgender patient. There is scant clinical or other relevant information related to this topic, as the phenomenon of gender incongruity has been largely misunderstood and underreported. It is important that guidelines for appropriate and sensitive care be established, as this population is proliferating due to media attention and greater access to care. RECENT FINDINGS: A preponderance of evidence exists establishing that gender nonconforming elders are subject to discriminatory healthcare treatment. Agencies that serve the elderly are rife with policies and practices that resist acknowledging the needs of this population. Most heathcare and service providers have little experience with this group and limited understanding of non-normative gender identification. Barriers to treatment amplify the challenges of ageing for the transgender person and can lead to nondisclosure of clinically relevant personal information. SUMMARY: Increasing numbers of ageing transgender individuals will be interfacing with health and care providers. Many of these individuals will require medical and surgical interventions for gender dysphoria. Therefore, a concise enunciation of guidelines and standards of care applicable to these elderly, and training of primary care and specialists to provide such care are necessary. Education for nurses, social workers, administrators and others who comprise the comprehensive care system must be mandatory. Finally, institutions and agencies must adapt and become inclusive of the spectrum of diverse individuals found across the changing social landscape.

Coordination of healthcare for transsexual persons: a multidisciplinary approach.

PURPOSE OF REVIEW: To describe the experience in Spain concerning the public healthcare for transsexual persons using a multidisciplinary approach and to review the relevant literature. Treatment includes social and psychological support, cross-hormone treatment, and sex reassignment surgeries. Although the recommendations of The World Professional Association for Transgender Health are used as guidelines, the application of these standards of care varies considerably, probably because of specific clinical and country factors. RECENT FINDINGS: The sex reassignment process is complex and requires not only coordination of multiple procedures, but also lifetime follow-up of transsexual individuals. Gender units must provide high-quality services, been essential the principle of accessibility to resources together with a protocolized follow-up and anticipation of secondary effects from the clinical surgical treatment. Two recent challenges are juvenile gender dysphoria and gender variants, which increasingly consult professionals. SUMMARY: Transsexualism affects all adaptive physical and psychosocial aspects of a person. As diagnosis is based only on the history and personal perceptions, a broad social debate exists about the need for treatment financed by the public health systems. Some countries restrict the care to transsexuals with private medical policies. Thus, coordination of care also requires participation of the family and associations, with continuous information to the health authorities, the judiciary, and the media of each country.