Addressing unmet health needs among Chinese transgender individuals

Keywords: China, health needs, recommendations, transgender individuals.

There are ~4 million transgender individuals living in China, where 8–17% are living with HIV, 56% have lifetime suicidal ideation, and 75% have experienced serious social discrimination.^1–6 These conditions reflect severe unmet health needs, which might further impede HIV control and other public health efforts. To fill the gaps, we put forward several recommendations that researchers, community members, clinicians, and policymakers can work together to implement.

First, improve access to HIV and sexually transmitted infection (STI) prevention services. In China, it is estimated that 8–17% of Chinese transgender individuals who have sex with men are living with HIV, while the HIV testing rate remains low (41% transgender individuals ever tested for HIV).^5,6 In addition, similar to transgender individuals worldwide, a high proportion of transgender individuals has also engaged in commercial sex, with low condom use rates, as well as a high level of intimate partner violence, reflecting structural conditions that increase risk.^3,4,7 The high burden of HIV and STIs, together with the high-risk contexts, are very likely to drive further transmission of HIV. However, there are no current peer-reviewed studies on the sexual health needs of transgender individuals in China. Additionally, health system barriers include current HIV and STI prevention services that are not tailored to transgender individuals, barriers to gender identity disclosure to health care providers, and lower likelihood of seeking health care services compared with cisgender populations.⁸ Strategies to deal with these issues are crucially needed. Community empowerment approaches would be a useful approach, as evidenced by the Thai experience in providing transgender-friendly services led by community members.⁹ Other innovative methods, such as crowdsourcing, can also be used to develop tailored prevention services for transgender individuals, and to sensitise healthcare settings to the needs of gender minority patients. More importantly, developing a national strategic plan for improving HIV/STI prevention among transgender populations would be critical.

Second, improve mental health services. Cross-sectional studies in China reported that Chinese transgender individuals are experiencing an extremely high burden of mental health problems. For example, previous studies reported that ~45% of Chinese transgender individuals have depression, 16% have attempted suicide, and 38% are at risk of anxiety disorders.^2,10 High levels of family and social discrimination, lack of legal and social support, and insufficient mental health services are the main reasons for this phenomenon.⁸ Further understanding of mental health service needs, developing tailored mental health service programs, and providing real-time counselling has the potential to solve these problems. Interventions to improve coping capabilities for gender minority stressors, especially internalised transphobia, may also be useful. Efforts to train mental health practitioners to be sensitive to the needs of gender minority patients should be scaled up.

Third, improve access to sex reassignment surgery and gender-affirming hormone therapy services. Gender-affirming care is essential to the psychological wellness and quality of life for transgender individuals.¹¹ In China, only ~10% of transgender individuals have obtained sex reassignment surgery, and more than 70% reported difficulties accessing hormones from providers.^3,10 The proportion of transgender individuals who have obtained sex reassignment surgery is much lower than that of transgender adults in the US and Cannada (59%).¹² One important reason for the low surgery rate is that Chinese national guidelines specify that the surgery should only be performed in third-level, grade-A or plastic-surgery hospitals, and the number of hospitals that can provide this surgery is very low.¹¹ The unmet need for sex reassignment in China has forced many transgender individuals to travel to nearby countries to seek services, which not only increases the financial burden of individuals but also surgical complications, due to the lack of clinician monitoring and post-surgery care. National guidelines that aim to facilitate access to sex reassignment and gender-affirming hormone therapy services are needed. In addition, strategies to increase the number of health facilities that can provide safe and affordable sex assignment surgery and gender-affirming hormone interventions are also needed.

Chinese transgender individuals encounter significant barriers to accessing health care, given a lack of health system capacity reflecting major inequities. Future operable interventions tailored to this group of individuals should take anti-stigma into consideration, as this is one of the main driving forces of health inequity among Chinese transgender individuals. While challenges remain ahead, an increasing number of studies on transgender health in China are being conducted or are under preparation. These studies will improve the understanding of how health care services can better meet the needs of transgender individuals and will guide the future design of tailored health care services. In addition, current stringent policies on sex reassignment surgery should be eased to increase access to these procedures and improve psychological wellness and quality of life for transgender people. Despite these challenges, progress on improving transgender health is feasible, evidenced by the experience gained from other successful countries, and current community efforts.

The authors declare no conflicts of interest.