Global access to healthcare across
primary and
secondary health settings remains fragmented for transgender people, with access and services highly dependent on a political administration's support for trans health in policy as well as globally-engrained health inequalities largely shaped by financial wealth inequalities such as the
Global North and Global South divide.
Africa South Africa Access to transition care, mental care, and other issues affecting transgender people is very limited; there is only one comprehensive transgender health care clinic available in South Africa. Additionally, the typical lack of access to transition options that comes as a result of gatekeeping is compounded by the relatively limited knowledge of transgender topics among psychiatrists and psychologists in South Africa. Puberty blockers and cross sex hormones are also available to minors in Thailand.
Transgender people are quite common in Thai popular entertainment, television shows and nightclub performances, however, transgender people lack various legal rights compared to the rest of the population, and may face discrimination from society. Transgender women, known as
kathoeys, have access to hormones through non-prescription sources. This kind of access is a result of the low availability and expense of transgender health care clinics. As a result, just a third of all trans men surveyed are taking hormones to transition whereas almost three quarters of kathoeys surveyed are taking hormones. On December 1, 2022, the Chinese
National Medical Products Administration banned online sales of
cyproterone acetate,
estradiol, and
testosterone, which are the most common hormones and
antiandrogens used in transgender hormone replacement therapy.
Europe Spain Public health care services are available for transgender individuals in Spain, although there has been debate over whether certain procedures should be covered under the public system. The region of
Andalusia was the first to approve sex reassignment procedures, including sex reassignment surgery and
mastectomies, in 1999, and several other regions have followed their lead in the following years. Multiple interdisciplinary clinics exist in Spain to cater specifically to diagnosing and treating transgender patients, including the Andalusian Gender Team. As of 2013, over 4000 transgender patients had been treated in Spain, including Spaniards and
international patients. Beginning in 2007, Spain has begun allowing transgender individuals who are eighteen years or older to change their name and gender identity on public records and documents if they have been receiving hormone replacement therapy for at least two years. In 1999, people who had been forcibly sterilized in Sweden were entitled to compensation. However, the sterilization requirement remained for people who changed their legal gender. In January 2013, forced sterilization was banned in Sweden. Depending on the person's health and wishes there are several different treatments and surgeries available. Today, no form of treatment is mandatory. Although to access medical and legal transitional treatment (e.g.
hormone replacement therapy, and top surgery to
enhance or
remove breast tissue), the person will need to be diagnosed with
transexualism or
gender dysphoria, which requires at least one year of therapy, during which they must live for one full year as their desired gender in all professional, social, and personal matters. Gender clinics are recommended to provide male-to-female patients with wigs and breast prostheses for the endeavor. The evaluation additionally involves, if possible, meetings with family members and/or other individuals close to the patient. Patients may be denied care for any number of "psychosocial dimensions", including their choice of job or their marital status. An individual with a transsexual or gender dysphoria diagnosis can, together with the assessment team and other doctors, decide what suits them. Medically transitioning in Sweden is covered by the high-cost protection for medications and doctor's visits, and there is no surgery fee. The fee the individual pays for a doctor's appointment or other care represents only a small fraction of the actual costs. If a person would like to change their legal gender marker and
personal identity number they will have to seek permission from the National Board of Health and Welfare. In Sweden, anyone is allowed to change their name at any time, including for gender transition. Up until January 27, 2017, being transsexual was classed as a disease. Two months earlier, on November 21, 2016, around 50 trans activists broke into and occupied the Swedish National Board of Health and Welfare (Swedish:
Socialstyrelsen) premises in Rålambsvägen in
Stockholm. The activists demanded that their voices be heard regarding the way the country, healthcare, and the
National Board of Health and Welfare mistreat
transgender and
intersex individuals. Sweden's
Karolinska Institute, administrator of the second-largest hospital system in the country, announced in March 2021 that it would discontinue providing puberty blockers or cross-sex hormones to children under 16. Additionally, the Karolinska Institute changed its policy to cease providing puberty blockers or cross-sex hormones to teenagers 16–18, outside of approved clinical trials. On 22 February 2022, Sweden's
National Board of Health and Welfare said that puberty blockers should only be used in "exceptional cases" and said that their use is backed by "uncertain science". However, other providers in Sweden continue to provide puberty blockers, and a clinician's professional judgment determines what treatments are recommended or not recommended. Youth are able to access gender-affirming care when doctors deem it medically necessary. The treatment is not banned in Sweden and is offered as part of its national healthcare service.
Netherlands Gender care in the Netherlands is insured under the national health care of third part insurer's, including laser hair removal, SRS, facial feminization surgery and hormones. Hormones can be prescribed by licensed endocrinologist in an academic hospital from the age 16 and older. Blockers can be prescribed from age 12 when puberty usually starts. The Dutch
Ministry of Health, Welfare and Sport publishes guidelines recommending the use of puberty blockers in transgender adolescents of at least Tanner Stage II with informed consent and approval of an endocrinologist. This guideline, published in 2016, is endorsed by the following Dutch medical organizations: • Nederlands Internisten Vereniging (Dutch Internists Association) and was described by Stephen Lodge (the solicitor representing the three women) as a "landmark in the continuing struggle for legal recognition" of transgender rights in Britain. The ruling means that it is illegal for any health authority in
England or Wales to put a blanket ban on gender-affirming surgery relating to
transgender people. A 2013 survey of gender identity clinic services provided by the UK
National Health Service (NHS) found that 94% of transgender people using the gender identity clinics were satisfied with their care and would recommend the clinics to a friend or family member. This study focused on transgender people using the NHS clinics and so was prone to
survivorship bias, as those unhappy with the NHS service are less likely to use it. Despite this positive response, however, other National Health Service programs are lacking; almost a third of respondents reported inadequate psychiatric care in their local area. Patients have the legal right to begin treatment within 18 weeks of referral by their GP, however the average wait for patients to gender identity clinics was 18 months in 2020 with over 13,000 people on the waiting list for appointments at gender identity clinics. As of May 2024, prescription of puberty blockers to new patients under 18 for the treatment of gender dysphoria is banned for both private medical practices (by a law in parliament in May) and the official state healthcare
National Health Service (NHS) which stopped their use earlier, in the aftermath of the
Cass Review except for use in clinical research trials. Previously, on 30 June 2020, the NHS changed its website, replacing the statement that puberty blockers were "fully reversible" and that "treatment can usually be stopped at any time"; with "little is known about the long-term side effects of hormone or puberty blockers in children with gender dysphoria. The
Bell v Tavistock decision by the
High Court of Justice for England and Wales ruled children under 16 were not competent to give
informed consent to puberty blockers, but this was overturned by the
Court of Appeal in September 2021. In 2022, the
British Medical Association opposed restrictions on puberty blockers, and the NHS restricted their use for children under 16 years of age to centrally administered clinical research. In April 2024, the
Cass Review stated that there was inadequate evidence to justify the widespread use of puberty blockers for gender dysphoria, and that more research was needed to provide evidence as to the effectiveness of this treatment, in terms of reducing distress and improving psychological functioning. This led to a
de facto moratorium of the routine provision of puberty blockers for gender dysphoria within
NHS England and NHS Scotland outside of clinical trials, and a subsequent ban private prescription of puberty blockers in the United Kingdom. Children already receiving puberty blockers via NHS England will be able to continue their treatment. In England, a clinical trial into puberty blockers is planned for early 2025. In July 2024, the
Royal College of General Practitioners stated that for patients under 18, no general practitioner should prescribe puberty blockers outside of a clinical trial, and the prescription of gender-affirming hormones should be left to specialists. They affirmed they will fully implement the Cass Review recommendations.
Scotland There are four
NHS Scotland Gender Identity Clinics providing services to adults and a separate service for younger people. The National Gender Identity Clinical Network for Scotland reported in 2021 that some patients had waited in excess of two years from referral for their first appointment.
Minister for Public Health Maree Todd has stated that the
Scottish Government wants to reduce "unacceptable waits to access gender identity services". Research has indicated patient dissatisfaction with long wait times. However, overall experience of treatment outcomes was largely positive, particularly for hormone therapy and surgery.
North America Canada A study of transgender
Ontario residents aged 16 and over, published in 2016, found that half of them were reluctant to discuss transgender issues with their family doctor. A 2013–2014 nationwide study of young transgender and
genderqueer Canadians found that a third of younger (ages 14–18) and half of the older (ages 19–25) respondents missed needed physical health care. Only 15 percent of respondents with a family doctor felt very comfortable discussing transgender issues with them. All Canadian provinces fund some sex reassignment surgeries, with
New Brunswick being the last of the provinces to start insuring these procedures in 2016. Waiting times for surgeries can be lengthy, as few surgeons in the country provide them; a clinic in
Montreal is the only one providing a full range of procedures. Insurance coverage is not generally provided for the transition-related procedures of
facial feminization surgery,
tracheal shave, or
laser hair removal. And in January 2024, The
Alberta government of
Danielle Smith announced plans to ban gender affirming surgeries for minors under the age of 18 and hormones and puberty blockers for minors under the age of 16. According to the
Canadian Pediatric Society, "Current evidence shows puberty blockers to be safe when used appropriately, and they remain an option to be considered within a wider view of the patient's mental and psychosocial health."
Mexico A July 2016 study in
The Lancet Psychiatry reported that nearly half of transgender people surveyed undertook body-altering procedures without medical supervision. Transition-related care is not covered under Mexico's national health plan. Only one public health institution in Mexico provides free hormones for transgender people. In June 2020, the Mexican federal government released "The Protocol for Access without Discrimination to Health Care Services for Lesbian, Gay, Bisexual, Transsexual, Transvestite, Transgender, and Intersex Persons and Specific Care Guidelines." The guidelines are used in healthcare facilities administered by the government. The guidelines state that the process of identifying one's sexual orientation, gender identify and/or expression can occur at early ages. Thus, the guidelines recommend that medical facilities and doctors consider the use of puberty blockers and cross-sex hormones as a treatment for transgender minors when appropriate. In addition to the guidelines, multiple Mexican states have modified their civil codes to recognize gender-affirming healthcare as a right for transgender people under the age of eighteen.
United States Transgender people face various kinds of discrimination, especially in health care situations. An assessment of transgender needs in Philadelphia found that 26% of respondents had been denied health care because they were transgender and 52% of respondents had difficulty accessing health services. Aside from transition related care, transgender and gender non-conforming individuals need preventive care such as vaccines, gynecological care, prostate exams, and other annual preventive health measures. However, insurance sold outside of the ACA marketplace does not have to follow these requirements. This means that preventive care, such as gynecological exams for transgender men, may not be covered. Starting in the early-2020s, as many as 13 U.S. states banned gender affirming health care for
transgender youth, with several states further restricting treatment for adults as well. In January 2024, several
Republican legislators have expressed their desire to ban gender-affirming healthcare altogether.
South America Colombia Transgender women sex workers have cited financial difficulties as barriers to accessing physical transition options. As a result, they have entered sex work to relieve financial burdens, both those related to transition and those not related to transition. However, despite working in the sex trade, the transgender women are at low risk for HIV transmission as the Colombian government requires education about sexual health and human rights for sex workers to work in so-called tolerance zones, areas where sex work is legal. == For transgender youth ==