During 2024, the High Authority for Health is expected to publish new medical recommendations for the care of transgender people. How are they currently supported with their care? What about their transition journey? How can it be improved? Researchers from Inserm investigated these questions.
An article in Inserm Magazine No. 59
It’s a huge project: For several months, the High Authority for Health has been preparing new recommendations for the medical care of transgender people. Advertised for “ in 2024 », its publication will be eagerly awaited by everyone who is in any way involved in the long and complicated care process for transgender people to date…
How many people are affected in France? According to health insurance figures, 8,952 people were 100% reimbursed for their “trans identity” insurance in 2020. By definition, a transgender person, or “trans,” identifies with a gender other than their birth gender, their biological sex, which refers to the reproductive organs, and their gender identity, the internal sense of being a man or a woman. This dissonance is called “gender incongruence” and can occur in early childhood. It can cause psychological distress called “gender dysphoria.” This may lead you to want to change your appearance to match the gender you identify with.
Support on this “transitional path” is initiated by the treating doctor, a psychiatrist or an endocrinologist, who is usually trained in university hospitals. “ The support provided by our team is very individual and depends on the expectations and level of reflection of the person concerned. It begins with multidisciplinary support (psychiatrist, endocrinologist, urologist, gynecologist, etc.). The aim is threefold: ensuring stability of demand, verifying the absence of contraindications to hormonal treatment (severe coagulation disorder, heart disease, etc.) and providing assistance in fertility preservation (sampling and freezing sperm or eggs). Treatment that affects it », develops Eva Feigerlova, endocrinologist and pediatrician at Nancy CHRU and researcher in a unit Insert.
A long and complex transition
As a cornerstone of the transition process, hormonal treatment aims to attenuate the secondary sexual characteristics of the undesired sex (physical peculiarities, apart from the sexual organs, that distinguish the two sexes: more developed breasts in women, greater hair and muscle mass in men…) and the To promote development of those of the desired gender. The ” thanks to a combination of hormones (GnRH analogues, testosterone, estrogen…), which makes it possible to reduce the level of sex hormones naturally produced by humans (testosterone in people born male, estrogen, etc.). progesterone in women born female) and replace them with hormones of the opposite sex », explains Eva Feigerlova. Over a very long period of time, sometimes several decades, this treatment, like any medication, can cause undesirable effects. In particular, it could weaken bones and promote cardiovascular diseases (heart attack, stroke, etc.), as studies show, the results of which still need to be confirmed. For example, during the work published in 2022noted Eva Feigerlova and colleagues: “ a significant proportion » cardiovascular events in transgender men under 40 years of age. Therefore, long-term medical monitoring is required.
The reassignment operation, which is permitted from the age of 18, is about bringing about physical changes that are difficult or impossible to achieve with simple hormone treatment, in particular the construction of a vagina (vaginoplasty) or a penis (phalloplasty). According to health insurance data, 432 people requested such an operation in France in 2020. However, it is no longer a mandatory passage: “ Since then, the law of November 18, 2016 on the modernization of the judiciary has been in effect since November 21e In the 19th century, genital surgery is no longer absolutely necessary to change gender in civil status », emphasizes Caroline Beyer, specialist in trans health law and project manager at Inserm. In a collection to be published in 2024, she analyzes the law on gender reassignment at the medical level and in civil status, comparing the procedures in France and Japan. Despite the recent positive developments “ We can question the need to change civil law or medical law in these two countries to improve care for transgender people », concludes the researcher.
Stereotypes that weaken health
But it’s not just the transition course! Medical care for trans people also includes other important aspects. In particular, the prevention and control of various disorders or diseases to which this group is more exposed than the general population: sexually transmitted diseases, in particular infection with the AIDS virus, HIV; psychological disorders, often accompanied by discrimination (suicide attempts, eating disorders: anorexia, bulimia, etc.); and the use of psychoactive substances. But here it is: “ There are not enough well-trained health professionals to adequately welcome and care for transgender people », regrets Simon Jutant, co-director of the Association for the Support of Transsexuals Acceptance T, which is collaborating on research with Inserm. Among them are the ANRS Trans & HIV Project aims, among other things, to identify the barriers to caring for trans people living with this virus.
To document the health, social and professional problems of the current organization of health services for sexual and gender minorities, including transsexuals, Gabriel Girard, Inserm researcher and sociologist in Marseille, is leading the project Sesame LGBTI+. This qualitative research includes around a hundred interviews with stakeholders: health professionals, community activists and citizens. “ Our results – due to be published in late 2024/early 2025 – highlight territorial inequalities in access to healthcare, as large metropolises are better equipped, as well as inequalities in public financing, which can lead to competition between structures and thus limit their collaboration. Furthermore, trans health often appears to be limited to sexual health issues, with issues related to systemic barriers to accessing medical care, mental health, or substance use often ignored… », reveals the researcher.
But there are worse things. “ The medical world is still rife with prejudice, even transphobia [hostilité, discrimination envers les personnes transgenres, ndlr.]which hurts support », adds Simon Jutant. According to a study of 633 French transgender people, more than one in two said they had been victims of transphobia in care facilities and 45% said they avoided these places for this reason. Will the long-awaited new HAS recommendations change the situation?
Author: KB
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