Short introduction
"Transgender" or "trans" means people whose gender identity is different from the sex they were assigned at birth, or people whose gender expression is considered nonconforming for their assigned gender. Diverse gender identity is not a pathological condition. However, the incongruence may result in severe distress and aggravation of social adaption. Health is achieved by not only good clinical care, but also by social climate, which ensure equality, tolerance, and human rights. This is especially important in advancing transgender health, because trans individuals need social recognition and access to health care at the same time. It is also known that there is negative chain due to lower self-esteem in sexual gender minorities. Regarding transgender health, medical interventions are available to alleviate gender dysphoria and assist these people to explore their gender identity. There are international guidelines for gender diverse people, SOC-7(Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7th version), which was issued by WPATH(The World Professional Association for Transgender Health) to provide them appropriate and evidence-based medical treatments. SOC is intended to be adapted to respective cultural context. Historically Gender Identity Disorder(GID) was placed in the mental health chapter in ICD, however, ICD-11 has been revised this year, and GID is moved to newly created chapter of "Conditions related to sexual health" as Gender Incongruence, based on better understanding of gender diversity.
We compared the current circumstances surrounding transgender and LGBT people in Denmark, India, Iran, Japan, Singapore, Spain and Switzerland at the 114th JSPN annual meeting, and discussed what our (psychiatrists' ) role should be for the future.
Accessing treatment
Referrals and requirements/examinations for treatment
Age requirements
Legal sex reassignment is possible after 18 years old in Iran.
The price
After primary diagnosis, supportive psychotherapy will be initiated including possible cross dressing therapies. Afterward, the hormone therapy is established and based on the results the patient might be considered for sex reassignment surgery. Fortunately, all these treatment expenses even the psychotherapies have been fully covered by the public insurance provided for all individuals with Iranian nationality. Patient should pay about 250000000IRR( about 2500 USD) in Iran.
Usage of the GID diagnosis
Abolished in Denmark and not needed in Spain
Consequences of not requiring a diagnosis
Protective and empowering in India, Iran, Singapore and Japan
Same-sex activity is legal prohibited in Iran, whereas TS patients are able to get married and even adopt a children after sex reassignment surgery.
Changes in ICD-11
Over the past years, a range of civil society organizations as well as the governments of several EU member states have urged the WHO to remove the categories related to transgender identity from its classification of mental disorders in the forthcoming ICD‐11 (REF). In most countries, the prerequisite of health services in diagnosis of a health condition that is specifically related to those services. If no diagnosis were available to identify transgender people who were seeking related health services, these services would likely become even less available than they are now
72,
73. Thus, the Working Group on Sexual Disorders and Sexual Health has recommended retaining gender incongruence diagnoses in the ICD‐11 to preserve access to health services, but moving these categories out of the ICD‐11 chapter on Mental and Behavioural Disorders (see Table
2). After consideration of a variety of placement options
72, these categories have been provisionally included in the proposed new ICD‐11 chapter on Conditions Related to Sexual Health.
Legislation
Formal legal sex change
The treatment procedures, distinguished as surgical procedures, have been permitted both legally and religiously since 1984. in Iran.
TABLE WITH LEGAL CONDITIONS
Closing remarks
Culture and stigma
Despite all the mentioned clinical and legal facilities provided, Iranian patients are subjected to extreme pressure forced by not only the society, but also their own family members.
Pregnant trans men
Progress is not inevitable
A warning on how progress is not inevitable with a reference to Indonesia labelling all LGBTQ mental disorders \cite{holmes2018,Yosephine2016}.
There are things to be changed.
Regarding transgender health, ensuring necessary access to health care, reducing stigma and rising social acceptance are needed.
There are serious negative chain in trans community; stigma, poverty, high risk of illness.
Stigma is the biggest obstacle to foster self-esteem.
Lower self-esteem results in self-despair behavior; not seeking health care, allowing high risk sexual intercourse, and results in poverty.
Rising awareness, and starting/spreading education will end/reduce stigma.
What we need is listening every client's story compassionately, identify what needs to be changed(find a gap), together with scientific understanding, and implement.
By the international comparison, we figured out significant difference.
Simple translation from one country to another is difficult.
However, by making the most of globalization, psychiatrists should learn widely and must be advocates for these (vulnerable) communities.