Gender is assigned at birth based on anatomical elements and the chromosomal set. However, sometimes the gender assigned following such criteria does not match the gender identity that the individual tries to express. The term “transgender” refers to those people whose gender identity and/or gender role are not in line with the sex they were assigned at birth. The more general definition instead encompasses a great variety of gender categories, which are part of a fluid spectrum that rejects the binary division between male and female imposed by society.
Being unable to identify with the gender you belong to can lead to personal and social conflicts that can trigger psychological issues such as depression and self-harming behaviours . The journey to get to a point of greater adherence between your assigned gender and your gender identity can vary and depends on the individual needs of the person in question. There might be other elements at play such as transitioning, social acknowledgment, partial interventions on the body, hormone therapy or surgical interventions to modify the anatomical and physiological features of the person. With regard to the latter, these are “healthcare interventions that affirm gender”, meaning that they help the transgender person better affirm their gender identity.
Is not having a gender a disorder?
Even though we are talking about healthcare interventions, having a nonconforming gender identity is not a disorder. Transgender identities should be viewed as normal variations of your behaviour and gender expression. In fact, in 2010 the World Professional Association for Transgender Health made a statement aimed at ‘depathologising’ the condition of transgender people. Furthermore, the eleventh edition of the “International statistical classification of diseases and related health problems (Icd-11)” of the World Health Organisation removed “gender identity disorder” from the list of mental disorders. This move from the list of mental and behavioural disorders to the one of sexual health conditions was intended to eliminate the stigma impacting transgender people, facilitate the opportunity to self-determine and guarantee the availability of the indicated treatments.
Some of those who research the cause of the tendency to feel that your attributed sex does not match with your gender believe that genetic or neuroanatomical factors might be involved. However, there is no sufficient evidence on this.
The concept of transgender health mainly refers to the provision of the same basic healthcare support services that the general population receives. In fact, transgender people often experience obstacles when accessing healthcare services. For example, it was shown that non-binary people have greater access to preventative screening exams compared to binary transgender individuals. At the same time non-binary people seems to receive lower psychological support compared to trans individuals, which causes them to develop self-harming behaviours [2,3].
Transgender people often experience obstacles when accessing healthcare services.
Some transgender people might experience gender dysphoria when the significant mismatch between their gender and the primary and/or secondary sexual characteristics is associated with deep suffering that compromises their ability to deal with social, work or other important contexts. The harmful health repercussions linked to stigma are extensively documented both by the American Psychological Association  and the Institute of Medicine of the United States .
When people wish to change their gender to make it match their identity better, thus overcoming gender dysphoria, they require support from a team of specialists. Transgender people might need mental health specialists and physicians that know how to face the benefits and risks associated to hormone and surgical interventions, which include thromboembolisms, fertility or bone density issues, cardiovascular conditions and dyslipidaemia.
The concept of transgender health therefore includes a wide range of interventions that are personalised and tailored to the variety of conditions and needs that one can present with.
The same goes for non-binary people, meaning those who do not identify univocally with either the male or female gender. According to a research study  published in 2017 a high percentage of non-binary people wishes to undergo hormone therapy or surgery to masculinise or feminise their body, even though only a small percentage actually accesses these treatments  in comparison to the binary transgender population.
In 2012 the World Professional Association for Transgender Health published the seventh version of the report on “Standards of care for the Health of Transsexual, Transgender and Gender Nonconforming People”. It is a clinical guide for the specialists working in transgender health and wellbeing services; it is intended to guarantee standards of care, promote best practice in health policymaking and ensure the provision of dignified and respectful assistance. The 2020 position paper of the European Society for Sexual Medicine offers a more up-to-date version, with suggestions obtained directly from clinical experience .
Protecting transgender health in Italy
Italy needs to first make a precise estimation of its transgender population to be able to set up the appropriate healthcare policies. However, this is one of the challenging aspects of the research on transgender people. “There is little data available and studies are very biased,” explains Marina Pierdominici, a researcher of the Reference Centre for Gender Medicine of the Italian National Institute of Health.
It is estimated that between 0.5-1.3 per cent of the population identifies as transsexual . These percentages might be an underestimation because the numbers are rising and there are wider categories that you could include in the assessment. Furthermore, the phenomenon is not distributed homogenously around the world.
Italy needs to first make a precise estimation of its transgender population to be able to set up the appropriate healthcare policies.
In Italy there is no up-to-date data. The information available dates back to ten years ago and is based on a subgroup of the transgender population. “Right now,” says Pierdominici, “we’re processing the data from the Spot research, which is aimed at assessing the number of transgender adults present in Italy. The work is conducted by the Careggi University Hospital in Florence, the Italian National Institute of Health and the Bridge Foundation, with the support of the Italian National Observatory on Gender Identity”.
Another problem that affects the research in this field is the scarce data available on the general health status and the access to healthcare services of the transgender population. “In June the Reference Centre for Gender Medicine of the Italian National Institute of Health, in collaboration with clinical centres and trans organisations, completed a study aimed at assessing the general health status of the transgender population in terms of lifestyle, access to healthcare services, prevalence of chronic conditions and therapy appropriateness. Research needs to be set up in a way that distinguishes the potential health needs of the non-binary transgender population from the needs of the binary one and the needs of the cisgender population,” emphasised Matteo Marconi, a researcher of the Reference Centre for Gender Medicine. Therefore there is still the need to create research routes able to manage the diverse and changing factors that represent the challenges to more adequate care of transgender people.
Furthermore, in Italy another unsolved issue is training healthcare staff. Training healthcare personnel is indeed fundamental. As a US study highlights , the perception of low preparation to deal with gender matters results in transgender people keeping a certain distance from treatment, therapy and support options.
“Only a few universities inserted trans health as a topic in their training programs. Short-term training for workers and professionals requires setting up courses focused on this topic. The training of general practitioners is essential in this regard because they are the first point of contact between service users and the National Healthcare Service. For this reason we’re about to distribute a book, intended to raise awareness and train on this topic, among GPs,” revealed Pierdominici.
Finally, it is important to pay particular attention to the communication and information delivered to citizens in general, especially transgender people. “The lack of independent, certified and up-to-date information represents one of the major challenges that the transgender population faces when trying to access healthcare services. Health choices are often based on word of mouth or unconfirmed information found online,” explained Pierdominici.
“In Italy the institutional body that deals with transgender health is the Reference Centre for Gender Medicine of the Italian National Institute of Health, which carries out biomedical research, training and communication activities as well as institutional work with a gender view. There are also different clinical centres spread around the country that support the medical journey of gender affirmation,” explained Marconi.
In order to fill the information and communication gaps, the Centre of the Italian National Institute of Health set up a workgroup that puts together the main associations of this field that are present in the country. The creation of the Infotrans portal is the product of this collaboration. “The website provides users with both healthcare and legal information,” continued Marconi. “It comes with an interactive map with the specialised services that are active in Italy. It also contains a glossary and a section around good practice for professionals”.
Overall, even though there are still some unsolved issues, in Italy there are various proposals for transgender health initiatives.
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 Scandurra C, Mezza F, Maldonato NM, et al. Health of non-binary and gender-queer people: a systematic review. Front Psychol 2019;10:1453.
 Scandurra C, Vitelli R, Maldonato NM, et al. A qualitative study on minority stress subjectively experienced by transgender and gender nonconforming people in Italy. Sexologies 2019;28:e61-e71.
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