Trans* people’s access to gender-affirming health care: A European comparison

Abstract Background Trans* people's life satisfaction is correlated with established legal frameworks for gender recognition and access to trans*-specific health care (Transgender Europe [TGEU], 2021). TGEU's guidelines to human rights-based principles of trans*-specific health care highlight bodily integrity/autonomy, free self-determination of gender, quality, specialized and decentralized care, and the right to determine reproductive paths as important pillars of gender affirming health care. We conducted a policy comparison across Europe regarding access to gender-affirming health care to assess how adherence to human rights-based principles could be strengthened. Methods We compared access to health care across four main domains: legal framework (e.g., legally recognised genders), insurance coverage (e.g., out of pocket costs), access barriers (e.g., legal requirements to access gender-affirming surgery), and health care offers (e.g., hormone replacement therapy). Criteria were developed in guided brainstorming sessions. Three researchers rated 28 countries across 28 items based on available policy documents. Results The majority of European countries prescribes a medicalised gender-affirming process rather than a self-decided process. Psychiatric diagnosis is also required in most countries to access gender-affirming health care. Gender-affirming health care is partly financed by statutory health insurance in most of the countries. Not all countries authorise full gender-affirming health care. Especially where statutory health insurance-covered gender-affirming health care relied centralised on single outpatient clinics or hospitals, waiting times between 6-24 months are found. Conclusions Many European countries fail to fully comply with TGEU's guidelines to human rights-based principles of trans* health care. Given the negative impact of access barriers on life satisfaction, European countries should target these shortfalls in ensuring gender-affirming health care. Key messages • Non- or only partly covered trans* health care contributes to health inequality. • Regarding trans* people, European countries need to strengthen human-rights based access to gender-affirming health care.


Background:
Trans Ã people's life satisfaction is correlated with established legal frameworks for gender recognition and access to trans Ãspecific health care (Transgender Europe [TGEU], 2021). TGEU's guidelines to human rights-based principles of trans Ãspecific health care highlight bodily integrity/autonomy, free self-determination of gender, quality, specialized and decentralized care, and the right to determine reproductive paths as important pillars of gender affirming health care. We conducted a policy comparison across Europe regarding access to gender-affirming health care to assess how adherence to human rights-based principles could be strengthened.

Methods:
We compared access to health care across four main domains: legal framework (e.g., legally recognised genders), insurance coverage (e.g., out of pocket costs), access barriers (e.g., legal requirements to access gender-affirming surgery), and health care offers (e.g., hormone replacement therapy). Criteria were developed in guided brainstorming sessions. Three researchers rated 28 countries across 28 items based on available policy documents.

Results:
The majority of European countries prescribes a medicalised gender-affirming process rather than a self-decided process. Psychiatric diagnosis is also required in most countries to access gender-affirming health care. Gender-affirming health care is partly financed by statutory health insurance in most of the countries. Not all countries authorise full gender-affirming health care. Especially where statutory health insurancecovered gender-affirming health care relied centralised on single outpatient clinics or hospitals, waiting times between 6-24 months are found.

Conclusions:
Many European countries fail to fully comply with TGEU's guidelines to human rights-based principles of trans Ã health care. Given the negative impact of access barriers on life satisfaction, European countries should target these shortfalls in ensuring gender-affirming health care.

Background:
Studies from across the world report that disability jeopardizes people's health and increases the risk of premature death. The trend has been demonstrated in present-day populations but there has been little research about whether disability affected survival in historical populations. Our objective was to identify long-term developments in the relationship between disability and survival.

Methods:
We focused on all causes of mortality in ages 25-42 among groups with any type of disability in Swedish populations in the 1800s, 1900s and 2000s. We used Cox proportional regression and longitudinal micro-level data, measuring both relative differences (HRs) and absolute differences (excess LYL) in premature mortality, across time by disability status and sex.

Results:
Although the overall mortality declined profoundly in Sweden during the centuries studied, the strong association between disability and premature mortality persisted, generating a significant disability-survival gap that has held since the 1800s. The absolute difference in this gap narrowed only slightly during the 1900s, from excess LYL due to disability for men of 1.67  in the 1800s, to 0.69 (CI 0.54-0.85) in the 2000s, while for women the change was even smaller, from 1.24 (CI -0.46-3.12) to 0.59 (CI 0.43-0.69). However, the relative difference widened, particularly for women, from HR of 2.46  in the 1800s to HR 12.00 ) in the 2000s. For men we found a change in HR from 2.30 (CI 1.31-4.06) to 8.48 ).

Conclusions:
Our study is unique in providing comprehensive results about how disability has limited survival for more than 150 years. In Sweden, fundamental societal changes and extensive welfare provisions promoting equality in health and social wellbeing of all citizens have not been enough to improve the survival of younger generations with disabilities. Key messages: The strong association between disability and premature mortality persisted from the 1800s to the 2000s. In Sweden, fundamental societal changes and extensive welfare provisions promoting equality in health have not improved survival of young adults with disabilities.
iii34 European Journal of Public Health, Volume 32 Supplement 3, 2022