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In Jamaica and the wider Caribbean, the legal system allows for discrimination based on gender and sexual identity with impunity. This exposes trans people to disparate risks of violence and barriers to accessing social services such as health care. In this paper we assess the social determinants of health in the Jamaican trans population using a modified social-ecological model of transgender stigma and stigma interventions. To conduct this assessment, we situated the findings of the 2021 Jamaican Trans Health Needs Assessment and Trans Health Strategy within the socio-ecological framework with direct application to rights-based health services as well as the Jamaican legal system to develop a model for understanding the socio-legal determinants of health. The social determinants of health identified within the Jamaican trans community are all influenced by a lack of legal protection suggesting a need for legal reform toward nondiscrimination of sexual and gender-diverse populations.

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INTRODUCTION: Removing legal barriers to HIV services is crucial for the global 2030 goal of ending the HIV and AIDS epidemic, particularly in eastern Europe, the Caucasus and central Asia. Despite state commitments to uphold human rights, gay, bisexual and other men who have sex with men (gbMSM), along with transgender people (TP) still face stigma and discrimination. This article presents an analysis of rights violations based on sexual orientation and gender identity (SOGI) and HIV reported in 2022 across six countries, highlighting features and their links to legislation and law enforcement practices. METHODS: We examined documented cases of rights violations among gbMSM and TP in Armenia, Kazakhstan, Kyrgyzstan, Tajikistan, Uzbekistan and Ukraine in 2022 using the REAct system, a tool for documenting and responding to rights violations against key populations. Initially, we employed directed content analysis based on Yogyakarta Principles to analyse narratives of violations. A codebook was developed through contextual, manifest and latent coding, with themes, categories and codes converted into quantitative variables for statistical analysis. Descriptive statistics were used to identify the characteristics of violations. RESULTS: A total of 456 cases of rights violations related to SOGI and HIV were documented, ranging from 22 cases in Tajikistan to 217 in Ukraine. Most violations concerned gbMSM (76.5%), with one-fifth involving TP, predominantly transgender women. Complex violations with multiple perpetrators or infringements were documented in Armenia and central Asia. Privacy rights were commonly violated, often through outing. Cases of violations of the right to the highest attainable standard of health (13.6%) and protection from medical abuses (2.6%) were also documented. Other rights violations were sporadic, with each country exhibiting distinct patterns of violated rights and types of violations. In Ukraine, the full-scale war in 2022 influenced the nature of documented cases, reflecting the challenges faced by gbMSM and TP. CONCLUSIONS: Monitoring rights violations proved effective for assessing the situation of gbMSM and TP, particularly in the insufficiently studied and diverse eastern Europe, Caucasus and central Asia regions. As rights violations are linked to both legislation and law enforcement practices, comprehensive interventions to minimize structural and interpersonal stigma are essential.

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The care and housing of transgender (TGD) incarcerated persons is a complex concern that is growing because of the increased recognition and diagnosis of gender dysphoria in society. To remain current in this evolving landscape, there have been updates to federal manuals and state guidelines regarding the medical care and housing of the TGD population. Since the publication by Glezer and colleagues in 2013, there has not been a comprehensive overview of current federal and state guidelines, and legal and other considerations on this topic. We provide an update with special consideration given to housing practices, safety, and access to care. A review of the literature shows that the World Professional Association for Transgender Health (WPATH) standards and Prison Rape Elimination Act (PREA) requirements are not uniformly implemented and enforced on a state level. In fact, some states have policies that are in direct conflict with federal requirements. The safety and equitable treatment of both TGD and cisgender populations is an important topic that merits attention. As new challenges emerge, an increase in federal enforcement and consistency is needed to ensure the humane treatment and protection of TGD inmates.

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OBJECTIVE: To examine the temporal relationship between the anti-discrimination rules of the Affordable Care Act, which took full effect in 2017, and the incidence of commercial claims for gender-affirming care, as well as cost sharing for these services. METHODS: We used a previously described algorithm to define a cohort of gender-diverse adults in the MarketScan Commercial Claims and Encounters Database. Claims for gender-affirming medical and surgical care were identified using International Classification of Diseases and Current Procedural Terminology codes plus pharmacy data; the annual incidence of surgical claims was calculated. Interrupted time series analyses were used to evaluate the temporal relationship between claims and anti-discrimination legislation. Claims data were also used to evaluate the patient contribution towards services. RESULTS: There were 70,733 gender-diverse adults included in the study and 36,702 (51.9%) of them filed claims for gender-affirming care. The incidence of persons with claims for gender-affirming surgery increased from 0.002% in 2009 to 0.012% in 2021. Interrupted time series analyses demonstrated a greater year-to-year increase in claims after anti-discrimination policy influences took effect. This change was greatest for transmasculine chest procedures. The median lifetime net payment for gender-affirming surgery was $12,429.10 and cost sharing was $1019.20 (8.6%). CONCLUSION: Commercial claims for gender-affirming surgery increased temporally with respect to implementation of anti-discrimination legislation and cost-sharing was reasonably low. However, many gender-diverse persons did not have claims for gender-affirming care, which may indicate continued out-of-pocket payment for these services.

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CONTEXT: Bans on gender-affirming care (GAC) for transgender and gender-expansive (TGE) people are grounded in scientific disinformation and have been challenged in American courts. METHODS: Five legal filings by state officials in defense of GAC restriction from initial litigation were analyzed using reflexive thematic analysis. Themes and subthemes of disinformation were identified after review and analysis of these filings. FINDINGS: Five themes of disinformation emerged: False and misleading claims about (1) gender dysphoria and gender identity, (2) the evidence regarding GAC, (3) standard practice of GAC, (4) the safety of GAC, and finally, (5) rejection of medical authority. These themes were well represented across the analyzed documents. CONCLUSIONS: The five disinformation themes and subthemes have been noted in lower courts, but have seen some purchase in appellate courts, suggesting that medical disinformation in law may have far-reaching consequences for medical policy.

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A deluge of state "anti-equity" legislative bills seek to reverse prevailing trends in diversity, equity, and inclusion; withdraw protections of LGBTQ+ communities; and deny access to gender-based care for trans minors and adults. While the political and constitutional fate of these acts is undetermined, profound impacts on patients and their providers are already affecting the delivery of health care and public health services.

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En este artículo se reflexiona sobre la reciente ley aprobada por el Congreso de los Diputados conocida como Ley 4/2023 para la igualdad real y efectiva de las personas trans y para la garantía de los derechos de las personas LGTBI (BOE-A-2023-5366, 2023). Se analizan inicialmente los artículos que más polémica han causado en el ámbito social, que son los relativos a la rectificación registral (Art. 43-51), y posteriormente los que hacen referencia directa o indirectamente a aspectos sanitarios; 1) el que prohíbe de métodos, programas o las llamadas terapias de conversión (Art. 17), 2) los que definen cómo debe ser en términos generales la atención sanitaria (Art. 56-59), y 3) finalmente el único artículo que menciona a los menores (Art 70). Se comenta que el término utilizado de persona trans, al englobar un amplio abanico de diversidades sexuales, variantes y expresiones de género, incluye tanto a personas que necesitan una atención médica como a otras que no. Se plantea que la rectificación registral acorde con esta ley 2023 al no precisar ningún requisito para su inscripción, ofrece menos garantías que la legislación ya existente de marzo 2007. Se considera que las directrices de la nueva ley se están traduciendo en una toma de decisiones por parte del usuario sin disponer de una valoración o diagnóstico por el equipo de profesionales que atienden el caso. Se destaca que la ley no incluye ninguna referencia a la atención por salud mental. Y en conjunto, se concluye que el texto aprobado, en el ámbito sanitario, puede mermar la calidad de la asistencia integral, sobre todo en menores, o personas con identidades complejas, dudosas, o con comorbilidades, que pueden generar discrepancia entre el criterio del profesional y la opinión del usuario.(AU)

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This study estimates changes in geographic access and drive times to gender clinics following legislation enacted to restrict puberty-suppressing medications and hormones for those younger than 18 years.

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La nueva ley sobre la igualdad de las personas trans y la garantía de derechos de las personas LGTBI (Ley 4/2023, de 28 de febrero) ha sido una ley discutida y criticada por algunos grupos de profesionales de la medicina que atienden a la población infantil. Las críticas desde el ámbito médico y pediátrico se pueden hacer siempre ante cualquier ley que consideremos que afecta a los derechos sanitarios de los menores. Lo que sucede es que algunas de esas críticas son sobre aspectos que no se recogen en la ley. En el siguiente artículo analizaremos lo que dice la ley, lo que dicen algunas asociaciones de profesionales y lo que dice la legislación sobre los derechos sanitarios del menor, con el fin de contribuir al debate de esos controvertidos aspectos de la ley (AU)

The new law on the equality of trans people and the guarantee of rights of LGTBI people (Law 4/2023, February 28th) has been discussed by some groups of medical professionals that have shown their disagreement.In relation to any law, criticism can be made from the medical or pediatric field; whenever it affects the rights of minors. However, criticisms, if they exist, should be made about what the law says, not about other aspects.In the following article we will analyze what the law says, what some professional associations say and what the legislation says about the health rights of minors, in order to contribute to the debate on these controversial aspects of the law. (AU)

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This Viewpoint explains the obstacles faced by individuals seeking gender-affirming care and summarizes needed changes to improve quality of care and access to care.

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