Frequently Asked Questions (FAQ)

WHO development of a guideline on the health of trans and gender diverse people

15 January 2024

1. Why is a technical guideline on the health of trans and gender diverse people needed?

Trans and gender diverse people encounter specific challenges that negatively impact their

access to quality health services, quality of life and life expectancy, violating their right to health

and associated rights, such as the right to free, informed consent to medical interventions. This

guideline has a specific focus on adults and will not address issues relating to children and

adolescents.

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Trans and gender diverse people often face barriers to accessing health care services, including

stigma and discrimination in health care settings. This can have serious impacts on their health.

Many settings also lack policies to facilitate access to inclusive and gender affirming care. Trans

and gender diverse people experience a high burden of mental health issues (including suicide)

and often experience high levels of violence. Thus, there is an urgent need for the health sector

to consider ways to provide more inclusive, acceptable and effective health care for trans and

gender diverse people.

This proposed guideline is guided by WHO's mandate to enable the attainment of the highest

possible level of health and well-being for all.

The guideline will reflect the principles of human rights, gender equality, universality and equity.

It is aligned with and responds to WHO's mandate to work for all people, the effort to reach the

furthest behind first, and a commitment to leave no one behind. The guideline also contributes

to ensuring universal health coverage (UHC).

● Additionally, the guideline aims to contribute to reaching the goals of the 2015 Joint Statement

of 14 UN agencies, including WHO, pledging to protect all people from discrimination and

violence on the grounds of gender identity and/or gender expression, as well as the 2017 United

Nations Joint Statement committing eliminate discrimination in healthcare settings, including

discrimination based on gender identity and gender expression.

2. Why is this guideline needed now?

The midterm review of the Sustainable Development Goal (SDG) agenda, including SDG 3

"Ensure healthy lives and promote well-being for all at all ages", has brought renewed attention

and commitment to the global goal of universal health coverage.

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This proposed guideline builds on more than 10 years of WHO work on trans and gender diverse

people's health. This includes:

o The International Statistical Classification of Diseases and Related Health Problems (ICD),

which in its 11th edition included changes to reflect scientific understanding of sexual

health, gender identity and gender incongruence. The ICD-11 was endorsed by WHO

Member States in 2019 and published in January 2022.

o Guidelines related to HIV, viral hepatis and sexually transmitted infections (STIS), which

include good practice statements on the enabling environments that are essential to

curb these epidemics among this disproportionately affected group of people.

o Guidelines related to self-care interventions that recognize the importance of gender

equality, rights in delivery of gender affirming care, and reducing discrimination.

There is an increasing body of scientific evidence highlighting the unmet health needs of trans

and gender diverse persons, due to stigma, discrimination, violence, and other human rights

violations, including in the health care settings.

Trans and gender diverse people are entitled to the full protection of their human rights, as

specified in international human rights instruments. Human rights include, but are not limited

to, the right to equal enjoyment of rights and non-discrimination; security of person and privacy;

recognition and equality before the law; the right to the highest attainable standard of mental

and physical health; education; employment and just and favourable conditions of employment;

freedom of movement; peaceful assembly and association; freedom from arbitrary arrest and

detention, and from cruel and inhumane treatment; and protection from violence. States have

an obligation to ensure that the above rights are enjoyed without discrimination of any kind,

including on grounds of race, language, national or social origin, political or other opinion, sex,

age, religion, disability, marital status or other status. United Nations human rights treaty

bodies have repeatedly held that sexual orientation, gender identity and sex characteristics are

prohibited grounds of discrimination under international law.

Some countries have laws, regulations, policies and practices that present barriers to equal

access to health care for trans and gender diverse people. A number of countries criminalize

gender identity in a de facto manner, by criminalizing cross-dressing or impersonation of the

opposite sex. For trans and gender diverse people, the lack of legal gender recognition is a key

barrier to access to health services, in addition to the full enjoyment of other rights, such as

freedom of movement, and right to adequate housing, education and employment. Harmful

practices include forced anal examinations, which are used to investigate or punish alleged

same-sex behaviour between consenting men or transgender women. These legal barriers have
3. What will the guideline cover?

This guideline will review evidence of the impact of specific interventions and on that basis

provide recommendations for enhancing the health of specifically, adult, trans and gender

diverse people,, and their access and utilization of health services.

Interventions to be assessed include:

O the provision of gender affirming care services for trans and gender diverse adults in a

clinical setting;

health workers' training and education approaches related to providing gender inclusive

care for adults;

o specific provisions of gender identity recognition laws, policies and administrative

procedures that may affect the health and wellbeing of adult trans and gender diverse

people; and

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provisions of health policies aimed at facilitating gender inclusive health care for adults.

The guidelines will also inform existing WHO recommendations that support health services and

health workers in providing empathetic and evidence-based clinical care to trans and gender

diverse people that addresses their needs, who experience interpersonal violence.

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measurable, detrimental effects on the health of trans and gender diverse people, as shown

by research.

4. How was the scope decided?

The scope was based on requests of some WHO Member States and on the outcomes of a

stakeholder consultation held in 2022 with experts in transgender health and representatives

from the affected communities from all WHO geographic regions. From the initial consultations,

it was agreed that the scope should focus on adults and not on children/adolescents.

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5. Why will the guideline only cover adults and not also children or adolescents?

The scope will cover adults only and not address the needs of children and adolescents, because

on review, the evidence base for children and adolescents is limited and variable regarding the

longer-term outcomes of gender affirming care for children and adolescents.

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6. What do we mean by 'trans and gender diverse people'?

"Trans and gender diverse people" is an umbrella term for those whose gender identity, roles or

expression do not conform to the norms and expectations traditionally associated with the sex

assigned to them at birth; it includes people who are transsexual, transgender, or otherwise

gender nonconforming or gender incongruent. Transgender people may self-identify as

transgender, female, male, trans woman or trans man, transsexual or one of many other gender

nonconforming identities. They may express their genders in a variety of masculine, feminine

and/or androgynous ways.

● See WHO's frequently asked questions on health and sexual diversity for further information.

7. What are the definitions of gender affirming and gender inclusive care used in this guideline

process?

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8. What is the timeline for this process?

2021: Establishment of an internal WHO steering group and the contracting of the first of two

independent and experienced guideline methodologists to impartially guide the process,

including the formulation of recommendations.

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In line with the 11th edition of the WHO International Classification of Diseases and Related.

Health Problems (ICD-11), gender-affirming health care can include any single or combination of

a number of social, psychological, behavioural or medical (including hormonal treatment or

surgery) interventions designed to support and affirm an individual's gender identity. Of note,

these new technical guidelines on the health of trans and gender diverse people will not

consider surgical interventions.

Gender inclusive care refers to gender diverse people's inclusion in, and access to, all forms of

health care, free of stigma and discrimination, facilitated by health policy, laws and/or health

interventions.

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2022: A stakeholder consultation (including with Member States) was conducted to define the

scope of this guideline, which led to the identification of the three areas of focus: service

delivery approaches, health workforce training, and health policy. A detailed proposal for the

guideline was submitted and approved by the WHO Guideline Review Committee.

2023: Evidence synthesis was initiated; the preliminary list and biographies of 14 proposed

Guideline Development Group (GDG) members was published on the WHO website for public

consultation; and an updated list of 21 proposed GDG members, with additions primarily of

public health policy experts from Ministries of Health, was published for a further period of

public consultation (extended until 2 February 2024). In December 2023, one member of the

proposed GDG list asked to be removed due to scheduling conflicts.

9. What are the criteria for selection of the GDG members?

The standard criteria for the selection of technical experts for the GDG include (a) technical

expertise in the subject matter as defined in the scope of the approved guidelines proposal; (b)

geographic representation; (c) gender diversity; (d) representatives of people affected by the

guidelines; and (e) end users (i.e., people who will use the guidelines such as health policy

makers and health professionals).

In the specific case of this guideline, the following profiles were considered for the members of

the GDG: