Policy Tag: Stigmatisation

Adopted by the 66th WMA General Assembly, Moscow, Russia, October 2015

PREAMBLE

In most cultures, an individual’s sex is assigned at birth according to primary physical sex characteristics. Individuals are expected to identify with their assigned sex (gender identity) and behave according to specific cultural norms strongly associated with this (gender expression). Gender identity and gender expression make up the concept of “gender” itself.

There are individuals who experience different manifestations of gender that do not conform to those typically associated with their sex assigned at birth. The term “transgender” refers to people who experience gender incongruence, which is defined as a marked mismatch between one’s gender and the sex assigned at birth.

While conceding that this is a complex ethical issue, the WMA would like to acknowledge the crucial role played by physicians in advising and consulting with transgender people and their families about desired treatments. The WMA intends this statement to serve as a guideline for patient-physician relations and to foster better training to enable physicians to increase their knowledge and sensitivity toward transgender people and the unique health issues they face.

Along the transgender spectrum, there are people who, despite having a distinct anatomically identifiable sex, seek to change their primary and secondary sex characteristics and gender role completely in order to live as a member of the opposite sex (transsexual). Others choose to identify their gender as falling outside the sex/gender binary of either male or female (genderqueer). The generic term “transgender” represents an attempt to describe these groups without stigmatisation or pathological characterisation. It is also used as a term of positive self-identification. This statement does not explicitly address individuals who solely dress in a style or manner traditionally associated with the opposite sex (e.g. transvestites) or individuals who are born with physical aspects of both sexes, with many variations (intersex). However, there are transvestites and intersex individuals who identify as transgender. Being transvestite or intersex does not exclude an individual from being transgender. Finally, it is important to point out that transgender relates to gender identity, and must be considered independently from an individual’s sexual orientation.

Although being transgender does not in itself imply any mental impairment, transgender people may require counseling to help them understand their gender and to address the complex social and relational issues that are affected by it. The Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM-5) uses the term “gender dysphoria” to classify people who experience clinically significant distress resulting from gender incongruence.

Evidence suggests that treatment with sex hormones or surgical interventions can be beneficial to people with pronounced and long-lasting gender dysphoria who seek gender transition. However, transgender people are often denied access to appropriate and affordable transgender healthcare (e.g. sex hormones, surgeries, mental healthcare) due to, among other things, the policies of health insurers and national social security benefit schemes, or to a lack of relevant clinical and cultural competence among healthcare providers. Transgender persons may be more likely to forego healthcare due to fear of discrimination.

Transgender people are often professionally and socially disadvantaged, and experience direct and indirect discrimination, as well as physical violence. In addition to being denied equal civil rights, anti-discrimination legislation, which protects other minority groups, may not extend to transgender people. Experiencing disadvantage and discrimination may have a negative impact upon physical and mental health.

RECOMMENDATIONS

  1. The WMA emphasises that everyone has the right to determine one’s own gender and recognises the diversity of possibilities in this respect. The WMA calls for physicians to uphold each individual’s right to self-identification with regards to gender.
  2.  The WMA asserts that gender incongruence is not in itself a mental disorder; however it can lead to discomfort or distress, which is referred to as gender dysphoria (DSM-5). 
  3. The WMA affirms that, in general, any health-related procedure or treatment related to an individual’s transgender status, e.g. surgical interventions, hormone therapy or psychotherapy, requires the freely given informed and explicit consent of the patient. 
  4. The WMA urges that every effort be made to make individualised, multi-professional, interdisciplinary and affordable transgender healthcare (including speech therapy, hormonal treatment, surgical interventions and mental healthcare) available to all people who experience gender incongruence in order to reduce or to prevent pronounced gender dysphoria.
  5.  The WMA explicitly rejects any form of coercive treatment or forced behaviour modification. Transgender healthcare aims to enable transgender people to have the best possible quality of life. National Medical Associations should take action to identify and combat barriers to care.
  6.  The WMA calls for the provision of appropriate expert training for physicians at all stages of their career to enable them to recognise and avoid discriminatory practises, and to provide appropriate and sensitive transgender healthcare.
  7. The WMA condemns all forms of discrimination, stigmatisation and violence against transgender people and calls for appropriate legal measures to protect their equal civil rights. As role models, individual physicians should use their medical knowledge to combat prejudice in this respect.
  8.  The WMA reaffirms its position that no person, regardless of gender, ethnicity, socio-economic status, medical condition or disability, should be subjected to forced or coerced permanent sterilisation (WMA Statement on Forced and Coerced Sterilisation). This also includes sterilisation as a condition for rectifying the recorded sex on official documents following gender reassignment.
  9.  The WMA recommends that national governments maintain continued interest in the healthcare rights of transgender people by conducting health services research at the national level and using these results in the development of health and medical policies. The objective should be a responsive healthcare system that works with each transgender person to identify the best treatment options for that individual.

Adopted by the 64th General Assembly, Fortaleza, Brazil, October 2013 and
revised by the 74th WMA General Assembly, Kigali, Rwanda, October 2023

 

PREAMBLE

Individuals who identify as LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual, and other identities beyond these) represent a broad and fluid spectrum of natural sexual orientations, gender identities, gender expressions, and sex characteristics. While LGBTQIA+ people may share common cultural and social experiences and shared goals of justice and equity in the face of detrimental, discriminatory treatment and even violence, these are diverse communities facing distinct challenges and with specific needs in healthcare and beyond.

This statement is specifically focused on lesbian, gay, and bisexual people.

Healthcare professionals encounter many aspects of human diversity when providing care, including different natural variations of human sexuality.

A large body of scientific research indicates that being lesbian, gay, or bisexual constitute natural variations of human sexuality without any intrinsically harmful health effects. They do not constitute a disorder or illness that requires treatment or cure and any efforts to do so are contrary to the ethical practice of medicine.

Homosexuality and bisexuality are consequently not included in the World Health Organization’s (WHO) International Classification of Diseases (ICD 11).

However, direct and indirect discrimination, both interpersonally and at the institutional level, anti-homosexual or anti-bisexual legislation and human rights violations, stigmatisation, criminalisation of same-sex partnerships, peer rejection, and bullying continue to have a serious impact upon the psychological and physical health of lesbian, gay, or bisexual people. These negative experiences are perpetuated by a lack of education in society on the different natural variations of human sexuality. They lead to poorer health outcomes, including higher prevalence rates of depression, anxiety disorders, substance misuse, and suicidal ideations and attempts. As a result, the suicide rate among lesbian, gay, or bisexual adolescents and young adults significantly higher than that of their heterosexual peers.

These negative outcomes can be exacerbated by other intersectional factors, including but not limited to national origin, race, ethnicity, gender, age, religion, gender identity, socioeconomic status, or disabilities.

In addition, false and baseless pathologisation of lesbian, gay, or bisexual identities leaves such individuals at risk of being coerced into so-called “conversion” or “reparative” procedures. These harmful and unethical practices, also sometimes referred to as sexual orientation and gender identity change efforts (SOGICE), are intended to suppress or change a person’s natural sexual orientation or gender identity. These methods have no medical indication, lack any evidence of effectiveness, and represent a serious threat to the health and human rights of those subjected to these practices. They can lead to anxiety, depression, low self-esteem, substance abuse, problems with intimacy, and suicide.

Negative experiences in healthcare may affect the patient-physician relationship, leading lesbian, gay, and bisexual individuals to avoid accessing care where it is available. They may also withhold their sexual orientation from physicians due to the resulting lack of confidence that they will receive the appropriate treatment and concerns about the safety and confidentiality of their healthcare environment. Without this information, it may be more challenging for physicians to provide targeted care that takes into account the specific health needs of lesbian, gay, or bisexual patients.

Lesbian, gay, or bisexual physicians, medical students, and other health professionals also face discrimination, disadvantages, marginalisation and bullying in the workplace, in schools, in professional organisations, and beyond. Harmful working and learning environments can lead to stress and burnout, especially among marginalised individuals.

 

RECOMMENDATIONS

  1. The WMA strongly asserts that being lesbian, gay, or bisexual does not represent a disease, but rather natural variations within the range of human sexuality.
  2. The WMA condemns all forms of stigmatisation, criminalisation of and discrimination against people based on their sexual orientation.
  3. The WMA asserts that psychiatric or psychotherapeutic support, when needed, must not focus upon the variations of sexuality itself, but rather upon conflicts which arise between those variations and religious, social and internalised norms and prejudices, as well as the health needs of the individual patient.
  4. The WMA unequivocally condemns so-called “conversion” or “reparative” methods. These constitute violations of human rights and are unjustifiable practices that should be denounced and subject to sanctions and penalties. It is unethical for physicians to participate during any step of any such procedures.
  1. The WMA calls upon all physicians to:
    • classify physical and psychological diseases on the basis of clinically relevant symptoms according to ICD 11 criteria regardless of sexual orientation, and to provide quality, evidence-based care in accordance with internationally recognised treatments and protocols and in keeping with the principles set forth in the WMA International Code of Medical Ethics;
    • provide a safe, respectful, and inclusive healthcare setting for lesbian, gay, and bisexual patients;
    • foster safe, respectful, and inclusive work and learning environments for lesbian, gay, and bisexual physicians, medical students, and other health professionals;
    • engage in continuing education and professional development to better understand the specific health needs of lesbian, gay, and bisexual patients and the benefits of certain treatments;
    • where appropriate, involve patients’ same-sex partners and same-sex parents in healthcare discussions in keeping with the patient’s preferences, respecting their consent, and with due regard for patient confidentiality;
    • speak out against legislation and practices violating the human rights of lesbian, gay, and bisexual people, which may also negatively impact the healthcare system at large;
    • reject and refuse to participate in any step of so-called “conversion” or “reparative” methods.
  1. The WMA calls upon constituent members and professional associations to:
    • advocate for safe and inclusive working and learning environments for lesbian, gay, and bisexual physicians, medical students, and other health professionals;
    • establish and enforce non-discriminatory policies in keeping with the WMA Statement on Non-Discrimination in Professional Membership and Activities of Physicians;
    • create guidelines for physicians outlining the specific physical and mental health challenges facing lesbian, gay, and bisexual patients, where appropriate;
    • Where possible, promote changes to medical education, specialty training and CME/CPD curricula to create sensitivity and awareness of the specific health needs of lesbian, gay, and bisexual patients;
    • establish channels for lesbian, gay, and bisexual physicians to report incidents of discrimination or bias against themselves or lesbian, gay, or bisexual patients;
    • in environments where confidentiality and patient safety are guaranteed and data cannot be abused, encourage voluntary data collection in the clinical setting and regular reporting on the health outcomes of lesbian, gay, and bisexual patient groups, while also taking intersectionality into account, to ensure and further improve targeted and appropriate healthcare provision;
    • actively condemn so-called “conversion” or “reparative” methods as unethical.
  1. The WMA calls upon governments to:
    • reject and repeal anti-homosexual or anti-bisexual legislation;
    • condemn and ban so-called “conversion” or “reparative” methods;
    • promote policies that counteract health-related and other inequities caused by overt and implicit discrimination against lesbian, gay, and bisexual people;
    • encourage education from an early age on diverse natural variations of human sexuality to increase acceptance and with the ultimate aim of promoting better physical and mental health for all individuals.