1 Reisner SL

Poteat T

Keatley J

et al. Global health burden and needs of transgender populations: a review. 1 Reisner SL

Poteat T

Keatley J

et al. Global health burden and needs of transgender populations: a review. 2 Hatzenbuehler ML

Pachankis JE Stigma and minority stress as social determinants of health among lesbian, gay, bisexual, and transgender youth: research evidence and clinical implications. , 3 White Hughto JM

Reisner SL

Pachankis JE Transgender stigma and health: a critical review of stigma determinants, mechanisms, and interventions. 3 White Hughto JM

Reisner SL

Pachankis JE Transgender stigma and health: a critical review of stigma determinants, mechanisms, and interventions. 1 Reisner SL

Poteat T

Keatley J

et al. Global health burden and needs of transgender populations: a review. Around the world, transgender and gender diverse (TGD) people experience striking disparities in mental health outcomes.TGD individuals are more likely to suffer from post-traumatic stress disorder, anxiety, depression, substance use disorders and suicidality compared to the wider population.These disparities are thought to be secondary to a range of factors including inadequate access to gender-affirming care, minority stress, and discriminatory public policies.Structural factors increase vulnerability among TGD people to discrimination and violence, limit educational and job opportunities, increase the likelihood of poverty, undermine housing stability, restrict access to health care, and contribute to social exclusion.Gender affirmation across legal, medical, surgical, psychological, and social domains appears in particular to have profound effects on the health outcomes of TGD individuals.

4 UN Office of the High Commissioner for Human Rights

Statement on the occasion of International Transgender Day of Visibility, the IACHR and a UN expert urge States to guarantee the full exercise of the human rights of transgender persons. 5 UN General Assembly

Report of the Independent Expert on protection against violence and discrimination based on sexual orientation and gender identity. According to the UN, “…it is vital that States fully recognize gender diversity in order to guarantee full exercise of all the human rights of everyone, including trans and gender diverse persons”.The UN has persisted in their commitment to make gender congruent identity documents (IDs) for TGD people available. In 2018, a UN-appointed expert upheld a recommendation made by the UN High Commissioner for Human Rights that states should create simple administrative processes to issue legal IDs that reflect gender identity solely based on individual choice.However, TGD people in many parts of the world face substantial barriers or a complete inability to obtain gender-congruent IDs, which indicates a failure among several UN member states, including the USA, to uphold a basic human right for their TGD citizens. Not being able to access gender-congruent IDs also impacts other fundamental rights, such as the right to self-determination, dignity, and freedom, and it impairs the ability of TGD people to travel, access education, seek employment, collect social benefits, and access health care. Other potentially dire consequences associated with an incongruent ID include increased harassment, discrimination, and social isolation, which could have direct impacts on health and quality of life.

6 Scheim AI

Perez-Brumer AG

Bauer GR Gender-concordant identity documents and mental health among transgender adults in the USA: a cross-sectional study. Although it is clear that the inability to obtain gender-congruent IDs undermines TGD individuals' human rights, little is known about the direct association between gender-affirming IDs and mental health outcomes among TGD people. In an effort to begin to address this gap in the literature, Scheim and colleaguesdid a secondary data analysis in The Lancet Public Health that included 22 286 TGD participants from the 2015 US Transgender Survey—the largest survey conducted to date. According to the study, 10 288 (weighted percentage 45·1%) of the respondents did not have their preferred name and gender marker on any IDs, whereas 2332 (10·7%) had all IDs congruent with their identified name and gender marker. When compared with participants with no gender-congruent ID, those with all congruent IDs had lower prevalence of severe psychological distress (adjusted prevalence ratio 0·68, 95% CI 0·61–0·76), suicidal ideation (0·78, 0·72–0·85), and suicide planning (0·75, 0·64–0·87).

6 Scheim AI

Perez-Brumer AG

Bauer GR Gender-concordant identity documents and mental health among transgender adults in the USA: a cross-sectional study. 7 Kattari SK

Bakko M

Hecht HK

Kattari L Correlations between healthcare provider interactions and mental health among transgender and nonbinary adults. 3 White Hughto JM

Reisner SL

Pachankis JE Transgender stigma and health: a critical review of stigma determinants, mechanisms, and interventions. Scheim and colleagueshighlight a range of potential mechanisms through which gender incongruent IDs influence the mental health of TGD people. Not having gender-congruent IDs might increase their risk of experiencing discrimination and violence in non-affirming environments. The increased psychological distress associated with using an ID that does not match one's identity and the frequent experience of structural violence affects the willingness and ability to look for care.Not having legal affirmation of one's gender identity impairs TGD people's access to health care, employment, and social services, among others. This scenario increases the likelihood of health-care avoidance by those most in need.

8 Winter S

Diamond M

Green J

et al. Transgender people: health at the margins of society. The cross-sectional study design prohibits causal interpretation of the identified relationships, and reverse causation is plausible—those with better mental health might be better able to navigate the difficult bureaucratic requirements to obtain gender congruent IDs. Even with those limitations, the large dataset and careful inclusion of potential confounders strengthen the study design. Thus, the authors' findings support the need to increase the availability of and streamline the processes to obtain gender congruent IDs. Gaining gender-congruent IDs should be easy, affordable, and quickly completed by adequately trained officials at TGD-friendly environments.

1 Reisner SL

Poteat T

Keatley J

et al. Global health burden and needs of transgender populations: a review. , 7 Kattari SK

Bakko M

Hecht HK

Kattari L Correlations between healthcare provider interactions and mental health among transgender and nonbinary adults. , 9 Turban JL

Beckwith N

Reisner SL

Keuroghlian AS Association between recalled exposure to gender identity conversion efforts and psychological distress and suicide attempts among transgender adults. The authors report that participants with gender-concordant IDs had a lower prevalence of suicidal ideation and suicide planning. However, it is important to note that even among those with all gender-concordant IDs, 712 (30·0%) of respondents reported suicidal ideation in the previous year, substantially higher than the general population in the USA. This high rate speaks to the fact that although gender-concordant IDs are one crucial aspect of improving mental health among this population, a range of other factors continue to contribute to mental health disparities. These factors include a low level of family support for TGD people's gender identity, exposure to gender identity conversion efforts, high rates of poverty, unstable housing, and inadequate access to gender-affirming care, to name a few.

The study is highly relevant to efforts to improve the health and wellbeing of transgender populations. We hope that the results will encourage governments worldwide to remove barriers to gender-congruent IDs for TGD people. Although such initiatives will probably improve mental health disparities experienced by this population, more work needs to be done. We must also address the multitude of other factors contributing to these disparities, including the high rates of violence and discrimination, limited access to gender-affirming medical, surgical, and mental health care, and a litany of minority stressors experienced by TGD populations.

We declare no competing interests.