Richard Horton

Transgender health: an opportunity for global health equity

The Lancet is publishing its fi rst Series on transgender health. Transgender people live in all countries, but their acceptance by communities and freedom to live with their chosen gender identity or expression varies according to culture and society. This Series, led by Sam Winter of Curtin University and Kevin Wylie of the University of Sheffi eld, is the result of a committed eff ort by experts and members of the transgender community—some of whom contributed to a piece about community voices for the Series. The initial peer review meeting held in Beijing, in 2014, engaged members of the regional Asia–Pacifi c transgender community and international reviewers. When the authors began their work in 2011, they warned The Lancet that transgender health was largely a concern of specialist journals. Yet the challenges that face the transgender community are global, multifactorial, and extend across all medical specialties. These challenges— so eloquently described by Sari Reisner and colleagues in their Series paper as “situated vulnerabilities”— demand intersectoral responses. Access to general health care is among the least researched fi elds of transgender health, and refl ects inadequate knowledge of transgender health needs by primary health care workers and health professionals in other specialties. In the process of developing this Series the very word transgender initially evoked surprising and varied responses, ranging from curiosity to dismissal as a “mere” psychiatric disorder. Other concerns were raised: the invisibility of transgender people because of lack of legal recognition; the inability to account for health risks and disease burdens in transgender people because of inadequate population approaches; and stigma which keeps individuals out of health services. Why is the average primary care physician, population researcher, or policy maker so uninformed about the needs of transgender individuals? The answers lie in insuffi cient awareness about transgender issues and a lack of acceptance of transgender people. This Series is an eff ort to further understand, and provide a framework to improve, the health and lives of transgender people globally. The Lancet Counting Births and Deaths Series in 2015 reported that “to achieve universal health coverage and sustainable development for all, we need to know who the so-called ‘all’ are, and measure the risks to their health”. However, as Sam Winter and colleagues point out in the fi rst Series paper, exactly how many transgender people there are, or how many experience a need for health care, is largely unknown. One of the challenges is the diversity of the transgender community. Some people live with their gender incongruence, but decide not to transition. Some individuals make a social transition only, without accessing any gender-affi rming health care. Yet stigma discourages many people from making their transgender status known to others or accessing health care at all. Furthermore, as highlighted by Sari Reisner and colleagues, few population level data exist with which to monitor the health of transgender people worldwide, because routine national and international health surveillance in most countries does not assess gender identity as an equity stratifi er. Studies restricted to people with gender identity disorder or gender dysphoria do not capture the full spectrum of transgender people, such as those with non-binary transgender identities. Meeting the diverse health needs of transgender people is possible as Kevan Wylie and colleagues show in the second Series paper. They provide a review of the various types of clinical services and models of care that the transgender community can use. But accessing this Published Online June 17, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)30675-4

Offline: Iraq—the prelude to a global war

“US military offi cials are expecting that Iraq will use chemical and biological weapons against US and allied forces in the event of war”, wrote our American correspondent, Michael McCarthy, on Feb 22, 2003. He reported on preparations by US forces, which seem surreal now, to protect troops in Iraq from nerve agents, anthrax, botulinum toxin, and even smallpox. Just a few weeks earlier, 500 public health scientists from the London School of Hygiene & Tropical Medicine had written an open letter to then Prime Minister Tony Blair on the consequences of a war in Iraq. They drew attention to likely civilian casualties, civil war and a refugee crisis, famine and epidemics, and the eff ects of confl ict on children’s health and development. Carolyn Stephens and her cosignatories also pointed (with disturbing prescience) to “the most worrying eff ect” of a war in Iraq—”its role as an escalator of collective violence”. “Confl ict”, they wrote, “escalates after use of collective force, as violence becomes a more common and legitimated form of political or social action.” On March 8, 2003, Elisabeth Benjamin and a team from the New York-based Center for Economic and Social Rights described the preparedness of Iraq’s health system to respond to the eff ects of a war. They reported pervasive weaknesses—in primary care and hospital services, basic equipment, supplies of medicines, and public health. “Our team found that military intervention in Iraq will severely aff ect an already vulnerable population—a humanitarian disaster is likely to ensue.” On March 20, the bombings on Baghdad began. This week, as violence in Baghdad continued unchecked, the long awaited Chilcot Inquiry published its fi ndings. What was the basis for war? How was the decision to go to war made? How was the war conducted? What lessons can be learned? Answers to these questions have now been off ered. But what of medicine and public health?

Offline: The crisis in scientific publishing

Back in 1990, no one used the words strategy, brand, or monetisation. Scientifi c publishing was a gentle and languorous aff air. Manuscripts edited by pencil. Page layout with scissors and glue. Proof reading over a pint of beer at our typesetters. And when the weekly issue went to press, a small toast made with a glass of sherry. The Lancet then occupied a beautiful rabbit warren of an 18th-century town house in Bloomsbury. You could see a blue plaque across Bedford Square marking the home of the journal’s founder, Thomas Wakley. It seems another world compared with today. Now we work on the hypermodern tenth fl oor of a steel and glass building in the City of London. Technology has transformed artisans into professionals. And the whole paraphernalia of what it takes to publish a journal—from media to marketing, bespoke production to digital publication—has allowed us to off er (what I sincerely hope is) a better service to authors and users (the reader, I am afraid, was an early casualty of the Internet). Yet despite these advances, the state of scientifi c publishing today has never been more precarious. And publishers (and editors) have few solutions. Instead, they are preoccupied by a host of anxieties. Will innovative startups, such as ResearchGate, eliminate the need for journals? Will predatory open access destroy public trust in science? Is copyright dead? Editors too are lost. Is peer review meeting the needs of modern multidisciplinary science? Does the threat of research misconduct mean we should be endemically suspicious of authors? Is lack of reproducibility in some categories of research proof of fatal fl aws in the scientifi c method? These are important questions. But they are peripheral to the main danger. The more serious question (that should be) gnawing away at the soul of the modern publisher/editor is: what am I here for?