Because of psychopathologization of transgender people, care systems around the world are organized around specialized psychiatric services that control access to other parts of transition related-care. This organization has been criticized for many years by transgender people and human rights organizations, indicating a low level of satisfaction with current systems. In addition, recent social changes have highlighted a significant gap between needs and access to services. These elements make it possible to establish that today, the organization of transition-related care by specialized psychiatric services is no longer consistent with issues of rights, public health and participation of service users.
These elements are largely present in France where care pathways are almost exclusively under the control of a small number of specialized services. This organization has long been criticized by organizations as well as by French authorities involved in rights or health. Although we lack national data, requests and delays, as well as the appearance of numerous alternative forms of community-based organization, highlight that the health gap is present in France. Finally, organizing through psychiatry also complicates access to other systems of care, particularly sexual and reproductive health.
The depsychopathologization by the World Health Organization (WHO) of transgender persons in the eleventh revision of the International Classification of Diseases adds a new conceptual limit to previous systems and calls for a rethinking of care pathways based on primary care. Beyond the inertia of existing systems and political considerations, the necessary reorganization of care pathways is slowed down by the absence of a clearly defined and tested alternative model.
The European metropolis of Lille represents a catchment area of more than one million inhabitants and has seen the emergence of several field initiatives centered around the Maison Dispersée de Santé, a community primary care center. These initiatives, which were originally developed in a harm reduction framework, now include care pathways that are entirely based on primary care, as well as a significant community participation component through a mixed group that includes transgender organizations and recently the formalization of a Trans User Committee in collaboration with the regional health authority. This system, which has been in place for several years, now supports nearly 500 people in their transition process.
Our work, which is part of a doctoral thesis in public health, aims to document these field initiatives, to conceptualize and to integrate them into a global and graduated approach built on the community health model developed by the WHO and Wonca. The objectives of this approach are to present a plausible alternative to the psychiatric pathways and to identify areas of future improvement.
In this presentation, we propose to present the contexts in which these initiatives have been developed, their current models and future avenues for evaluation and development. We believe that these local elements can participate in and enrich a more global reflection on the transformation of care pathways. Finally, since its creation, our work has involved transgender persons as researchers, which we believe is a guarantee of conceptual relevance and applicability.