CHAPTER TWO: REVIEW OF THE LITERATURE

Outline of Literature Review

This thesis explores a vital area yet emergent = area of inquiry. While much has be= en done to explore social determinants of health, the body of literature on transgender health is considerably = less developed. Many have decried = the lack of research in this area, especially in light of the disproportionate burden of morbidity and mortality demonstrated in early studies. In 2002, Boehmer attempted to quantify the disproportionate lack of LGBT research by reviewing all Medline articles dealing with these topics. In the past 20 years, only 0.1% of Medline articles dealt with issues related to lesbian, gay, bisexual, or transgender health. Of this set, articles addressing transgender health (including word variants such as transexual, intersex, or transvestite) were the most underrepresented. Only 346 of the 3777 LGBT articles= , or 0.0000% of all Medline articles addressed transgender health³². Three factors contribute to this dearth. First, the phenomena = of being transgender is low-incidence, resulting in a relatively small sample = population. Second, researchers have difficulty accessing this hidden population. Third, bias has directly affected the ability of researchers to get funding for this research area, and likely impacts personal choices about whether to study it as well. = In light of this acknowledged dearth, extra effort has been taken to augment published literature with locally published community needs assessments in = this review.

The review begins with a very brief overview of social determinants of health to provide a necessary foundation for the wor= k. This review will be based around t= he framework for social determinants proposed by the World Health Organization (WHO). Following this, the literature on transgender health outcomes will be presented. After these two fundamental areas = are covered, the literature on social determinants of transgender health will be presented, again organized as per the WHO framework.

Social Determinants of Health

The emergence of the importance of social determinants of health is intertwined with two major epidemiological shifts= in health during the 1900s. In t= he year 1900, eleven major infectious conditions accounted for 40% of all population mortality³³. Infectious viruses were the single largest cause of death, and as a result, a major health threat on both a pu= blic and a personal level. Epidemi= cs that affected full communities were all too common. In comparison, the three major chr= onic conditions: heart disease, cancer, and stroke; were responsible for less th= an 20% of the full mortality burden. The early 1900s marked an enormous shift in public health. During this era, many of the virus= es that had routinely taken thousands of lives in each new generation lost the= ir ability to sweep through populations with such vigor. Scarlet Fever, Typhoid, Measles, Whooping Cough, Diphtheria and others slowly faded from being household nam= es and fears. This precipitous d= rop in viral outbreaks was roughly coincident with the development of effective vaccinations or treatments for the diseases. This fact fueled theories that med= ical advancements were spurring declines in mortality. But as early as the 1950s, dissent= ers started to challenge that view³⁴. By the 1970s, evidence had accumul= ated and that widespread view started to change. As McKinlay and McKinlay aptly poi= nt out, the history of health improvements in the 1900s is relatively independ= ent of medical interventions³³. McKinlay refers to McKeown’s theories that nutrition, rising standard of living, and better hygiene may = all be key factors in this change^35-37. McKeown’s factors each close= ly intertwine with social class, opportunities and environmental infrastructure. In an epidemi= ological shift that did much to transform the face of health on a personal and public level, the original bio-chemical explanation was proven incorrect, and a social-environmental explanation replaced it as the largest causal factor.<= span style=3D'mso-spacerun:yes'> In the years following, a substant= ial body of work on social determinants of health developed, and has served as = the basis for and foreshadowed our current understanding of the balance between biological and social explanations for health outcomes.

Cassel ³⁸uses the insights of R. = Dubos³⁹ to demonstrate a second fundamental shift in disease epidemiology, this time in the later 20^th= century. While epidemiologica= l work early in the century had necessarily centered on destructive viruses, many = of the diseases faced later in the century were not the result of a contagious= and highly destructive agent, instead “the [most common] microbial diseases... [arose] from the activities of microorganisms that are ubiquito= us in the environment”³⁸. Thus, instead of the epidemics of = years before, it was now most often endemic factors that defined the landscape of disease. The magnitude of this change was demonstrated by the shift in mortality demographics by the 1970s. The eleven viral condi= tions which had reigned as the single largest health threat in 1900 were now attributed to less than 10% of all mortality. This represented a precipitous dro= p from the 40% of all deaths they caused at the beginning of the century. Further, the three major chronic conditions, which had previously accounted for less than 20% of all mortali= ty, now accounted for well over 50% of all mortality³³. This shift in mortality call= ed for new paradigms to understand the question, “then why this person and n= ot that one”? If all peopl= e are exposed to disease causing agents, what differentiates those who get disease and those that do not?

From this question arose the theory of gener= alized effect of the social environment on host resistance³⁸. Cassel elegantly builds the case that social support systems and other social fact= ors, such as integration, identification and expectation, all combine to create = an effect on a person that either renders them more or less susceptible to the= ir environmental disease causing agents. If the experiences are negative, such as isolation, unmet expectatio= ns, or lack of identification, then the person is more susceptible to illness a= nd will become sick more often. = If the experiences are positive, such as greater level of social support, then the person is more resistant to endemic disease causing agents, and therefore g= ets sick less often.

Cassel&#= 8217;s theory is directly evocative of a seminal work in the field of sociology, Durkheim’s Suicide^40<=
/sup>. “Durkheim was perhaps the fi= rst scholar to attempt to explain social phenomena not only in terms of individ= ual characteristics but in terms of population-based characteristics.”^41<=
/sup> His analysis of statistical data f= rom the late 1800s directly echoes the work of social epidemiologists today. By disaggregating suicide data, he= was able to demonstrate that a seemingly individual phenomenon, suicide, follow= ed different patterns in different communities. Further, he posited that these differences were explained by social environmental issues, such as common beliefs, customs, and religious ideology.&= nbsp; This work led to a long tradition of sociological studies that used = both social markers and health outcomes to explore an issue^41<=
/sup>. Increasingly, scientists from both= the field of sociology and epidemiology (as well as psychology) are working together^{42,=
43}. To the credit of these collaborati= ons, Medical Sociology is a burgeoning subfield of sociology. As well, Social Epidemiology is a promising subfield of epidemiology. While some detractors argue that social factors and biological facto= rs should remain more separate^44<=
/sup>, an increasing number of researchers and health policymakers have wholeheartedly adopted an expanded version of Durkheim’s original proposition, that social determinants provide key insight into health outcomes.&= nbsp;

Social determinants of health have been defined by the World Health Organization (= WHO) as “the economic, social and cultural factors that influence individu= al and population health both directly and indirectly, through their impact on psychosocial factors and biophysiological responses.^45<=
/sup>” Recognizing the importance and pot= ential large-scale impact of basing economic and health policy decisions on knowle= dge of social determinants, WHO’s Regional Office for Europe has launched a campaign to promote public awareness of social determinants = of health. A key component of th= is campaign is to disseminate the latest available information on the topic. To that end, WHO’s Social Determinants of Health: The Sol= id Facts⁴⁶, summar= izes the current scientific knowledge of social determinants in a straightforward framework. In this publication, WHO posits a framework for social determinants of health, organizing them into ten key categories.<= span style=3D'font-family:Arial;mso-bidi-font-family:"Times New Roman"'>

<= span style=3D'font-family:Arial;mso-bidi-font-family:"Times New Roman"'>

To provi= de a foundation for the specific topic of this thesis, a brief summary of the is= sues and evidence in each category will be presented here.

The social gradient

Perhaps = the most fundamental of social determinants of health, the social gradient of health refers to an axiom that has been proven repeatedly: health is direct= ly proportional to socio-economic status (SES). As ones socio-economic status climbs, ones health can be expected to improve as well. Further, happiness and = life expectancy are also bundled in this gradient and will improve concomitant w= ith health^47<=
/sup>. While the magnitude of the effect varies, this relationship holds true across societies and over time periods= ^48<=
/sup>. It is named a gradient because the= re is no threshold level of effect of SES on health as might be expected. The impact of SES on health starts= at the lowest measurable level, and increases gradually past the point where a person is able to reasonably afford and access all needed prevention or care interventions^47<=
/sup>. The differences are profound, “People further down the social ladder run at least twice the risk of serious illness and premature death as those near the top.” ADDIN EN.CITE <EndNote><Cite><Author>WHO Regional Office for Europe.<= ;/Author><Year>2003</Year><RecNum>2</RecNum><= record><rec-number>2</rec-number><ref-type name=3D"Electronic Source">12</ref-type><contributors><authors><a= uthor>WHO Regional Office for Europe.,</author></authors></contributors><titles>&= lt;title>Social determinants of health: the solid facts</title></titles><volume>2005</volume><numb= er>February 6th</number><edition>2nd</edition><dates><year&g= t;2003</year></dates><pub-location>Denmark</pub-locati= on><publisher>World Health Organization</publisher><isbn>92 890 1371 0</isbn>= <urls><related-urls><url>http://www.euro.who.int/document= /e81384.pdf</url></related-urls><pdf-urls><url>http= ://www.euro.who.int/document/e81384.pdf</url></pdf-urls></ur= ls><research-notes>The field of the social determinants of health is perhaps the most complex and challenging of all. It is concerned with key aspects of people’s livi= ng and working circumstances and with their lifestyles. It is concerned with t= he health implications of economic and social policies, as well as with the benefits that investing in health policies can bring. Agis D. TsourosH= ead, Centre for Urban HealthWHO Regional Office for Europe</research-notes></record></Cite></EndNote>^46<=
/sup>

The prof= ound impact of SES on health has led some to consider SES a key risk factor for disease^47<=
/sup>. But the social gradient is a macro= -level explanation of effect, encompassing many others. According to Marmot, “The so= cial gradient in health is influenced by such factors as social position; relati= ve versus absolute deprivation; and control and social participation.” Most of these factors, along with = other components of SES, interact with other social determinants listed here.

Stress

In contr= ast to SES, the bio-physical effects of stress can be easily measured. Under stress the human body has an immediate neuroendocrine response, releasing both adrenalin and cortisol, w= hich in turn trigger a host of physical responses. An evolutionary adaptation, this reaction assists in dealing with short-term, possibly lethal threats. While short-term, possibly-l= ethal threats are less common as humans diverge from their hunter-gatherer ancest= ry, short term stress such as might be experienced under a work deadline, follo= wed by reward, has been shown to be generally health promoting^49<=
/sup>. But evidence shows that frequent or long-term stress may be mal-adaptive, essentially creating “wear and = tear on the organism”^50<=
/sup>, and leading to a broad rang= e of health problems. Research on = stress related health problems demonstrates adverse outcome in such disparate area= s a mental health to immune functioning to cardiovascular disease.^{46,=
51,
52}

Mal-adap= tive, long-term stress can be a result of many factors, among them: inferior soci= al position, low sense of control, social isolation, low self-esteem, insecuri= ty, and anxiety. Further, the eff= ects of stress have been shown to accumulate over the life-span. With repeated stress, a person’s physiological response changes, creating a new lev= el of stress-reactivity. In 1998, McEwan coined the term “allostatic load” to describe the physic= al damage caused by accumulated stress.^53<=
/sup>

Early life

Regardless of culture or local health systems, = health in later life is strongly influenced by early life experiences⁵⁰. Health stressors in pregnancy can = have a direct and long-term effect on the child.&= nbsp; Likewise, early life experiences impacting growth and social develop= ment affect the biological development of a child, ultimately impacting later he= alth outcomes. Lastly, many health habits are set early in life, affecting a person’s predisposition to risky healthy behaviors such as smoking or poor diet.^{46, 54}<= !--[if supportFields]> Education affects this rubric as w= ell, as youth who achieve greater levels of education are prone to better health behaviors, higher SES, and concomitant access to health care. As summed up by Wadsworth, “A principal process in the association of childhood social factors with adult illness is the accumulation of vulnerability during childhood and adult life.”⁵⁰ (p. 50).

Social exclusion

The category of social exclusion includes pover= ty, social exclusion, and discrimination. While this demonstrates the intertwined nature of the subcategories,= it also makes the macro level category of social exclusion broad and unwieldy.= Social gradient is a phenomenon that affects all classes. In compa= rison, poverty as a specific health risk is listed separately here, because of the stark deleterious impact it has on health.= Epidemiological studies have shown the close relationship between poverty, addictions, and mental health issues⁴⁶. Evidence is accumulating to sugges= t that material conditions are the foundation for this progressive slide into ill = health. Lack of access to adequate housing, nutrition, respite, and medical care, employment, and opportunities to participate in society compromises ones physical health, mental health, and drives choices about healthy behaviors.&nb= sp; As with the allostatic load, the effects of poverty are also being s= hown to be cumulative, decreasing resistance over the lifespan. Increasingly researchers are broad= ening this perspective, focusing not only at poverty, but at the newer category of “social exclusion”. Social exclusion includes poverty, but adds a second key phenomenon,= the “process of marginalization” (p. 222)