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Caitlyn Jenner. Laverne Cox. Ruby Rose. The so-called bathroom wars. Transgender issues have never had a higher profile.

But visibility doesn't necessarily translate into equality, human rights, improved health or better lives for transgender people. Beyond the distorting Hollywood spotlight and the infantile U.S. political disputes about who can pee where, very real issues remain for the 25 million transgender women and men (and those who identify as non-binary) worldwide.

One of the biggest challenges is getting decent health care, an issue highlighted in a recent edition of the British medical journal The Lancet.

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The authors, led by Professor Sam Winter of the School of Public Health at Curtin University in Perth, Australia, provide the first firm estimates of how many transgender people are living around the world – somewhere between 0.3 and 0.5 per cent of the population. While that is a small minority, it is a larger number than many assumed. That is because, like gay men and lesbian women of yore, many remain closeted and hidden, often out of fear for their safety.

The research found that 35 per cent of transgender people have been victims of violence because of their gender (or ambiguity of their gender, if you prefer.)

Between 2008 and 2016, researchers catalogued 2,115 murders of transgender people, likely a large underestimate of the extent of these hate crimes. Self-inflicted violence is an even bigger problem, with 41 per cent of transgender people having attempted suicide at least once.

For a long time, "gender incongruity" has been considered a mental illness (homosexuality was long classified in the same manner). The Lancet articles make it clear that it is not. The way that transgender people are treated, however, causes considerable stress and isolation which, in turn, can trigger depression, anxiety, post-traumatic stress disorder and suicidal ideation. Navigating the health-care system can be difficult, particularly for young people struggling with their sexual identity. Gender dysphoria can be frightening and confusing.

The health system should be a safe place, where there is understanding and compassion. Yet, when people reach out for help they too often find doctors, nurses and other health professionals who are ill-informed, openly display prejudice and resist offering treatment and care. This discrimination and stigma can push transgender people away, leaving them at risk of further ill health.

Transition can be tough and, in much of the world, almost impossible. Some make a physical transition, undergoing hormone therapy and surgery, while others choose a social transition, adopting a new gender (or no specific gender) without physical changes. And, of course, some hide their sexual identity and feelings. While access to gender-confirming surgery is important, transgender health is more than hormones and surgery.

The lack of legal and human-rights protections often drives transgender people to the fringes of society, for example to sex work. As a result, they have rates of HIV-AIDS that are 49 times those of the general population, as well as high rates of smoking, alcohol abuse, drug abuse and the most damaging health conditions of all, homelessness and poverty.

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According to the authors of the Lancet articles, the solution begins with legal recognition and rights. In most countries, there is no legal right to change your name or gender. Transgender people are often subjected to mandatory sterilization, including in a number of European countries. So-called conversion therapy to "cure" people of gender preferences is still commonplace. In a number of countries in Africa and the Middle East, ambiguous sexuality is equated with homosexuality and can result in criminal prosecution and jail, not to mention persecution by police.

In Canada, the situation is markedly different. The federal government has promised to protect gender identity in the Human Rights Act and the Criminal Code and is moving toward gender-neutral identity policies. All-gender bathrooms are becoming commonplace. Yet the health system remains a tough nut to crack. There are still long waits and many barriers to gender-confirming therapy, and little gender-affirming care, other than some groundbreaking programs such Trans Care B.C. As Prof. Winter writes: "In no other community is the link between rights and health so clearly visible as in the transgender community."

When we respect and normalize the rights and choices of others, including the right to determine one's gender, we are all healthier for it.

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