In a society that has long struggled to shake off the effects of discrimination and disenfranchisement, we have looked to our institutions to act as neutral mediators, unbiased by constructs of race, gender, class, or experience. Yet we have found that our public services, our courts, and our bureaucracies have often functioned with prejudice. Medicine is no different. Despite taking an oath which states that, “warmth, sympathy, and understanding may outweigh the surgeon’s knife”, and a culture that promises fair and equal treatment, history and controversy have long attested to the reality of medical discrimination (Tyson, 2001). Much like many other groups dealing with disenfranchisement, the transgender community has frequently faced such injustice. Despite the trans experience having a close relationship with modern medicine, which was intensified by the advent of sex reassignment surgery1 in the early 20th century, the system has often failed this community. Sadly, medical professionals have contributed to the disenfranchisement and disparate health outcomes of a group that already faces sociocultural persecution.
Transgender individuals often face a number of societal barriers in addition to those they encounter within medicine. According to the National Center for Transgender Equality, more than 60% of trans individuals have experienced serious acts of discrimination, which include eviction, loss of jobs, sexual or physical assault, and incarceration on the basis of their gender identity or expression (Grant, Mottet, & Tanis, 2015). Up to 50% of transgender people have experienced sexual violence, a proportion that is markedly higher than their cisgender2 counterparts (Transgender Rates of Violence, 2012). Trans individuals are also up to four times more likely to live in poverty (Kellaway, 2015). This financial insecurity further exacerbates issues that disenfranchise them, such as substance abuse, social immobility, and violence (Kellaway, 2015). The barriers of societal discrimination, economic instability, and physical danger leave trans individuals vulnerable to exploitation and compound the problems they face while attempting to access healthcare.
From a medical perspective, trans individuals suffer from depressingly bleak health outcomes. They are almost ten times as likely as the general population to attempt suicide, with almost half of all trans people attempting suicide during their lifetime (Testa, Sciacca, Wang, Hendricks & Goldblum, 2012). Depending on factors such as racial demographic and education level, trans people may have life expectancies as low as 30 years, in contrast to the average global lifespan of over 70 (Murphy, 2012). Due to economic instability and employment discrimination, trans people are often forced into “off the book” occupations, such as prostitution. Around 11% of those responding to the National Transgender Discrimination Survey have participated in sex work (Grant et al., 2015). These issues, along with a vulnerability to sexual assault and a lack of proper sex education resources, contribute to high HIV infection rates in trans communities, which are up to three times the national average (Clark, Babu, Wiewel, Opoku, & Crepaz, 2016). To compound this, HIV/AIDS programs fail to effectively address the needs of trans people, as it has been found that transgender HIV-positive patients were less likely to be virally suppressed than their cisgendered counterparts (National Healthcare Disparities Report, 2013). Viral suppression is the successful use of antiretroviral medication to keep the viral load of an HIV-positive patient below detectable levels and is considered a benchmark of successful ongoing treatment of the disease (National Healthcare Disparities Report, 2013). Dealing with the numerous and complex factors that have contributed to these health disparities is difficult, but addressing the problematic barriers that are present in clinical and professional environments is an important first step towards changing this issue.
New York City provided the perfect opportunity to explore and understand the experiences of those who work with transgender populations in clinical settings, bureaucratic capacities, or engage in academic research on the topic. Over the course of a week in NYC, I conducted interviews with practicing physicians, professors, and other experts who could provide insights into the issues faced by the trans community in medical settings. Each interview was 30-60 minutes and conducted in relatively informal settings. I asked experts a variety of open-ended questions focused on their concerns about the relationship between physicians and their transgender patients, the experiences of those disclosing their gender identity to medical professionals, the advancement of LGBTQIA+ issues in clinical and professional settings, and the effects that discrimination could have on patients in need of care.
Inclusivity of the Clinical Practitioner
I interviewed Dr. Mark Courey, the Division Chief of Laryngology at Mount Sinai Medical Center. Dr. Courey is experienced in procedures including vocal feminization/masculinization,3 which are pursued by many trans patients over the course of their transition care. He reflected on the fact that many professionals in the field were uninformed or even dismissive of trans identities, remarking that even those involved directly in trans care had been accosted for ignorant comments (Dr. Mark Courey, personal communication, March 5, 2018). Between misgendering4 and directly criticizing the interests of trans individuals pursuing surgical interventions, it seems that a fundamental barrier to effective care is having informed and respectful physicians. This issue has serious consequences which can extend to outright discrimination. Up to 1 in 5 transgender or gender non-conforming individuals have experienced refusal of care due to their gender identity (Grant et al., 2015). Historically, this denial had been acceptable. Up until the Affordable Care Act’s major provisions were enacted in 2014, many physicians held the right to exclude care on such grounds (Health Care Reform and LGBTQ People, 2018). Though this legislative protection has been valuable, it may not last, as many fear that the Trump Administration’s push to empower a Division of Conscience and Religious Freedom in the Department of Health and Human Services could re-invigorate such blatant discrimination (Kodjak, 2018). The experiences of Dr. Courey and his contemporaries reflect the inadequate inclusivity on the part of some physicians. Around half of trans people report having to educate their own doctors on trans medical care, a statistic reflected by the lack of education many professionals receive on the issue (Grant et al., 2015). Outside of the doctor’s office, the administrative elements of the American healthcare system produce similar issues.
Inclusivity of Insurance/Administrative Professionals
The administrative and insurance elements of healthcare suffer many of the problems experienced on the clinical side. I interviewed Cris Benjamin, a billing specialist working at Mount Sinai, who talked about lengthy battles with insurance providers to ensure clients received proper coverage. The American Medical Association, whose authority on medical ethics and practice is supported by its status as the largest organization of medical professionals in the United States, explicitly outlines policies that emphasize the importance of transition care in Resolution 122. The resolution states, “An established body of medical research demonstrates the effectiveness and medical necessity of mental health care, hormone therapy and sex reassignment surgery as forms of therapeutic treatment” (American Medical Association). Despite this, many providers work to challenge claims and create organizational roadblocks to avoid paying for critical treatments (Policies on LGBTQ Issues, 2018). Mr. Benjamin even outlined a specific tactic companies would use to delay treatment access: requiring that letters supporting the medical necessity of the procedure be filled out by two different physicians less than 60 days apart. Acquiring both supporting letters in under two months is a task that is often difficult to coordinate, especially for patients who lack robust financial resources or experience difficulty accessing healthcare (Cris Benjamin, personal communication, March 6, 2018). Despite often losing money, many companies will be voluntarily taken to court in order to delay paying for such procedures, adding extra time and anxiety to an already difficult process. Overcoming these barriers is arduous even in an urban setting, where professionals trained to help patients navigate these networks are readily available. For low income or rural populations, these extra steps may prove to be insurmountable. Even if a patient has access to experts that can help them navigate these barriers, the added stress of waiting and being scrutinized by administrators who do not understand their needs may dissuade individuals from trying to access this care at all.
General Perceptions of Transition Care
As a more general trend, I observed a lack of understanding about transition procedures such as facial feminization5 even from medical providers.6 Despite the fact that the American Psychiatric Association outlines a number of potential procedures that patients may wish to undergo in their guidelines for Gender Dysphoria treatment, which expands far beyond the narrow perceptions of the general public (What Is Gender Dysphoria, 2018), it seems that much like the general population, many professionals not specializing in LGBTQ+ healthcare hold very narrow views of trans care, understanding little more than the basics of sex reassignment surgery and “top surgery”.7 Everyone from insurance agents to physicians are in need of further education on the topic, a task that is frequently left to their own clients. Facial restructuring, vocal cord surgeries, and other procedures may be important components of an individual’s gender expression and social interaction, which are often key elements of the trans experience. Dr. Courey specifically addressed a lack of incentive for many providers to support these procedures, due to them being less intensive and less profitable than other more well-known procedures such as sex reassignment. In addition to this misperception of care, broader education on gender identity is also critical for improving patient experiences.
The Gender Binary and Its Effect on Clinical Practice
An unfortunate issue in trans medical care is a conceptual understanding that operates almost entirely in a gender binary. Many physicians perceive their patients as transitioning completely from a male to a female identity (or vice versa) rather than recognizing the complexity of gender identity and expression, which is often inadequately addressed by a binary system. Patients’ identities may not fall within a gender binary, and they may not wish to undergo treatments that would reflect such a limited view of gender identity and expression. While procedures such as sex reassignment may be seen as an important step for numerous individuals undergoing transition, this feeling is not universal. Physicians must be capable of considering their patients’ individual gender identity and presentation in order to be accommodating. On a more fundamental level, physicians and insurance providers must work to properly clarify pronouns and other identifying information their clients wish to utilize. Insurance providers are often guilty of this, as Mr. Benjamin discussed clients experiencing misgendering on their own insurance documentation. This is something which is sure to damage trust and create anxieties about the quality of care provided.
Many professionals observed a change in physicians after the Affordable Care Act banned open discrimination on the basis of sexual orientation and gender identity, with some making conscious efforts to be more accommodating. While this sort of policy may not have addressed more subtle forms of discrimination, it seemed to reduce the institutional tolerance of flagrantly biased treatment. As has been seen in the recent rise of hate crimes and acts of discrimination against trans individuals, some worry that the current administration’s apathy and discriminatory policy may be viewed as an endorsement by those determined to mistreat trans individuals (Strangio, 2018).
Diagnostic Policy and Its Controversies
These changes in medical culture will need to be complemented by shifts in diagnostic policy in order to repair the profession’s historically strained relationship with the trans community. A contentious issue has been the involvement of psychiatric diagnoses in the care process, with the inclusion of Gender Dysphoria in the DSM-V being particularly controversial. Especially considering psychiatry’s troubled history with the LGBTQIA+ community, such as the DSM-II pathologizing homosexuality and the creation of Transvestic Disorder in the DSM-V, many fear the consequences of the stigma that may be attached to such a diagnosis (Messih, 2017). In addition, there is criticism that the diagnosis opens the door to potentially distressing and abusive “treatments” that fail to effectively recognize the societal rejection which contributes to many patients’ distress (Messih, 2017). Perhaps this criticism reflects the inability of the DSM’s disease model to effectively encapsulate an issue with broader social implications. Yet there has been justification for Gender Dysphoria’s inclusion within the industry, as the diagnosis has been perceived as addressing the need for effective insurance coverage in order to access treatment, with the American Psychiatric Association outlining this need (What Is Gender Dysphoria, 2018). During my meeting with Renee Reopell of Children’s Hospital at Montefiore, they detailed the need to outline a tangible diagnosis in order for insurance companies to cover costs. Especially considering the economic vulnerability of trans populations, receiving a Freitagdiagnosis may be the deciding factor in whether their care is affordable (Renee Reopell, personal communication, March 8, 2018). Having an outlined diagnosis and treatment for Gender Dysphoria limits the ability of insurance providers to deny coverage or force costs on clients. Although in recent years, the policies tacked on by insurers have rendered this a moot point, as these extra roadblocks have negated the supposed benefits of the diagnoses’ inclusion.
Narrow Research Focus
On a broader population health level, improved research and representation is perhaps one of the most pressing issues that needs to be addressed. For example, the National Healthcare Disparities Report, conducted by the Department of Health and Human Services, only began tracking LGBT populations in 2011, reflecting a lack of long-term data for many of these groups (National Healthcare Disparities Report, 2013). Especially considering the disparities in lifelong health outcomes for trans individuals, longitudinal studies and comprehensive data will prove to be critical in helping to improve health outcomes. Additionally, a prominent issue that was brought up in several of my interviews was the narrow proportion of the trans community represented in most healthcare settings. Those who lack access to insurance don’t live in urban settings which provide a suitable variety of medical resources and don’t benefit from supportive social networks. Thus, they face a much more daunting path to transitioning. Considering the significant number of trans individuals—especially trans people of color—who live in poverty, face homelessness, or live in rural settings, our understanding of trans health issues may fail to adequately reflect the experiences of the greater population.
The Effects on Basic Care
There are a wide variety of experiences that reflect the challenges faced by individuals attempting to access basic medical care. Perhaps the best example of this experience is the documentary, Southern Comfort (2001), which details the experiences of Robert Eads, a trans man attempting to access treatment for his ovarian cancer in rural Georgia. Sadly, he finds that the resources available to address his illness are woefully inadequate, with many gynecologists outright refusing to treat him on the basis of his gender identity. While it is impossible to know what his health outcome would have been if he had had access to better care, there is speculation that his premature death may be largely attributed to the significant delay in the treatment he experienced. Though the physicians who denied him care may have retained the right to do so on the basis of his then legally unprotected gender identity, this discrimination cost Robert his life. It is clear from stories like these that prejudice has rippling effects throughout the entire lifespans of those affected, even impacting basic care for issues which have no direct relation to one’s gender identity or expression.
In contrast to this, a supportive social environment has been found to have overwhelmingly positive impacts on patient mental health. In a study on young transgender individuals in supportive social environments, it was found that children whose gender identity and expression were respected had rates of depression and anxiety at levels comparable to their peers (Olson, Durwood, Demeules, & Mclaughlin, 2016). Especially considering the tendency of the LGBTQIA+ community to suffer from disproportionately high rates of mental illness, this research indicates that societal acceptance may be an important component of a successful and healthy transition.
Suggestions and Solutions
In an era of bathroom bills and military bans, it has become increasingly important for our established institutions to promote the rights of transgender individuals. As religious groups and political bodies attempt to facilitate the discrimination and societal isolation of trans people, healthcare providers must strive to rebuff these attacks and defend those populations which are most vulnerable. While addressing healthcare issues will not change all aspects of the trans experience, it will help counteract some of the effects of societal discrimination and quantifiably improve their quality of life.
There are many steps to take in order to have an impact on the culture and society which has endorsed this discrimination. Further study on transgender health is critical and this research will hopefully focus on broader populations whose needs may not be adequately met. The subjects of many studies on trans healthcare issues are primarily those who are white, financially stable, and live in urban areas which are supportive or tolerant of their gender identity. This narrow focus fails to effectively accommodate for trans individuals of color and the ways in which racism may exacerbate their discrimination, those who lack financial stability such as homeless populations, and individuals in rural settings whose health care access may be limited and gender identity may be rejected. Education is another important aspect of this healthcare revolution. Many in the medical field are continuing to push for greater inclusivity training in medical education and this trend should continue as we begin to develop an appreciation for the importance of cultural sensitivity in effective healthcare delivery (Kripalani, Bussey-Jones, Katz, & Genao, 2006). Finally, the development of clearly outlined and enforced policy concerning respect for transgender individuals within medicine is crucial, whether it be in clinical practices, professional associations, or government administrations. This will help to create a better standard of care as well as set a precedent of progress and an interest in repairing medicine’s troubled relationship with the greater LGBTQIA+ community.
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1 It should be noted that many transgender and gender nonconforming individuals prefer terminology such as “gender-affirming procedures” instead of “sex reassignment surgery”. This term was used due to its greater understanding in the vernacular of the general public.
2 Cisgender refers to those whose sense of gender identity corresponds with the sex they were assigned at birth
3 Vocal feminization/masculinization may combine both a surgical change to one’s vocal chords as well as behavioral therapy to help introduce stereotypical male or female inflections into speech patterns.
4 Misgendering is the process of referring to someone with pronouns that do not reflect the gender with which they identify. In some cases, this may be done intentionally by those who refuse to recognize the identities of transgender or non binary individuals.
5 Facial feminization surgery is a series of procedures which alter facial features typically perceived as being “male” and bringing them closer in size/shape to typical “female” features.
6 The text “The Look of a Woman”, by Eric Plemons, expands greatly on this issue.
7 Top surgery refers to procedures that modify the breasts or chests of transgender patients, such as breast augmentation