Life in the Margins

By Dr. Heather Tillewein

Transgender Individuals and Healthcare Barriers

"In many medical encounters, I have found myself in the educator's position. There is a clear lack of training for healthcare personnel regarding transgender patients, and treatments pertaining to transitioning. While I have no qualms about providing very detailed responses to healthcare workers, I am alarmed at the frequency this happens. As a transgender individual, trying to find a primary healthcare provider can be extremely challenging. I called 5 different doctor's offices before I found a doctor that would accept me as a patient. I saw them 4 times (2 years) and then they retired. The only other provider that would see me after that was an APN (advanced practice nurse) working under a Doctor that wouldn't see me themselves, but "agreed to let the APN see me". The APN admitted during our first appointment that she had "no experience in this area, but was willing to try it out". That was certainly reassuring. But I stuck with her, and I have been able to give her the "Intel" to help other transgender patients and provide a better standard of service to our rural area. I was told by 3 different gynecologists that they wouldn't see transgender patients, one stating, "we don't do that kind of thing here". As a transman who is married to a cisgender female, I was once asked during a health screening if I was using condoms during intercourse. I then had to explain the mechanics of sexual intercourse between a pre-op transgender male and cisgender female individuals to two nurses, and explain why male condoms were not necessary...I had to use hand gestures. While I do have a very good sense of humor, I look forward to a day where I don't have to worry about my standard of care being a transgender individual."

Alex Socorro

Transgender Health

According to the Williams Institute, there are an estimated 1.4 million U.S. adults that identify as transgender.¹⁸ However, determining the true population of gender minority groups is difficult due to transgender individuals’ concerns with being identified due to discrimination.³ These concerns are amplified by transphobia in many areas of the United States. Transgender individuals face multiple forms of discrimination, stigma, psychological abuse, physical abuse, bullying, and economic alienation.^1,8,11 Transphobia influences societal and economic marginalization and can negatively impact the health status of the transgender population.^2,6,8 Also, the transgender population faces a high prevalence of anxiety, depression, eating disorders, social phobia, and psychological distress.^11,13 Furthermore, transgender individuals also face verbal, physical, and sexual violence.^5,9,12,14Transgender individuals also suffer from higher mortality and morbidity rates compared to heterosexual individuals.⁶ Compared to heterosexual, cisgender males and females, transgender individuals are more likely to commit suicide.⁹

Barriers to Transgender Health

Transgender individuals face barriers to transgender-specific health care, such as refusal of care from medical care providers, harassment in the medical setting, or lack of knowledge of trans-specific health among medical care providers.^5,6,15 According to the National Transgender Discrimination Survey, 33% of respondents reported delaying medical care due to discrimination and disrespect from medical providers, 28% reported verbal harassment in a medical setting, and 19% reported being denied services due to their gender identity.⁶

Provider-based barriers to treating transgender individuals may be due to the lack of knowledge or lack of confidence of transgender-specific health care. These barriers may arise from lack of exposure to transgender patients or lack of training among medical professionals.¹⁷ Other barriers providers face is the lack of training in trans-specific care or lack of insurance coverage for trans individuals.^7,15,17 In the National Transgender Discrimination Survey, transgender individuals reported being less likely to have health insurance, either individually or through an employer.⁶ Even if transgender individuals have insurance, insurance companies routinely deny coverage of transition-related health care.¹⁵Transgender individuals have thus had to find loopholes in insurance policies to get trans-specific services covered.¹⁵

Call for Action

Due to provider-based barriers and discrimination transgender individuals face, the transgender populations are faced with several health disparities. This blog calls for:

continuing education opportunities on transgender-specific health needs for medical providers;
medical doctoral programs with intensive courses on sexual and gender minority health;
insurance companies with expanded services to cover transition-related medical services;
transgender-specific questions on the medical board licensure exams to ensure medical professionals have comprehensive training;
medical professionals to act as gatekeepers between health insurance companies and transgender patients; and
medical professionals to advocate for transgender medical needs and to end transphobia in the medical field.

References

Bostwick, W. B., Boyd, C. J., Hughes, T. L., & West, B. (2014, January 1). Discrimination and mental health among lesbian, gay, and bisexual adults in the United States. American Journal of Orthopsychiatry, 84(1), 35-45. https://doi.apa.org/doi/10.1037/h0098851

Bradford, J., Reisner, L. S., Hannold, A. J., & Xavier, J. (2013, September 9). Experiences of transgender-related discrimination and implications for health: Results from the Virginia transgender health initiative study. Journal of Public Health, 103(10). 1820-1829. https://dx.doi.org/10.2105%2FAJPH.2012.300796

Centers for Disease Control and Prevention. (2016). Gay and bisexual men’s health: stigma and discrimination. Retrieved from https://www.cdc.gov/msmhealth/stigma-and-discrimination.htm.

Factor, R. J. & Rothblum, E. D. (2008, October 11) A study of transgender adults and their non-transgender siblings on demographic characteristics, social support, and experiences of violence. Journal of LGBTQ Health Research, 3(3), 11-30. https://doi.org/10.1080/15574090802092879

Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. I., & Keisling, M. (2011) Injustice at every turn: A report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force

James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The Report of the 2105 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality.

Kanamoria, Y. & Cornelius- White, J. (2016, October 7) Big changes, but are they big enough? Healthcare professionals’ attitudes toward transgender persons. International Journal of Transgenderism, 17(3-4), 165-175. https://doi.org/10.1080/15532739.2016.1232628

Lombardi, E. (2001, June). Enhancing transgender health care. American Journal of Public Health, 91(6), 869-872. https://dx.doi.org/10.2105%2Fajph.91.6.869

Lombardi, E. L., Wilchins, R. A., Priesing, D., & Malouf, D. (2008, October 12). Gender violence: Transgender experiences with violence and discrimination. Journal of Homosexuality, 42(1), 89-10. https://doi.org/10.1300/J082v42n01_05

Mathy, R. M. (2008, October 22). Transgender identity and suicidality in a nonclinical sample: Sexual orientation, psychiatric history, and compulsive behaviors. Journal of Psychology & Human Sexuality, 14(4), 47-65. https://doi.org/10.1300/J056v14n04_03

Moleiro, C. & Pinto, N. (2015, October 1). Sexual orientation and gender identity: Review of concepts, controversies, and their relation to psychopathology classification systems. Frontiers in Psychology, 6(1511), 1-6. https://doi.org/10.3389/fpsyg.2015.01511

Nuttbrock, L., Hwahng, S., Bockting, W., Rosenblum, A., Mason, M., Macri, M., & Becker, J. (2009, June 29). Psychiatric impact of gender-related abuse across the life course of male to female transgender persons. Journal of Sex Research, 47(1), 12-23. https://doi.org/10.1080/00224490903062258

Pflum, S. R., Testa, R. J., Balsam, K. F., Goldblum, P. B., & Bongar, B. (2015). Social support, trans community connectedness, and mental health symptoms among transgender and gender nonconforming adults. Psychology of Sexual Orientation and Gender Diversity, 2(3), 281. https://psycnet.apa.org/doi/10.1037/sgd0000122

Reisner, S. L., White, J. M., Bradford, J. B., & Mimiaga, M. J. (2014, September 1). Transgender health disparities: Comparing full cohort and nested matched-pair study designs in a community health center. LGBT Health, 1(3), 177-184. https://dx.doi.org/10.1089%2Flgbt.2014.0009

Roller, C.G., Sedlak, C., & Draucker, C.B. (2015, August 15). Navigating the system: How transgender individuals engage in health care services. Journal of Nursing Scholarship. 47(5),417-424. https://doi.org/10.1111/jnu.12160

Sanchez, N., Sanchez, J., & Danoff, A. (2009, April). Health care utilization, barriers to care, and hormone usage among male-to-female persons in New York City. American Journal of Public Health, 99(4) 713-719. https://dx.doi.org/10.2105%2FAJPH.2007.132035

Vance, S. R., Halpern- Felsher, B. L., & Rosenthal, S. M. (2015, February 1). Health care providers’ comfort with and barriers to care of transgender youth. Journal of Adolescent Health, 56(2), 251-253. https://doi.org/10.1016/j.jadohealth.2014.11.002

Williams Institute. (2016). How many adults identify as transgender in the United States? Retrieved from: https://williamsinstitute.law.ucla.edu/wp-content/uploads/How-Many-Adults-Identify-as-Transgender-in-the-United-States.pdf.