Editor’s Note: Part One of this series discusses the results of the 2015 U.S. Transgender Survey and the multiple barriers to care faced by transgender individuals in the United States.
Homelessness is a prominent concern among LGBT+ people, particularly the transgender community. Nearly one-third of the respondents who completed the 2015 U.S. Transgender Survey reported homelessness at some point in their lives, with even higher rates (74%) among individuals whose families had rejected them. Additionally, at the time the survey data was collected, the number of respondents who were concurrently homeless (0.53%) was three times that of the general U.S. adult population (0.18% according to the Department of Housing and Urban Development). This prevalence demonstrates the pervasiveness of home insecurity in the transgender community, which is partially caused by the transphobic socioeconomic discrimination mentioned in the first part of this series.
Homelessness can create a multitude of risks that directly cause health problems, exacerbate existing illness and make conditions more difficult to treat or manage. Therefore, housing insecurity may create complicated clinical scenarios that cannot be readily resolved by our standard health care system. As stated by the National Health Care for the Homeless Council (NHCHC) in the Homelessness & Health Fact Sheet, “The best, most coordinated, medical services are not very effective if the patient’s health is continually compromised by street and shelter conditions. Even inpatient hospitalization, or residential drug treatment and mental health care (when available), do not have lasting impacts if a client has to return to the streets upon discharge.”
Transgender individuals’ health may be more severely impacted by homelessness because of the decreased availability of supportive public services. In Transitioning Our Shelters: A Guide to Making Homeless Shelters Safe for Transgender People, the National Gay and Lesbian Task Force and the National Coalition for the Homeless assert that transgender people have a greater need for shelter and other social services because of lack of education, discrimination, increased ejection from homes, inability to access quality health care and inability to pay for transgender-specific health services such as hormones, counseling and gender-affirming procedures. Lifelong, systemic discrimination against transgender individuals can cause them to have an increased need for institutional support while also denying them access to such assistance.
Services available to cisgender individuals are also not always accessible to transgender persons. Homeless shelters are often thought of as a step towards escaping homelessness, but shelters can be especially unsafe for this patient subset. In the 2015 U.S. Transgender Survey, 26% of respondents who were homeless in the past year avoided shelters for fear of maltreatment. Of those who did stay in a shelter, 70% experienced this identity-based mistreatment. Both staff members and residents were responsible for the discrimination. Shelter staff ejected some respondents (9%) after they became aware of the participant’s identity and forced even more (14%) to present as the wrong gender. Transphobia from shelter staff also prevented some individuals (4%) from being initially approved as residents. Forty-four percent of the respondents who lived at a shelter eventually left because of poor treatment or unsafe conditions.
A 2016 telephone test conducted by the Center for American Progress (CAP) and Equal Rights Center also illustrates the prevalence of discrimination from shelter staff. Only 30% of the shelters contacted by the study indicated that were willing to accommodate transgender women, with 13% stating that the resident must be placed in isolation or with men and 21% refusing shelter entirely. Instances of discrimination from shelter staff in this test and other surveys by CAP were not localized to a specific area, but were reported across the country. Rather than being a site of stability, homeless shelters are a place of targeted harassment and anxiety for transgender residents. By increasing their experiences of discrimination and hostility, shelters might contribute to transgender individuals’ negative health outcomes and decreased health service utilization. However, avoiding or not being able to access a shelter may also cause transgender individuals to face unsafe conditions on the streets. If providers are not aware of specific programs’ policies towards transgender people, they may risk recommending unaccepting housing rehabilitation or shelter programs to their homeless transgender patients.
A new proposal from the Department of Housing and Urban Development (HUD) would risk making this patient subgroup even more susceptible to discrimination when seeking shelter services. The proposal would allow for HUD-funded shelters to refuse admission based on factors such as religious beliefs. Religious freedom has frequently been cited as a tactic to avoid providing services to LGBT+ individuals, including health care services. Sasha Buchert, a senior attorney with Lambda Legal, said of the proposal, “This would be absolutely devastating in the sense that it would send a message to shelter providers that they can turn away trans people with impunity. They’re wrong. The law is the law and the federal housing Title VII [of The Civil Rights Act] prohibits discrimination based on sex and that would encompass gender identity.”
However, Buchert’s statement does not take into account the difficulties that rejected applicants would have in filing such discrimination claims and the current federal deliberations on whether laws prohibiting discrimination on the basis of sex apply in cases of transphobia. Allowing for refusal of shelter admission may further reduce the small number of services transgender people can and are willing to access, and sets a precedent for discrimination from shelter and governmental staff. Both results will cause homeless transgender individuals to experience more shelter-based and street-based instances of discrimination and violence. Such experiences can contribute to diminished physical and emotional wellness among this population. Additionally, homeless transgender people may avoid other organizations that they perceive to be discriminative or religiously intolerant, such as religiously-affiliated hospitals.
The HUD’s proposal would also federally define an individual’s sex as the sex listed in their governmental documents. This definition of sex specifically targets the transgender community by invalidating their gender. Although some states allow for a person to change the sex listed on their governmental documents, many transgender individuals are unable to update their gender marker because of legal, cost and time restraints. Additionally, altering legal documents may necessitate listing a location of residence, a catch-22 for homeless transgender individuals. This definition of sex may force transgender individuals to misgender themselves, unwillingly disclose their transgender identity to shelter staff or reside at sex-specific shelters that do not match their gender. These actions of misgendering may lead to diminished self-esteem and make transgender individuals more susceptible to discrimination, judgment and violence at shelter facilities.
In a statement on the proposal, Mara Kiesling, the executive director for the National Center for Transgender Equality, stated that, “The programs impacted by this rule are life-saving for transgender people, particularly youth rejected by their families, and a lack of stable housing fuels the violence and abuse that takes the lives of many transgender people of color across the country.” The press release further details that transgender people who have experienced homelessness are more likely to face physical and sexual violence than those who have not. By denying homeless transgender individuals the opportunity to escape unsafe environments, the HUD’s proposal may increase homeless transgender peoples’ need for supportive services while causing them to be more fearful of seeking assistance. To prevent harm to patients and avoidance of care, physicians must address the impacts of proposals such as this, even though they may seem outside the realm of the medical community. Without being aware of current policies, physicians will continue to create treatment plans that are impossible for patients to follow or will inadequately address their needs.
Although changing homeless services may seem outside the realm of physician practice, the authors of Transitioning Our Shelters have previously made several recommendations on how health care practitioners could make clinical decisions that would improve transgender patients’ experiences in shelters. Transgender people need advocates for their continued access to hormone treatments while in shelters because of the undesirable mental and physical effects that cessation can have on their bodies. Therefore, transgender shelter residents may need protection from shelters’ syringe bans so that they can continue their hormonal injections. Without defending these needs, transgender individuals’ mental and physical health could worsen despite the best clinical visits. Physicians could provide statements asserting the medical necessity of gender-affirming medications and further work with transgender individuals in their community to dismantle the existing barriers at shelters. To truly care for vulnerable patients, physicians must be willing to partner with them to think of innovative ways to counteract cisnormative and transphobic practices.
If physicians advocate for transgender patients’ right to access medical services, such as hormone treatments in homeless shelters, they could also challenge the dehumanization and discrimination that these individuals face. With the societal and scientific authority granted to physicians for their title and training, they could lend validity to transgender individuals’ existing acts of advocacy through partnerships with transgender advocates and patients. Such efforts could help bridge the divide between health care providers and transgender individuals and improve societal acceptance of transgender people. By addressing larger political, social and economic barriers to health for oppressed patients and by partnering with them, physicians could prevent harm altogether and avoid searching for a cure to complex social problems during their brief clinical visits.