I was in high school, unsure how to assist a friend who was living between suicide attempts due to transphobic harassment. After he had a threatening altercation with his family, I was desperate to find safe living conditions for him. My impasse was that he was still their financial dependent.
“Could you move in with a friend?” I asked over text. “Or is there a shelter that you could turn to if things get too rough?”
“I can’t,” he responded. “I’ve already looked it up; the women’s shelter here won’t accept me, and I’ll be harassed at the others.”
Like many transgender individuals in the United States, my friend could not access mental health services because of the ways in which transphobia intersected with other constraints in his life. Harassment was the catalyst behind his failing emotional health, but his depression was fueled by invectives in his home environment and lack of accessible treatment. His economic dependence on his abusive family made his attempts at attaining medical assistance futile. When he received treatment during his hospital stays, his health care providers would advise he pursue outpatient psychiatric care without recognizing the impediments to their recommendations. They would discharge him only for him to be readmitted weeks later.
The 2015 U.S. Transgender Survey conducted by the National Center for Transgender Equality demonstrates the national relevance of my friend’s case. Its responses substantiate the U.S. transgender community’s need for mental health services and unique barriers to care. Respondents self-reported significant psychological distress at the time of the survey at an almost eight times greater prevalence than that of the general U.S. population (39% versus 5%). Despite these findings, 23% of respondents had avoided physician medical care out of fear of identity-based mistreatment. This apprehension was partially fueled by provider insensitivity — both intentional and unintentional — as evidenced by one-third of respondents reporting one or more negative interactions with a health care provider in the past year.
Even when transgender individuals receive care, their fear of judgment and discrimination may prevent them from disclosing information to their providers. Nearly one-third (31%) of the survey’s subjects stated that none of their health care providers knew that they were transgender and an additional 17% reported that only some of their providers knew. In certain clinical scenarios, ignorance of a transgender person’s identity may lead to medical mismanagement, inappropriate risk assessment and lack of patient-centered practices. Although identity nondisclosure might obviate intentionally transphobic comments and actions, a hidden identity is still likely to cause psychological distress. Unintentional misgendering has been associated with negative affect, worse self-esteem and feelings of stigma.
Conversely, actions of gender affirmation, such as using a chosen name, have been associated with better psychological well-being, decreased suicidal behavior and reduced depression. The results of the 2015 U.S. Transgender Survey elucidate the need for providers to affirm transgender patients or risk perpetuating their isolation and inadequate treatment. Regardless of a patient’s gender identity, a provider must examine their interactions for microaggressions and transphobia. Additionally, providers should openly support transgender individuals within their practice settings through processes such as normalizing pronouns and representing transgender people in waiting room materials. These small actions of validation have the potential to improve patient trust, outcomes and quality of life.
Providers must also work to resist myopic understandings of the transgender community and their needs. Even individuals within the transgender community may have different access to health care based on their life experiences. Differences in financial stability can be one contributor to differences in care among this population. In the 2015 U.S. Transgender Survey, 33% of respondents indicated they were not able to seek care from a physician because of monetary limitations. The survey’s report draws connections between how state-specific transphobic job and housing policies could be contributing to the higher rates of poverty and unemployment in this population.
These identity-based blockades to achieving economic stability complicate the process of navigating health care. It is already well-known that a lower socioeconomic status worsens health outcomes and access to health care, but how identity-based discrimination outside of medicine leads to poor health is less emphasized. However, these constant stressors can create cycles of adverse health conditions that may not be resolved without addressing their underlying sources.
If the providers treating my high school friend had understood the intersection between his transgender identity and his socioeconomic status, they would have recognized his inability to consistently access outpatient services. His suicidal ideations recurred because the treatment he received lacked both affirmation and a comprehensive understanding of his identity. Although I was not able to fix his area’s local health system or manage his depression, I did help him create an online fundraising page. With donations, he was able to attend a higher education program, build a support network and obtain a job that made him more financially secure. His success predicated recognition of the underlying cause of his helplessness — the everyday familial discrimination that he could not escape due to socioeconomic constraints.
To truly address the health concerns of future patients, aspiring physicians have to be aware of their patients’ unique needs and limitations. Providers who want to help oppressed populations must revise their knowledge and practices and remain up to date on the dynamic social, economic and legal issues affecting the populations that they may encounter. Those who are aware of the current political climate know that the existing restrictions for transgender people accessing supportive services have not been improving.
Over the past two years, the National Center for Transgender Equality has recognized over 30 new policy changes that weaken the rights of LGBT+ individuals. Of these, several directly alter the ways that transgender patients receive care, including a proposal from the Department of Health and Human Services that is expected to remove federal prohibition of health care-based discrimination towards transgender individuals from ACA Section 1557. However, the majority of these proposals threaten to damage the health of LGBT+ communities through more indirect, insidious means.
Part 2 of this series seeks to analyze one such policy to illustrate the complexities of transgender health and advocate for present action in support of trans health.