As a native New Yorker, I was thrilled when last month Governor Cuomo announced plans for an executive order that prohibits discrimination against transgender people. This executive order would apply to issues such as employment and housing, expand existing anti-discrimination protections to include gender identity, transgender status and gender dysphoria.
There have also been advancements involving the protection of transgender people from discrimination in health care settings. Just two months ago, the Department of Health and Human Services (HHS) proposed legislation that clarifies protection for transgender individuals from discrimination by health care providers and insurers. This legislation builds on a portion of the Affordable Care Act in order to ensure that patients are not treated unjustly due to their gender identity.
The question remains: Why is government action even necessary?
In 2011, the National Center for Transgender Equality and the National Gay and Lesbian Task Force surveyed 6,450 transgender and gender non-conforming individuals. Their report found that discrimination against the respondents was widespread. Those who identified as transgender or gender non-conforming were twice as likely to be unemployed as the general population. Almost half of all respondents (47 percent) said that, “they had experienced an adverse job outcome, such as being fired, not hired or denied a promotion because of being transgender or gender non-conforming.”
With respect to direct housing discrimination, 19 percent of respondents reported “having been refused a home or apartment” and 11 percent reported “being evicted because of their gender identity/expression.” Those who identified as transgender or gender non-conforming were also twice as likely to be homeless as the general population.
The field of health care was not immune to this dismal outlook. Many of the respondents postponed their medical care due to an inability to afford care (48 percent) or due to perceived discrimination (28 percent). 19 percent of these respondents reported “being refused medical care due to their transgender or gender non-conforming status, with even higher numbers among people of color in the survey.”
What remains particularly alarming to me, as a physician-in-training, is that half of respondents in the report said that they had to educate their medical providers about transgender care.
I unfortunately cannot say that I am surprised. In my medical training so far, I have only received a single lecture on lesbian, gay, bisexual and transgender (LGBT) health. However, my school is far from being the only institution that needs to have improved training on the health needs of transgender patient populations. A recent study asked deans from medical schools across the United States and Canada about their school’s coverage of LGBT-related content in the curriculum: less than one out of every four deans felt that their schools did at least a “good” job. One-third of participating medical schools reported having zero hours of content on LGBT health in the clinical curriculum. While the vast majority of medical schools (97 percent) reported teaching students to ask patients if they have “sex with men, women or both” during the sexual history component of the patient interview, only 30.3 percent reported to have instruction on gender transitioning and 34.8 percent reported to have instruction on sex re-assignment surgery.
Last month, in-Training published a podcast that features Olivia, who is “one of the few openly trans medical students in the country.” With her unique perspective as a member of both a marginalized community and an institution with traditional privilege, Olivia describes the history of medical discrimination against transgender individuals and how to counter this through curricular reform.
Even if medical schools actively work to increase LGBT-related curricula, there needs to be an increased mindfulness about not perpetuating continued marginalization of LGBT populations. A commentary in JAMA published last month describes how, by creating a speciously distinct category for “transgender health instruction,” medical schools run the “risk of casting transgender people as ‘other’.” Rather, schools should integrate instruction on transgender care throughout the cultural humility, biochemical, psychosocial and psychiatric components of the curriculum.
Medical schools do not have the luxury to procrastinate making the appropriate and needed changes to their curricula. There have recently been some innovative initiatives that seek to leverage the power that transgender patients have as consumers of health care. For instance, RAD Remedy provides a national database of health care providers with the aim of “connecting trans, gender non-conforming, intersex and queer folks to accurate, safe, respectful and comprehensive care.”
While this is a fantastic project, it demonstrates the limited access to good health care that transgender individuals continue to suffer from. Poor health outcomes from discriminatory barriers to health care are exacerbated by an increased risk for HIV infection, violence and substance abuse among transgender patient populations. Consequently, medical schools must act now to ensure that they are adequately training future physicians whose capacity is not limited to patients of a certain gender identity.