Transgender Day of Visibility is observed on March 31 globally. In the US alone, it is estimated that over 1.6 million children and adults identify as transgender. This time provides an opportunity for reflection on the unmet needs and ongoing discrimination faced by this group, as well as an opportunity to learn about the history of the transgender community. Part 1 of a three-part series on LGBTQ+ healthcare may explore the history, evolution, and current state of transgender healthcare while considering the significant decisions that have influenced the context of available solutions in the US.
In response to a study conducted at Johns Hopkins Hospital, the Gender Identity Clinic (GIC), the first gender-affirming surgery (GAS) clinic in the US, was shut down. This study suggested that sex change procedures did not provide significant mental benefits to recipients and that individuals who underwent these procedures were not better off mentally compared to those who did not.
The increase in academic interest in transgender care during this time led to the formation of the Harry Benjamin International Gender Dysphoria Association, now known as the World Professional Association for Transgender Health (WPATH). However, there is speculation as to whether this decision was solely based on evidence or influenced by bias. WPATH created the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming Persons in response to a decline in public support for transgender healthcare issues.
In 1980, the American Psychiatric Association added “gender identity disorder” to the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-3). Although categorizing transgender individuals as having a “disorder” may seem regressive, Farah Naz Kahn, MD, argues that “this controversial move actually helped transgender people gain access to an often opaque healthcare system.”
The DSM-5 revised the definition of transgender identity as “disordered” until 2013, and the language continued to label it as “disordered.” This significant change renamed it as “gender dysphoria.” Further progress was made in 2014 when a federal appeals board mandated that Medicare cover gender transition treatments in its policies. This decision was supported by updated studies from WPATH demonstrating the benefits of these procedures and the recognition that sex reassignment was no longer experimental.
In 2016, President Barack Obama ended a longstanding policy banning open service for transgender soldiers. This policy change was another step forward for the transgender community, as the previous policy was based on outdated, biased health information. Before this change, transgender individuals could be discharged from the military regardless of their abilities and without proper health evaluations. Before the ban was lifted, transgender soldiers were unable to express their gender identities because a diagnosis of gender dysphoria was seen as “a state of emotional distress caused by dissatisfaction with one’s body or the gender assigned at birth, which could interfere with one’s ability to serve due to the potential for severe depression and anxiety.” Over the following year, as this policy was phased in, transgender soldiers gained access to essential gender-affirming healthcare.
On April 12, 2019, this policy was overturned during the Trump administration. Individuals diagnosed after this date were required to serve according to their assigned gender at birth, and those diagnosed with gender dysphoria before the reversal could continue to serve. Those who had not yet enlisted and had a diagnosis of gender dysphoria were prohibited from enlisting in military service or attending military academies. Although officials argued that this policy reinstatement was not discriminatory or a “ban on transgender individuals,” it effectively ended “presumptive accommodations” for transgender service members, such as access to gender-affirming healthcare, which President Donald Trump claimed imposed a significant financial burden on the military. For context, the Department of Defense’s annual spending on care related to gender transitions was less than 0.1% of the annual healthcare budget in 2017, the first year of Trump’s presidency.
In 2021, President Joe Biden used an executive order to reverse the Trump-era Pentagon policy. With this order, essential healthcare was once again made available to transgender service members, and discriminatory measures were eliminated. The contradictory history of the past decade demonstrates how transgender rights can be easily granted or revoked.
Samantha Rosenthal, PhD, of Roanoke College, addressed myths about the healthcare needs of transgender and gender-diverse patients in an email interview with The American Journal of Managed Care (AJMC). She stated, “One of the biggest misconceptions about transgender medicine is that treating transgender patients is only about gender-affirming procedures such as hormonal or surgical treatments. However, transgender medicine must be integrated into medical school curricula and across a range of clinical specialties, including urology, endocrinology, gynecology, and beyond.” When transgender patients engage with medical professionals about how their bodies function and how to advocate for their healthcare needs, they have an opportunity for autonomy and agency. It is crucial to recognize that transgender patients understand their bodies in ways that make them co-experts in transgender medicine.
Much discussion has focused on the evolution of transgender healthcare rather than the policies that impact gender-affirming care. Lack of awareness, respect, and access to care for transgender patients, as well as healthcare disparities exacerbated by discrimination and stigma, also significantly impact the quality of life of this community.
These issues have been consistently highlighted in the Behavioral Risk Factor Surveillance System, a health survey on behavioral risk factors that has shown the mental and physical health disparities experienced by transgender respondents. According to the 2019 survey results, transgender individuals were more than twice as likely as their cisgender counterparts to have a depressive disorder or experience a bad mental health day.
Additionally, a nationwide survey conducted by the Center for American Progress in 2020 on the experiences of LGBTQ+ individuals found that over 60% of transgender individuals reported experiencing discrimination in the past year. TransPop data from The Center for American Progress also revealed that 90% of transgender individuals felt less respect or courtesy in various settings. Although these
data did not specifically pertain to healthcare settings, Medina et al. explain how the stress caused by discriminatory experiences can increase a person’s risk of developing post-traumatic stress disorder, anxiety, depression, and other forms of psychological distress, which can lead to suicide attempts and substance abuse.
“Discrimination also impacts the ability to access services,” they wrote, “as TransPop data show that 61% of transgender respondents report having a personal doctor or healthcare provider, compared to 76% of cisgender heterosexual respondents. Reproductive health services for transgender individuals are also less accessible, with 37% having to travel more than 10 miles for routine medical care.”
Visiting a doctor’s office can be a stressful experience on its own. Among other surveys, 2 in 3 transgender adults reported concerns about bias in clinical treatment they receive and that their gender identity or sexual orientation could impact their care. In addition, 33% of transgender respondents said they needed to educate their clinician about transgender people in order to provide adequate care, and 15% said they had been asked “invasive or unnecessary” questions about being transgender that were unrelated to their visit.
Access to care and the willingness to seek it out are tremendous issues in the scope of transgender healthcare. Greater effects on a transgender patient’s overall well-being are brought on by added stressors from either one’s interactions with clinicians or the insufficient supply of necessary services. The transgender community’s disproportionate mental and physical effects demonstrate the urgent need for more adequate and accessible care.
Mandi Pratt-Chapman, PhD, clinical researcher at GW Cancer Center, sat for an interview with AJMC to explore these issues further. In her discussion, she addresses the misconceptions that affect the availability of adequate, accessible healthcare for transgender patients, what she sees as the most urgent need to address in this field, and how policy-level changes might benefit transgender patient care and experiences in clinical settings.
A colleague who claims to be a member of the LGBTQ+ community was the subject of a story that Pratt-Chapman shared. As a clinician, he has felt people assume he has a degree of expertise regarding servicing transgender patients but, in fact, he admitted the opposite. His inclusion in the LGBTQ+ community did not automatically mean he could treat transgender patients adequately. In response to Rosenthal’s assertions, Pratt-Chapman and I had a conversation about the transgender community’s unique needs, which was consistent with Rosenthal’s. However, as Pratt-Chapman said, each patient comes from a unique background with their own experiences and needs.
Therefore, although the implementation of policies to require or encourage education centered on transgender patients might be beneficial, there isn’t a one-size-fits-all curriculum to adequately prepare healthcare providers in this regard. Pratt-Chapman advocated that clinicians devote themselves to lifelong learning without having to confront something or someone they don’t understand completely in order to fill these gaps. She said relying on curriculum to paint the picture of a “mythical patient” could have drawbacks that distract from one’s ability to truly focus on the needs of the body in front of them.
Despite the fact that medicine has made significant patient improvements over the years, many transgender patients have lost faith in the system. It has only been ten years since transgender identities were declassified as “disordered,” and it may be difficult to believe in the care they are receiving when they still find themselves teaching clinicians about their bodies and their needs, face hostility, or are turned down by the doctors they rely on.
Medina et al write: “Supporting transgender people through the medical system can only be achieved with the trust of transgender patients. This trust has been repeatedly, violently, and fatally violated, from the long-standing distinction between transgender identity as a mental disorder to the psychologically abusive use of pseudoscientific conversion therapy, as well as the public health response to the HIV epidemic’s historical and ongoing failures. If transgender people want to effectively address health disparities, medical systems must earn their trust.
System-wide policy changes could go a long way in counteracting the negative perceptions and lived experiences of transgender patients navigating healthcare. As Pratt-Chapman points out, the development of welcoming environments that emphasize anti-discriminatory policies, the promotion of diverse leadership and clinicians, and the amplification of voices that support evidence-based medicine to influence legislation are essential for improving the current state of transgender patient care.
References
1. How many adults and youth identify as transgender in the United States? The Williams Institute 2022, June. Accessed March 19, 2024. https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/
2. W.J. Magrath The fall of the nation’s first gender-affirming surgery clinic. Ann Intern Med. 1462-1467, 2022-4182. doi: 10.7326/M22-1480.
3. Khan FN. A background on transgender health. Scientific American. 16 November 2016 Accessed on March 15, 2024, at https://www.scientificamerican.com/blog/guest-blog/a-history-of-transgender-health-care
4. The US military’s ban on transgender soldiers is lifted by the Obama administration. Vox. June 20, 2016. Accessed on March 22, 2024, at https://www.vox.com//2016/6/30/12070746/transgender-military-ban.
5. Year after trans military ban, legal battle rages on. NBC News April 11, 2020 Accessed March 22, 2024. https://www.nbcnews.com/feature/nbc-out/year-after-trans-military-ban-legal-battle-rages-n1181906
6. Trump’s restrictions on transgender troops are removed, according to De Luce D and Pettypiece S. Biden administration. NBC News 31-Mar-2020 Access on March 22, 2024 at https://www.nbcnews.com/news/military/biden-admin-scraps-trump-s-restrictions-transgender-troops-n1262646.
7. @realDonaldTrump… victory and is ineligible due to the high medical bills and disruption transgender members would cause. I appreciate it. July 26, 2017. Accessed on March 28, 2024, at twitter.com/realDonaldTrump/status/8990951546369?s=20
8. Transgender military experiences: from Obama to Trump, Dietert M. and Dentice D. J Homosex. 2023, 70 (6): 993-1010. doi: 10.1080/00918369.2021.2012866
9. Promoting and advancing health care for transgender adult communities: a mission statement from Medina C, Santos T, Wahowald L, and Gruberg S. American Progress. 2021, August 18. Accessed on March 15, 2021, at https://www.americanprogress.org/article/protecting-advancing-health-care-transgender-adult-communities/.
