March 27, 2016

Trans* Health Disparities and Barriers To Healthcare Access

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Recently many transgender-specific healthcare coverage exclusions have been overturned, and thanks to the Affordable Care Act more transgender persons have at least nominal access to healthcare than at any time in history. Social attitudes have also shifted such that healthcare providers are increasingly open to providing transgender-specific care and making their general practice more transgender-inclusive. Yet healthcare organizations and providers remain uninformed about the unique needs of transgender patients. This ignorance unintentionally creates uncomfortable and even hostile situations for transgender persons that prevent them from seeking routine healthcare. A recent New York Times article quoted Tari Hanneman, deputy director of the Health and Aging Program at the Human Rights Campaign (HRC), discussing the challenges transgender persons face in seeking respectful and appropriate healthcare: “The first time you think about where you are going to put a transgender patient should not be when they arrive.”

It’s hard to disagree with this statement. Healthcare providers should be prepared to address the specific needs of transgender patients and system-wide protocols should be in place to guide what providers do when they see a transgender patient. Unfortunately, it’s not that simple.

Hanneman’s proclamation masks an important conundrum faced by patients and providers across the US: in order to reduce the barriers that prevent transgender persons from seeking care, healthcare organizations need direct experience working with transgender patients so that they can learn how to be transgender-inclusive. And transgender persons are understandably reluctant to put themselves through uncomfortable and possibly damaging experiences of serving as test-patient for inexperienced providers.

Recent evidence has shown that transgender persons often forego preventative medical care, especially care that is not related to gender-transition, and this is a major contributing factor explaining health disparities in the transgender population. The most often cited reasons for avoiding medical care are having past experiences of discrimination, harassment and violence in medical settings, fear of future discrimination, and limited provider knowledge.

Healthcare organizations around the country are trying to reduce these negative experiences for transgender patients. As part of my research I have conducted a  system-wide survey of Hayward Hospital (pseudonym), a large chain of clinics in California, and found that over 90% of their clinic staff felt comfortable with seeing transgender patients but a majority also expressed concern about how to approach them. For example, the staff expressed significant discomfort with the prospect of asking a patient their preferred gender pronoun. The solution suggested by an administrative analysis of the survey was to design more transgender-inclusive intake forms and electronic medical records, so that staff could avoid potentially awkward interactions.

Los Angeles County Public Health Clinics have tried an approach of creating as many categories as possible to avoid symbolic violence of forcing someone into a category with which they do not identify. Four gender categories, along with five homelessness statuses, and lots of ‘unknown’ and ‘other’ options appear in every demographic category.

But with each addition of a category comes more questions. For example, when Sandy (pseudonym), a transgender female interviewee in my study, visited a clinic that had recently updated its intake forms to be more transgender-inclusive by providing space for both “legal name” and “preferred name,” she was skeptical that this change in procedure would help much. “I and many others would simply put the name we use under ‘legal name’ regardless of its legal status. ‘Preferred name,’” she said, “just felt like ‘nickname.’”

In three years of my ongoing research with healthcare providers, hospital administrators, and transgender patients, one of the most striking patterns I have noticed is that there is often a sharp contrast between what transgender patients and those shaping healthcare policies imagine are most important for making healthcare more transgender-inclusive. Providers, administrators, and policymakers tend to focus on technical details, such as whether transgender men need regular mammograms and pap smears (they do) or transgender women need regular prostate exams (they do). They express frustration or a sense of being overwhelmed that they “have to become experts” of transgender identity in order to provide transgender-inclusive care.

Transgender patients, on the other hand, highlight the importance of genuine openness to meeting them where they are regarding their gender identity and taking that gender identity seriously. Moreover, transgender patients rarely expect that their providers will be experts in transgender identity and care, and are quite accustomed to knowing far more about what is appropriate for their care than the average patient. Technical knowledge alone is not enough to make transgender patients feel safe to seek care.

The tough lesson for scientifically-minded providers is this: eliminating transgender health disparities will never just be a technical matter of identifying scientifically and objectively neutral knowledge. Policies for transgender care will have to be customized into protocols at the local level, and there is no one-size-fits-all solution that will work for all patients. Most importantly, transgender-inclusion requires a genuine affirmation of diversity, a willingness to listen and to learn, and a willingness to accept that transgender persons are the experts of their own gender.

The good news is that there are many practices providers can easily implement to make their care settings more transgender-inclusive. Gender Odyssey, Philadelphia Trans-Health, the Center of Excellence for Transgender Health, the Fenway Institute, and other smaller events offer training opportunities complete with continuing education credits for providers to gain technical and practical knowledge from other healthcare providers about transgender care. These conferences also typically offer a wide variety of panels that can help providers understand the broader cultural, historical, and political context surrounding transgender care. This supplemental training can’t transform a hospital overnight, and a period of mistakes and learning will still be necessary. Still, these opportunities are a great way to foster an awareness of the subtle ways in which routine behaviors in healthcare settings can stifle and exclude transgender patients. It is a slow, nuanced, and community-informed process that is essential for closing the gap in transgender health outcomes.

Additional Resources For Patients And Providers:

If you would like more information about transgender health issues, transgender healthcare rights, transgender-inclusive clinics, or about upcoming conferences focused on transgender health, feel free to explore the links below.


Demetrios Psihopaidas is a doctoral candidate in Sociology at the University of Southern California. He is currently completing international archival research on his dissertation project “Unsettled Lives: How transgender became a global health policy priority.” More information about his research and publications can be found here.