Transgender people are one of the most marginalized groups in society, and often face discrimination in schools, workplaces, and in public. The transgender population experiences high rates of poverty, homelessness, violence, and lack of employment opportunities, among other social disadvantages (Bauer et al., 2009). It is known that social determinants of health that can put marginalized groups at higher risk for chronic health problems, infections, substance abuse, and even some cancers (Safer & Tangpricha, 2019). Unfortunately, the discrimination that transgender people experience extends to experience in the healthcare system as well. Studies have found that transgender people experience more discrimination and marginalization than lesbian, gay, and bisexual populations (Ali, Fleisher, & Erickson, 2016). In a survey from 2011, 50% of transgender and gender non-conforming individuals reported having to teach their medical providers about transgender care, and 33% of respondents reported that they postponed preventative medical care due to discrimination (Ali et al., 2016). Research has shown that they are also at risk for higher rates of health issues such as sexually transmitted diseases including HIV, and mental health problems including suicidal ideations. Despite the fact that transgender people are disproportionally impacted by mental health and reproductive issues, they still experience systemic bias when seeking treatment from physicians in these fields. Transgender people are individuals whose gender identity does not match that of which they were assigned at birth. It is estimated that they represent 0.6% of the American population (Mehta et al., 2018). In modern American society, transgender rights are still progressing, and there are still many negative perceptions of gender non-conforming people, and both conscious and unconscious ways in which they are excluded. In the healthcare setting, there is an implicit bias in the form of the default assumption that patients are cissexual, and that their gender has been the same throughout their lifetime (Bauer et al., 2009). Negative attitudes toward transgender patients can stem from religiosity or conservatism, as well as a lack of knowledge (Ali et al., 2016). In general, most healthcare providers support the human rights of transgender people, but individuals’ biases and some ways the system is structured serve to marginalize the transgender population. In the context of mental and reproductive health, transgender people do experience barriers to care, mostly due to healthcare providers’ discomfort or inexperience with treating transgender patients.
On a systemic level, healthcare has cisnormativity built into everything from health records to pharmaceutical research. Although many clinical practices have made improvements over the years, many medical records only have options for male and female, and some healthcare providers only accept patients of one gender. Similarly, electronic medical records rely on legal names, and other personal info that is associated with the individual’s gender assigned at birth. Lack of training and knowledge about transgender patients’ needs is also a systemic issue, as the needs of gender minorities are slow to be added to academic curriculum and continuing education for healthcare practitioners (Bauer et al., 2009). Because transgender people are often stigmatized and excluded in this way, there is less academic research about them. More research needs to involve transgender people, even if the studies are not directly related to sex or gender, because it should be known if different treatments or health issues affect transgender individuals in different ways (Bauer et al., 2009).
In the field of psychiatry, considerations for transgender patients are especially important because transgender individuals on average have more need for psychiatric care than the general population. Therefore, psychiatrists and psychologists treat a disproportionate amount of transgender patients. Studies have shown that when these professionals have more experience with transgender patients, they have better attitudes and perceptions of transgender people generally. In 2012, the American Psychiatric Association removed “Gender Identity Disorder” from their mental health guide, replacing the guidelines with those for “Gender Dysphoria,” which gave new validation to the chosen identities of transgender and gender non-conforming individuals (Heffernan, 2012). This relatively recent shift likely spurred the need for more training and adjustment on the part of psychiatrists and psychologists. Due to a lack of information on gender dysphoria, there are often misunderstandings around how other mental health issues are or are not connected to a transgender individual’s gender identity or dysphoria, which may result in incorrect diagnosis or treatment. The best option to fight the stigma against transgender people and provide mental health professionals with the tools they need to properly treat transgender patients is to provide them with adequate training, and academic institutions should be teaching this too.
Lack of education around transgender health persists throughout even the most critical fields of medicine for this group, showing the systemic bias towards cisnormative medical training. In a recent study, 80% of surveyed gynecologists said that they had never received any training in transgender health, and only one third felt comfortable providing care to transgender patients (Mehta et al., 2018). Hormone therapies and surgeries that transgender people can receive add another dimension to their reproductive health needs, and while traditionally transgender people were treated at select clinical practices, an important part of removing barriers to healthcare is to make sure transgender people can receive adequate care at any clinic. In the case of reproductive health, access to care is a barrier, but also receiving the right kind of care. One study found that although transgender men were receiving hormone therapy and adequate access to healthcare, approximately half were not receiving preventative pelvic exams, and were likely being underdiagnosed for polycystic ovarian syndrome (Ali et al., 2016). This example shows how a lack of knowledge on the part of providers can impact specific aspects of a transgender person’s health that may not be addressed when that person is classified and treated the same way as a cisgender person.
One important solution to lessen the impact of this healthcare disparity is training healthcare professionals to administer proper treatment and be sensitive to the unique considerations of transgender people. One key indicator of whether or not a healthcare professional will be comfortable treating a transgender patient is if they have personal experience with transgender individuals (Ali et al., 2016). However, it is difficult to mechanize the exposure healthcare professionals have to transgender people, other than to encourage the presence of transgender healthcare professionals, and perhaps to provide training sessions taught by
transgender instructors. The most practical and important solution to fighting systemic bias against transgender people is to provide more training for healthcare professionals around not only the specific medical considerations for transgender people, but also culturally competency to fight stigma.
It is evident that physicians are much less comfortable and knowledgeable with transgender patients than with lesbian, gay, or bisexual patients, likely because they are cisgender and can still be treated the same way as straight cisgender patients in many cases (Mehta et al., 2018). Researchers have observed that because there are barriers to healthcare, and because transgender people are treated differently by healthcare workers, they are less likely to see doctors in general (Bauer et al., 2009). Of course, this has negative impacts on many aspects of a person’s health, because preventative care is the key to avoiding many serious health problems. That is why it is critical not only to make sure that doctors know how to meet the medical needs of patients, but also to treat them in an inclusive and respectful way that makes them comfortable in a clinical setting, hence encouraging them not to be afraid to seek care.
References
Ali, N., Fleisher, W., & Erickson, J. (2016). Psychiatrists’ and Psychiatry Residents’ Attitudes Toward Transgender People. Acad Psychiatry, 40(2), 268-273. doi:10.1007/s40596-015-0308-y
Bauer, G. R., Hammond, R., Travers, R., Kaay, M., Hohenadel, K. M., & Boyce, M. (2009). “I don’t think this is theoretical; this is our lives”: how erasure impacts health care for transgender people. J Assoc Nurses AIDS Care, 20(5), 348-361. doi:10.1016/j.jana.2009.07.004
Heffernan, D. (2012). The APA Removes “Gender Identity Disorder” From Updated Mental Health Guide. Retrieved from https://www.glaad.org/blog/apa-removes-gender-identity disorder-updated-mental-health-guide
Mehta, P. K., Easter, S. R., Potter, J., Castleberry, N., Schulkin, J., & Robinson, J. N. (2018). Lesbian, Gay, Bisexual, and Transgender Health: Obstetrician-Gynecologists’ Training, Attitudes, Knowledge, and Practice. J Womens Health (Larchmt), 27(12), 1459-1465. doi:10.1089/jwh.2017.6912
Safer, J. D., & Tangpricha, V. (2019). Care of the Transgender Patient. Ann Intern Med, 171(10), 775-776. doi:10.7326/L19-0535