Trans Health Blog
Access to Healthcare for Trans
Transgender persons suffer significant health disparities in multiple arenas. Real or perceived stigma and discrimination within biomedicine and the health care provision in general may impact transgender people’s desire and ability to access appropriate care. Transgender women (Male to Female, MTF) are internationally recognized as a population group that carries a disproportionate burden of HIV infection, with a worldwide HIV prevalence of 20%. A US sample of 1093 transgender persons demonstrated a high prevalence of clinical depression (44.1%), anxiety (33.2%), and somatization (27.5%). In the largest national transgender survey to date (n= 6,456), 30% of the respondents reported current smoking (1.5x the rate of the general population), 26% reported current or former alcohol or drug use to cope with mistreatment, and 41% report having attempted suicide (26x higher than the general population). While some of these health care barriers are faced by other minority groups, many are unique, and many are significantly magnified for transgender persons.
In addition to the usual care, transgender patients often require medical interventions such as hormone therapy and/or surgery. The purpose of this manuscript is to briefly review the current literature characterizing barriers to high quality health care for transgender individuals and to propose research priorities to understand both the mechanisms of those barriers and potential interventions to overcome them.
The biggest barrier both to safe hormonal therapy and to appropriate general medical care for transgender patients is the lack of access to care. Despite both guidelines and data supporting the current transgender medicine treatment paradigm, transgender patients report that lack of providers with expertise in transgender medicine represents the single largest component inhibiting access. Transgender treatment is not taught in conventional medical curricula and too few physicians have the requisite knowledge and comfort level.
Other reported barriers include: financial barriers (lack of insurance, lack of income), discrimination, lack of cultural competence by health care providers, health systems barriers (inappropriate electronic records, forms, lab references, clinic facilities) and socioeconomic barriers (transportation, housing, mental health). While some of these health care barriers are faced by other minority groups, many are unique, and many are significantly magnified for transgender persons.
The two most common factors in a positive experience with a medical provider were respecting the person’s name and their gender pronouns. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4802845/)
Silicone Injections / Hormones
Silicone, a permanent synthetic substance, is not FDA-approved for cosmetic purposes, but since it was greenlighted in the 1990s for certain uses in ophthalmology (serious stuff, like retinal detachment), injecting it into the skin to plump and fill lips, breasts, and butts is technically considered “off-label”. The use of unmonitored silicone injections is also a health concern for trans people who may be unable to access professional cosmetic surgery. These
illegal injections often contain toxic ingredients and can lead to severe disfigurement and even death. (https://www.harpersbazaar.com/beauty/health/a14478122/silicone-injection-danger/)
Transgender hormone therapy, also sometimes called cross-sex hormone therapy, is a form of hormone therapy in which sex hormones and other hormonal medications are administered to transgender or gender nonconforming individuals for the purpose of more closely aligning their secondary sexual characteristics with their gender identity. This form of hormone therapy is given as one of two types, based on whether the goal of treatment is feminization or masculinization: · Feminizing hormone therapy – for transgender women or transfeminine people; consists of estrogens and antiandrogens · Masculinizing hormone therapy – for transgender men or transmasculine people; consists of androgens Some intersex people may also undergo hormone therapy, either starting in childhood to confirm the sex they were assigned at birth, or later in order to align their sex with their gender identity. Non-binary or genderqueer people may also undergo hormone therapy in order to achieve a desired balance of sex hormones.
Complications of feminizing hormone therapy might include:
- A blood clot in a deep vein (deep vein thrombosis) or in a lung (pulmonary embolism)
- High triglycerides, a type of fat (lipid) in your blood.
- Weight gain.
- Elevated liver function tests.
- Decreased libido.
- Erectile dysfunction.
- Infertility. (https://en.wikipedia.org/
The CUNY researchers, who published their findings in the LGBT Health journal, looked at the responses of 6,456 adults who participated in the 2008 and 2009 National Transgender Discrimination Survey. The adults were asked if they had ever attempted suicide or took drugs and/or alcohol to feel better about discrimination they had experienced as a result of their transgendered identities. The survey further asked how the adults’ families (where applicable) reacted upon learning that they were transgendered (or gender nonconforming). Examples of reactions included the termination of the relationship with a spouse or partner and whether family members refused to speak or spend time with them.
Around 54 percent of participants said that the amount of family rejection they experienced was “low”; as many as 14 percent of the adults said that the rejection they received from their family could be considered “high.” Approximately 42 percent of the adults said that they had tried to commit suicide at least once, and 26 percent said they abused drugs or alcohol.
The higher the levels of family rejection, the greater the likelihood of drug or alcohol abuse.
Transgender Mental Health and Poor Outcomes
For many transgender people, their struggles with addiction don’t end with treatment. Most facilities separate their clients by gender, to better address gender-specific issues of mental health and substance abuse. Transgender clients, however, are left feeling out of place, especially those who are still in the process of transitioning to their desired gender. Such individuals require regular hormone treatments, which could take years; some treatment centers may not be in a position to continue the facilitation of estrogen or testosterone infusions, and some healthcare providers may be uneducated as to the importance of keeping up with the procedure, mistakenly believing such treatments to be “elective.”
Such is the state of healthcare serving transgender people that many transgender individuals face discrimination in the healthcare services they need. A Reuters report from March 2015 found that 42 percent of transgender people said they received verbal or even physical abuse at their doctor’s office or were denied equal treatment because of their gender identity. Most of the people who reported discrimination were “young, white, college-educated people with jobs and private health insurance,” suggesting that transgender individuals who did not fit into those categories (those who are older, not white, uneducated, unemployed, and without adequate health insurance) could be subject to even greater levels of discrimination within treatment.
For example, “nearly all research into transgender individuals’ mental health shows poorer outcomes,” says NPR, especially for transgender people who are low-income, female, and of color. While nearly one-third of trans Americans are HIV-positive, transgender women of color have an even greater risk of being diagnosed with HIV; a 2009 study by the National Institute of Health found that over 56 percent of black transgender women have HIV-AIDS. Most research on transgender health has used white Americans; more is known now about black transgender individuals than before, but “there is almost nothing” known about Hispanic transgender people.
Barriers to Treatment
Bad experiences in healthcare settings may preclude some trans people from seeking out medical help for their problems. The Journal of Gay & Lesbian Mental Health surveyed 130 trans volunteers and found that fear of treatment and past negative experiences accounted for some of the most common barriers to seeking mental health services. Participants most frequently mentioned stigma as their main concern; they were scared of “mistreatment at the hands of someone who could not understand them.” The American Psychological Association noted that “dealing with discrimination results in a state of heightened vigilance and changes in behavior,” so trans people who have been negatively treated by caregivers and health providers are likely to anticipate further discrimination, “which in itself can trigger stress responses.”
An assistant professor at the University of Buffalo School of Nursing points out that “there is evidence that healthcare providers do tend to be judgmental,” and for many transgender people, that extra layer of stigma (combined with other factors) is enough to dissuade them from seeking medical help.
Transgender Violence/Intimate Partner Violence
In 2019, advocates tracked at least 27 deaths of at least transgender or gender non-conforming people in the U.S. due to fatal violence, the majority of whom were Black transgender women.
These victims were killed by acquaintances, partners or strangers, some of whom have been arrested and charged, while others have yet to be identified. Some of these cases involve clear anti-transgender bias. In others, the victim’s transgender status may have put them at risk in other ways, such as forcing them into unemployment, poverty, homelessness and/or survival sex work.
While the details of these cases differ, it is clear that fatal violence disproportionately affects transgender women of color — particularly Black transgender women — and that the intersections of racism, sexism, homophobia, biphobia, transphobia and unchecked access to guns conspire to deprive them of employment, housing, healthcare and other necessities.
As is too often the case in the reporting of anti-transgender violence, many of these victims are misgendered in local police statements and media reports, which can delay our awareness of deadly incidents. In the pursuit of greater accuracy and respect for transgender and gender non-conforming people in both life and death, HRC offers guidelines for journalists and others who report on these communities.
Sadly, 2020 has already seen at least 18 transgender or gender non-conforming people fatally shot or killed by other violent means. We say at least because too often these stories go unreported — or misreported.
Intimate partner violence (IPV) is a serious, preventable public health problem that affects millions of Americans. The term “intimate partner violence” describes physical violence, sexual violence, stalking, or psychological harm by a current or former partner or spouse. This type of violence can occur among heterosexual or same-sex couples and does not require sexual intimacy.
IPV can vary in how often it happens and how severe it is. It can range from one episode of violence that could have lasting impact to chronic and severe episodes over multiple years. IPV includes four types of behavior:
- Physical violence is when a person hurts or tries to hurt a partner by hitting, kicking, or using another type of physical force.
- Sexual violence is forcing or attempting to force a partner to take part in a sex act, sexual touching, or a non-physical sexual event (e.g., sexting) when the partner does not or cannot consent.
- Stalking is a pattern of repeated, unwanted attention and contact by a partner that causes fear or concern for one’s own safety or the safety of someone close to the victim.
- Psychological aggression is the use of verbal and non-verbal communication with the intent to harm another person mentally or emotionally and/or to exert control over another person.