Transgender discrimination: Physicians must not lag behind

As a native New Yorker, I was thrilled when Governor Cuomo announced plans for an executive order that prohibits discrimination against transgender people in areas such as employment and housing. Specifically, this executive order would expand existing anti-discrimination protections to include gender identity, transgender status, and gender dysphoria. There have also been advancements regarding the protection of transgender people from discrimination in health care.

Recently, the Department of Health and Human Services (HHS) proposed legislation that clarifies protection for transgender populations from discrimination by healthcare providers and insurers. This legislation builds on Section 1557 of the Affordable Care Act to ensure that patients are not treated unjustly due to their gender identity.

Why has such government action been 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, with people of color disproportionately being affected. Those who identified as transgender or gender-nonconforming 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-nonconforming were also twice as likely to be homeless as the general population.

Health care was not immune to this dismal outlook. Many of the respondents postponed their medical care due to an inability to afford it (48 percent) or due to discrimination (28 percent); 19 percent of 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.” Poor health outcomes from such barriers to health care are exacerbated by an increased risk for HIV infection,violence, and substance abuse among transgender patient populations.

What was particularly alarming to me as a physician-in-training was that half of respondents in the report said that they had to teach their medical providers about transgender care.

And, yet, I unfortunately cannot say that I am surprised. In my medical training so far, I have only received a single lecture on LGBT health. However, my school is far from being the only one that needs to have better training on the health needs of transgender patient populations.

A recent study asked deans from medical schools all across the U.S. 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 populations 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.

Even if medical schools actively work to increase LGBT-related curricula, they need to be mindful about not perpetuating the marginalization of LGBT populations. A commentary in JAMA earlier this 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 competency, biochemical, psychosocial, and psychiatric components of the curriculum.

In the past year, we have seen great strides in countering the stigma and discrimination faced by transgender and gender non-conforming individuals in this country. Elected officials and government agencies are engaging in a much-needed call for action. Medical schools need to start working now on ensuring that future physicians do not remain complicit in the discrimination against marginalized populations.

Tehreem Rehman is a medical student who blogs at her self-titled site, Tehreem Rehman.  She can be reached on Twitter @tehreem_rehman.

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