On June 12, 2016, during LGBTQ+ pride month, a gunman opened fire inside Orlando’s Pulse nightclub, an LGBTQ+ venue, killing 49 and wounding 53 others. Four years later, on June 12, 2020, the LGBTQ+ community mourned the deaths of Dominique “Rem’mie” Fells and Riah Milton, two black transgender women found murdered in Pennsylvania and Ohio, respectively. That very same day, the Department of Health and Human Services (HHS) reversed a 2016 Rule regarding Section 1557 of the Affordable Care Act which protected patients from discrimination on the basis of gender identity based on “one’s internal sense of gender,” reverting instead to nondiscrimination on the basis of sex “as male or female and as determined by biology.” The new rule effectively removes certain legal protections for transgender patients, therefore putting an already vulnerable population at greater risk in the middle of a global pandemic. The timing of these events is drastic, but outlines the stark reality of transgender life in the United States: one lived under constant and unrelenting threat.
The HHS defends the new rule by stating that “concern about denial of basic health care to transgender individuals appears to be based largely on unsubstantiated hypothetical scenarios.” This claim either ignores the volume of published literature to the contrary, or conflates the concept of “basic” health care with that of “minimum” health care. For example, a 2013 study of 350 transgender people living in Virginia found that 27 percent experienced transgender-based health care discrimination, citing several factors in addition to gender, including socioeconomic status, inability to obtain care, history of violence and substance abuse, and interpersonal factors. The 2008 National Transgender Discrimination Survey (NTDS), a landmark survey of 27,715 transgender patients, found that 31 percent delayed or avoided health care due to discrimination and that gender-nonconforming patients face more transphobic discrimination and experience more health-harming behaviors. While a survey of 131 transgender adults in Massachusetts found no significant health differences from non-transgender adults, these results were limited to patients with stable housing and situated in an area with traditionally high levels of health care and strong statewide anti-discrimination laws. Overall, these studies clearly demonstrate that health care discrimination against transgender patients is neither unsubstantiated nor hypothetical.
It is not enough for transgender care to be made equal. Transgender patients often face health care issues far beyond the experience of non-transgender patients, and which demand an additional degree of clinical awareness. The increased risk of mental health compromise among transgender individuals is well-documented, and inseparable from the challenges they face across all aspects of society. The increasing prevalence of cross-sex hormone therapy is another such example, with likely side-effects of exogenous hormones including but not limited to sexual dysfunction, cardiovascular disease, and weight gain. Sex reassignment (or gender-affirming) surgery is often a necessary step in the treatment of gender dysphoria, and these patients accept the burden of a physical and financial toll in their search for well-being. For many transgender people, mistreatment is simply a way of life, one that extends to the health care they receive, and it should not be this way. Framing all patients within a binary of male vs. female is unacceptable and fails to acknowledge the interactions between a patient’s sex and multiple internal and societal factors, all of which contribute to their overall state of health.
The health care system has never been kind nor fair to transgender individuals. A retrospective study of 79 transgender adolescents found that only 30 percent received insurance coverage for gonadotropin-releasing hormone analogues, in spite of significant concurrent mental health conditions. The aforementioned 2008 National Transgender Discrimination Survey also found that more than half of patients who sought insurance coverage for sex reassignment surgery had their claims denied, regardless of evidence suggesting that gender-affirming care is cost-effective in the long term. In 2019, a federal judge found the Wisconsin Department of Health Services in violation of the law for denying Medicaid coverage for sex reassignment surgery, a policy rooted in a 1997 state regulation. It is this very law that has now been reversed by the HHS, and this exact form of discrimination which we are being told is merely hypothetical.
As health care providers, there is much we can do to support our transgender patients today. Many health care systems have already instituted changes in response to the 2016 Rule, for example, a brief-but-important distinction between a patient’s gender identity and biologic sex within the electronic medical record. We can push to keep these changes in place, regardless of the new rule, and continue to further our efforts toward nondiscrimination. We can identify LGBTQ+ resources within our systems if they exist, and petition for their creation if they do not. We can identify and support local trans-positive organizations, such as Brooklyn’s Audre Lorde Project or Boston’s Boston Area Trans Support, and nationwide organizations such as the National Center for Transgender Equality. We can take a moment to understand transgender terminology. We can incorporate transgender health education at all levels of medical learning, hire more transgender staff, and support open gender nonconformity in the workplace. We can educate ourselves on the LGBTQ+ experience through literature and discussion, and work to dismantle our own explicit and implicit biases. What we cannot do is allow politics to dictate the scope of our practice when so many vulnerable lives are at stake. As the world changes rapidly around us, we must be there to extend a hand, solemn in our knowledge that too many, too often, are left behind.
Aaron Jen is a radiology resident.
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