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  • Brian Mastroianni — US

Addressing disparities in trans healthcare

Trans people largely feel locked out of a healthcare system that is beset by cultural bias, transphobic political rhetoric, and socioeconomic disparities. Besides efforts to spread awareness about trans issues and rights, growing representation of the community in the medical fraternity can go a long way in fighting stigma and creating inclusive caregiving spaces.

Complex social and economic factors can make health systems seem impenetrable for trans people.

Among the many challenges confronting transgender people around the world today, lack of access to healthcare is especially worrying. The experiences of transgender people as they navigate healthcare systems globally, whether for gender-affirming care or even general healthcare, vary from community to community, culture to culture, and nation to nation.

A combination of factors can make health systems seem impenetrable for trans people—entrenched cultural norms colliding with more expansive and evolving understandings of the gender spectrum; a lack of vocabulary around trans health in some healthcare settings; transphobic political rhetoric; and socioeconomic disparities that put quality, equitable healthcare out of reach for the most vulnerable.

"Access to healthcare for TGD [transgender and gender diverse] people has greatly improved over the past 20 years, but what we’ve seen recently is some fairly disturbing backlash."

It’s an environment that Dr Marci Bowers, a US-based medical pioneer in gender affirmation surgery, says is particularly treacherous due to the structural barriers that exist in societies around the world. These barriers can make a trans person in need of healthcare feel excluded from the medical process. It’s a reality that Bowers, the first woman globally to perform transgender surgery who is trans herself, wants the medical community at large and policymakers to address.

“Structural barriers—those are imposing for people. Access to healthcare for TGD [transgender and gender diverse] people has greatly improved over the past 20 years, but what we’ve seen recently is some fairly disturbing backlash,” says Bowers, who currently practises in Burlingame, California, and serves as president of the Executive Committee and Board of Directors of the World Professional Association for Transgender Health (WPATH).

“A lot of that backlash is based on misinformation. Some of it is ignorance. Some of it is purposeful retrenchment of gains that have been made in the social justice area. That is what concerns a lot of us—that healthcare has been weaponised as a political tool.”

As with all disparities in care, those who are most vulnerable in society can face the biggest roadblocks to quality and safe care. What this underscores is that more needs to be done to create inclusive care for transgender people.

Addressing global challenges for transgender people

Trans people face high rates of violence worldwide. The United Nations Free & Equal campaign from the UN Human Rights Office reports that "disaggregated records" collected by national authorities around the world make it hard to quantify the incidence of transphobic violence. Citing data from The Trans Murder Monitoring project, the campaign documents more than 2,000 murders in 66 countries between 2008 and 2016—or one killing of a trans person every two days.

The ever-present threat of physical violence is compounded by the criminalisation of gender identity or gender expression, and the failure to recognise a person’s identity or accurately refer to their correct pronouns. Trans people also regularly face harassment and discrimination in spaces that should ideally feel safe, such as workplaces, schools, and hospitals.

As with quantifying the scale of violence against trans people, there are challenges in defining the barriers to accessing inclusive healthcare, too.

A 2016 report published by The Lancet reveals that while the “challenges that face the transgender community are global, multifactorial, and extend across all medical specialities”, the realities of access to medical care for transgender people are among “the least researched fields of transgender health”.

Additionally, the report points to the dearth of population-level data to monitor and assess the overall health experience of transgender people globally since “routine national and international health surveillance in most countries does not assess gender identity”. The authors point out that many studies don’t necessarily examine the full spectrum of trans identities. Non-binary identities may not be examined at all.

The question of who devises strategies to provide healthcare to transgender and gender diverse people is a major one. A 2019 report by Global Health 50/50, an initiative by the University College London Centre for Gender and Global Health, found that only 14 of the 198 global health organisations surveyed “specifically recognise transgender people in their commitment to gender equality”. Just 15 had “programmatic strategies” that refer to transgender health.

This lack of emphasis on the realities of transgender care—and strategies to improve it—filters down from adult to adolescent and children’s care.

Global programmes “aimed at improving the health of young people” generally did not focus on LGBTQ+ young people at all, according to a study funded by Bill & Melinda Gates Foundation that was cited by a 2021 review in the journal Transgender Health.

This lack of awareness of issues surrounding transgender health and trans issues in general at a global health policy- and decision-making level can exacerbate the disparity in care.

Tackling entrenched structural barriers

A major issue in how transgender people access and navigate healthcare is the lack of training among healthcare providers.

“Among the biggest barriers are lack of trained providers in many locations and hostile environments interfering with care in some locations,” says Dr Joshua Safer, director of The Mount Sinai Center for Transgender Medicine and Surgery in New York City. This, in turn, means that trans and gender diverse people “receive less opportunity for healthcare than the rest of the population”, he adds.

This leads to a cascade of delays in preventive care, delayed diagnoses and, ultimately, delayed treatment, Safer says. And it isn’t exclusive to gender affirming care—it applies to routine screenings and life-saving preventive treatment.

The good news is educational tools do exist. WPATH publishes the Standards of Care for the Health of Transgender and Gender Diverse People, an international protocol and guidelines for health professionals around the world.

From the perspective of low- and middle-income countries (LMICs), Dr Gabe Murchison, a postdoctoral fellow at the Center for Interdisciplinary Research on AIDS, the Yale LGBTQ Mental Health Initiative, and the Yale School of Public Health, says he is hesitant to generalise about the overall state of healthcare for trans and nonbinary people “since experiences vary so much across cultures and health systems”.

"Trans and nonbinary people are increasingly able to switch away from nominally trans-competent clinicians who are negligent and disrespectful, or abusive, but were previously the only local option."

But Murchison, who is trans, points to the larger trends that have been on his radar as a public health researcher. One positive he identifies is the “enormous growth” in the number of health providers who now have training and experience working with trans and nonbinary people.

“That is a huge deal, because it means trans people are now much more likely to find a good provider who’s geographically and financially accessible,” Murchison says. “It also means more accountability for providers, because trans and nonbinary people are increasingly able to switch away from nominally trans-competent clinicians who are negligent and disrespectful, or abusive, but were previously the only local option.”

Throughout the world, clinicians who are best trained in gender-affirming, trans-specific care serve communities where low-income patients need to be the priority, but those clinics often have long wait lists, Murchison adds. This lack of availability can force some people to turn to for-profit services, such as “concierge medicine clinics” that promise care at a high cost. “This is not a sustainable or equitable model, particularly since trans communities tend to be economically marginalised as a result of discrimination,” Murchison says.

Stigma is yet another major barrier facing trans people seeking and receiving medical care. Murchison says “it’s impossible to overstate” the harmful impact of stigma and discrimination on a trans or nonbinary person’s health.

“The burden is enormous and wide-ranging, from the high prevalence of suicidality to employment discrimination that shunts trans and nonbinary people into potentially health-damaging occupations,” he adds.

Murchison says trans and nonbinary people do an extraordinary job of caring for one another as a community, but community can only do so much “in the face of pervasive mistreatment and structural disadvantage”.

Stigma is a major barrier facing trans people seeking and receiving medical care.

Photo: Karollyne Hubert

Pushing through obstacles to quality care

Despite the challenges, efforts that enable clinicians to connect and collaborate, as well as improving representation, are helping improve access to quality care for trans people.

Dr Nick Gorton is a California-based emergency medicine physician who volunteers as a primary care provider working with trans patients at Lyon-Martin Health Services in San Francisco. Gorton, who is trans, is also the lead clinician for TransLine, an e-consultation service for physicians seeking up-to-date clinical information and advice on providing care to transgender patients and communities.

It would be "very helpful" if more healthcare settings gave trans and gender diverse clinicians and office staff visible roles.

Gorton describes the online service as a means for clinicians to connect with peers in the field. If a physician needs help or has a question, they can create an online ticket and the mental health provider or medical provider on call each month will respond to the query.

Gorton says “there is still a long way to go” to improve clinical awareness of trans-specific health issues, but given that physicians across the US have used TransLine, he believes it can serve as a model for clinicians elsewhere in helping to break down divides and creating more inclusive care for transgender and nonbinary patients.

Often it comes down to representation and hearing directly from people whose lived experiences can help inform healthcare.

Candace Nguyen is a Boston-based trans woman who has seen firsthand the impact of trans-inclusive medical spaces and why they are so vital. Born and raised in Boston, Massachusetts, Nguyen is a Vietnamese American queer and trans advocate who has a separate career as a drag performer under the name ‘Candace Persuasian’.

Until recently, she worked as a plastic surgery coordinator at the state’s largest hospital, Massachusetts General Hospital (MGH), where she helped trans and nonbinary patients navigate the hospital as they sought gender-affirming care. In 2022 she received the Massachusetts Transgender Political Coalitions 2022 Gunner Scott Trans Excellence Award for her work.

Nguyen says that as a trans person herself it was important that someone like her had a front-facing role when trans patients came for appointments. She says she’s witnessed “both ends of the relationship between patient and institution” firsthand and that it would be “very helpful” if more healthcare settings gave trans and gender diverse clinicians and office staff visible roles. “Don’t count other people out if their experiences are different from what you are used to,” she says.

Combating misinformation and divisive rhetoric

Nearly every expert interviewed cited misinformation about trans-specific healthcare—and the transphobic rhetoric that accompanies it—as a major hurdle trans people and their providers face around the world.

From the vantage point of the US, “unscientific debate about healthcare and human rights for trans and gender diverse people” has resulted in “shockwaves of intimidation through health systems” nationwide, says Dr Meredithe McNamara, an assistant professor of paediatrics who specialises in adolescent medicine at Yale School of Medicine and an affiliate faculty member at the Yale Institute for Global Health.

"What we are doing is responding to a population that has always been here. People are stepping up and acknowledging that their gender identities are not measured by their birth assignment."

“In jurisdictions of proposed bans on gender affirming care, clinics that offer full-spectrum services face excessive and undue scrutiny simply for offering the standard of care. In a wild violation of our social norms, children’s hospitals have faced bomb threats and hateful protests, while clinicians have incurred death threats.”

Murchison agrees, saying that many of the clinicians who offer care to trans people in this charged environment remain brave and committed to their work, but there is “a lot of variability” in how their employers and associated hospital systems protect and support them.

Safer says the medical establishment must “keep reminding our fellow citizens that this is just health care” and that divisive political rhetoric exists in this arena.

Murchison adds that medical care is crucial but “mental health and poverty both need to be central parts of the trans health conversation in the US and globally.” He also hopes to see the number of openly trans and nonbinary clinicians continue to grow. “Working alongside trans and nonbinary colleagues will be critical in convincing many cisgender medical providers to see and treat us as equals.”

It’s really harmful and really hurtful,” Bowers, the gender affirmation surgery expert, says. “There are people that are making it sound like [trans and gender diverse healthcare] is a medical industrial complex and we are grooming patients and recruiting patients. It could not be farther from the truth.”

“What we are doing is responding to a population that has always been here. People are stepping up and acknowledging that their gender identities are not measured by their birth assignment,” she says.

“As providers, we are just providing medical care using the best practices wherever possible. We are just trying to keep people safe.”


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