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Transgender Perspectives on Medical Care

By Julie A. Sayre

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In 1999, the American Public Health Association issued Public Policy 9933, stating the need for increased acknowledgement of transgender individuals and their “distinct health needs.” 1 The policy encouraged healthcare providers to be sensitive to the needs of transgender individuals and to treat them with respect. Ten years later, the transgender com- munity, as well as the rest of the LGBT community, continues to experience some of the greatest disparities the United States healthcare system, even in some of the most progressive states. In a study in 2009 conducted by the Massachusetts Department of Public Health, the health of transgender population was found to be “somewhat worse” than heterosexual and non-transgender counterparts, with “worse outcomes with respect to self‐reported health, disability status, depression, anxiety, suicide ideation, and lifetime violence victimization.” 2 Though societal acceptance of homosexuality and gender nonconformity has increased in the last several decades, studies have shown that varying degrees of homophobia and heterosexism in healthcare negatively impacts the quality of care received by lesbian, gay, bi and transgender individuals. 3

Within the LGBT community, the transgender population is perhaps the most understudied and misunderstood by society. Often when people think of a transgender person, they think of a transvestite or a drag queen. In fact, the term “transgender” covers transsexuals, cross-dressers, drag kings/ queens, bigender, and androgynous individuals. 4 According to definitions provided by a Columbia study, transsexual individuals desires to “fulfill their lives as members of the opposite gender” and often seek medical treatment such as hormone therapy or surgery. 5 A transgenderist might desire to live part-time as another gender, whereas transvestite may dress in the clothing of the opposite gender for “emotional satisfaction or erotic pleasure.” Gender performers such as drag kings or queens cross dress for entertainment purposes, for fun, or to challenge stereotypes.
Two final categories include androgynous individuals who might portray both sexes or neither, and intersex or hermaphrodite individuals who have medically established traits of both genders. 5

Trans people endure the same challenges when it comes to receiving quality healthcare as much of the gay community, which might includes enduring stigma, economic barriers, and trouble obtaining insurance and visitation rights, and more. However, transgender individuals may face the additional barriers of increased stigmatization, having their desire to transition treated as pathological, difficulty obtaining coverage for treatment relating to transitioning, and increased economic barriers. Some of these factors, in addition to often being and stigmatized by both homosexual and heterosexual communities alike, may explain the high incidence of depression, anxiety, and suicide. 5 (p.38) The higher incidence of health problems has also been attributed to many “cultural stressors,” in addition to simple fear of prejudice and discrimination at the doctor’s office. Several of these stressors include rejection by family members, harassment (particularly if a transgender man or woman does not “pass” as the gender they desire to portray), as well as job discrimination leading to unemployment, poverty and homelessness. 5 (p. 38 – 39) All these factors often lead to both an increased propensity towards health problems combined with an inability to cover medical costs, which is often compounded by denial by insurance companies for certain medical treatments.

As previously mentioned, many of the health disparities experienced by trans people are the result of lack of cultural competency on the part of healthcare providers, rang- ing from benevolent ignorance to overt transphobia. Often gender nonconformity is viewed in the healthcare industry as pathological, much like homosexuality before the mid- 1970s when the American Psychiatric Association deleted it from the Diagnostic and Statistical Manual of Mental Disorders. The Columbia University study cited the problem of pathologizing gender non-conformity as “one of the most significant barriers” to adequate transgender healthcare. Due to all these factors, transgender individuals often neglect to seek out medical care due to fear of being misunderstood or discriminated against. These individuals may resort to black market acquisition of hormones, may undergo gender reassignment surgeries by illegitimate or unlicensed providers, or might resort to trading sex for services. 5 (p. 37 – 39)

For many transgender people, their health issues often revolve around the process of transitioning, or adopting the physical characteristics of the sex they identify with. This is usually achieved through either hormone therapy or surgery, or both. Sexual reassignment surgery (SRS), also referred to as gender affirmation surgery, is a procedure sought by many transgender individuals in order to obtain these physical characteristics. This surgery sits at the crux of a unique merging of mental health diagnoses and medical treatment, and has been demonstrated in studies to increase the well- being of the recipient as well as effectively treat gender dysphoria and Gender Identity Disorder (GID). 6 This expensive surgery—which is rarely covered by health insurance in the United States—normally requires adherence to the WPATH Standards of Care, which contains a detailed set of guidelines followed by surgeons and mental health professionals outlin- ing various prerequisites for obtaining the surgery, which can include months of therapy and letters of recommendation from both therapists and other health professionals.

Many people take issue with the diagnosis of GID itself, which requires that the individual experience “clinically sig- nificant distress” as a result of their gender. 7 Some GID reform advocates feel that depicting transgenderism as a mental illness is disparaging and/or heterosexist. Others find that the criterion of “clinically significant distress” can be vague and subject to the whim of the clinician, making them into gatekeepers. Since this diagnosis is often necessary in order to obtain hormone therapy or surgery, some transgender individuals who want to transition but may not be experiencing “clinically significant distress” may not qualify for treatment. 8 Individuals who are diagnosed with the disorder experience difficulty of obtaining medical care with the diagnosis of GID on their record. Since most insurers do not cover treatments related to transgenderism, the diagnosis of GID can be problematic in that it could provide a way for insurance companies to deny coverage for any treatment they determine to be related to the disorder. 8

In conclusion, transgender individuals face many unique barriers in obtaining good healthcare. Increased awareness on the part of doctors—and society as a whole—would likely accelerate further reform in favor of these individuals as well as improve overall healthcare quality.

References

1. “The Need for Acknowledging Transgendered Individuals within Research and Clinical Practice,” Policy 9933. 1999. American Public Health Association. Web. 2/27/10. <http://www.apha. org/advocacy/policy/policysearch/default.htm?id=204. org/advocacy/policy/policysearch/default.htm?id=204>
2. Landers, Stewart JD, MCP and Paola Gilsanz, MPH. “The Health of Lesbian, Gay, Bisexual and Transgender (LGBT) Persons in Massachusetts: A survey of health issues comparing LGBT persons with their heterosexual and non- transgender counterparts.” Massachusetts Department of Public Health (2009).
3. Dean, Laura MEd et al. “Lesbian, Gay, Bisexual, and Transgender Health: Findings and Concerns.” Journal of the Gay and Lesbian Medical Association Vol. 4 Issue 3 (2000). 126-127.
4. Gay and Lesbian Medical Association and LGBT health experts. “Healthy People 2010 Companion Document for Lesbian, Gay, Bisexual, and Transgender (LGBT) Health.” Gay and Lesbian Medical Association (2001). 15.
5. Dean, Laura MEd et al. “Lesbian, Gay, Bisexual, and Transgender Health: Findings and Concerns. Conference Edition. Gay and Lesbian Medical Association (2000) 37-38.
6. Wittle, Stephen PhD. “WPATH Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage in the U.S.A.” 2008. World Professional Association for Transgender Health. Web 2/27/10. <http://www.wpath.org/documents/Med%20Nec%20on%202008%20Letterhead.pdf>
7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th Edition. 2000. Pg. 576.
8. Cohn-Hopwood, Melanie LICSW. Fenway Health. Personal Interview. 2/20/10.


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