ORIGINAL ARTICLES

Transgender Health: Current Social Movements, the Ethics of Fighting on their Behalf and Analysis for Further Change

By Ryan Rifkin

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Abstract

Transgender people face health disparities far exceeding those of most other demographics and minority populations in the United States of America. Hate crimes have only been recorded since October 2009 when the Matthew Shepard Act to expand the definition of hate crimes was ratified, rendering highly underestimated statistics. Grassroots organizations seek to help the community directly while others aim to create institutional change. By examining these “bottom-up” and “top-down” approaches, respectively, a course of action will be recommended for the social movements fighting for equitable transgender care. Many questions must be considered throughout this process in order to understand how to achieve a cohesive and successful movement for this particular minority population. First, the barriers preventing transgender people from accessing care in social, legal and physical contexts and the differences between necessary health care for transgender people versus their cisgender– when one person’s sex and gender match one another and are acceptable in the context of that society- counterparts must be understood. Many health care workers are indeed sympathetic to gender issues, so why these workers are unsuccessful in their attempts and the consequences of not providing equitable care must be considered before reaching concluding suggestions. Finally, this article will look at current transgender health social movements and compare them to principles of social movements, concluding with my thoughts on what the community should do to remove the barriers I establish. The goal of this article is to reveal the barriers transgender people face, many of which relate to issues their cisgender counterparts take for granted. By unearthing and demystifying transgender people and their health issues, I aim to increase passion about providing equitable care.


Introduction: Identifying the Issue

Transgender people face extreme difficulties attaining quality healthcare, despite high-risk health status. These difficulties permeate all areas of well-being. Between 50% and 88% of transgender identifying teens attempt suicide, revealing deficient mental health services and lack of access. 2 In one study, 12% of trans-people studied self-identified as HIV-positive, though after testing 28% of them tested positive. 3 This shows not only misinformation within the trans-population regarding HIV prevalence, but also a lack of public health measures to provide outlets for testing and to train doctors in necessary precautions and measures. Furthermore, studies indicate that trans-people are paid up to 1/3 less during and post transition, 4 revealing social gradients that inevitably affect health outcomes.

Many transgender people are knowledgeable about their health and do seek care, often in desperation and without success. The story of Robert Eads has been popularized in the film “Southern Comfort,” but he is unfortunately not the only person in his predicament. Eads, a post-operation transgender man (born a woman), developed cervical cancer. Over the course of a year he visited over twenty doctors, but all refused to treat his condition. He eventually died in 1999 as a result of doctors refusing to treat the condition earlier, 5 demonstrating that even within the medical community there is a strong aversion to dealing with transgender issues.

This disparity cannot be attributed solely to a lack of training for doctors and community awareness. Many discriminatory laws and practices prevent transgender people from attaining quality care. Transgender people are legally protected from employment termination based on gender representation in only 12 states. Transgender people endure a 30% unemployment rate, and 59% earn less than $15,900 a year. 6 Limited opportunity for employment and unfair pay greatly reduce access to healthcare, both by providing less health insurance coverage and reducing the ability to financially support the care, and yet these two forms of discrimination do not even account for other biases within the workplace. Experiences in doctor’s offices and medical facilities also directly impact transgender healthcare. In one survey conducted by the Pennsylvania Department of Public Health in Philadelphia, nearly 20% of transgender people reported verbal or physical harassment in a mental or behavioral health facility. 7 Bear in mind, this is in Philadelphia, an urban environment in the northeastern United States – generally considered a relatively “accepting” environment in the United States, and yet even there the statistics are staggeringly high. Evidently, discrimination is institutionally as well as culturally present.

Kevin Irwin, professor of Community Health at Tufts University, breaks social movements down into three “buckets:” the Fundamental bucket, the Realization bucket and the Scale bucket. 8 The Fundamental bucket posits the need for a clear vision and framing, authentic base in the constituency and a commitment to work for years. The Realization bucket encompasses economic viability, a shared vision of governance, research supporting the cause and in a sense, a pragmatism or a belief that their cause can indeed be “won.” Finally, Scale must be considered, and the organization must have a plan for growth and increasing visibility as well as have a willingness to network with other movements. This framework provides us with a clear way to analyze and compare social movements and will be used towards the end of this article.

I have further consolidated the transgender community’s issues by classifying three “impasses” the transgender social movement faces. The first impasse describes how transgender people are suppressed and blamed in dominant political, legal and medical discourses, which not only leads to misinformation, but also causes transgender people to internalize transphobia. The second impasse is the transgender community’s small population size. This draws attention away from their staggeringly weak health outcomes. The first impasse further diminishes the size of active transgender people fighting for better care and rights openly. The third impasse is the lack of cohesion between the transgender rights movements due to ideological and political differences, making it very difficult to have a unified voice and therefore more difficult to be an ally.

Rationale

People generally feel connected with specific social movements due to personal investment. Whether they have a certain medical condition or are advocating for a family member or demographic, it is normal and more common to feel passionate about an issue that in some way affects you. Though I do not identify as transgender, I have noticed that different groups have very different perceptions of the involvement of the “T.” It is becoming increasingly easy to marginalize transgender people in an effort to further the lesbian and gay agendas. The balance between sexual orientation and gender variance is at play here, and though they have historically been associated, the two causes are becoming increasingly juxtaposed due to various legal and social technicalities.

Thus, transgender people effectively have no allies. They are not classified with women due to gender identification issues, nor with lesbians and gays because trans-issues relate to gender and not sexuality. They are also rejected from many groups due to religious affiliations. Furthermore, many politically active gays and lesbians have come to believe they can act more effectively on the political front, helping to pass antidiscrimination laws more easily, if those laws exclude protection of trans-people, leading many in the gay political community to disavow associations with trans-issues.

Adding to this difficulty, transgender people represent only 0.04% to 0.2% of the population, 9 so they have little political clout of their own compared, for example, with women who compose about half of our population or with African-Americans who represent approximately 12.8%, 10 and so these groups and others had more political representation in their struggles than transgender people do now. So in the end, who is left to defend this group? Who is willing to take a stand and say hurting anyone for any biological reason is a hate crime, and preventing anyone from accessible healthcare, employment and fair wages is unethical? Transgender people cannot fight alone. Trans-people need more voices, and through measures to promote awareness of transgender issues we can increase their system of support and their ability to speak up. By not speaking we are condoning both institutionalized discrimination and physical violence.

Caveat and Limitations

Issues faced by transgender people are particularly salient now, amidst recent successes and failures in the fight for Lesbian and Gay equality and the Matthew Shepard Act, which passed in October of 2009, protecting all LGBT people, regardless of location in the United States, from hate crimes– just as laws protect African Americans, the disabled, and many other minorities. It is interesting to note that the Matthew Shepard Act also requires the FBI to track crimes committed against transgender people. 11 Though this will provide statistical information of discrimination against transgender people in the future, the number of crimes already committed is forever unknown. It must be understood before reading this analysis that all statistical information is based on reported cases and incidences. It is therefore likely that the rates of such crimes are far higher than recorded.

Background

Prominent analyses explore the role of male hegemony and its suppression of transpeople through notions of sexrole oppression. This notion examines the stereotyped views of male and female roles in society. The analysis posits that transpeople assimilate patriarchal beliefs that certain behaviors and feelings are reserved for specific bodies into their self-schemas, thereby causing gender dysphoria. 12 This suppression of transgenderism lends itself as a reason for the diminished presence of transgender people fighting for rights in political discourse, as it blames the individual as the cause of his or her own “condition.” Thus, our notions of gender and sexual attraction not only cause “gender dysphoria,” but also prevent transgender people from engaging in the political discourse. This is what I have referred to as the first impasse to creating a movement to support transgender health.

The relatively small population of transgender people, as compared to other minority groups such as African Americans or lesbians and gays, also reduces the attention this group receives. Compounding this problem, the transgender minority further reduces its perceived size by seeking to mask itself in ways other populations such as African Americans, women, and the disabled cannot. Transgender people seek to “pass” as the so-called “opposite” gender (internalizing transphobic gender binaries), and once they can pass, the community potentially loses another passionate voice. In Social Movement Theory, and political and feminist discourses, when a population is fundamentally (in terms of identity and ideology) at odds with itself, fluidity increases between different facets of an individual’s identity. 13 The small size of this minority and its self-debasing efforts, which further reduces the size of the active and collective group, may be considered the second impasse to creating a movement to support transgender health by bifurcating their population into distinct, weaker factions.

An additional arena in which transgender people have been suppressed is in medical discourse and the medicalization of the condition through pathologization. Transgender identity could alternatively be treated or respected as a function of bio-diversity. Science sees the need to find the etiology of this “deviance,” buying into traditional hegemony. Recent studies have shown that regions of the brain controlling sexual function, which are typically smaller in women than in men, in fact mirror the gender rather than the sex 14 of transgender people, 15 revealing a potential biological basis. Many transgender people want their “condition” to be further medicalized hoping it would better standardize treatment and potentially be covered by insurance. Others in the transgender community, however, don’t want to be perceived as psychologically debilitated and fight both the medicalization and notion of “gender dysphoria.” Many movements find this a hard rift to mend, forcing these movements to “pick sides” in a small community where standing together is so important to attain a political voice. This presents the third impasse of supporting the transgender community.

Findings: Movements and their Respective Causes

Transbucket.com is a movement based in Boston, Massachusetts. As this is an Internet-based grassroots movement, transgender people across the nation are able to reap the benefits of Transbucket’s work. The movement was founded in the summer of 2009 as a unifying effort; while there had previously been separate online resources for FTMs (Female to Male), MTFs (Male to Female) and genderqueers (someone who identifies with efforts to subvert oppressive power dynamics by undermining traditional gender roles), 16 never before had an online community existed to consolidate the transgender community’s needs and resources. Transbucket.com is “dedicated to the collection of images and information on trans-related surgeries and heath care”. 17 Among other benefits, users log on to the website and write reviews on doctors and therapists around the nation. Transbucket is the first of its kind of be founded and run by members of their community, which is a boon to the movement as the people who operate the site understand the community’s needs. For example, on other websites doctors could actually log in themselves to write their reviews, or post photos of only their successful surgeries to cast themselves in a particularly positive light.

This website is also an effort to reduce the number of unfortunate cases like Robert Eads. If he had known of doctors willing to treat him in other locations, he would have had a far greater chance of survival.

In a personal interview with Kit, the web master of Transbucket.com, he informed me that his movement has been extremely successful. Though it was just started this year, there are already more than 5,100 active members from all over the world. Additionally, thousands of others who log on as “guests” use the resources but do not contribute their own photographs and experiences. 18 This extends their reach well beyond their 5,100 active members. As this site was created on Kit’s own home computer as a personal project, he does not have the resources to advertise the site. Therefore, word of mouth has been the primary mode for communicating this resource, and considering their thousands of users in just a few months of existence, the demand for this type of service is widespread.

While transbucket.com works with transgender people to access better care, the World Professional Association for Transgender Health (WPATH) works with medical institutions to “promote evidence based care, education, research, advocacy, public policy and respect in transgender health.” They seek to accomplish this through “expanding [their] worldwide authority by promoting, education, advocacy, training, research, quality health care and best practice standards for service providers and policy makers regarding gender variant individuals.”

WPATH is one of the strongest resources for doctors seeking to open their practices to the needs of transgender individuals. Their Board of Directors and Executive Committee consists of 12 doctors around the world. They have published guidelines for doctors seeking to treat those with “gender dysphoria”. Their ultimate goal is to guide the medical discourse to become cognizant of transgender needs.

Discussion and Analysis

The first group I discussed, transbucket.com, may be viewed as a “bottom up” movement. More than a mere website, it is a social movement seeking to empower individuals with knowledge that otherwise would not be afforded to them. Often, these types of movements have better outcomes as they are rooted and founded within their community. The ways in which this organization seeks to empower individuals are similar to notions of lay expertise as explored by Steven Epstein in his article “Construction of Lay-Expertise”. 19 In his work, Epstein discusses how a community is empowered when its members are knowledgeable about their own health needs. Though transbucket.com does not inform individuals about their health needs, it does equip transgender people with the knowledge and resources to find equitable care.

The transbucket.com movement is growing and successful because it avoids the three major impasses created by the nature of transgender suppression and discrimination I have previously discussed: (1) It is public and offers a political forum thereby facilitating political discourse, (2) it is engaging and empowering to its community and therefore does not encourage “passing” or otherwise artificially reducing the size of the movement, and (3) it cohesively addresses the medical and psychological needs of its community in a way that does not further segregate the community.

The movement is somewhat successful at filling the three “buckets” described by Professor Irwin. First, since transgender individuals within the community manage the website, the leaders of this online community better understand the needs of the transgender community at large. They have a clear vision for their work, are based within the community and do not see the need to close anytime soon – thereby filling the Fundamental bucket. Second, in order to mobilize an entire community, the community has to agree about the cause they are fighting for. This site avoids the politics over the causes of transgenderism and is focused just on accessing care. Users of transbucket.com are seeking quality care for themselves and giving advice to others in the community, bypassing the need to have the entire community agree about politics of the movement and touching upon if not fulfilling the demand of the Rationalization bucket. Third, the movement is completely inclusive and virtual, large and growing larger, perhaps someday meeting the demands of the Scale bucket.

Though the movement is very successful in helping transgender people to access care, they focus on “downstream” issues. Transbucket.com only seeks to help users get care and not to reform medical institutions. Thus we must define here what constitutes “success” in social movements. In terms of its mission and the first “bucket,” transbucket.com is extremely successful, in that it has improved accessibility to qualified doctors. Their model is not sustainable though, as they do not seek to create any institutional change. Kit has accomplished inspiring work in supporting his community, and though he may not have the capabilities to expand and create institutional change, I feel the network he has created may be only serving the individuals searching on the website, and is therefore limited in how well it can meet the demands of the Scale bucket.

WPATH, on the other hand, seeks to reform the medical institution and prepare doctors for transgender needs. They have conducted research to determine the best courses of action for doctors to take and have advised both psychologists and doctors on proper conduct with transgender individuals. WPATH partially fulfills the demands of the metaphorical buckets. They have a clear, sustainable mission, but are not based within the community and have difficulty assessing the community’s needs. They are economically sustainable and have supportive research, meeting the demands of the second bucket. Unfortunately, as they follow a top-down model, they are as a result incompatible with many of the other transgender health access movements, and thus do not meet the requirements of the third bucket.

This model benefits the transgender community because individuals should not have to bare the burden of finding equitable care and knowledgeable physicians when they may not in fact know their own medical needs. After all, we pay our doctors with the understanding that they have medical expertise exceeding our own. Though WPATH’s mission is beneficial for the transgender community at large and will create more sustainable change than transbucket.com, they run into several impasses.

WPATH, by nature of their service in working with the providers, seeks to better the health of transgender individuals. As they serve this purpose regardless of the size of the transgender community, they inherently overcome the first impasse of the small size of this community and representation. Unfortunately, in working with the healthcare providers, they are forced to take a stance on the medicalization of the transgender identity. In fact, as the organization is run solely by doctors, the organization lends itself to this medicalization.

Practical Implications and Recommendations

Considering discussed analyses, experiences, social movements and statistical information, this portion of the article recommends courses of action for the aforementioned organizations as well as explains what these social movements must do to improve health outcomes for transgender individuals and overcome the impasses.

The largest issue transbucket.com faces is their lack of sustainability. They do not seek to create sustainable change, but rather to empower individuals in their decision-making. Transbucket.com should consider the third bucket by recognizing the need for scaling up and the potential power they can harness through their sheer numbers. They could perhaps create a section of their website to educate the general public or work with another organization to educate Americans about the needs and the horrors the online community alone has endured. In effect, transbucket.com does not actually reform institutions, but manipulates the ways in which transgender people navigate it. Though it requires “outing” many of the individuals who use the service, much could be accomplished by putting thousands more faces behind the cause of supporting transgender health. This online network could be used in the future to mobilize constituents for rallies, voting, fundraising to support lobbying and countless other political demands. Power lies in numbers, and as this community is a small one, they should muster all of the face-power they have.

WPATH faces a very different set of issues. Their vision is clear: to create institutional change. WPATH has significant research supporting their claims and has a growth strategy, unlike transbucket.com. Unfortunately, they are not based within the constituency, so it is hard to gain momentum for their efforts. In my interview, Kit, the webmaster of transbucket.com, explained to me that “there is a fine line between ‘lending social power’ and the ‘I am here to save you’ mentality”. 18 Not only is WPATH based outside of the transgender constituency, but it is made up of members who could be construed as “enemies” since they are working with one of the most contentious issues in the transgender community: the etiology of gender dysphoria. This organization could thus be perceived as following the savior mentality rather than benevolently seeking to lend their social power. In lacking these three crucial components of successful movements, I must question the viability of WPATH and whether they are advocating for the greatest needs of this community.

The Social Deprivation Theory, as explained by Joel Blau in his book “The Dynamics of Social Welfare Policy,” states that people feel deprived not by their own personal lack but in comparison to those surrounding them. 20 The transgender community, as small as it is, cannot help but feel deprived when considering their accessibility to fair, considerate treatment and health outcomes. This environment is therefore conducive to creating strong social movements. With organizations ranging from grassroots to international medical institutions supporting transgender people, what can we do to make trans-movements less fractured? What can we do to help the general population better understand trans issues?

As previously discussed, transgender movements must decide where they stand on the etiology of their circumstances. Other steps may be taken to create greater cohesiveness. Many causes use a well-respected spokesperson to create greater visibility, leverage and solidarity. Adopting a unifying and informative spokesperson employs the notion of “cultural authority,” which brings solidarity to a population to form a cohesive community. 21 A prime example of a cultural authority increasing recognition is the movement that follows Amyotrophic Lateral Sclerosis, now better known as Lou Gherig’s Disease. Prior to Lou Gherig, this condition was not nearly as well known or researched. Since he has passed away from this disease, far more recognition has been devoted to this cause due to his cultural authority as an immensely respected athlete. More recently, consider the effects of Rock Hudson’s public announcements on general awareness and attitudes toward AIDS. Currently, there is no single highly visible person advocating for transgender rights. Hillary Swank, though she is involved in transgender cinema in her Oscar winning film “Boys Don’t Cry,” has not made herself as visible as other celebrities have for their causes. In finding a respected, visible spokesperson, more attention will be brought to transgender health needs. This spokesperson must inevitably frame transgender health in a certain light as he or she is communicating this condition to the masses. Detailed attention must be paid to how this issue is presented as this will be the most individual’s first exposure, or at least positive exposure, to transgender issues.

Currently, many see transgenderism as a condition for social and sexual deviants without a cure but a “quick fix.” This issue should be framed as a human and civil rights as well as ethical issue, such as “We cannot permit people like Robert Eads to die when preventative measures were not exhausted, as they would have been for anybody else with cervical cancer. Anyone else with a cervix would have had access to the necessary treatment.” Mobilizing community resources to bring attention to this issue is not enough; we must also consider the ways we want this issue to be understood. By increasing sensitivity to transgender issues, transgender people will hopefully feel more comfortable vocalizing their needs. Bringing more attention to this issue will not only increase empathy but also lessen the fear of coming out, thus removing a barrier of entry into the movement.

Conclusion

While there are many groups advocating for transgender rights, there is very little cohesion. This lack of cohesion exists for several reasons, but particularly because of barriers to entry, the relatively small size of the community, lack of public awareness and the need for a unifying spokesperson to deliver this message to the American populace. Fortunately, transgender people have a pre-existing community that may be tapped into as a resource. Transbucket.com benefits individuals seeking care, but could use their website as a platform to mobilize users who would otherwise be alone. They are a social movement of transgender individuals, but could use their power to benefit the entire community rather than individuals looking for a particular health care provider.

WPATH, though they seek to create institutional change in a more enduring way than transbucket.com, are disconnected from the transgender community. They are not based within their constituency. Other groups advocate for transgender rights as well, though they all take different slants in their stances, the level at which they want to create change and their target populations. I do not, however, find the ideologies of most of these groups to be mutually exclusive. In fact, each of these groups could work well with other activist organizations. For example, WPATH could inform users of transbucket. com when they are holding a conference with physicians and invite them in the effort to further include people affected by the policies made at the conference. Essentially, marrying the concepts of these “bottom-up” and “top-down” approaches will benefit all organizations seeking to diminish transgender health disparities.

Existing groups must mobilize their resources more efficiently in order to create greater impact. Future groups must mind the three buckets. By minding these buckets, increasing community visibility and locating a prominent and positively viewed spokesperson, social movements for transgender issues have a fighting chance.

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