By Tiffany Jeong
Our generation has never experienced a circumstance as universal as the COVID-19 pandemic; but we know that the impacts are not felt equally. Now more than ever, mainstream media has been more attentive to health inequities in communities of color. A recent article published by the Center for Disease Control (CDC) states that black and Latino Americans are more than twice as likely to die from COVID-19 than their white counterparts. While it is necessary to address these health disparities, there is still more work we need to do simultaneously in our pursuit of health equity. As we approach the anniversary of America’s first COVID-19 lockdowns, we want to call attention to transgender and gender non-conforming (TGNC) people whose needs and vulnerabilities we have not attended to.
The complex relationship between TGNC and the healthcare system begins at birth when providers medicalize gender by imposing a binary sex classification based on anatomical features. Sex assignment at birth is both a product and producer of the gender binary. This social construct, which is widely accepted as normal, has shaped modern medical practice. A prominent example of this is the standard of care for babies who are intersex. The term intersex refers to those who are born with a combination of male and female sexual characteristics. Many providers in the past fifty years have recommended gender aligning surgeries at an early age to protect intersex children from psychological hardship, although these intentions are not substantiated in the literature. These procedures are often unnecessary, irreversible, and may result in sterilization without the consent of the child. One woman who discovered she was intersex well in to her adult life explains “this way I was treated was never about me—it was about my doctor and my parents and everyone feeling uncomfortable with how my body was.”(Human Rights Watch, 2017).
TGNC face barriers to receiving healthcare on multiple levels. Systemically their access to healthcare is at the mercy of the political administration. After the Trump era, the government does not hold insurance companies and healthcare providers accountable for discriminatory actions; and can deny TGNC gender-transition services or care that is consistent with their gender identity. Discrimination in the workplace results in many transgender people being low income and unable to afford private medical coverage. It is estimated that 1 in 5 people who are trans do not have health insurance and are less likely overall to have healthcare coverage than their cis counterparts (Dickey et al., 2016). Even with insurance, 19% of TGNC have been refused medical care (Grant et al.,2011). This staggering figure calls attention to the interpersonal discrimination that is permitted by cisnormative healthcare systems.
While collectively TGNC are vulnerable to these care gaps, it is important to not erase individuals’ experience by over-generalizing. Race, socioeconomic status, and congruency of gender presentation with assigned sex complicate the discussion of anti-TGNC discrimination in healthcare. Transgender people of color experience significantly more anti-transgender discrimination across healthcare settings (Kattari et al, 2017). Furthermore, TGNC whose gender presentation is perceived as very congruent with their birth-assigned sex reported better health and fewer long-term mental health problems (Rider et al, 2018). Some TGNC have expressed a desire to conceal their gender in healthcare settings. While code-switching may confer comfortability, providers who are unaware that a patient is TGNC may make unsuitable health recommendations.
Negative experiences in the healthcare system can lead to feelings of shame and anticipation of rejection. In one population-based study, researchers found that transgender and gender non-conforming adolescents report poorer health and fewer preventative health visits than their cisgender counterparts (Rider et al, 2018). These health disparities continue into adulthood for TGNC individuals (Dickey et al, 2016). A global health crisis may amplify these care gaps. While variable across states, qualification for a vaccine is determined by healthcare providers in most cases. Previous studies have shown the unique barriers to accessing preventative healthcare for TGNC and suggest TGNC communities may not get vaccinated against COVID-19 at the same rate as their cis counterparts.
The movement towards trans-affirmative healthcare needs to be multifocal. One survey found that 50% of TGNC reported having to teach their medical providers about transgender care (Grant et al.,2011). To overcome the knowledge deficit, there need to be changes in professional school curriculum and continuing education for healthcare providers that includes treatment of TGNC. Additionally, we need to take large steps by politically opposing policies that permit TGNC discrimination from insurance companies and medical providers. Our current understanding supports that TGNC avoidance of the healthcare system can be moderated by adequate access to health insurance (Dickey et al., 2016). Lastly, one small step I encourage everyone to take is introducing yourself to healthcare providers with your preferred pronouns. When gender identity is not part of the conversation, trans folks are excluded. It may feel “strange,” for cisgender people to do this. But by taking on this small amount of discomfort, you are creating space for TGNC in our healthcare system.
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Grant JM, Mottet LM, Tanis J, Harrison J, Herman J, Keisling M. “Injustice at Every Turn: A Report of the National Transgender Discrimination Survey.” Education Week 30, no. 20 (2011): 5.
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Rider GN, McMorris BJ, Gower AL, et al. Health and Care Utilization of Transgender and Gender Nonconforming Youth: A Population-Based Study. Pediatrics. 2018;141(3): e20171683
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