How Healthcare Fails Transgender Patients With Medical Stigma, Misunderstanding & Policy

By Elaine Reilly

We have recently covered the ways in which women are failed by the healthcare system. Women’s pain is often taken less seriously by doctors, making it harder for many women to get the care that they need. Unfortunately, this is one part of a trend in which underprivileged groups are dissuaded, hindered, or even flat out denied important medical care. Perhaps one of the lesser known of these challenges has to do with the ways in which transgender patients are treated by doctors and nurses across the country.

To understand the barriers that trans people face when seeking healthcare, we need to first understand why medical care is often so important for them.

What’s Up With Hormones?

Let’s go back to Biology 101 for a minute. Virtually all of us have some combination of hormones swimming around in our bodies. Among other things, some of these hormones, known as sex hormones, help to determine the secondary sexual characteristics in our bodies. In conjunction with other factors like genetics, hormones help to determine things like fat distribution, muscle mass, and body hair. So traits like facial hair, which we usually associate with men, or breasts, which we usually associate with women, are all thanks to the amount of testosterone or estrogen in a person’s body.

Now that we’ve passed Biology 101, let’s head over to Trans 101. You might already know that many trans people experience gender dysphoria, or an innate sense of discomfort with the gendered aspects of their bodies or social circumstances. One of the most promising ways to respond to dysphoria is to administer hormone treatment consistent with the person’s gender identity. To that end, trans women often take an androgen blocker to cancel out testosterone and an estrogen medication like estradiol. Trans men usually take testosterone shots, which are enough to block estrogen by themselves.

Clearly hormone therapy is critical to improving the lives of trans people, but, in spite of all the good that it can do, it is notoriously difficult for those who need it to get a hold of it.

Barriers to Entry for Hormone Therapy

Perhaps the healthcare first barrier that any trans person who wants hormone therapy will have to face is the dreaded letter. (Note: I say healthcare barrier here because many trans people have to contend with family or even themselves before ever showing up at a doctor’s office.) Now, in order for a doctor to prescribe hormones to a transgender patient in the United States, that patient must produce a letter of recommendation from a therapist. This letter is basically an official diagnosis from the therapist clearing their patient to receive treatment.

There are a few problems with this, each of which deepens the plight of trans individuals who are seeking care. First, therapy takes time and, since the changes that hormones can bring about take years to become realized, no time is too early to start for most trans patients. In general, it shouldn’t be crazy to say that the sooner patients can be cared for, the better, in virtually every situation.

Second, not all therapists are trans-friendly and it can sometimes be difficult to tell whether or not they’ll provide assistance until several sessions in. Additionally, for trans kids and teenagers especially, it’s not uncommon for parents to pair their children with a therapist whom they know to be unhelpful. This kind of collusion to harm young trans people is made possible by the letter paradigm.

Finally, forcing trans patients to go through therapy for the sole purpose of receiving hormones creates an awkward and unhelpful relationship between therapists — even those who want to help — and their patients. Many trans people suffer from mental health problems born of a lifetime spent in self-denial and in hostile environments. Therapy can be very helpful for anyone who needs to find a way to accept herself or the abuse that she’s suffered. Unfortunately, when a letter of recommendation is the focus, mental health concerns are pushed to the wayside.

Proponents of the current model might point out that the letter helps us to prevent the mistaken treatment of cisgender people through the use of hormone therapy. This sort of accidental treatment would cause permanent changes to their bodies that could’ve been avoided with a more thorough diagnosis.

I don’t buy this for a few reasons, and I don’t think that you should either. Firstly, keep in mind that trans people are often in the process of suffering these same permanent changes, or have already suffered through them. To hinder a trans patient’s access to care on the basis that you’re worried about a cis person’s well-being is basically to say that the health of a cis person matters more than that of a trans person.

Secondly, as we’ve seen with cis women in healthcare, the letter paradigm perpetuates the idea that trans people (as well as other disadvantaged groups) are unfit to make their own health decisions.

Finally, I wonder how many cisgender people would really show up at their doctor’s office asking for cross-gender hormones? How many cis boys think that their friends would think more of them if they were running on estrogen, or how many cis girls feel that broader shoulders and a lower voice would make them more popular? The fact of the matter is that transitioning with hormone therapy is an incredibly difficult experience, and someone would need a powerful driving force, such as gender dysphoria, to push them down that path.

Problems Continue at Doctors’ Offices

Unfortunately, getting the letter is just the beginning for most trans people. Once they have it, it’s time to visit a doctor or endocrinologist (a hormone specialist) to receive a prescription. However, many doctors are unable, unwilling, or unprepared when it comes to treating trans patients.

They are unable because many doctors simply don’t have the requisite training. In a survey, 80 percent of endocrinologists said that they didn’t have any formal training when it came to administering hormone therapy to trans patients. Given that endocrinologists specialize in hormones, we can expect that the numbers are worse among general practitioners.

They are unwilling either because they don’t feel properly trained, as discussed above, or they are uncomfortable with the idea of trans people and others who disrupt the gender binary. Similar to picking out a therapist, trans patients don’t always know if a doctor is trans-friendly until they’re in the office.

Doctors and nurses are also unprepared when it comes to working with trans patients. Incidents like misgendering, arm’s-length treatment, and general insensitivity can make healthcare visits a nightmare for trans patients. In order to fix this, it’s on both doctors and nurses to adopt techniques similar to cultural awareness and leave their personal thoughts and feelings at the clinic door.

And Things Don’t End With Hormone Access…

It isn’t just hormone therapy where trans patients face a cruel healthcare system. Even for ailments that have nothing to do with their trans status, transgender patients find themselves fighting against the system for recognition. It’s called trans broken arm syndrome, and it’s both hilarious and nightmarish.

It happens like this: A trans person will go to the doctor about some routine condition. In the eponymous scenario, it’s a broken arm. However, instead of treating the patient for this condition alone, doctors will try to find some way to connect this malaise to the patient’s trans status.

One trans woman, Robyn Kanner, described her experience with trans broken arm syndrome to the Daily Dot. She was suffering from a kidney stone and saw a doctor to get it taken care of. Instead, she was treated to a lecture on trans people and public bathrooms.

Incidents like this aren’t uncommon. The hashtag #transhealthfail has recorded numerous cases of trans patients being turned away for unrelated treatment on the basis of their trans status.

Beyond trans broken arm syndrome, trans individuals face financial and insurance-related challenges when it comes to accessing healthcare. Section 1557 of the ACA protects patients from healthcare discrimination based on gender identity, but with the current administration doing everything in its power to gut the ACA and threats of repeal on the horizon, transgender people could lose this valuable protection.

Without the ACA or something similar, insurance companies could pull the rug out from under transgender patients, refusing to cover classically gendered conditions for trans patients. For example, a trans man could be denied coverage for a yeast infection, caused by a hormonal imbalance from his testosterone, on the basis of his gender identity.

Some companies are picking up the slack where the law and insurance providers fail. For example, Accenture covers the cost of transition as a perk. However, it would be unreasonable to let the fates of trans people hang on the whims of their employers. Strongly worded legislation that protects the rights of trans patients is needed now.

Transgender people face overwhelming barriers to entry when it comes to getting the care they need. Even once they’re admitted, the trouble doesn’t stop. It’s critical for allies to hold healthcare providers responsible when it comes to caring for trans patients and others from underprivileged groups.




Elaine Reilly is a writer from Boise, Idaho. After completing her Masters in medical ethics at the University of Colorado at Boulder, she enjoys writing on difficult subjects in healthcare, especially as they disproportionately affect women. You can follow her on Twitter @elliemreilly1.


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