The Current State of LGBTQIA2S+ Healthcare in the United States: An Under-Recognized Public Health Crisis

The impact of words can resonate for an eternity in a person’s mind and body. For me, I battled to confront and overcome speaking three words that consumed my identity and altered my place within the worlds of others. Those words are: “I am transfeminine.” If I could help to shield and heal other transgender people from the trauma sustained in socially transitioning, my career will have an impact greater than what I can currently accomplish solely as a neurologist. I could help play a small part in reducing the stigma that shrouds people who bravely shout their authenticity.

My personal experience as a transgender person has caused me to lose many basic rights. However, the human right most important to my identity as a physician is the right to basic healthcare. I am drowning as a patient and provider within a system that accepts that there is no mandatory training in transgender healthcare in education curricula nor is there required testing for transgender competency by certification and licensing organizations (Caceres et al., 2020). It is a system where I was trained to treat diseases with an incidence of one in a million (e.g., primary angiitis of the central nervous system) but not the skills to treat patients who identify as one in two hundred and fifty people, i.e., the transgender population in the United States) (Salvarani et al, 2007; Meerwijk & Sevelius, 2017). It is a system that ignores the scientific evidence regarding the range of normal biological gender diversity. Healthcare providers know from their medical literature that misgendering (intentionally referring to a patient with incorrect gender pronouns) worsens mental health outcomes for transgender patients, yet providers often continue to misgender patients without apology or accountability (Bauer et al., 2015; Russell et al., 2018). Furthermore, providers fail to update intake forms and electronic health records to have appropriate options to accommodate those who are not cisgender (Deutsch et al., 2013). I believe these issues represent a largely-ignored public health crisis, and they are not solely a matter of social justice.

There are over a million Americans who identify as transgender, and there are not enough experienced, affordable mental health providers capable of accommodating the specific mental health needs of this population (Meerwijk & Sevelius, 2017). This is particularly true in areas outside of major cities (Whitehead et al., 2016). The higher rates of substance abuse as a coping mechanism and systemic discrimination leading to increased joblessness, homelessness, lack of insurance, and incarceration create a vicious cycle that punishes the transgender population for failing in a system designed to avoid providing them with the basic mental health tools needed to succeed (Oberheim et al., 2017; Begun et al., 2016; Hughto J.M.W. et al, 2019; Abeln & Love, 2019). I have been humbled to be one of the many transgender people who have experienced various failures within this system, which I have had to overcome with great effort and mental fortitude. I often still struggle to find meaning, value, self-worth, and success in our society, which is not changing fast enough to protect me on its own.

As a physician, I have had the privilege of caring for transgender patients. One person continues to stand out to me because I faced a particular difficulty in preserving their dignity as they died under my care as a neurology intern.  This patient was a transgender person of color with advanced AIDS. I remember a resident referring to them as “it,” and the attending physician would often skip them on rounds so that I was the only doctor physically seeing them each day, despite being the most junior person on the medical team. I spoke to this patient daily for a week, until they died; every time they were alone. I wish I could go back in time as my authentic self and better empathize with this patient as a fellow transgender person. Since that time, I too have been admitted to hospitals as a transgender patient where my humanity was stolen by the medical professionals assigned to care for me.

Although I have lost many things in coming out as my authentic self, I have never lost my strong desire to protect others, to advocate on their behalf, and to facilitate a solution for them. I have also gained something extremely meaningful: a purpose. That is, to reduce gaps for the transgender population in providing reliably affirming, affordable, available, and experienced healthcare providers trained to treat the LGBTQIA2S+ community.


Abeln, B., & Love, R. (2019). Bridging the gap of mental health inequalities in the transgender population: The role of nursing education. Issues in Mental Health Nursing, 40(6), 482-485.

Bauer, G.R., Scheim, A.I., Pyne, J., Travers, R., & Rebecca Hammond (2015).  Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada. BMC Public Health, 15, 525. doi: 10.1186/s12889-015-1867-2.

Begun, S., & Kattari, S. K. (2016). Conforming for survival: Associations between transgender   visual conformity/passing and homelessness experiences. Journal of Gay & Lesbian Social Services, 28(1), 54-66.

Caceres, B.A., Streed, C.J., Corliss, H.L., Lloyd-Jones, D.M., Matthews, P.A., Mukherjee, M., Poteat, T. Rosendale, N., & Ross, L.M (2020).  Assessing and Addressing Cardiovascular Health in LGBTQ Adults.  Circulation, 142, 00-00.

Deutsch, M.B., Green, J., Keatley, J., Mayer, G., Hastings J., & Hall, A.M. (2013).  Electronic medical records and the transgender patient: recommendations from the World   Professional Association for Transgender Health EMR Working Group.  Journal of American Medical Informatics Association, 20, 700–703. doi:10.1136/amiajnl-2012-001472.

Hughto, J.M.W, Reisner, S.L., Kershaw, T.S., Altice, F.L., Biello, K.B., Mimiaga, M.J., Garofalo R., Kuhns, L.M., & Pachankis, J.E. (2019). A multisite, longitudinal study of risk factors for incarceration and impact on mental health and substance use among young transgender women in the USA. Journal of Public Health, 41(1), 100-109. doi:     10.1093/pubmed/fdy031.

Meerwijk, E.L & Sevelius, J.M. (2017). Transgender Population Size in the United States: a Meta-Regression of Population-Based Probability Samples. American Journal of Public     Health. 107(2), e1–e8. doi: 10.2105/AJPH.2016.303578.  Oberheim S.T., DePue, M.K., & Hagedorn, W.B. (2017). Substance Use Disorders (SUDs) in Transgender Communities: The Need for Trans-Competent  SUD Counselors and Facilities. Journal of Addictions & Offender Counseling, 2017, 38, 33-47. doi: 10.1002/jaoc.12027.

Russell, S.T., Pollitt, A.M., Li, G., & Grossman, A.H. (2018). Chosen Name Use Is Linked to Reduced Depressive Symptoms, Suicidal Ideation, and Suicidal Behavior Among Transgender Youth. Journal of Adolescent Health, 63(4), 503-505.  doi:

Salvarani, C., Brown, R.D., Calamia, K.T., Christianson, T.J.H., Weigand, S.D., Miller, D.V., Giannini, C., Meschia, J.F., & Hunder, G.G. (2007). Primary central nervous system vasculitis: Analysis of 101 patients. Annals of Neurology, 62, 442–451. doi: 10.1002/ana.21226

Whitehead,J., Shaver, J., & Stephenson, R. (2016). Outness, Stigma, and Primary Health Care Utilization among Rural LGBT Populations. PLoS One, 11(1), e0146139. doi: 10.1371/journal.pone.0146139.


Ethical Questions in the Field- Is Refusal of Service to a LGBTQIA2S+ Client Acceptable in Social Work Practice?

November 12, 2022

By Z Paige L’Erario, MD, NYS CRPA/CPS-provisional and Holly Fancher, LMSW, MSEd

Originally Posted in Social Work Today; Vol. 22, No.4, P.22 


This case study examines a field intern’s right to refuse clinical services to a sexual or gender minority client.

Discriminatory behavior against sexual and gender minority clients is often more a systemic issue than an individual one. Social workers have professional and ethical duties and obligations to provide culturally competent clinical services to every client, regardless of their sexual orientation and gender identity. However, there are several states currently introducing anti-LGBTQ legislation, which raises a question about the ways in which a supervisor may handle a social work student who refuses to provide clinical services to a sexual or gender minority client.

Refusal by a field intern to provide services to a sexual or gender minority client should be viewed through the lens of a person-in-environment, which requires a biopsychosocial approach to fully address the issue. Techniques for approaching a social worker who refuses to work with a client based on their sexual orientation or gender identity include the following:

• engaging, assessing readiness for change, and motivating social work students to learn more about culturally competent care for sexual and gender minorities;

  • pairing the student with a more experienced social worker to observe culturally competent practice;
  • providing the student access to sensitivity and diversity training;
  • increasing supervision sessions to include discussions of values, stereotypes, and oppression that currently impact social work practice and skills to learn to address gaps in culturally competent practice; and
  • reassigning the student to an agency where their personal beliefs and institutional values will not be in conflict.



Case Study
The following case study has been presented within the Fordham Graduate School of Social Service’s online Master of Social Work curriculum:

At Field Agency X, a social work intern refuses to provide clinical services to their assigned client due to the client’s perceived or confirmed gender identity or sexual orientation. For example, the intern is assigned the case of a same-sex couple who wish to begin a family. They seek support and advisement on options for fertility treatments. However, the intern demands the case be reassigned, citing religious and moral objections. In essence, the intern has requested not to engage diversity and difference in practice, one of the core competencies of social work education.

How should a field supervisor, who oversees social work students, address this situation? To get a handle on the matter, the following questions should be considered:

  • Can a social worker refuse service to someone solely because of their identity or the way they look or act? What if the client had been refused care because they were a racial minority?
  • Can a social work student be allowed to graduate if they refuse to learn about or cannot adopt the core competencies of social work practice, such as the biological diversity of gender, sexuality, and identity formation? Should personal beliefs or lack of cultural competency be allowed as a reason to refuse service to a client?
  • Should we allow a social work student to practice in ways contrary to professional and ethical standards?



Case Study Discussion
In answering these questions, it’s imperative to consider the ethical, professional, and legal obligations that govern a social worker’s practice. Professional social workers have a foremost “duty of care” in which they are “legally obligated to provide a reasonable standard of care in delivering social work services.”1 Furthermore, “clients have a right to expect that [social workers] will discharge professional responsibilities in a competent manner.”1

Excluding clients on the explicit basis of their sexual orientation or gender identity disregards this duty of care and is in opposition to the United Nation’s Universal Declaration of Human Rights and the NASW’s Code of Ethics.2,3 Furthermore, discrimination involving medically necessary health care needs based on sexual orientation or gender identity is federally illegal, with additional protections against discrimination in public accommodations in many states and localities.4-6

Therefore, this social work intern’s refusal to treat a client due to their sexual orientation or gender identity raises multiple ethical concerns and violations of social work practice policy.


Social Work Code of Ethics
NASW identifies social work’s core values in the preamble to its Code of Ethics. Two core values (social justice and dignity) are violated when a social worker refuses to treat a client on the sole basis of their sexual orientation or gender identity. The preamble suggests that “the primary mission of the social work profession is to enhance human well-being and help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty.” Therefore, social workers have an intrinsic professional responsibility to care for those of sexual or gender minority status.

In the Ethical Standards Section 1.05 of the Code of Ethics, social workers are described to have specific ethical responsibilities to clients: “Social workers should demonstrate understanding of culture and its function in human behavior and society, recognizing the strengths that exist in all cultures.”

Professional ethics dictate that students develop and demonstrate cultural awareness and humility by engaging in serious and critical self-reflection, defined as understanding their own biases and engaging in self-correction. It is essential that those working with sexual and gender minorities be able to fulfill their professional responsibilities outlined in the Code of Ethics by demonstrating a working knowledge of social diversity and the nature of oppression, which applies to sexual orientation and gender identity. At the very least, social work students should remain open to learning more about queer culture.


Universal Declaration of Human Rights
The Universal Declaration of Human Rights applies to all people, including sexual and gender minorities. Article 1 specifically states that “all human beings are born free and equal in dignity and rights.” Social workers should not be allowed to purposefully exclude clients based on their minority status; that kind of personal decision does not fulfill either their professional responsibilities or the basic human rights defined in the Universal Declaration.

Article 16 of the Universal Declaration of Human Rights reads, “Men and women of full age … have the right to marry and to found a family.” Social workers must not discriminate against those who choose to do so based on personal beliefs. Instead, they should fulfill their professional responsibilities as outlined in the Code of Ethics.


Legal Protections Against Clinical and Public Service Discrimination
In the case study, the intern’s choice to exclude clients from clinical services based on their sexual orientation or gender identity may be illegal, depending on the intern’s practice location and the reimbursement and funding sources. Health care can be considered a segment of social work services, a part of the clinical support services that clients may receive at their social work agencies. There are federal protections against health care discrimination for sexual and gender minority clients in Section 1557 of the Affordable Care Act, which established broad civil rights protections in health care, barring discrimination based on sex (including sexual orientation and gender identity) in “any health program or activity” that receives federal financial assistance.6

This policy was upheld recently by the Department of Health and Human Services in the Biden Administration.6 There are additional health care and public accommodations nondiscrimination laws that would apply at the state and local level.4,5 However, recent legislation introduced in several states has attempted to criminally ban transgender adolescents from receiving medically necessary gender-affirming care, which may embolden agencies and their representatives from refusing clinical services related to their sexual and gender minority clients.7


Professional Development Plan
In the best-case scenario, this intern is responding to their client without the ability to separate their professional responsibilities from their personal beliefs. In other words, the intern is unable to practice cultural awareness or incorporate sensitivity and diversity into their practice. In the worst-case scenario, the intern is acting unethically, unprofessionally, and possibly illegally.

Ethics flow from values and can be thought of as values in action. In the case study, by refusing to work with a same-sex couple, the intern is choosing their personal beliefs over their professional obligations, which means their actions amount to unethical practice. As the field instructor and intern work collaboratively to search for ways to resolve the conflict between their personal beliefs and professional obligations, it is hoped the intern learns to be comfortable with discomfort.

The supervisor should recognize that the agency’s staff are entitled to their personal beliefs, but these beliefs cannot be incorporated into their practice at the expense of their clients. Still, changing attitudes and behaviors takes time, effort, a flexible perspective, patience, persistence, and coordinated planning. A supervisor should be ready to support an intern going through such changes.

In the short term, the best way to serve these clients is to reassign them to a more experienced social worker. Outside of a research study with informed consent, it is not acceptable to use this client as part of the intern’s professional development.

After reassigning this client to another social worker, assessing the intern’s readiness for change is important. Using a 1 to 10 scale outlining “readiness for change” may be helpful to better comprehend this individual’s starting point—their motivations, perspectives, and understanding of the situation.8

Dealing with values is central to social work practice. As an inexperienced professional, the intern needs to learn they belong to both their individual value system and the value system governing the profession of social work practice. As a person also belonging to their environment, the student is defined by both. The intern’s attitudes and behavior are shaped by the complex interactions of their environment in the same way as are their clients.

By understanding that everyone involved in the situation belongs to systems composed of interrelated and interdependent parts, the supervisor—using ethics as their practice framework—must find ways to support the intern while they grow into a social worker. A good starting point would be to ask the intern: “How open are you to learning more about sexual and gender minorities?”

A biopsychosocial assessment means a nonjudgmental exploration of the intern’s capacity to nonjudgmentally respond to the concerns, needs, and problems of sexual and gender minority clients. Depending on the student’s answer, the supervisor can ascertain where the intern is in the process of addressing their implicit biases and their desire to learn more about queer culture.

The supervisor is ultimately responsible for providing ethical clinical services for all clients seeking services at that agency. While the profession undoubtedly wants interns to succeed, there needs to be a timeframe established for professional improvement. The agency’s mission cannot be indefinitely sacrificed for one staff member, but nonjudgmental practice dictates that goals be created and a contract established with the intern in the same manner they would be with any client. Ethical social work practice is not just about clients; supervisors must also adhere to the same values and standards.

The supervisor should earnestly attempt to develop awareness and empathy by setting up additional clinical sessions with the intern to discuss the following:

  • how the intern’s attitudes and beliefs about sexual and gender minorities influence their capacity to practice social work;
  • the historical and current stereotypes, prejudice, discrimination, and oppression impacting sexual and gender minorities; and
  • the skills that the intern could use when providing services in an ethical manner, including engagement, empathy, cultural competency, active listening, and reflection.

Supervisors may want to consider having the intern shadow more experienced social workers to see ethical practice firsthand. Keep in mind that such a strategy requires the client’s consent. Additionally, the supervisor could help the intern enroll in culturally competent practice trainings to develop diversity practice skills.

If, however, the intern found the discontinuity and conflict between their personal and professional selves too much to handle, it may be time to acknowledge that they are not a good fit for a secular agency. One option for the intern would be to consider working for a faith-based agency that is more consistent with their religious or moral perspective.

Once it becomes clear that an individual needs a different kind of working environment, it is important that supervisors do not fall into unprofessional practice, displaying negative behavior themselves by thinking about or treating the intern in disparaging or derogatory ways. All relevant parties practicing social work should use the theories and skills taught in everyday environments.

Often, personal vs professional difficulties reflect a systemic issue more than an individual one. What is considered right and wrong in terms of behavior is always rooted in the social environment, and it is still likely that this social worker will be able to provide meaningful services for other clients whose social and religious upbringing is more aligned with their own, thus integrating micro and macro practice lenses. A nonjudgmental approach requires that supervisors also apply a strength-based model toward interns, clients, and the larger agency. Hopefully, this social work intern will be able to reconsider their perspective and practice. Sometimes it is hard to know exactly where people exist along the change continuum, and it often takes several cycles for the planted seeds to produce new awareness and understanding.




Revisiting the Discussion Questions
Embedded in social service education, competencies, values, ethics, and practice is the tenet that no one should be refused service based on a historically oppressed identity. If such discriminatory behaviors arise, steadfast interventions should encompass the person-in-environment and systems perspectives. Agencies should also engage individuals displaying cultural insensitivity with a motivational interviewing approach, as well as provide dedicated inclusivity training and positive role modeling.

For social workers, it would be contrary to professional duties and responsibilities to remain intentionally ignorant of diverse cultures and refuse services on this basis. Social work students continually need to reach outside their comfort zones to learn culturally inclusive practices for all clients.

Supervisors must lead by example and commit to a high standard of ethical and inclusive conduct for both themselves and students.


— Z Paige Lerario, MD, NYS CRPA/CPS-provisional, is a neurologist and transgender activist. They are a graduate student of social service at Fordham University.

— Holly Fancher, LMSW, MSEd, holds two master’s degrees, one in social work and one in higher education. She teaches at Fordham University in the online MSW program and is working on her PhD in social welfare at the CUNY Graduate Center.


1. Cournoyer BR. The Social Work Skills Workbook. 8th ed. Cengage Learning; 2017.

2. Universal declaration of human rights. United Nations website. Accessed August 17, 2021.

3. Code of ethics. National Association of Social Workers website. Accessed April 13, 2022.

4. New York State Division of Human Rights. New Yorkers Are Protected From Gender Identity Discrimination by Hospitals.

5. Nondiscrimination laws. Movement Advancement Project website. Accessed April 13, 2022.

6. Shear MD, Sanger-Katz M. Biden administration restores rights for transgender patients. The New York Times. May 10, 2021. Accessed October 1, 2021.

7. Turban JL, Kraschel KL, Cohen IG. Legislation to criminalize gender-affirming medical care for transgender youth. JAMA. 2021;325(22):2251-2252.

8. Rollnick S, Heather N, Gold R, Hall W. Development of a short “readiness to change” questionnaire for use in brief, opportunistic interventions among excessive drinkers. Addiction. 1992;87(5):743-754.


Disclosures: Lerario serves on the editorial board of Neurology: Clinical Practice, has been hired as an expert witness for plaintiff by Weiss Law, and is the vice-chair of the LGBTQI section of the American Academy of Neurology. Fancher reports no financial disclosures relevant to the manuscript.

My Experience as a Transgender Physician with Mental Illness


  By Z Paige Lerario, MD, NYS CRPA/CPS-p

  Originally posted July 20th, 2022 in NAMI Blogs


AlabamaArizona and Texas have recently passed legislative efforts to ban gender-affirming health care to transgender adolescents. This is highly concerning and relevant, as 2% of younger Americans identify as transgender, a term that refers to people whose gender identity (an internal sense of self) does not align with the sex they were assigned at birth.

A gender transition, or the process a transgender person undergoes to express their gender more in line with their internal identity, is a critical component of maintaining their mental health. Research shows that transitioning in affirming environments is life-saving for many transgender people; supportive communities, culturally competent health care and choosing a new name and gender pronouns improves mental health outcomes, including suicidality (which transgender people are significantly more at risk for).

Conversely, non-affirming environments and systemic barriers to health care result in higher rates of depression, suicidality and substance misuse in the transgender community, as compared to their cisgender peers. Therefore, we have reason to believe that this anti-LGBTQ+ legislation will worsen the mental health of our transgender youth and adolescents, in addition to increasing the stigma experienced by an already vulnerable population.

This challenge is compounded by a shortage of affirming health care providers for the transgender community. As a transgender physician living with mental illness, I understand the fear and pain that the stigma of transgender identity and mental illness can bear when receiving health care services. I am often left feeling unseen or ignored by the health care system at times of my greatest need. 

Unpacking The Reality In Numbers

In 2015, the National Center for Transgender Equality performed the largest survey of adult transgender community members living within the U.S. The results are eye-opening and point to largescale systemic barriers preventing transgender people from receiving medically-necessary health care services of adequate quality and cultural competence. 

  • At least one in four (25%) of the survey respondents reported issues with health insurance coverage, including the denial of medically necessary gender-affirming services, such as hormone therapy or transition-related surgeries.
  • One-third (33%) had at least one negative experience with a health care provider related to being transgender, such as verbal harassment, refusal of treatment or having to educate the provider to receive the standard care for transgender patients.
  • Approximately one in five (23%) respondents did not see a doctor when they needed to because of fear of being mistreated as a transgender person.

These findings demonstrate an unaddressed public health issue, but also, they are impacting real people in their everyday lives.

While my experience does not represent the full diversity of the gender expansive community, my hope is that sharing my experience will help other transgender people with mental illness feel less alone and have hope for recovery in their journeys.

My Experience In The Health Care Field

Since coming out and transitioning, I have faced unexpected discrimination within the health care system, even as a physician myself. On multiple occasions, I have been refused medically necessary health care specifically due to my gender identity. This discrimination worsened when I began openly identifying to my providers as a patient experiencing a serious mental illness. Even living in New York City, there are few mental health providers who understand and are affirming of transgender patients. There are even fewer who are transgender themselves or willing to disclose they have lived experience with a serious mental illness.

I would have more trust in a mental health provider who is my peer: that is, someone who has lived experience with mental illness and the resulting stigma. As a result, I often need to teach my mental health providers about what it is like to live as a transgender person in recovery from serious mental illness. And professionally, I am left with a small number of colleagues who openly share my identities.

When I do find affirming providers, my commercial health care insurance has not covered their services on multiple occasions. I am privileged to be a physician, and therefore, can pay for many of these transition-related expenses out of pocket. This in turn buys me further “passing” privilege, meaning I have undergone a medical and surgical transition, which allows me to appear cisgender. However, there are many others who cannot afford to undergo a medical or surgical transition, or do not wish to do so.

Navigating Patient-Doctor Relationships

I often ask my treating physicians if they have experienced serious mental illness. This is most often met with, “that is none of your business,” when, in fact, I believe it is highly relevant. In these moments, my provider made me feel like they believed mental illness was something shameful. In many stigmatized and shame-based mental illnesses, disclosing a shared identity with a patient can be healing and increase trust in the relationship between patient and physician. Conversely, acknowledging potential awareness gaps and implicit bias is also an important practice for all health care providers. 

For me, once experiencing the societal sting of transphobia, any other stigmas I hold are no longer worth hiding. I proudly share my identities as a transgender physician living with mental illness, and I believe these experiences have increased my value to society as I can better understand my patients’ perspective and their place within the full range of humanity. This understanding is the basis for a cultural awareness which can improve the healing environment of our offices and the social well-being of our patients.

In recent years, I have met many adolescents who boldly identify as neurodivergent, transgender community members. I have faith this generation can help teach physicians to holistically treat their patients and the environmental factors impacting the health of their brains and bodies. I hope some of these adolescents will say, “I can become a doctor, too.”  Because they can, and we can do better to make room for them.


If you are transgender and have symptoms of mental illness, please contact a provider experienced in gender-affirming therapy at the World Professional Association of Transgender Health:

The Trevor Project has free, confidential, 24/7 support services for LGBTQ+ youth:

The following are resources from the Human Rights Campaign on LGBTQ+ youth:

The following are educator resources from the Gay and Lesbian & Straight Education Network:

Pledge to take the 2022 US Trans Survey and increase transgender representation in health care policies, research, education and practice:



“Now is the time we need pride the most. We cannot succumb to fear or shame, and we cannot stand down to threats of violent oppression. We are under attack by a conservative legislative agenda that ignores our medical evidence and peer-reviewed literature. We must fight for our patients to receive the medically necessary health care they deserve. We should call in allies to actively engage and support those of historically oppressed genders the other 11 months of the year.” 

By Z Paige Lerario, MD, NYS CRPA/CPS-p

Originally published in Psychiatric Timeson June 13, 2022

Pride: An Opposite Action Against Unnecessary Shame


Let’s face it: Being part of a historically oppressed community can be stressful. We know that individuals who identify as transgender or nonbinaryface higher rates of discrimination at all levels of American society.1 This discrimination ranges from microaggressions to lack of accessibility to frank violence, including verbal harassment and physical assault. The peer-reviewed literature describes the impact of oppression in minority stress models.2 Cumulative exposure to discriminatory environments create systemic health care disparities and worsened outcomes for historically oppressed communities.3

More recent data evaluate the transgender and nonbinary community’s resiliency through the building of positive coping skills and psychosocial support.4,5 These resiliency factors protect transgender and nonbinary individuals from the deleterious health consequences of systemic oppression. The list of resiliency factors is long and includes community building, activism, and role modeling. But, when discussing what best fights the harmful effects of systemic oppression, the common denominator remains: “pride.”

Attribution theory—developed by Fritz Heider and later modified by Bernard Weiner—examines the thought processes behind behaviors, their causes, and their effects.6 People make sense of the world around them by grouping behaviors into those that are internally or externally controlled. Society tends to view more favorably and support those who are deemed not to have control over their problems. Conversely, society often punishes those whose problems are believed to be caused by internal or individual-level factors and decisions. Attribution theory has been tested in multiple policy areas, including issues surrounding historically oppressed genders.6 Such theories are important to explain the impact of medically incorrect ideology that being transgender or nonbinary is a personal “choice” that can be prevented.

Many in the United States misunderstand, hate, fear, shame, or frankly deny the existence of historically oppressed genders. The majority of Americans have never personally met someone who is transgender or nonbinary.7 Those who know a transgender or nonbinary person are more likely to believe that a person’s gender can differ from their sex at birth. Gender minorities have existed in various cultures for centuries, including in people indigenous to North America.8 Although often stigmatized, in some cultures gender diversity has been legally recognized, celebrated, or even revered. In the 1950s, a psychologist named John Money proposed a theory of “gender neutrality” at birth.8 He described gender as developing from a socialization process occurring after birth. Although initially criticized, such theories are becoming more accepted in Western society as rights for nonbinary-identifying individuals are gained. Therefore, it is important to note that gender is a sociocultural construct, and the acceptance of gender diversity is impacted by exposure to transgender and nonbinary individuals.

Shame can be internalized when it is placed on individuals of historically oppressed genders in a broad range of formats and contexts. Persistently invalidating environments can lead to emotional dysregulation and associated areas of interpersonal dysfunction.9 This is unfortunate, since gender identity (referring to an individual’s innate internal sense of self) is not a choice and is found to be largely stable even amid exposure to nonaffirming environments and external pressures to “detransition,” or to go back to living as the sex assigned at birth.10

As a transgender physician, in moments when I begin to internalize oppression, I remind myself of Marsha Linehan’s groundbreaking work creating treatment for borderline personality disorder. Linehan developed dialectical behavioral therapy, which has now been proven to be effective in multiple clinical trials to reduce suicidality and inpatient hospitalization in various high-risk conditions.11 Dialectical behavioral therapy skills have been applied to the treatment of clinical distress caused by gender dysphoria.9

In dialectical behavioral therapy, Linehan teaches the use of “opposite action” when emotions do not fit the facts of reality.12 Experiencing shame, for example, produces the action urge to hide or avoid the shaming stimulus. The opposite action of an urge to hide is sharing the secret with others who will accept it. Over time, an individual practicing opposite action will develop feelings of pride. They will realize there is no fact-based reason to continue to feel shame.

Obviously, facts are important. So, what are they?

Gender diversity is real and exists. Gender-affirming environments, policies, and medical care are lifesaving and should be normalized.13 Being transgender or nonbinary is nothing to be ashamed of. Instead, many from these communities provide the world a sense of creativity and inspiration.

And then some of the facts are more saddening, particularly in the fields of medicine and psychiatry. Throughout the last century, patients of historically oppressed genders and sexual orientations have faced forcible silencing, violence, and medical atrocities. These horrors occurred at the hands of our predecessors and continue in many ways today. Our treatment of and experimentation with these communities include castration, lobotomies, electroconvulsive therapy, and aversive conversion therapy, all based on pseudoscience.14 The lack of our profession’s support for these communities persists in ongoing legislation and policies that ban transgender and nonbinary children from receiving medically necessary and lifesaving health care.15-17

We have pathologized normal diversity, identities, behaviors, and practices in our diagnostic and statistical manuals for far too long. For example, homosexuality was removed as a listed disorder in 1974, but persisted in various forms as an ego-dystonic condition until 2013.18 Transgender identity existed in various forms of the manual and persists today as an ego-dystonic condition known as gender dysphoria, a condition expressed by some transgender and nonbinary individuals.8 A gender dysphoria diagnosis is often necessary to justify coverage of lifesaving interventions to public and private health care insurers. This implies that a transgender or nonbinary patient is required to concede a mental health diagnosis before attaining medically necessary health care. In many ways, those in the psychiatric profession remain the gatekeepers of gender expression in patients from historically oppressed genders who wish to undergo a transition.

Yet, through it all, the transgender community has championed pride alongside their cisgender allies. The numbers within the community grow, particularly in younger generations, where 2% identify as transgender.19 And the pride celebrations every June have become bigger, bolder, and more accepted by mainstream society.

Now is the time we need pride the most. We cannot succumb to fear or shame, and we cannot stand down to threats of violent oppression. We are under attack by a conservative legislative agenda that ignores our medical evidence and peer-reviewed literature. We must fight for our patients to receive the medically necessary health care they deserve. We should call in allies to actively engage and support those of historically oppressed genders the other 11 months of the year. We need to mentor, develop, and promote trainees and colleagues from historically oppressed communities, and include them in the research and peer-review process. We should value their professional contributions and provide them with authorship and payment for their lived expertise (which is what I prefer to call lived experience).

Most of all, we need to remain composed, as we are the eye of the hurricane. And this month, our pride will sweep across the country.


Dr Lerario (@MPLerario) is a board-certified neurologist and graduate student of social service at Fordham University, where they perform activism and research for the transgender community. Their work has been published in Neurology: Clinical Practice, the Journal of Speech Language and Hearing Research, and the Harvard Public Health Review Journal, among others.



1. James S, Herman J, Rankin S, et al. The Report of the 2015 U.S. Transgender Survey. 2016. Accessed June 10, 2022.

2. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychol Bull. 2003;129(5):674-697.

3. Streed CG, Beach LB, Caceres BA, et al, on behalf of the American Heart Association Council on Peripheral Vascular Disease; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Radiology and Intervention; Council on Hypertension; and Stroke Council. Assessing and addressing cardiovascular health in people who are transgender and gender diverse: a scientific statement from the American Heart Association. Circulation. 2021;144(6):e136-e148.

4. Matsuno E, Israel T. Psychological interventions promoting resilience among transgender individuals: Transgender Resilience Intervention Model (TRIM). The Counseling Psychologist. 2018;46(5):632-655.

5. Testa RJ, Habarth J, Peta J, et al. Development of the gender minority stress and resilience measure. Psychology of Sexual Orientation and Gender Diversity. 2015;2(1):65-77.

6. Haeder SF, Sylvester S, Callaghan T. Shared stigma: the effect of LGBT status on attitudes about the opioid epidemic. World Medical & Health Policy. 2021;13(3):414-435.

7. Minkin R, Brown A. Rising shares of U.S. adults know someone who is transgender or goes by gender-neutral pronouns. Pew Research Center. July 27, 2021. Accessed June 10, 2022.

8. Turban JL, de Vries ALC, Zucker KJ, Shadianloo S. IACAPAP Textbook of Child and Adolescent Mental Health: Vol. Transgender and Gender Non-Conforming Youth (2018th ed). International Association for Child and Adolescent Psychiatry and Allied Professions; 2018.

9. Sloan CA, Berke DS, Shipherd JC. Utilizing a dialectical framework to inform conceptualization and treatment of clinical distress in transgender individuals. Professional Psychology: Research and Practice. 2017;48(5):301-309.

10. Turban JL, Loo SS, Almazan AN, Keuroghlian AS. Factors leading to “detransition” among transgender and gender diverse people in the United States: a mixed-methods analysis. LGBT Health. 2021;8(4):273-280.

11. Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006;63(7):757.

12. Linehan MM. DBT Skills Training Manual. Guilford Press Publications; 2015.

13. Dolotina B, Turban JL. A multipronged, evidence-based approach to improving mental health among transgender and gender-diverse youth. JAMA Network Open. 2022;5(2):e220926.

14. Blakemore E. Gay conversion therapy’s disturbing 19th-century origins. June 28, 2019. Accessed June 10, 2022. History.

15. Cole D. Arizona governor signs bill outlawing gender-affirming care for transgender youth and approves anti-trans sports ban. CNN Politics. March 30, 2022. Accessed June 10, 2022.

16. Goodman JD. How medical care for transgender youth became ‘child abuse’ in Texas. The New York Times. March 11, 2022. Accessed June 10, 2022.

17. Miles K. Families of transgender youth in Alabama face some difficult choices. National Public Radio, National (Morning Edition). May 3, 2022. Accessed June 10, 2022.

18. Drescher J. Out of DSM: depathologizing homosexualityBehav Sci (Basel). 2015;5(4):565-575.

19. Jones JM. LGBT identification in U.S. ticks up to 7.1%. Gallup. February 17, 2022. Accessed June 10, 2022.


My Authentic Voice: Expanding the Sound Between Man and Woman

By: Z Paige Lerario, MD, NYS CRPA/CPS-p

May 2, 2022

Blog originally posted in:

Neurology Blogs, Voices: Lived Experience

Based on the original research article published in:

The Journal of Speech, Language, and Hearing Research

In collaboration with the team at New York University’s:

Acoustic Phonetics and Perception Lab


Nearly a decade ago, when I started to come out as transgender, I knew I had two major counts against me if my goal was to “pass” as a cisgender woman in society. One was my large skeletal size, and the other was my deep, natural voice.  At the time, I was too afraid to irreversibly change my biology with vocal feminization surgery. So, I was excited to find affordable vocal feminization services at NYU’s Speech-Language-Hearing Clinic in 2014. 


“We need more nonbinary voices speaking out publicly.”

Words Matter:  The words we use to describe gender influence how listeners perceive gender. 

Learn more about pronouns and and gender wording issues at:

GLSEN Pronouns Guide

As a clinical resident in neurology, my paycheck barely covered the rent and utilities of my fourth-floor walkup apartment on the Upper East Side, which had twice more animals living in it than rooms.  Health care insurance coverage of medically necessary, transition-related expenses was not a privilege I had at the time. I paid low-fee, out-of-pocket expenses to meet confidentially with students supervised by expert speech pathologists for vocal feminization services. I remember begging them not to tell anyone that I went there, since I worked frequently with speech pathologists in New York City as part of my job as a neurologist. The care and compassion I received in this clinic remains some of the best treatment I have received by any healthcare provider during my transition. They say you “get what you pay for,” but I think health care too often overlooks the healing value of providing an affirming environment to patients from historically oppressed communities. 

At the time, I was in intense denial of my transgender identity, and I dared not use the word “transgender” out loud in my sessions. Nevertheless, I was encouraged gently to explore my physical and vocal femininity, and I was thanked for my presence and authenticity. There were support groups with others at similar points in their transitions who were also struggling with their vocal identity.  I even wore some makeup and women’s jeans during one of my sessions.

The most intense gender euphoria I experienced during my transition came in a letter from this clinic describing my semester performance achievements. The first sentence described me as a “transgender woman.” I felt these words made my existence real for the first time ever. Although I had never used these words myself, this report from my assigned speech pathologist had provided me with the permission to be myself. Still to this day, I never allowed another person to read this letter. At the time, I was too afraid that if someone invalidated this experience, I wouldn’t have the confidence to come out and transition. Today, I know no one can take my identity away from me, but I keep that letter to myself, proof that I owe no one of my existence.

Another important lesson that I learned at NYU is how disabling and life-limiting a masculine voice can be for some transfeminine speakers. My masculine voice seemingly gives permission to others to question my existence. Male puberty poisoned my larynx, and feminizing hormones could not restructure my misshapen vocal organ. As my body changed with hundreds of thousands of dollars of doctor’s visits, medications, and surgeries, my natural speaking voice remained the same as before my transition, without dedicated intervention. I felt like my voice was no longer mine, and the dissonance between my speech and physical appearance became apparent. 

If I chose to use the phone, I either allowed myself to be misgendered and unseen, or I risked outing myself and the resultant discrimination that follows. Therefore, I stopped using the phone whenever I could.

When I publicly spoke or met a new person, I needed to make a quick judgement as to the safety of using my natural voice or manipulating my vocal gender expression to match my physical appearance. This is an exhausting exercise, and I often made mistakes on who was safe to trust when revealing my gender identity. The process of coming out never ends.

I dare not use my natural voice at airport security or in geographic regions that delegitimize the existence of transgender identities. These situations could pose threats to my human rights or physical safety.  Although my identity is nonbinary, and therefore “passing” is not a goal of mine, I acknowledge that in many spaces being visibly or audibly gender nonconforming can be dangerous emotionally and physically. I hope safety for the transgender community improves, but on the Transgender Day of Remembrance, we count the number of brutally murdered transgender people.

As a result, my life feels painstakingly performative, and the stigma of transgender identity can be silencing. I frequently code-switch between either speaking in my natural voice and a learned feminine vocal expression, or even between speaking and remaining silent. When my performance fails, I constantly fight to not internalize the stigma of gender nonconformity and the resultant public humiliation, defeat in self-confidence, and societal devaluation which may come with it, especially if I’m having an already bad day.

These concerns were specifically measured by the Steinhardt clinic throughout my gender transition. Two scales were used, the Voice Handicap Index (VHI-10), a scale commonly used to measure impairment for people with voice disorders, and the Trans Woman Voice Questionnaire (TWQV), a scale developed to specifically look at the voice concerns of transfeminine speakers. I scored a 68 on the VHI-10 in June 2020, which ranges from 0-120.  Scores over 60 on the VHI-10 indicate severe impairment, as seen with patients with vocal cord paralysis or severe vocal fold scarring.1 My areas of highest disability were noted in the questions: “I find other people don’t understand my voice problem” and “my voice problem upsets me.” Through gender-affirming medical services, including feminizing speech therapy, my scores on the TWVQ, a self-evaluation survey consisting of 23 questions, I found my scores and self-confidence gradually improve by almost 75%.2 For me, such gender-affirming services are lifesaving. They should be considered medically necessary and covered by health care insurance on a national basis.

I do not aim to project my experience onto others: many transgender people are not disabled, by their voices or otherwise. Most transgender people lead functional, inspiring, productive lives doing everything and anything.  Many had the confidence to be themselves for decades before me. And every transgender person — past, present, and future — is my role model, as every transition is unique, inspiring, and educational in its own light.

I am privileged to benefit from the system those before me have begun to change, and for so many reasons, still requires much substantial change. We are everywhere and have been everywhere throughout our shared human histories. Now, I hope more of us make the difficult decision to be ourselves visibly and to stop conforming to a gender binary that is holding us back from recognizing the true beauty and diversity of gender and sexuality. We need more nonbinary voices speaking out publicly.



1. Jacobson BH, Johnson A, Grywalski C, Silbergleit A, Jaconsen G, Benninger MS.  The Voice Handicap Index (VHI): Development and Validation. American Journal of Speech-Language Pathology 1997;6(3):66-70.

2. Dacakis G, Davies S, Oates J, Douglas J, Johnston J. Development and preliminary evaluation of the Transsexual Voice Questionnaire for male-to-female transsexuals. J Voice 2013; 27(3):312-320. doi:10.1016/j.jvoice.2012.11.005


“Children remember what they are taught; What they should do, And what they should not. Whom they should love, And whom they should hate. What is one’s choice, And what is one’s fate.”

Wei Dewdney (they/it)

Greenburgh Pride 2021 | Edgemont GSA


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What We Are Taught

Children remember what they are taught;

What they should do,

And what they should not.

Whom they should love,

And whom they should hate.

What is one’s choice,

And what is one’s fate.


Children are computers

Storing codes and data.

And the teachers and the tutors,

They reach into the corners of their minds

And shove fistful after fistful 

Of corrupted files.

Ignorant and blissful.


Children learn and grow,

Some may even mature.

All those years ago

And all those things they learned

Will stick with them


The seeds will sprout a stem.


Children are watered and fertilized 

With opinions from those who 

Anticipate our demise.

But it’s all just a joke.

Acquire an extended vocabulary,

Of slurs and insults,

As our corpses collect in the cemetery.


Children keep secrets

In well-hidden files,

It’s where they hide their weakness.

Their identity.

Their so-called “unholy” desires

So they hate themselves and others

Like them, to please those whom they admire.


Children programmed to hate themselves often meet their end too soon.

I hope you enjoyed the funeral service

This afternoon. 

You got what you wanted.

Blood on your hands.

I hope you are proud

Of where you stand.


Children die, wanting to be free.

Those seeds that were first planted

Have now become a tree.

With the swing of an axe,

Its wood is collected

And turned to a casket.

Buried by those to whom the children were subjected.


Children remember what they are taught.

Their shoulders weighed down

By the hate you’ve brought.

How to close our minds,

How to traditionalize our thoughts,

The reality is that this is

What we are taught.


I creep out of the solitude

Of sleep

And meet my reflection with

A sigh


Of confusion,

As I still cannot recognize

That person in the mirror.

My body’s 


Surface area is

Disproportional to the amount

Of utter hatred that protrudes

From my own 



My ears are pierced

With rusted metals,

Engraved the words



My voice lingers in the

Air as I laugh

And smile.

Who is that?


Who is that?

Who is that?

I can’t recognize this name

You have assigned me.

Who is that?

Who is that?

You tack paper onto

My forehead that writes;



My head starts to bleed

What did you expect?

You stuck a damn tack into



Who are you

To stick tacks into my



Who are you

To tell me who I can

Or can’t be?

Who are you?


Strange figure in the mirror.

Strange voice that fills the air.




Who am I?


The Nonbinary Physician Activist: “Do No Harm” Implies Equity as the Outcome.


Gender nonconformity and outspoken nonbinary voices are stigmatized in medical professionalism.  Anti-LGBTQ climates in healthcare and research settings are psychological iatrogenesis which require structural changes to avoid further malpractice.  Academic medicine should take largescale and immediate action based on lessons learned from the lived expertise and the paid work being performed by activist and social justice thought leaders.  Intersectional, community-based participation, autonomy, and ethical representation should be standard in all components of clinical care and research.  This is especially true in post-pandemic practice, in which historically-oppressed communities’ trust in our healthcare system continues to decline.  We must move focus of translational care “from bench to bedside to embrace,” and we should target equity as our main quality assurance outcome.


 Originally Posted in: Harvard Public Health Review: Edition 42 



What Does Visibility Mean to Me?

I view my gender expression as free expression of identity, of thought, of self, and of art. Some forward-thinkers may perceive my gender expression favorably, some may feel ambivalent, and some may laugh or scowl at it or have violent or shocked reactions to it. Nevertheless, it commands attention.”



Original Post Found at:

Fordham GSS News

(Read It Here)



Fordham GSS

The Daily Visibility of Nonbinary Identity in Social Innovation

Z Paige Lerario, MD, NYS CRPA/CPS-provisional                                                                                                 

MSW Candidate, Fordham Graduate School of Social Service
Vice-Chair, LGBTQI Section of the American Academy of Neurology 

March 31, 2022

Dr. Z Paigle Lerario


As a graduate student of social service at Fordham University, I take my positionality seriously. I am white, I am a physician, I am able-bodied, and I have had every educational opportunity available to a person born in the United States. I am also transgender and nonbinary, which too often takes a front seat in how people perceive me. I am visibly out and trans most days of the year. And because of this, most people are surprised to learn I am a neurologist.

That’s probably because I do not “pass” in society as a cisgender person and because I exist in this world as neither a man nor a woman. I am in the mindset that I do not owe it to society, to my colleagues, to my clients, or to anyone else to look or act in a specific way before I am respected as myself and the identities I claim. I am exactly what a neurologist looks like, nothing more and nothing less.

I have learned the importance of this self-affirmation as a social work student. Loving oneself is a part of self-care, self-improvement, and self-empowerment. And I believe as a future social worker, I should first make progress toward loving myself before I can be fully available to the clients I serve.

Often the societal expectation is transgender people should “pass” visibly and behaviorally as cisgender; that is, we should not appear as transgender openly. In many of the helping professions, this forced cisgender normalization erases culturally appropriate standards of transgender and nonbinary expression and identities. Although transgender people have existed everywhere through all of time, many of us are silenced by violent oppression: such as banning healthcare, banning sports participation, banning representation in education, and banning facilities access, among various others.

The majority of Americans have not knowingly had a conversation with a transgender person (Minkin & Brown, 2021). This includes some of our country’s decision makers and thought leaders (Crary D & Whitehurst L, 2021). So how can they make informed decisions on laws and policies which affect transgender people? And do those of us with a transgender family member, coworker, fellow student, teammate, or friend wish for these policies to be made without adequate representation from the communities affected? This is a time when one in fifty members of generation Z identify as transgender, and one in five identify within the LGBTQ+ community (Jones JM, 2022). We need social innovation and structural adaptations to accommodate a quickly changing demographic of the incoming American workforce.

On this day, now nationally recognized by President Biden, we acknowledge what barriers and biases many transgender people encounter daily in achieving the many successes of our community. For me, the Transgender Day of Visibility shows respect for the authentic self which I (and so many others before me) display to the world, and the consequences we have faced in doing so.


Dr. Z Paige Lerario


I admit I am privileged. I am privileged to afford health insurance and surgeries and new wardrobes and legal name changes. Too many transgender people do not have these privileges. Some may need to hide, out of safety—emotional or physical— or for fear of losing employment, housing, healthcare, family, friends, mentorship or education.

Nevertheless, gender diversity in any form or voice is a gift to be celebrated. Nonconformity to outdated binary standards of gender expression need not only be championed by those who are transgender or nonbinary. I view my gender expression as free expression of identity, of thought, of self, and of art. Some forward-thinkers may perceive my gender expression favorably, some may feel ambivalent, and some may laugh or scowl at it or have violent or shocked reactions to it. Nevertheless, it commands attention.

Therefore, I urge readers to stand out in their gender expression, today, and every day. And above all, recognize the gift of authenticity and empowerment transgender people provide to the world every day of the year.



Crary D & Whitehurst L (2021). Lawmakers can’t cite local examples of trans girls in sports. Associated Press News. Accessed online on March 15, 2022 at:

Jones JM (2022). LGBT Identification in U.S. Ticks Up to 7.1%. Gallup: Politics. Accessed online on March 15, 2022 at:

Minkin R & Brown A (2021). Rising shares of U.S. adults know someone who is transgender or goes by gender-neutral pronouns. Pew Research Center. Accessed online on March 15, 2022 at:


Because in authenticity, I have found inspiration, strength and passion in leadership. And when you have these qualities, there is no longer reason for dominance and no longer room for complicity or silence.

Mackenzie P Lerario, MD, NYS-CRPA/CPS-p

                                                                                                  The Necktie in Professional Dress Codes: An Outdated Symbol of Masculine Oppression

My dad taught me many things. One lesson that remains with me to this day is the importance of a good necktie. “Power ties” he called them in my childhood, often citing the symbolic authority of the red necktie on Donald Trump, then a real estate mogul. In these moments, my dad reinforced a learned cultural value that masculinity represents strength, and that this messaging should be front and center in our leaders. At the time, I did not understand how personally significant this social cue was for me. Nor did I know the same man would later write historic executive actions as President which rolled back eras of progress for gender-expansive citizens of our country.


Read the Whole Story Here at Neurology Blogs, Voices: Lived Experience

A Preventable Trauma: The Urgent Need to Expand Gender Diversity in Neurologic Health care

Originally published in: Neurology Blogs, Voices: Lived Experience

Mackenzie P Lerario, MD, NYS CRPA/CPS-p

American Academy of Neurology, Emerging Leaders Program

We are at the precipice of an emerging professional and public health care crisis within neurology.  We are at a time when the number of Americans who self-identify as transgender is  quickly increasing; as many as one in fifty members of Generation Z are transgender.1

However, we do not have the infrastructure or training necessary to accommodate this incoming surge of gender-expansive patients into our neurologic practices.

The Human Rights Campaign annually publishes a Healthcare Equality Index, which allows for hospitals and health care systems to voluntarily participate in surveys of their transgender employee and patient care practices. In 2020, only half of participants indicated that their facility has policies aimed at “eliminating bias and insensitivity, and ensuring appropriate, welcoming interactions with transgender patients.”2 Furthermore, a large, representative survey of 6,450 transgender Americans demonstrated that one in five transgender patients are refused care due to their gender identity, and half found it necessary to teach their medical providers about transgender care during appointments.3 

This is no different in the neurologic professions. A 2019 survey of a representative, random sample of 1,000 American Academy of Neurology members showed that more than 40% of participants were unaware how gender identity may impact the management of neurologic illness.4 These awareness gaps are not surprising since there are no required educational or competency standards for the care of transgender neurologic patients in our profession,5 which is in contrast to a growing body of literature that transgender neurology is an important part of our clinical practice.6 If we do not immediately begin to make progressive changes to our clinical care, medical education, and research, we will remain grossly unprepared to treat a large and growing segment of our patient population.

As a transgender neurologic patient and practitioner, these statistics are personally significant to me, as my lived experience (which I now prefer to name ‘lived expertise’) is consistent with these data. The following is a common phone conversation I have had with multiple health care providers in the early stages of my gender transition:


Me: “I am transgender and looking to make an appointment with [provider’s name].  Does [he/she/they] accept transgender patients?”

Practice: “No, [provider’s name] does not see transgender patients.”

Me: “Does that not come off to you as discriminatory?”

Practice: <hang up> or “Wouldn’t you want to see a provider who knows how to treat transgender patients?”


Since this time, I have learned that I must travel far distances to see providers competent to provide my health care. Additionally, I must painstakingly vet any new providers through online forums that specifically cater to the transgender community or through recommendations from transgender community members with lived expertise as a patient under said providers. I have found many times that those who advertise themselves as practitioners serving the transgender community may have limited or no training and professional experience actually treating transgender patients. My experience with these providers were mainly harmful. This professional mistreatment ranged broadly from microaggressions to blatant harassment.  For example,


  • Providers assumed my sex, gender, and pronouns based on my physical appearance.
  • Providers were unable to adapt to my correct pronoun usage, and I was publicly mis-pronouned in waiting rooms, typically without an apology when I requested one.
  • Providers invalidated or frankly questioned my lived expertise as untruthful.
  • Providers asked questions irrelevant to the reason for my visit.  I believe this typically satisfied their curiosity about my sexuality or genitalia (as this was often the content of the questions).
  • Providers have yelled at me during an appointment.
  • Providers have called me transphobic slurs, and I experienced increased mis-pronouning when I pointed out a provider’s mistakes or requested an apology.


I have specific trauma from my experiences as a transgender patient within our healthcare system. I avoid seeing providers for routine and preventative care. I often require additional psychotherapy services to address my health care trauma around times I am specifically mistreated by health care professionals who took an oath designed to protect my rights as a human being. 

This trauma is not always because I am mistreated in the first place. It is more the result of health care providers’ ignorance to their own biases in a cisgender-dominated profession which has historically promoted an acceptable, systemic standard that the transgender patient needs to change their expectations, rather than the provider making the necessary adjustments to treat the patient with the humanity, dignity, professionalism and respect they deserve. As a vulnerable community member from a historically-marginalized group, I take great risk by educating or asking for an apology when a clinical provider mistreats me. And I often have no recourse through traditional structures where I can insist on holding healthcare providers accountable or receive an apology when I am grossly mistreated as a patient.

These problem statistics are not just a faceless noise in a rising sea of meaningful use and required educational modules. We are actively harming the patients we intend to serve, and some of our most vulnerable patients are afraid to even say the word “transgender” in our presence. We cannot partition our patients to treat only those parts of their identity with which we are comfortable; we must treat the whole patient and better understand their experiences within a largely unjust environment.

I encourage those in our profession to join me as allies (and accomplices) and to take action against this urgent and evolving  public health crisis facing our transgender patients. Spend time learning about the transgender community and transgender patients, and do not ask our transgender co-workers to help us with this self-work without paying for their lived expertise. We should correct our co-workers who persistently call a colleague or patient by the wrong pronouns or name.

The work of deconstructing our implicit biases should be performed on our own time. We should do this not just because it is the right thing to do, or because we care about our patients and colleagues who are transgender, or because we feel shame or social pressure to do so. We should do this because we have a professional standard and obligation to care for our patients without harming them through documentable health care trauma. And in my lived expertise, and based on many objective data cited herein, we are unwittingly and unintentionally harming our transgender patients if we do not take immediate and ongoing action in order to continuously adapt our professional culture to the demands of an ever-changing world.



  1. Jones JM. LGBT Indentification Rises to 5.6% in Latest U.S. Estimate. Gallup, Inc. February 24, 2021. Accessed August 12, 2021.
  2. Human Rights Campaign. Healthcare Equality Index 2020. Washington, DC: Human Rights Campaign Foundation.  Accessed August 26, 2021.
  3. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi Ma. The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality. 2016. Accessed August 26, 2021.
  4. Rosendale N, Ostendorf T, Evans DA, et al. American Academy of Neurology members’ preparedness to treat sexual and gender minorities. Neurology 2019;93(4):159-166. doi:10.1212/WNL.0000000000007829
  5. Caceres BA, Streed CG, Corliss HL, et al. Assessing and Addressing Cardiovascular Health in LGBTQ Adults: A Scientific Statement From the American Heart Association. Circulation 2020;142(19):e321-e332. doi:10.1161/CIR.0000000000000914
  6. Rosendale N, Wong JO, Flatt JD, Whitaker E. Sexual and Gender Minority Health in Neurology: A Scoping Review. JAMA Neurol 2021;78(6):747–754. doi:10.1001/jamaneurol.2020.5536




Outdated Binary Standards in Youth Athletics: A Need for Gender-Inclusive Policies


Mackenzie P Lerario, MD, NYS CRPA/CPS-p

Neisha G Wiley, MSW, LSW  

“What are you doing in here?”   

A middle-aged, white woman approached me fiercely in the women’s bathroom.  Her tone implied that my Y chromosomes were most unwelcome, let alone the fact that the sex on my driver’s license and my genitals were the same as hers. 

            Although she was successful in scaring me, she did not prevent me from using the bathroom aligned with my gender identity. She was at no risk of being assaulted or harassed by me, but in contrast, I was harassed while also being disrespected and publicly humiliated over a simple toilet. Why she felt the need to disturb another woman using the bathroom was beyond me, and I had no clue who deputized her with this role to police the women’s bathrooms. This trauma was jarring  enough to me as an adult of transfeminine experience, so I cannot imagine how harmful such behavior is when it is brought upon a transgender child.

            Earlier this year, 36 US states have introduced legislation to ban transgender youth from participating in sports based on their gender identity rather than their sex at birth, citing safety concerns for the cisgender students and maintaining the purity of competition (National Public Radio, 2021; Sharrow et al, 2021).  In nine states, these bills have become law (Sharrow et al, 2021).  Now, more than 1 in 10 members of the LGBTQIA2S+ community live in states with laws preventing transgender students from participating in sports consistent with their gender identity (Movement Advancement Project, 2021).

            Sex discrimination based on gender identity (including in the context of school sports participation) is federally illegal under Title IX  due to the recent USSupreme Court ruling on Bostock v Clayton County and upheld in recent Federal Policy issued by the Department of Education (Sharrow et al., 2021).   In terms of K-12 athletics, 17 states and Washington, D.C.  have gender-inclusive policies allowing transgender students to participate in school sports without requirements of medical or legal transition (Sharrow  et al., 2021; @THECHRISMOSIER, 2021; Goldberg et al, 2021).  Other states either offer no guidance, have invasive policies placing the student under medical or administrative scrutiny, or limit participation solely on the basis of the institutions’ individual definition of “biological sex” rather than scientific evidence and individual identity (@THECHRISMOSIER, 2021; Goldberg et al, 2021).  National surveys demonstrate that transgender youth are discouraged from playing sports based on their gender identity, and more than half have been prevented from using bathrooms and locker rooms based on their identified gender (Kosciw et al. 2019; Goldberg et al., 2021).

            This is in the face of increasing amounts of data demonstrating that gender-exclusive policies worsen mental health outcomes for transgender youth (Goldberg et al, 2021).   Transgender youth who experience discriminatory athletic policies report lower self-esteem and school belonging, as well as higher rates of depression and school absenteeism (Clark et al, 2021; Goldberg et al, 2021).  Other data show that transgender high school students feel less safe using sex-segregated facilities, which may explain lower levels of sports participation in this student population (Kulick et al. 2018).  On the other hand, gender-inclusive policies lower the reported risk of self-harm, depressive symptoms, and unsafety at school for transgender students (Goldberg et al, 2021). 

            Furthermore, there is no data that signifies any safety risk for transgender students.  Politicians involved in this legislation are unable to name a single transgender athlete, let alone name an example of a safety issue or violation of athletic policies perpetrated by transgender women (Crary et al, 2021). 

            In fact, leading experts in pediatrics and genetics suggest that gender-exclusive policies diminish the diversity of athletes’ bodies (National Public Radio, 2021).  Dr. Eric Vilain explains: “every sport requires different talents and anatomies for success. So I think we should focus on celebrating this diversity, rather than focusing on relative notions of fairness. For example, the body of a marathon runner is extremely different from the body of a shot put champion, and a transwoman athlete may have some advantage on the basketball field because of her height, but would be at a disadvantage in gymnastics. So it’s complicated” (National Public Radio, 2021).  Gender varies by culture and often differentiates diversity into discrete, but subjectively-created, categories.  Therefore, we may need to rethink how gender is viewed in athletics, and focus the debate on the realities of sex and gender, and not lose the facts for outdated traditions and standards which discriminate against many student athletes who identify as transgender.

            Historically women who look different have been targeted for discrimination, whether cis or transgender.  For those who are transgender, there are additional layers of intersecting identities which further prevent transfeminine student athletes from receiving equal treatment in school athletics.  Transmisogyny, defined as oppression at the intersection of femininity and transgender identity (Serano, 2007), is displayed in the imbalanced NCAA policies regarding gender-affirming hormone therapy in transmasculine versus transfeminine athletes.  As Dr. Vilain describes, testosterone is the main discriminator in these policies, as it effects muscles and red blood cells and therefore speed, strength, and endurance (National Public Radio, 2021).   Many transgender children choose to go on medications that delay puberty while they make decisions on whether to medically transition.  In the absence of a male puberty, all children should roughly be at similar advantage in sports (National Public Radio, 2021).  But this biology and scientific evidence  is not reflected in many US state’s policies regarding student athletes.

            Therefore, we need to review our own implicit biases regarding sex and gender, as the gender binary has made it difficult for any woman– cis or transgender– to be accepted in competitive athletics if they do not conform to strict societal standards of what it means to be a woman.  Implicit bias testing can be taken online at  Diversity is natural to biology, and there is great variation between members of the same sex, which can give some cisgender women advantages over others in some sports and disadvantages in other sports.  Some cisgender men and women have high levels of testosterone and others have low levels of testosterone, yet they are not excluded from play in athletics.  The same thinking should be applied to transgender women in sports, who present with a diverse range of sizes, strength and athletic abilities. 

            The existence of nonbinary gender identities and intersex conditions demonstrate that dividing sports into binary gender categories is too limited a worldview  (De La Cretaz, 2021).  The solution would be to either open up categories to include genders outside of man and woman or to find a different means to categorize athletes separate from chromosomes, hormones, and genitals, which in no way define an athlete or their skills.  If critics of gender-inclusive athletic policies cite the relatively larger musculoskeletal size of transgender women (which is not true of all transgender women), then would not body measurement be a better distinguisher between categories than gender?  I think it is time we reconsider how we view gender in our world, because our world is already changing whether we want it to or not.  And fear of change is not an adequate reason to discriminate against a marginalized community.

            I am lucky to be in a profession that is accepting of gender variety, and I therefore have the privilege to learn contemporary social welfare policy from diverse faculty who are accepting of my authentic gender expression, such as Dr. Neisha Wiley.  I find within social work education, my pronouns “they/them/their” are often viewed as an asset rather than a liability to the classroom experience.  It is no coincidence that social work is the profession with the largest code of ethical responsibility (National Association of Social Workers, 2021).  The dignity and worth of the person and challenging social injustices are engrained as core ethical responsibilities of social workers.  I believe it is time social workers continue to become more involved in schools to ensure that gender inclusive policies are created and enforced.  To do otherwise would be contrary to our professional ethics.


Clark, C.M., Kosciw, J.G. (2021).  Engaged or excluded: LGBTQ youth’s participation in school sports and their relationship to psychological well-being.  Psychology in the Schools. 1-20.

Crary, D., Whitehurst, L.  (2021).   Lawmakers can’t cite local examples of trans girls in sports. The Associated Press.  Accessed online September 9, 2021 at:

De La Cretaz, B. (2021).  Living Nonbinary in a Binary Sports World.  Sports Illustrated: WNBA.     Accessed online September 18, 2021 at:

Goldberg, S.K., Santos, T.  Fact Sheet: The Importance of Sports Participation for Transgender Youth.  Center for American Progress: LGBTQ RIGHTS.  Accessed online September 9, 2021 at:  transgender-youth/

Kosciw, J.G., Clark, C.M., Truong, N.L, Zongrone, A.D. (2020). The 2019 National School Climate   Survey. New York: GLSEN. Accessed online September 18, 2021 at:

Kulick, A., Wernick, L.J., Espinoza, M.A.V., Newman, T.J., and Dessel, A.B. (2018).  Three strikes   and you’re out: culture, facilities, and participation among LGBTQ youth in sports.  Sport, Education, and Society. 1-15.

Movement Advancement Project (2021).  Bans on transgender youth in participation in sports.  Equality Maps.  Accessed online September 18, 2021 at:

National Association of Social Workers (2021).  Read the Code Of Ethics.  Accessed online            September 23, 2021 at: Ethics/Code-of-Ethics-English

National Public Radio (2021).  Wave Of Bills To Block Trans Athletes Has No Basis In Science,        Researcher Says.  Sports.  Accessed online September 9, 2021 at:  

@THECHRISMOSIER (2021).  Policies. Accessed online September 9, 2021 at: .

Serano, J. (2007) Whipping girl: A transsexual woman on sexism and the scapegoating of femininity. Emeryville, CA: Seal Press.

Sharrow E., Schultz J, Pieper LP, Baeth, A, Lieberman, A. (2021).  States are still trying to ban trans youth from sports.  Here’s what you need to know.  The Washington Post: Monkey Cage.  Accessed online September 18, 2021 at: youths-sports-heres-what-you-need-know/