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.

References

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. https://doi.org/10.1080/01612840.2019.1565876.

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:https://doi.org/10.1016/j.jadohealth.2018.02.003.

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.