Transgender Healthcare

Transgender Healthcare

Definition of Term and Historical Context:

This encyclopedia entry will examine the state and history of transgender healthcare specifically in the United States. Before I can get in to the intricacies of transgender health care, I will define “transgender”. The American Psychological Association (APA) is the leading resource for psychology in the United States. Their current definition of “transgender is an umbrella term for persons whose gender identity, gender expression or behavior does not conform to that typically associated with the sex to which they were assigned at birth.”¹ This definition is broad enough to encompass any of those who identify as transgender and would therefore be affected by any laws or stigma that come from being transgender. People can be transgender from male-to-female (MTF), female-to-male (FTM), or anywhere in between.² MTF and FTM tend to be older descriptions of transgender people as some people do not necessarily fit directly in that binary or they do not think of themselves as anything but the gender they identify with today. The APA includes a broad list of terms that relate to gender identity that are quoted below directly from the site for reference.

• Gender – denotes the public (and usually legally recognized) lived role as boy or girl, man or woman. Biological factors combined with social and psychological factors contribute to gender development.
• Assigned gender – refers to a person’s initial assignment as male or female at birth. It is based on the child’s genitalia and other visible physical sex characteristics.
• Gender-atypical – refers to physical features or behaviors that are not typical of individuals of the same assigned gender in a given society.
• Gender-nonconforming – refers to behaviors that are not typical of individuals with the same assigned gender in a given society.
• Gender reassignment – denotes an official (and usually legal) change of gender.
• Gender identity – is a category of social identity and refers to an individual’s identification as male, female or, occasionally, some category other than male or female. It is one’s deeply held core sense of being male, female, some of both or neither, and does not always correspond to biological sex.
• Gender dysphoria – as a general descriptive term refers to an individual’s discontent with the assigned gender. It is more specifically defined when used as a diagnosis.
• Transgender – refers to the broad spectrum of individuals who transiently or persistently identify with a gender different from their gender at birth. (Note: the term transgendered is not generally used.)
• Transsexual – refers to an individual who seeks, or has undergone, a social transition from male to female or female to male. In many, but not all, cases this also involves a physical transition through cross-sex hormone treatment and genital surgery (sex reassignment surgery).
• Genderqueer – blurring the lines around gender identity and sexual orientation. Genderqueer individuals typically embrace a fluidity of gender identity and sometimes sexual orientation.
• Gender fluidity – having different gender identities at different times.
• Agendered – ‘without gender,’ individuals identifying as having no gender identity.
• Cisgender – describes individuals whose gender identity or expression aligns with the sex assigned to them at birth.
• Gender expansiveness – conveys a wider, more flexible range of gender identity and/or expression than typically associated with the binary gender system.
• Gender expression – the manner in which a person communicates about gender to others through external means such as clothing, appearance, or mannerisms. This communication may be conscious or subconscious and may or may not reflect their gender identity or sexual orientation ³

 

This list of terms is one of the examples that show how complicated the concept of being transgender can be to understand if someone has not been exposed to it before. In my liberal-minded college student opinion, this misunderstanding is what causes the discrimination and stigma against transgender people.

The first time being transgender was classified as a mental disorder was in 1980 in the third edition of the Diagnostics and Statistical Manual of Mental Disorders (DSM-III) as a Gender Identity Disorder (GID).² It was not until the DSM-V, published in 2013, that GID was declassified as a mental disorder. In an article on Psychiatric News, Mark Moran clarified the reason for the change. He wrote, “criteria for the new category emphasize the phenomenon of ‘gender incongruence’ rather than cross-gender identification.” This new term, gender dysphoria, applies to the symptoms of being transgender, rather than describing the idea of being transgender as a mental illness.⁴

The diagnostic criteria for gender dysphoria in the DSM-V and GID in the DSM-IV. ⁵

The APA is the organization that is in charge of creating the DSM. They decided to change the name of GID to gender dysphoria because “persons experiencing gender dysphoria need a diagnostic term that protects their access to care and won’t be used against them in social, occupational, or legal areas.”⁶ In order for individuals to get covered by insurance, they need a diagnosis. This is a catch-22 because while transgender people do not see themselves as mentally ill, but they do need medical intervention to help them better adjust to transitioning into their preferred gender. This classification removed the negative connotation from the word “disorder” and stresses the physical symptoms that arise from being transgender.

Because of the unique characteristics and stigma of being transgender, individuals have different mental and physical health needs. Some of the stigma includes: refusing to call an individual by their preferred pronouns, not allowing someone to use the bathroom of the gender that they identify with, being called “crazy” or “mad,” and people being scared of possibly getting “transgender” germs on them.⁷ The risk of violence, suicide, and sexually transmitted diseases increases.⁸ Because of the discrimination that transgender people face, their access to healthcare is limited. Some transgender people also need transition-related healthcare. This includes counseling, surgery, and hormonal treatment. ⁸

Main healthcare options:

Younger people who identify as transgender have the option of using a puberty suppressing hormone. Those who are qualified tend to be at the beginning of puberty, the onset of puberty has worsened their gender dysphoria, any concurrent disorders have been recognized, and they (or their guardians) have given informed consent to the hormones.⁹ This option is important because it is reversible. Once the individual stops the treatment, they will progress through puberty. This extra time allows for the individual to confirm their identity without developing any irreversible sex characteristics.

Hormone Therapy by Age of Respondent. ⁸

Hormone replacement therapy is one of the more common reasons why transgender people need healthcare. Transgender people can take hormones that will increase either their male or female characteristics. Transgender men or someone who does not identify as female can take exogenous (synthetic) testosterone to suppress feminine characteristics, such as getting a more chiseled jaw, increase in body hair (including facial hair), or lowering the voice. Transgender women can take exogenous estrogen to increase feminine features. They can also take anti-androgens, which suppress masculine features.¹⁴ The graph above is from the Report of the National Transgender Discrimination Survey (NTDS) and it shows that more transgender people either have had hormone therapy or want it and fewer people never want it. This is important because it shows the prevalence of people who want to have physical characteristics that match their gender identity. It would be beneficial to them if we increase the availability of their options to have the physical characteristics that they identify with.

One source states that “cross-sex hormone therapy has been shown to have positive physical and psychological effects on the transitioning individual and is considered a mainstay treatment for many patients.” ⁸ However, in a meta-analysis done at researchers from the Mayo Clinic, they concluded that “very low-quality evidence suggests that sex reassignment that includes hormonal interventions in individuals with GID likely improves gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life.”¹⁰ The “low-quality” comes from the fact that many of the studies were only observational and lacked control subjects. But the evidence that the hormone therapy had a positive influence on their lives supports the desire of transgender people to obtain hormone therapy.

Another option that transgender people have is sexual reassignment surgery (SRS). “Transgender women may elect to undertake a variety of surgeries, including breast augmentation, orchiectomy (removal of testes), vaginoplasty (creation of a vagina and/or removal of the penis), and facial feminization surgeries.”⁸ According to the survey, most women have either had the surgery or want the surgery in the future. “Transgender men may elect to undertake a variety of surgeries, including chest reconstruction, hysterectomy, metoidioplasty and other genital surgeries” ⁸ According to the survey, most men have either had or want chest surgery or a hysterectomy, although most respondents do not want to have genital surgery. The survey does have a caveat, though, that they do not know what the percentages and likelihood of getting the surgeries would be if financial concerns were not a reality. ⁸

Cost of Transgender Healthcare:

According to a publication website by Ceatus Media Group LLC that has estimates of the cost of plastic surgery, the average cost of counseling per session is $50-$200 per session. The average cost of hormone therapy is $300-$2,500 yearly. The average total cost for transgender men is around $50,000. The average total cost for transgender women is between $7,000 and $25,000. This all depends on if the individual is covered by insurance or how much insurance is willing to cover. Also, some individuals choose to leave the country to get surgery. ¹⁷

 

Transgender health vulnerabilities and controversies:

Many transgender people face discrimination when seeking healthcare. ⁸

Percentages of transgender people who were denied equal care when seeking help. ⁸

 

The NTDS found that 19% of their respondents have been outright denied service because they identify as transgender. This percentage is higher for people who are also people of color. Doctor’s offices, hospitals, and other places of care also have an increase in being unsafe for transgender people.

Over one-quarter of respondents (28%) reported verbal harassment in a doctor’s office, emergency room or other medical setting and 2% of the respondents reported being physically attacked in a doctor’s office. ⁸

 

In order for transgender people to get the help that they need, they need to be out to their doctor. However, “[NTDS] data shows that doctors’ knowledge of a patient’s transgender status increases the likelihood of discrimination and abuse.”⁸ Transgender people will likely not want to publicize their identity if they will be denied equal care when they seek help. In addition, the NTDS survey found that around 50% of transgender patients had to educate their doctors about transgender care.

In a podcast by National Public Radio (NPR), real life examples of being transgender and receiving healthcare were investigated. Kellan Baker is a doctoral candidate at Johns Hopkins University studying how healthcare policies affect LGBT Americans. He provided an example from a man named Yee Wong Chan. Chang was diagnosed with stage two breast cancer after getting top surgery, and his doctor did not know how to enter that into the computer. The questions include, “‘What do you mean you need a cervical Pap test for a man or a prostate exam for a woman?’ he asked. ‘How do we compute that? You shouldn’t have that part, so we don’t know what to do with you.’” ¹¹ This is only one example that demonstrates the lack of knowledge and awareness that some healthcare providers have.

 

Transgender people are less likely to have insurance. ⁸

Breakdown of sources of insurance for transgender people. ⁸

Overall, 19% of the transgender population is uninsured, compared to 17% of the general population.⁸ They also have a lower percentage of employee-based coverage (51% compared to the general population’s 58%).⁸ With less access to insurance, the surgeries that they may want or need are not as financially accessible, decreasing the likelihood that they will be able to get the surgery. Besides surgery, they also can have trouble affording their hormone therapy.

In 2016, Section 1557 of the Affordable Care Act (ACA) was finalized. This section forbids any health plans covered by the ACA to discriminate on the basis of sex or gender identity. However, President Trump has made it known that he plans to repeal Section 1557 and defend healthcare workers that do discriminate because of religious opinions.¹²

The stigma and discrimination that transgender people face also increases their risk of having anxiety, depression, and HIV.¹³ Respondents from the survey reported a 2.64% HIV infection rate, compared to the 0.6% infection rate for the overall US population in 2007. ⁸ The current estimates find that there are around 1.2 million people living with HIV in the United States, which changes the overall infection rate to 0.3%.¹⁵ Being transgender increases the likelihood of getting HIV by over eight times.

The most recent report from the government states that 0.5% of the general population has attempted suicide.¹⁶ However, 41% of the respondents in the NTDS have attempted suicide, which is a dramatic increase in risk for transgender people. The survey reported that the “those who were bullied, harassed, assaulted, or expelled because they were transgender or gender non-conforming in school (at any school level) reported elevated levels of suicide attempts (51% compared with 41% of our sample as a whole). Most notably, suicide attempt rates rise dramatically when teachers were the reported perpetrators: 59% for those harassed or bullied by teachers, 76% among those who were physically assaulted by teachers and 69% among those who were sexually assaulted by teachers.” ⁸ The survey also connected low incomes as another source of stress for transgender people and those who earn $10,000 a year or less are at extreme risk (54%), but even those who make more than $100,000 still have an elevated risk compared to the general population (26%).⁸

Relation to Politics of Health:

The issue of transgender healthcare relates to politics of health because of the medicalization of being transgender, and how that has affect their access to healthcare. When GID entered the DSM-III, it supported the idea that people who are transgender are mentally ill and need help to cure themselves. This increased the stigma against transgender people because it was classified as a disorder and that something was wrong. The act being a transgender person was demedicalized in 2013 with the new edition of the DSM-V. However, the symptoms that come from being in the wrong genders body is medicalized as a separate entity. Gender dysphoria, which is what replaced GID, was specifically named as to emphasis the difference between the concept of being transgender as a mental illness and the effects of feeling as if someone is not the gender they were classified as.³ The problem with demedicalizing transgender is that those who identify as transgender need a diagnosis in order for insurance to cover their healthcare which is why the symptoms of gender dysphoria were medicalized. ⁶  The concept of biopower can also be applied to transgender healthcare because the government is controlling the regulations about who can access insurance as a transgender individual and this limits people’s abilities to get the help that they need.

 

References:

1. “Transgender People, Gender Identity and Gender Epression.” American Psychological Association. Accessed March 03, 2018. http://www.apa.org/topics/lgbt/transgender.aspx.
2. Byne, William, Bradley, Susan, Coleman, Eli, Eyler, A. Evan, Green, Richard, J., Menvielle, Edgardo, F. L. Meyer-Bahlburg, Heino, R. Pleak, Richard, and Tompkins, Andrew. “Report of the APA Task Force on Treatment of Gender Identity Disorder.” APA Official Actions. 2011. https://www.psychiatry.org/File Library/Psychiatrists/Directories/Library-and-Archive/resource_documents/rd2012_GID.pdf.
3. Parekh, Ranna. What is Gender Dysphoria?. American Psychiatric Association. 2016. https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria.
4. Moran, Mark. “New Gender Dysphoria Criteria Replace GID | Psychiatric News.” Psych News Psychiatry Online. April 5, 2015. Accessed March 3, 2018. psychiatryonline.org/doi/10.1176/appi.pn.2013.4a19?code=psychnews-site.
5. Williams, Published By Cristan. “You’re very wrong about trans kids.” The TransAdvocate. February 25, 2018. Accessed March 03, 2018. http://transadvocate.com/youre-very-wrong-about-trans-kids_n_21938.htm.
6. Gender Dysphoria Fact Sheet. American Psychiatric Association. 2013. https://www.psychiatry.org/File Library/Psychiatrists/Practice/DSM/APA_DSM-5-Gender-Dysphoria.pdf.
7. “Transgender Rights: A Short Documentary.” YouTube. May 27, 2015. Accessed March 03, 2018. http://www.youtube.com/watch?v=G0zYKdkmDQU.
8. Grant, Jaime M., Lisa A. Mottet, Justin Tanis, Jack Harrison, Jody L. Herman, and Mara Keisling. 2011. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force. http://www.thetaskforce.org/static_html/downloads/reports/reports/ntds_full.pdf
9. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. World Professional Association for Transgender Health. Vol 7. 2011. https://s3.amazonaws.com/amo_hub_content/Association140/files/Standards%20of%20Care%20V7%20-%202011%20WPATH%20(2)(1).pdf.
10. Murad, Mohammad Hassan, Mohamed B. Elamin, Magaly Zumaeta Garcia, Rebecca J. Mullan, Ayman Murad, Patricia J. Erwin, and Victor M. Montori. “Hormonal therapy and sex reassignment: a systematic review and meta‐analysis of quality of life and psychosocial outcomes.” Clinical Endocrinology. May 16, 2009. Accessed March 03, 2018. http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2265.2009.03625.x/full.

11. Ulaby, Neda. “Health Care System Fails Many Transgender Americans.” NPR, NPR, 21 Nov. 2017, npr.org/sections/health-shots/2017/11/21/564817975/health-care-system-fails-many-transgender-americans.
12. Wallace, Lewis, Ivy Hill, Sammy Feldblum, and Austyn Gaffney. “How transgender people in the South are helping each other get health care.” Scalawag. February 16, 2018. Accessed March 03, 2018. https://www.scalawagmagazine.org/2018/01/how-transgender-people-in-the-south-are-helping-each-other-get-health-care/.
13. Poteat, Tonia, German, Danielle, and Kerrigan, Deanna. Managing uncertainty: A grounded theory of stigma in transgender health care encounters. Social Science & Medicine 2013. Pgs 22-29. Doi:10.1016/j.socscimed.2013.02.019
14. Unger CA. Hormone therapy for transgender patients. Translational Andrology and UrologyDec; 5(6): 877–884. Doi:10.21037/tau.2016.09.04
15. HIV in the United States: At a glance. Center for Disease Control. 2017. https://www.cdc.gov/hiv/statistics/overview/ataglance.html
16. National Institute for Mental Health. 2017. https://www.nimh.nih.gov/health/statistics/suicide.shtml.
17. Hanson, Holly. “Understanding the Cost and Criteria for Gender Reassignment Coverage.” Consumer Guide to Plastic Surgery. Accessed March 03, 2018. http://www.yourplasticsurgeryguide.com/reconstructive/gender-reassignment-cost.htm.

 

 

 

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