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Trans Health Care Discrimination

Megan P.

Social, economic, and political factors such as stigma, discrimination, and violence greatly affect the mental, physical, and behavioral health of transgender people. Research analysis clearly indicated that transgender people suffer significantly more severely from health conditions related to HIV/AIDS, mental illness, poor physical health, and substance abuse in the general population.

It is also evident that transgender adults experience earlier onset of certain disabilities that lead to threatening health issues.

Not only do transgender people confront poor health outcomes, but they also face several challenges regarding access to health insurance and basic health care in general. During the struggle of the pandemic, the inequalities concerning transition-related care only became highlighted, especially when it comes to transgender people of color.

Enforcement strategies and policies in health facilities are just as crucial as implementing laws designed to protect transgender people from gender identity discrimination. These mechanisms should be inclusive and affirming, and health care providers need to be thoroughly informed about the discrimination that frequently emerges in transition-related care.

We will now examine the unique challenges that transgender adults face by incorporating real experiences to better comprehend the matter’s severity.


Health Status And Barriers Of Transgender Health And Human Services

Mental and physical health are both vulnerable areas for transgender people, and it so often goes unrecognized by health care providers. The elevated levels of stress and anxiety that so many transgender patients experience are largely attributed to discrimination and harassment.

Stress is always detrimental to one’s health, and transgender individuals are at high risk for experiencing poor health outcomes due to this factor.

The individual and institutional barriers in access to adequate health care services combined with inadequate cultural competency from many health care providers result in the immense discrepancy between trans- and cisgender individuals regarding essential human services.

A study performed by the Behavioral Risk Factor Surveillance System in 2019 concluded that experiences of poor mental health are 23% more prevalent among transgender respondents than cisgender respondents. The results also indicated that trans individuals have 18% more poor physical health incidence than cisgender people.

The transgender population has a significantly increased risk of developing asthma and cardiovascular disease and is much more likely to live with HIV. Chronic depression is another critical generality among the transgender community.

In the recent time when the coronavirus pandemic threatened the whole world, transgender people were especially susceptible to infection and complications because of their elevated rates of asthma, among other health issues. In addition, social inequalities and economic factors made trans people reluctant to seek health care during the pandemic, leading to higher complications in this group.

Transgender individuals were also much more likely to encounter the virus due to overrepresentation in specific industries such as restaurants, hospitals, colleges, and retail environments. The mental health of a large segment of the transgender population underwent a notable downwards spiral when isolation was mandatory. Many transgender patients reported having suicidal thoughts during the pandemic.

Many individuals could not access gender-affirming care during this time, further decreasing the frequency at which trans people could visit the necessary health services and receive the medical care required to maintain transgender health.

Health effects of minority stress

Mental and physical health conditions that transgender individuals often experience can be partly clarified under a “minority stress” model. This model entails a well-supported theory that minority groups that fall victim to social discrimination, stigma, and prejudice experience a lot of hostility and stress in social environments that could significantly impact mental health problems like anxiety and depression that drive unhealthy behaviors.

These psychological factors affect the physiology of the body more than we realize. For example, persistently elevated stress levels cause a dysregulation of cortisol secretion and uptake, which can, in turn, affect many vital bodily functions such as metabolism, cardiovascular health, mood, and the immune system.

The aftermath of experiences with discrimination is comparable to post-traumatic stress disorder, depression, anxiety, and psychological distress. Such events are also directly connected to nonsuicidal self-harm and attempted suicide.

Hostility In The Medical System

Clinics, hospitals, and other health care facilities are meant to be a place of safety and reassurance where people get the care they need, regardless of gender identity or sexual orientation. However, we do not live in an idealistic world, and this is not always the case.

Gender identity and sex discrimination are all too prevalent in these settings and, even when patients are not blatantly refused treatment, discrimination manifests in various ways. It is ubiquitous for trans patients to encounter verbal or physical abuse in medical settings, trans people of color being especially vulnerable to such occurrences.

It is commonly known that the medical system has been extremely hostile to minority groups. Racism and sexism are commonplace in the medical industry, and transphobia is definitely not an exception to these injustices. Transgender individuals who suffer from mental illness, disabilities, drug use, and issues with behavioral health commonly prefer turning to informal networks and black markets for medical attention. It is unimaginable to think that trans people feel safer in these settings than in a medical facility. It speaks volumes about the significant shortcomings of the medical care system.

It seems an impossible task to restore the trust of transgender individuals in the medical system. After so many years of discrimination based on gender identity and sexual orientation and a long history of refusing health insurance, the medical system will have to go to great lengths to prove its alliance and support for the transgender community.

Poor Access to Quality Health Care

Equal access to quality health care does not rely on the policies and legal protections of health care providers alone but also on the reassurance of transgender people that sex discrimination will not prevent them from getting access to public health services.

It is common for transgender people to conceal their gender identities in fear of harassment and retaliation from health providers. As little as 40% of transgender people have reported being out to their health care providers regarding their gender identity and gender transition.

A large percentage of trans people have reported being confronted with verbal harassment in a medical care setting. Some are even denied medical care altogether. Due to the stigmatization that comes with a gender identity that strays from the traditional binary, many trans individuals avoid health and human services entirely.

Many trans people who manage to disclose their gender identity to health and human services report that they often need to teach medical providers as they are so frequently unaware, uninformed, and incompetent to adequately provide transition-related care.

Apart from the obvious inadequacies of public health systems, there could also be serious repercussions if a medical provider is unaware of certain aspects relating to gender identity. These include transgender status, transition-related surgery, previous gender-affirming care, and sexual orientation and history.

Discrimination in health care settings

Health programs that receive federal funding are legally obligated by section 1557 to ensure a complete lack of discrimination based on race, color, age, sex, or gender identity. This section also includes enforcement mechanisms of many civil rights statutes, including Title IX of the Education Amendments that prohibit discrimination based on sex in health programs. Section 1557 statute includes the fundamentals of the existing federal civil rights act and bans transgender exclusions regarding participation and benefits of medical providers funded by the federal government.

The HHS Office for Civil Rights issued a rule systemizing nondiscrimination protections for transgender individuals in health services. This rule specifies that the nondiscrimination protections in Section 1557 accurately protect transgender individuals against discrimination based on gender identity or sexual orientation.

The act explicitly states that trans people must have access to health care facilities and health providers and services.

How To Solve This Problem

Get involved in rule-making to further reinforce nondiscrimination protections in Section 1557 as well as Centers for Medicare and Medicaid Services regulations.

While we are in the process of clarifying explicit protections for the LGBTQA+ community in health programs with federal funding, there is still a lot of ambiguity. An example includes that there are no clear requisites for health care services to not discriminate based on gender identity, sexual orientation, and behaviors. Section 1557 does not fo yet resolve the litigation over the 2020 rule.

Discrimination In Health Insurance Coverage

A growing number of medical providers believe that gender-affirming health care and transition-related care is an absolute necessity for transgender people. Unfortunately, in the past, transgender exclusions were established by both public and private health insurance companies, preventing trans people from obtaining coverage for necessary health care, including both transition-related care and general health and human services.

Most insurance companies deny coverage for transition-related services such as hormone therapy, surgeries, preventive screening, and mental health counseling. However, such procedures are regularly covered for cisgender individuals. From 2016 to 2020, it became evident that numerous insurers started promoting transgender equality by eliminating restrictions based on gender identity and gender expression and implementing coverage on gender-affirming health care. However promising this may have seemed at the time, the final rule in 2020 removed all of these regulatory protections.

How To Solve This Problem
  • Explicate that transgender exclusions do not obey federal law.

The HHS should issue official guidance to state Medicaid program directors stating that the exclusion of transition-related care does not comply with federal law. This guidance should include enforcement mechanisms and urge insurers to clarify the plans that will cover medical care for gender dysphoria.

  • Encourage federal and state regulatory entities to incorporate similar affirmative coverage language.

This solution involves improving the review process of the Center for Consumer Information and Insurance Oversight. The review of coverage plans should comply with the federal- and state-level gender identity nondiscrimination conditions. It is crucial that the federal government invests in LGBTQA+-specific outreach and enrollment support for transgender patients in the health insurance market and Medicaid services.

  • Improve Medicare coverage.

Decisions regarding medical coverage primarily fall on the Medicare Advantage plans and Medicare Administrative Contractors. These entities still harbor a large amount of discriminatory and restrictive policies relating to gender identity. Provisions should be instated by the CMS that distinctly prohibit discrimination on the basis of gender identity gender transition.


Know Your rights In Insurance Coverage

Examples of illegal discrimination in insurance:

  • No health plan is legally allowed to have categorical or automatic exclusions of transition-related care.
  • Health plans are legally prohibited from excluding specific transition-related procedures. For example, health plans cannot exclude coverage for masculinizing facial surgery. Health insurance should cover all medically necessary procedures.
  • Discriminatory limits on transition-related health insurance are strictly prohibited. An insurance company cannot exclude a procedure from coverage if that same procedure is covered for non-transgender people. Examples include breast reconstruction surgery and hormone therapy that can be used to treat gender dysphoria as well as other gender unrelated conditions. Health insurance companies are legally obligated to provide coverage for transition-related health care services.
  • Refusal of enrollment, cancellation of coverage, or charging higher health care costs is strictly forbidden. No insurance company is legally allowed to treat you any differently because your gender identity, gender expression, or sexual orientation varies from the traditional binary and sexuality.
  • Health insurance is not allowed to be prejudiced in denying coverage for health care that is typically associated with a single gender. It is prohibited to deny coverage for treatment because the gender listed on the company records differs from the gender commonly associated with the treatment. For example, a transgender woman cannot be denied coverage for gynaecological care simply because she was assigned male at birth.

Which Health Care Providers Are Prohibited From Discriminating Against Transgender People

  • Hospitals
  • Health clinics
  • Physicians
  • Drug rehabilitation programs
  • Nursing homes
  • Home health providers
  • Prison or detention center health services
  • Veterans Affairs health care services
  • Rape crisis clinics
  • Assisted living facilities
  • Reproductive health services

In-practice Policies To Promote Affirming And Inclusive Care

Beyond Nondiscrimination Legal Protections

Implementing nondiscrimination protections is undoubtedly a step in the right direction, but it cannot rectify the enduring structural exclusions that transgender face alone. Trans people have much more access to legal resources to retaliate against discrimination in the medical system, but addressing certain issues contributing to insufficient medical care remains a challenge.

There are also various behaviors by medical professionals that aren’t formally classified as discrimination by the federal government but yet contribute to the general lack of respect toward trans people.

Correcting the issue of discrimination is no small feat and will require proactive measures and widespread support. The first step is to promote access to medical care and implement proper training regimens in Medicaid services.

Necessities beyond nondiscrimination protections are evident in certain locations more than others. In Washington DC, research shows that trans people are much more likely to encounter problems when seeking health insurance, be HIV positive, misuse substances, and experience suicidal thoughts. Transgender sex workers in this area reported housing insecurity and criminalization to be the greatest contributors to their struggle with their health and well-being.

When we think of transgender health, it is easy to dwell on procedures such as sex reassignment surgery and hormone therapy. These are very limited understandings of what transgender health entails, as many trans individuals need care related to chronic conditions, disabilities, and mental health treatment. These are examples of medical care that most people take for granted, but it presents a much greater struggle for the transgender community.

There is a general lack of knowledge about transgender health issues and experiences, and professionals have to be thoroughly educated on these matters. Funding from state and federal governments would advance the medical sector’s ability to instate training programs that could hopefully become part of the standard education of medical professionals.

The following policies are interconnected and, when executed well, could lead to more inclusive health care facilities for transgender and gender-nonconforming individuals.

  • Increase funding for programs that advance transgender health care.
  • Implement LGBTQA+- inclusive administrative systems.
  • Promote affirming environments in health care settings.
  • Provide staff training
  • Develop policies that prevent violence against transgender people

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