The Evolution of Transgender Health Care

March 31 is globally recognized as Transgender Day of Visibility. In the US alone, it is estimated that over 1.6 million youth and adults identify as transgender.¹ This day offers the opportunity to not only educate oneself on the history of the transgender community but also reflect on the unmet needs and ongoing discrimination this population faces. As part of this reflection, part 1 of a 3-part monthly series on LGBTQ+ health care will dive into the history, evolution, and current state of transgender health care while paying mind to the influential policies that have affected the scope of available services in the US.

Clinician Holding Transgender Pride Pin | image credit: Jo Panuwat D - stock.adobe.com

The first clinic for gender-affirming surgery (GAS) in the US, the Gender Identity Clinic (GIC), was opened by Johns Hopkins Hospital in 1966.² After 13 years, however, Johns Hopkins Hospital banned GAS and closed the GIC in response to a study out of Johns Hopkins.³ This report suggested that gender reassignment procedures did not provide substantial psychosocial benefits to those who received it and that these individuals were not better off in this regard compared with those who went without the procedure.

While there is documented speculation on whether this decision was purely evidence-based or was motivated by bias, the surge of academic interest in transgender care during this period led to the establishment of the Harry Benjamin International Gender Dysphoria Association, known today as the World Professional Association for Transgender Health (WPATH).² Amid a decline in mainstream approval of transgender health care topics, WPATH developed the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People.

In 1980, the American Psychiatric Association added “gender identity disorder” to the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-3). Categorizing transgender people as having a “disorder” may appear like a step back; however, as Farah Naz Kahn, MD, posits, “this controversial move actually helped transgender individuals gain access to an often impenetrable healthcare system.”³

The language classifying the transgender identity as “disordered” continued until 2013, when it was renamed “gender dysphoria” in the DSM-5.³ The new classification went a long way to combat stigma associated with this diagnosis. Further progress was achieved in 2014 as a government appeal board mandated that Medicare include gender transition procedures in its coverage. This ruling was supported by available research in the updated WPATH that indicated the associative benefits of these surgeries and that sex reassignment was no longer experimental.

In 2016, President Barack Obama ended long-standing military policy that barred transgender troops from serving openly.⁴ This policy change was another step forward for the transgender community, as previous policy was established according to outdated, discriminatory medical information. Previously, transgender individuals could be dismissed from service regardless of their abilities and without proper medical reviews. Prior to the ban lift, transgender troops were barred from expressing their gender identities because a gender dysphoria diagnosis was understood to be “a state of emotional distress caused by how someone’s body or the gender they were assigned at birth conflicts with their gender identity,” that “may interfere with someone’s ability to serve since it can lead to severe depression and anxiety.”⁴ Over the next year as this policy was phased in, transgender troops were given access to essential gender-affirming health care—such as hormone replacement therapy—that would not impact their ability to serve.

On April 12, 2019, this policy was overturned during the Trump administration.⁵ While service members who had a gender dysphoria diagnosis prior to this reversal could continue serving in accordance with their preferred gender, those diagnosed after that date had to serve in alignment with the gender and sex they were assigned at birth. Those yet to enlist who had a gender dysphoria diagnosis were no longer allowed to enroll in military service or academies. While officials contended this policy reinstatement was not discriminatory or “a ban on transgender persons,” it put an end to “presumptive accommodations” for transgender service members—such as the availability of gender-affirming health care, which President Donald Trump said added a tremendous financial burden on the military.^{6, 7} For context, in 2017, the first year of Trump’s presidency, the Department of Defense’s annual cost for care related to gender transitions was less than 0.1% of the annual health care budget.⁸

President Joe Biden used an executive order to reverse the Trump-era Pentagon policy in 2021.⁷ With this order, necessary health care was made available once again to transgender service members and discriminatory measures were erased. This back-and-forth over the last decade demonstrates the fragility of health care policy and how transgender rights can still easily be given or erased.

In an email interview with The American Journal of Managed Care (AJMC), Samantha Rosenthal, PhD, of Roanoke College, spoke to misconceptions about the health care needs of transgender and gender-diverse patients. “One of the biggest misconceptions about trans medicine is that treating trans patients is only about gender-affirming procedures such as hormonal or surgical treatments. But trans medicine actually needs to be threaded throughout medical school curricula and across many branches of clinical practice, from primary care to urology, endocrinology, gynecology, and beyond,” she wrote. “Every time a trans patient interacts with a medical professional is an opportunity for patient autonomy and agency in explaining how our bodies work and advocating for our healthcare needs. It is crucial to recognize that trans patients understand our own bodies in ways that make us co-experts in trans medicine.”

Discussing the evolution of transgender health care in the US is a much larger conversation than the policies that impact gender-affirming care. Health care in this community is also heavily influenced by lacking education on, respect for, and attention given to transgender patients, their access to care, and health disparities that are exacerbated by discrimination and stigma.

These issues have been continually represented in the Behavioral Risk Factor Surveillance System, a health survey on behavioral risk factors that highlighted the mental and physical health disparities experienced by transgender respondents. Results from the 2019 iteration of the survey revealed that transgender individuals were more than twice as likely to have a depressive disorder or experience a poor mental health day compared with their cisgender counterparts.⁹

Additionally, the Center for American Progress conducted a nationwide survey in 2020 on the experiences of LGBTQ+ people and found that over 60% of transgender individuals reported experiencing discrimination in the last year.⁹ The Center for American Progress also reported TransPop data indicating that 90% of transgender individuals felt they were treated with less respect or courtesy in various spaces. These data were not specific to health care settings; however, Medina et al detail how the stress stemming from discriminatory experiences can increase someone’s likelihood of developing posttraumatic stress disorder, anxiety, depression, and other forms of psychological distress—which can increase the likelihood of self-injuring, suicidal attempts, and substance abuse.

“Discrimination also affects the ability to access services,” they wrote, “as TransPop data show that 61 percent of transgender respondents report having a personal doctor or health care provider, compared with 76 percent of cisgender heterosexual respondents. Transgender individuals are less likely to have access to reproductive health services, and 37 percent have to travel more than 10 miles in order to receive routine health care.”⁹

Visiting the doctor’s office can be a stressful experience of its own. Among other surveys, 2 in 3 transgender adults reported concerns about bias in clinical treatment they receive and that their gender identity or sexual orientation could impact their care.⁹ Furthermore, 33% of transgender respondents reported needing to teach their clinician about transgender people to get adequate care and 15% confirmed they’d been asked “invasive or unnecessary questions about being transgender” that were unrelated to their visit.⁹

Access to care and the willingness to seek it out are tremendous issues in the scope of transgender health care. Added stressors from either one’s experiences with clinicians or the scarcity of necessary services carry bigger implications for the overall health of a transgender patient. The disproportionate mental and physical impacts felt by the transgender community demonstrate the dire need for more adequate and accessible care.

Mandi Pratt-Chapman, PhD, clinical researcher, GW Cancer Center, sat for an interview with AJMC to explore these issues further. In her discussion, she shares her perspectives on the misconceptions affecting adequate, accessible health care for transgender patients and what she sees as the most pressing need to address in this community, and explores the potential for policy-level changes to benefit transgender patient care and experiences in clinical settings.

Pratt-Chapman shared a story about a colleague who identifies as a member of the LGBTQ+ community. As a clinician, he has felt people assume he has a degree of expertise regarding servicing transgender patients but, in fact, he admitted the opposite. His status as a member of the LGBTQ+ community did not automatically qualify him to provide adequate treatment to transgender patients. This sparked a conversation with Pratt-Chapman, echoing Rosenthal’s thoughts, about lacking education and training on the unique needs of the transgender community. However, as Pratt-Chapman said, each patient comes from a unique background with their own experiences and needs.

Therefore, although the implementation of policies to mandate or encourage education centered around transgender patients could be a positive step, there is no one-size-fits-all curriculum to sufficiently prepare health care providers in this regard. To fill in these gaps, Pratt-Chapman advocated that clinicians dedicate themselves to lifelong learning without fear of confronting something or someone they do not fully understand. She said relying on curriculum to paint the picture of a “mythical patient” could have drawbacks that distract from one’s ability to truly focus on the needs of the body in front of them.

While medicine has made significant advances in patient care over the years, many transgender patients have lost trust in the health care system. It has been only 10 years since transgender identities were declassified as “disordered” and it may be difficult to believe in the care they are receiving when they still find themselves teaching clinicians about their bodies and their needs, and encounter hostility or are turned away by providers they rely on.

Medina et al write: “Supporting transgender people through the medical system can only be achieved with the trust of transgender patients. This trust has been violated repeatedly, violently, and fatally—from the long-standing classification of transgender identity as a mental disorder to the psychologically abusive use of pseudoscientific conversion therapy to the historical and continued failure of public health responses to the HIV epidemic. Medical systems must earn transgender people’s trust if they hope to effectively address health disparities.”⁹

System-wide policy changes could go a long way in counteracting the negative perceptions and lived experiences of transgender patients navigating health care. As Pratt-Chapman highlights, the creation of welcoming spaces that place anti-discriminatory policies at the forefront, the promotion of diverse leadership and clinicians, and the amplification of voices that promote evidence-based medicine to influence legislation are crucial for improving the current state of health care for transgender patients.

References

1. How many adults and youth identify as transgender in the United States? Williams Institute. June 2022. Accessed March 19, 2024. https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/

2. Magrath WJ. The fall of the nation’s first gender-affirming surgery clinic. Ann Intern Med. 2022;175(12):1462-1467. doi:10.7326/M22-1480

3. Khan FN. A history of transgender health care. Scientific American. November 16, 2016. Accessed March 15, 2024. https://www.scientificamerican.com/blog/guest-blog/a-history-of-transgender-health-care

4. Obama administration ends US military’s ban on transgender troops. Vox. June 20, 2016. Accessed March 22, 2024. https://www.vox.com/2016/6/30/12070746/transgender-military-ban

5. Year after trans military ban, legal battle rages on. NBC News. April 11, 2020. Accessed March 22, 2024. https://www.nbcnews.com/feature/nbc-out/year-after-trans-military-ban-legal-battle-rages-n1181906

6. De Luce D, Pettypiece S. Biden admin scraps Trump’s restrictions on transgender troops. NBC News. March 31, 2021. Access March 22, 2024. https://www.nbcnews.com/news/military/biden-admin-scraps-trump-s-restrictions-transgender-troops-n1262646

7. @realDonaldTrump. ....victory and cannot be burdened with the tremendous medical costs and disruption that transgender in the military would entail. Thank you. July 26, 2017. Accessed March 28, 2024. twitter.com/realDonaldTrump/status/890197095151546369?s=20

8. Dietert M, Dentice D. Transgender military experiences: from Obama to Trump. J Homosex. 2023;70(6):993-1010. doi:10.1080/00918369.2021.2012866

9. Medina C, Santos T, Wahowald L, Gruberg S. Protecting and advancing health care for transgender adult communities. American Progress. August 18, 2021. Accessed March 15, 2021. https://www.americanprogress.org/article/protecting-advancing-health-care-transgender-adult-communities/