For trans people, medical visits can be more traumatizing than healing
"Trans patients share their stories of subtle discrimination, outright hostility and ill-informed medical professionals
One trans woman recalled a doctor calling her “it.” A nonbinary person was grilled about their use of “they/them” pronouns during an ultrasound. A trans-masculine person moved out of Tennessee, fearing they would lose access to hormone therapy as legislators passed bills restricting gender-affirming care.
Transgender Americans often face subtle discrimination, outright hostility and ill-informed medical professionals in their interactions with the health-care system, according to a poll by The Washington Post and KFF, a nonprofit focused on national health issues.
Challenges arise during routine medical visits as well as when transgender people seek hormone therapy and other forms of gender-affirming care.
Nearly half (47 percent) of trans adults say the health-care providers they have come in contact with know “not too much” or “nothing at all” about providing health care to trans people. Just 10 percent say the health-care providers they have come in contact with know “a lot” about caring for trans people. About 4 in 10 (37 percent) trans adults say it is “somewhat” or “very” difficult to find a health-care provider who treats them with dignity and respect; while about a quarter (24 percent) of cisgender adults say the same. Just over half (53 percent) of trans adults say it is easy to find health care they can afford, less than the 63 percent of cisgender adults who say the same.
Activists say a welcoming health-care system would include affordable access to gender-affirming care from counseling to surgery. Good care also includes professionals treating transgender people with respect, using their preferred pronouns and not being quick to blame hormone treatment for unrelated medical problems.
About 3 in 10 trans adults say they have had to teach a doctor or other health-care provider about trans people so they could get appropriate care, had a doctor or other health-care provider refuse to acknowledge their preferred gender identity and instead refer to their sex assigned at birth, or been asked unnecessary or invasive questions about their gender identity unrelated to the medical reason for their visit. About 1 in 6 trans adults say they have had a doctor or other health-care provider refuse to provide them with gender-affirming care, such as hormone treatments.
The Post-KFF poll is the largest nongovernmental survey of U.S. trans adults to rely on random sampling methods. It builds on a body of research that has often demonstrated poor access to health care for transgender people but with limited data.
“LGBTQ+ people experience high levels of stigma and discrimination and victimization that persists across the lifetime, and this new work amplifies that,” said Lindsey Dawson, director of LGBTQ Health Policy at KFF.
“To have your gender affirmed and to be in an inclusive environment where you have to be quite vulnerable about gender identity can be quite meaningful,” Dawson said. “To have negative experiences might dissuade somebody from accessing health care in the future."
As Republican state lawmakers mobilize to restrict access to gender-affirming care for children — and in some cases, adults — the poll offers a reminder of the basic struggles transgender adults face in medical environments.
The poll finds trans people’s ease of access to health-care providers who treat them with dignity and respect is not significantly different in states that former president Donald Trump won compared with states President Biden won. The survey also finds that trans adults in urban areas are more likely to report having to educate health-care professionals (38 percent) than those in suburban/rural areas (23 percent) — challenging perceptions that more liberal areas are havens for tolerance and inclusivity.
In follow-up interviews, five transgender and nonbinary Americans who responded to the poll elaborated on their experiences:
Corey Brooks (they/them)
Even the name of the place Corey Brooks frequented for routine medical care — Magee-Womens Hospital — felt alienating.
Patients donned pink gowns. Cutouts of pink bras were plastered on the walls. A sign urged patients to “fight like a girl.”
“Things like that are just incredibly disorienting for someone going into those spaces who is always being reminded, hey, this wasn’t designed for you,” Brooks said. “You’re not really sure if you should disclose to these people that you’re trans or not.”
Brooks identifies as nonbinary and transgender, but as someone who was assigned female at birth, they share similar health needs as cisgender women for gynecologic care and screenings for chest health as they age.
Brooks was used to uncomfortable visits to the doctor, based on their college experiences when university health services staff peppered them with questions about birth control and sexual activity, assuming they were a cisgender heterosexual woman. They wrote their senior thesis on health access issues for transgender people and avoided the doctor for a few years after graduation.
The worst experience came while undergoing an ultrasound on their chest at the women’s hospital in Pittsburgh. The doctor paused and stared at Brooks’s medical file, spotting a note that they use they/them pronouns.
“What does that even mean?” Brooks recalled the doctor asking in a tone dripping with hostility rather than curiosity.
“As a trans person, that’s unfortunately not uncommon where you’re expected to provide all of this education for your providers,” Brooks said. “You wouldn’t expect a patient who is diagnosed with diabetes to have to educate their doctor on what diabetes is.”
Suzanne Rathburn (she/her)
70, Weed, Calif.
In the 1980s, a psychiatrist pushed his chair away from his desk and abruptly ended a meeting after Suzanne Rathburn explained she was trans. In 2012, a Veterans Affairs doctor referred to her as “it.”
In hundreds of medical visits over decades of navigating gender-affirming care and a rare genetic disease, Rathburn said she’s only had a few doctors she considers “good.”
As she began her transition in the 1980s after leaving the Air Force, Rathburn turned to the library to learn more about gender dysphoria and to find a therapist. She received a vaginoplasty. At the Oakland VA where she underwent hormone therapy, Rathburn said just one of the doctors treated her with respect, while others were dismissive of her medical needs or made negative comments about her gender identity — despite being in the LGBT-friendly San Francisco Bay Area.
Fed up after repeated indignities, Rathburn filed a discrimination complaint against another VA hospital that declined to perform a Pap test after several years of her requests. She said the VA eventually referred her to a doctor outside the system, and her complaint remained unresolved.
It wasn’t until she moved to rural Weed near the Oregon border in 2011 at age 59 that Rathburn experienced some of the best medical care of her life. A medical practice she visited near Medford, Ore., changed its intake forms when she pointed out gender questions were binary. A doctor in the nearby town of Mount Shasta, Calif., treated her trans identity as no big deal and spent time researching her genetic disease. Her therapist, also in Mount Shasta, specializes in supporting trans patients.
“I don’t have to explain it to her,” Rathburn said. “We talked about stuff I haven’t talked about with other therapists or to the psychiatrists I’ve had over 20 years.”
Hans Dirkmaat (they/he)
29, Longmont, Colo.
Hans Dirkmaat knew the nurse practitioner was ill-suited to care for transgender people when they had to explain what top surgery was.
During the primary-care visit, the provider marveled at why someone would want to remove their breasts. She asked, “When are you going to get a penis?”
Another medical professional in the room mouthed, “I’m sorry.”
Dirkmaat, who identifies as trans-masculine and nonbinary, didn’t have many choices for medical care that were in their insurance provider network when they lived in Nashville. They hoped the provider would have been more sensitive because she had mentioned having a lesbian daughter during their first appointment.
But tolerance for gay people does not mean a medical provider is attuned to the health-care needs of trans people. Transgender people weigh the risks and benefits of different aspects of gender-affirming medical care, and most have not received hormone therapy or transition-related surgeries.
Dirkmaat was wary of taking testosterone because of a heightened risk of cardiovascular complications. Their mother had died of heart disease at 41.
But that same nurse practitioner declined to prescribe medication to treat their high cholesterol because it could create pregnancy complications. The fact that Dirkmaat is married to a cisgender woman and has no plans to have children did not sway the provider. She said she would only authorize the pills if Dirkmaat were to undergo testosterone treatment.
“It’s very frustrating,” Dirkmaat said. “Like I can’t make decisions for me.”
The climate for transgender people in Nashville was starting to feel more unsafe, they said. The clinic specializing in transgender care where they received chest masculinization surgery became a magnet for right-wing protests, forcing the clinic to close on some days to protect patients. They drew more disgusted looks on the streets.
Tennessee GOP lawmakers joined the vanguard of a national movement to restrict care for transgender people, passing legislation to ban gender-affirming care for minors. Activists fear care for adults is next, noting legislation introduced to prohibit the state Medicaid program from working with insurers that cover gender-affirming care.
As Dirkmaat weighed whether to take hormones, they feared such therapy could be banned next.
So they moved to a suburb of Boulder, Colo., where a doctor who specializes in hormone therapy and its effects on the cardiovascular system is just an hour drive away.
Ezekiel Scott (he/they)
31, Columbus, Ohio
When Ezekiel Scott left Minnesota to attend college in Ohio last year, he brought six months’ worth of hormone medication just in case he ran into trouble resuming care. It wasn’t enough.
Administrators at Ohio State University assured Scott, who identifies as transgender and nonbinary, that hormone therapy would be covered under student health insurance. But first he needed to reestablish care with a doctor — and that proved to be a challenge.
He didn’t want to go to just any doctor, but one familiar with treating transgender patients. He had had negative experiences with doctors who were quick to blame the hormone therapy for mundane medical conditions, including one whosuggested ending it to address a rash on his arm.
“That’s the first thing we’re going to try? Not like, I don’t know, a skin cream?” Scott said.
The hormones were essential to feeling comfortable in his own skin and affirming his gender identity, but the treatment was cast as cosmetic and unnecessary. “It’s like being told to stop having your own face,” he said.
It took four months to get an appointment at a university health clinic. After obtaining authorization to receive testosterone, a national shortage of the intramuscular injections further delayed his access to treatment as he exhausted his previous supply.
For several months, he had to ration weekly hormone injections that helped him develop facial hair and a deeper voice in line with his gender identity. And because he had had his ovaries removed, the absence of natural hormones risked his heart health.
His depression and anxiety grew worse, and he experienced suicidal ideations. Medication management for ADHD, once balanced with the hormone therapy, became complicated. He experienced hot flashes, an apparent result of early menopause caused by hormones not coming in properly.
Months later, he found a walk-in clinic recommended by a nonbinary friend. He got hormones that same day, eight months after he moved. His mental health improved, he could focus in school again, and the hot flashes ended.
“All of it is back in balance,” Scott said.
Richael Faithful (they/them)
37, Washington, D.C.
Richael Faithful is no stranger to cringeworthy moments during visits to the doctor.
Staff at some offices would misgender them. The first dermatologist they saw appeared nervous and avoided eye contact after Faithful disclosed being trans. One lung specialist they saw for breathing issues who seemed well-meaning shared a story about knowing “a transgender.”
“Once folks have bad experiences, it’s really hard to trust the health-care system again,” said Faithful, a D.C. resident who identifies as nonbinary and trans-masculine. “But I do want other trans folks and other cis folks to know there are good providers out there providing high-quality care.”
Faithful does not identify as a woman but is not transitioning to be a man either. For them, gender-affirming care means presenting more masculine to the world.
Faithful considers themselves part of the top 1 percent in being able to access gender-affirming care because they have the financial means and emotional support network to do so.
Faithful sought hormone therapy through a nurse practitioner at a medical concierge service with a reputation for being trans friendly and where membership costs $300 a year. They pay $265 every month and a half for hormones. They were able to travel with their partner to Florida for two weeks to undergo chest reconstruction surgery from a well-known plastic surgeon who does not accept health insurance and charges $15,000, paid in advance.
The staff at another dermatology practice where Faithful received acne treatment used the correct pronouns and showed a nuanced understanding of the relationship between hormone treatment and acne.
Faithful said they could afford these services as a consultant for social justice organizations who receives health insurance through their partner’s plan — while other Black transgender people living in the poorest parts of the city struggle to access basic gender-affirming care.
“My stress level is just kind of lower because I notice I’m not navigating even seemingly small things that just are distracting or annoying when they continue to happen,” Faithful said.
Scott Clement and Emily Guskin contributed to this report."
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