It’s Not ‘All Psychological’: How the Medical Establishment Fails Transgender Patients

While medical protections for transgender patients may be gradually increasing, many in the trans* community continue to experience disturbing levels of discrimination from health-care providers.

Despite the gender-identity nondiscrimination provision of the Affordable Care Act, doctors say some insurance companies are rejecting coverage of basic preventive care. health care - Stethoscope via Shutterstock

Seeking health care when you’re sick or injured can sometimes be a confusing, nerve-racking, or frustrating experience. Patients, already in a compromised position, may not know how best to advocate for themselves or what rights they have. But for transgender and gender nonconforming people, just going to the doctor means risking mistreatment, misdiagnosis, hostility, or aggression.

A number of professional medical organizations, including the American Medical Association and the American Psychiatric Association, have drafted resolutions in recent years affirming equal treatment for trans* and gender variant individuals. And according to M. Dru Levasseur, transgender rights project director at Lambda Legal, 17 states and more than 150 jurisdictions now have protections regarding gender identity. “These are all great steps,” Levasseur told Rewire. “But one of the things we still hear is that, when people are at their most vulnerable moment of need, like going to the hospital for emergency care, horrible things still happen.”

Indeed, while medical protections for transgender patients may be gradually increasing, many in the trans* community continue to experience disturbing levels of discrimination from health-care providers.

“Every once in a while I get really anxious about what would happen if I had a major accident and had to go to the emergency room,” Kara Baker, a researcher in plant pathology, told Rewire. “I constantly worry about upcoming appointments with doctors or clinics I don’t know.” Baker, who identifies as genderqueer and prefers the pronouns “they/their,” says most of their negative experiences with medical care have been relatively minor, like a doctor or nurse using non-preferred pronouns. But those interactions still cause uncertainty, anxiety, and self-blame.

That anxiety can lead some transgender people to avoid seeking medical care when they need it. According to a 2011 survey of over 6,000 trans* Americans, a third of respondents had put off or avoided seeking preventative care, and 28 percent had avoided seeking necessary care. Patients may be flat-out denied treatment, and not just for transgender-related health needs—8 percent of people surveyed as part of a 2009 survey were refused emergency care, with another 8 percent denied necessary surgery. In the same survey, a staggering 70 percent of trans* patients had experienced abusive language, physical abuse, blame for their health status from health-care providers, or providers refusing to touch them.

For MJ, who sought medical treatment for recurring physical symptoms, including trembling, blackouts, fatigue, and migraines, trying to get care felt overwhelming and silencing. After blood work and an EEG failed to lead to a diagnosis, MJ’s doctor began to focus on the patient’s mental health. “When I disclosed that I was a recent rape survivor, that was all he needed to be convinced it was all psychological,” MJ said. “He then referred me to a therapist.”

MJ wanted to see another doctor for a second opinion, but he was a student relying on campus health services. “I wish I had a kick-ass story about how I put my women’s and gender studies to use [and] just went off on him for being so quick to tell me my health issues were ‘all in my head,’ but I did not say anything,” said MJ. “I was scared; it was my personal health and I was so overwhelmed at the point that I was willing to do anything he told me if there was a chance it would make me better.”

So MJ went to the therapist the doctor recommended. At the time, he identified as queer, but was not yet openly trans*. He talked with the therapist about feeling isolated due to his politics, sexual orientation, and learning disability. “She seemed fascinated with the fact that I entered my first relationship with a female after I was raped with by a man,” MJ said, adding that he felt the therapist was implying that his sexuality was some sort of coping mechanism. “It was only with my queer sexuality in question that I opened up about being trans*.”

After that, things with the therapist got worse. Even though MJ wasn’t out as trans* at the time, he told the therapist that his close friends weren’t using his birth name and pronouns. “The therapist then asked me if I was sure that I was actually trans* or if I was just so used to being an outcast that I did not know how to function when I actually fit in for a change,” said MJ. “At this point I stopped going to therapy altogether.”

Levasseur says MJ’s experience is not uncommon for trans* and queer patients. “That kind of pathologizing is rampant,” Levasseur said. “Being told that there’s something wrong with you mentally is something trans* people face on a daily basis.” Although there are internationally recognized standards of care, he says, many licensed therapists are not trained in how to properly treat trans* patients.

This problem is even more urgent, Levasseur emphasizes, because of the increased risk of suicide for trans* people. More than 40 percent of trans* individuals in the United States have reported attempting suicide, compared to about 1 percent of the country’s population at large.

“When we’re talking about a therapist getting it wrong, the threat is very real,” said Levasseur. “You’re in the hospital because you need help. You are in a very vulnerable position.”

“I have never been to talk to a doctor or therapist about being trans*,” Jamison Bradshaw told Rewire. While Bradshaw admits that this is partially due to being busy and feeling generally positive about how things are going, it’s also “in very large part because I’m scared that they would tell me it’s all in my head, try to convince me that I should just keep working at being more feminine, or that it’s clearly because there’s some underlying problem with my brain that needs to be ‘fixed.’”

At the same time, Bradshaw knows that there are doctors who really can provide support for the trans* community. “There are supportive and understanding ones out there, and ones that have gone through similar things themselves.”

As a trans* medical student, Bradshaw has some experience working on inclusive policies at his school, like changing intake forms so patients can state their gender and preferred name and pronouns. “While it did take some thought, it didn’t take that much time and was overall a pretty smooth process,” said Bradshaw.

Many medical providers are interested in improving their policies to better treat trans* patients, says Levasseur, but don’t always know how to do so. That’s why Lambda Legal, along with the New York City Bar Association’s LGBT Rights Committee, authored a guide to facilitate providers’ implementation of gender supports and protections. Creating Equal Access to Quality Health Care for Transgender Patients: Transgender-Affirming Hospital Policies outlines specific practices for treating trans* and gender nonconforming patients. Like Bradshaw, the document emphasizes the need for more inclusive admitting procedures.

“I don’t know what to do half the time!” said Baker, of filling in the “gender/sex” portion of medical forms. “I am an assigned male at birth, genderqueer-identified, trans* femme. Basically I could put anything on that selection, and I would technically be right in my head. But what info does the medical personnel need to adequately treat me?”

Making forms more inclusive will also make them more accurate. Restrooms, room assignments, privacy laws, patients’ rights, and protocols for general interaction with patients are all covered in the document, which Levasseur hopes is an important step toward addressing the pervasive discrimination and mistreatment of trans* people seeking health care.

Alongside specific policy changes, Bradshaw hopes to see an increased “cultural competency” with how health-care professionals talk about, and talk with, queer and trans* communities. “Hearing things from other medical students and doctors, the problem isn’t that they’re discriminatory, it’s that they are uneducated about that population and the correct way to talk about LGBTQ health issues,” Bradshaw said.

For MJ, the negative experience from two years ago is still with him. “I am still very distrusting of doctors and have the tendency to self-medicate when possible,” he said. After college, he started therapy, and is planning on starting hormones soon. “I’m privileged enough to live in an area where I have access to a nonprofit clinic that specializes in LGBT care,” he said. “I feel much more comfortable there.”