Over the weekend, the White House announced that it intends to roll back an Obama-era rule prohibiting gender-based discrimination in health care—covering not just individual health providers, but also most hospitals and insurance companies. This is just one of a number of recent moves indicating the Trump administration’s hostility to the transgender community, including plans to allow so-called religious or moral objections to dictate access to care and the fight to keep transgender people out of the military. And like the others, it could have grave consequences for trans people like me around the country.
Section 1557 of the Affordable Care Act offered civil rights protections to health-care consumers in marginalized groups. Under the final rule to implement Section 1557 in 2016, the government interpreted these protections as applying to transgender people, barring discrimination on the basis of gender identity as well as nonconformity to gender stereotypes.
That means, in theory, that a transgender patient arriving in the emergency room with a broken leg should receive prompt, courteous, and professional treatment that adheres to the standard of care. It means that an insurance company cannot deny a treatment or therapy to a transgender person if it cannot show how it would deny the same therapy to a cisgender person—thus, for example, trans people who need hormones to correct an endocrine imbalance should be entitled to them. It means that a doctor approached by a trans patient for a referral to a gender clinic should provide one. It means, in short, that trans people should be able to access health care just like cis people.
And yet, this isn’t always the case. Even with the rule in place, transgender people, especially women, are embroiled in legal fights with insurers to access transition care, while health–care refusal endangers the safety of trans patients. Still, Section 1557 did establish an enforceable framework to protect trans patients—one that was, and is, sorely necessary.
A 2010 study by the National Center for Transgender Equality (NCTE) and the National Gay and Lesbian Taskforce found 19 percent of trans or gender non-conforming respondents experienced denial of care. A more recent NCTE study found that nearly one-quarter of respondents deliberately delayed care due to concerns about discrimination, and with good reason—one-third had “at least one negative experience related to being transgender” in a medical setting. These issues were especially pronounced for Black, Latinx, and Native people.
Access to health care should be a given human right for everyone, but for the trans community, it can be an especially fraught topic. Transgender people face health–care disparities like greater risks of mental health conditions, cancer, HIV infection, and stigma-associated self-medication with alcohol and other drugs. The racism experienced by people of color in the United States that contributes to unequal health care outcomes can be amplified for transgender people of color. Meanwhile, trans people are four times as likely to be poor, overall, as cis people, which can exacerbate health-care disparities and make it harder to obtain treatment.
The news that the Trump administration is sniffing around for ways to dismantle the rule designed to help address those disparities isn’t surprising. The Department of Health and Human Services (HHS) is using the outcome of a lawsuit filed in Texas by a team of conservative Christian entities to take the tack that the entire rule should be thrown out. District Judge Reed O’Conner issued an injunction against the gender-specific component of the rule, and the agency suggests this should be grounds to modify it.
The Christian right in the United States is fond of inserting itself into the lives of others via policy like this, often while claiming it’s necessary to “defend religious freedom.” This regulatory shift is necessary, the right argues, to allow care providers to refrain from participating in activities they do not agree with. On the extreme end of the spectrum, there’s even an ongoing myth that doctors and nurses would be forced to perform gender confirmation surgeries. But some religious impositionists resent providing any kind of health care to trans people.
Care providers who do not want to provide health care should perhaps not go into the health-care field, but it bears noting that trans-specific health care—including gender confirmation surgeries and hormone therapy—is usually offered by doctors who specialize in such care. They electively pursue additional training and work to create inclusive practices for trans patients; trans women are not typically chasing down plastic surgeons and compelling them to perform vaginoplasties. Gender clinics, meanwhile, strive to hire inclusively for their nursing, support staff, and other personnel, because no patient wants to receive gender-affirming care from someone who doesn’t want to be there.
But trans health-care needs go beyond transition services—something not all members of the trans community are even interested in accessing. Trans people can have bronchitis, chronic illnesses, depression, and dental problems, just like cis people. Yet they’ve been denied insurance coverage for blood work, or forced to get pelvic exams in order to receive treatment for sore throats. According to the Center for American Progress, the resolved by the HHS prior to the injunction involved care that wasn’t related to transition services. Imagine going to the doctor for stitches and being told no one will treat you because of your gender.
Bluntly, transgender people are dying preventable deaths now due to health-care discrimination. The community lives with the legacy of the death of Tyra Hunter, a Black trans woman who died in 1995 after emergency responders mocked her body and refused to continue care at the scene of an accident. In 2012, another trans woman, Shaun Smith, died when EMS allegedly denied care for her diabetes. Pursuing rollbacks of civil rights protections and actively affirming the “right to discriminate” is an indicator that the administration is making war on the trans community. Impositionists don’t just want to defend their right to bigotry: They knowingly want to erase the communities they dislike by way of refusing to extend equal access to health care.
As a white trans person accessing health care in the Bay Area, a region that includes a wide spectrum of diverse and inclusive health care, I’m extremely privileged. I’m among the extremely small minority of people who hasn’t experienced harassment, denial of care, or abuse because of my gender. My pronouns are listed on the front of my chart so that when I walk into any of my provider’s network of hospitals, the admitting nurse knows how to address me. My insurance company has never discriminated against me, and in fact, sent out notices to trans patients to inform us that they intended to maintain their existing gender-inclusive coverage regardless of changes on the federal level. My coverage-related disputes have had nothing to do with my gender, which is as it should be.
But these are issues I think about when I travel, and when I interact with trans people in regions of the country where insurance companies, hospitals, and doctors are not so supportive of trans patients. I think about them when I interact with people who lack the financial and racial privilege to make broad health-care choices, like refusing to seek treatment at a facility where they know they will be misgendered and harassed, or switching primary care providers to access someone explicitly identified as trans-inclusive. I think about them when I see trans people crowdfunding not just for transition care, but also for basic medical needs. What if I lose my insurance coverage? What will happen to me if I need emergency care in a conservative area of the country, including the rural hospital in the Northern California community where I spend much of my time? What will happen to my trans siblings across the country as their access to health care crumbles?
Jeopardizing access to health care is one of many ways that the Trump administration hopes to push the trans community not just out of public life, but out of existence altogether. Rulemaking like this slowly moves the bar, opening up the opportunity for future discrimination in turn. What will impositionists decide they can’t, in “good conscience,” do next?