Homophobia and Health Disparities for the Transgender Community

Author: Lily Davis

Despite great strides for lesbian, gay, bisexual, and transgender (LGBT) individuals, homophobia continues to limit the rights and resources of this community. One of the most significant areas in which this community lacks resources is that of the health care system. LGBT persons face many barriers to health care due to financial issues and socioeconomic status, stigma and discrimination, and most significantly, a lack of sufficiently educated physicians (Safer, et al., 2016). Trans individuals often face difficulties regardless of the types of care they are seeking, such as; preventative medicine, routine and emergency care, or transgender-related services. Lack of access to health care is contributing to overall poorer health for trans individuals.

            Overall, transgender individuals face many health disparities as compared to their heterosexual counterparts. In 2010, a national transgender discrimination survey on health and health care found that respondents reported much higher rates of HIV, drug and alcohol abuse and suicide attempts (Grant, et al, 2010). For example, respondents reported over four times the national average of HIV infection; 2.6% of the sample compared to 0.6% in the general population. The rates of HIV were even higher for transgender women, those who were unemployed, and those who had engaged in sex work (Grant, et al., 2010). Additionally, more than ¼ of the sample misused drugs or alcohol specifically to cope with discrimination they faced because of their gender identity or expression. Even more surprising, 41% reported attempting suicide compared to 1.6% of the general population. The risk of attempted suicide was even greater for those who were unemployed, low-income, or had experienced sexual and physical assault (Grant, et al., 2010). Similarly, a US sample of transgender individuals demonstrated a high prevalence of clinical depression, anxiety, and somatization (Lombardi, 2011). These health disparities are likely due, at least in part, to a combination of discrimination and poor access to health care.

Graffiti seen in Athens, Greece showing support for trans prisoners, possibly providing insight into the views of Greek citizens towards the LGBT community.

One barrier to health care reported by the trans population is financial constraints. Socioeconomic status and finances often hinder access to health care for many disadvantaged groups and has many negative health effects. Those in poverty often struggle to see general health practitioners due to financial barriers, thus they only seek care in times of medical emergency and further hinder their health and wellbeing, especially long term. Trans persons also face similar issues of financial barriers. For example, 48% of a sample of trans individuals reported postponing medical care when sick or injured due to an inability to afford it (Grant, et al. 2010). Not only do trans individuals require routine medical care like the general population, this group also requires unique medical attention such as hormone treatments or HIV care, making affordability and access even more important. Similarly, this population often struggles to gain access to health insurance, primarily due to financial strain. As previously mentioned, this population experiences disproportionally high rates of mental health issues, which can contribute to the ability to maintain employment for extended periods of time. Discrimination and stigma also often prevent transgender men and women from stable employment, making health insurance difficult to maintain. My family member, Eliot, shared their experiences with health insurance as a transgender male. In order to gain better access to trans services, Eliot left Missouri for Washington state. When Eliot turned 26, they were left without health insurance and was unemployed at the time, but due to government assistance was able to easily gain access to health insurance through the state. Issues arose again when Eliot became employed and was no longer living under the poverty line of Washington and was required to pay a monthly amount for health insurance that they could not afford, causing them to lose health insurance again. But, again, government assistance in Washington allowed them to regain access to health insurance by covering a portion of the costs. While Eliot faced and continues to face financial barriers to both insurance and medical treatments, the programs of Washington state have allowed them to gain greater access to insurance and care, which is not always the case for this population.

A second major barrier to health care for this population is stigma or discrimination. The National Transgender Discrimination Survey reported that 19% of respondents had been denied services altogether by doctors and other providers (Grant, et al., 2010). This survey depicts the lived experiences of many transgender individual in the United States, especially more conservative states, such as Missouri.

         (Grant et al., 2010)

My family member, Eliot, has also faced discrimination as a barrier to medical treatment. When Eliot first sought hormone treatments from a doctor, they were told that they were required to be in therapy with a gender dysphoria diagnosis for two years before they could be approved to being hormone treatments. Gender dysphoria is a condition of feeling one’s emotional and psychological identity as male or female to be opposite of one’s biological sex. Health insurance companies will also deny hormone treatments to individuals who have not been in therapy, with a diagnosis, for two years. At the time, Eliot had already been living with gender dysphoria for over two years but had not received an actual diagnosis from a doctor, thus would have to wait another two years, which was not an option for them due to growing discomfort and declining mental health. These requirements are extremely discriminatory and harmful to the transgender community, as they invalidate their identities and prevent them from gaining access to a necessary medical treatment.

Similarly, trans individuals often struggle to receive proper treatment for HIV due to discrimination and bias from health care providers, this is especially true in countries outside of the US that are not as open and accepting of the transgender community. Millie Milton, a transgender woman living in Guyana, where laws prohibit LGBT people from outwardly being who they are, is HIV positive and struggles daily to receive proper treatment for her illness (CNN Wire, 2018). Milton has struggled with abuse in the workplace, violence and hate crimes on the street, and discrimination on public transportation. In order to receive antiretroviral drugs for her HIV, Milton is forced to travel to a clinic farther from her home to avoid further discrimination. No longer able to use public transportation and too afraid to walk, Milton is forced to take a taxi, which is a large expense. Due to these things, Milton faces many obstacles when it comes to getting treatment for her HIV. This is not only true for Milton, but for many other transgender individuals world wide, and the more obstacles there are, the more likely it is that people will stop taking their treatment altogether (CNN Wire, 2018). Studies have shown that continuously taking antiretroviral drugs can reduce HIV to undetectable levels, but homophobia often blocks many LGBT individuals from accessing services that provide this treatment (CNN Wire, 2018). Thus, homophobia is a likely component in fueling the HIV epidemic, which is not only an issue for the LGBT community but for the global community.

Implicit biases are attitudes and stereotypes that affect our understanding, actions, and decisions in an unconscious manner. These implicit biases are likely to play a significant role when it comes to discrimination of transgender individuals in the medical setting. Doctors may have negative feelings and connotations associated with this group of individuals due to a lack of education and understanding towards their experiences, as well as overall societal views towards this population. The Stereotype Content Model suggests that when people see another group of individuals as having low competence and low warmth, then they will feel disgust towards this group (Fiske, 2015). Thus, due to societal structures and beliefs about the transgender community, doctors may see these individuals as having low competence due to their lack of ability to maintain employment or health insurance, despite many outside factors against them. Additionally, societal views towards the transgender community are often negative, which may also lead doctors to have negative feelings towards these individuals as well. A combination of feelings of low competence and warmth can lead doctors to feel disgust towards transgender individuals and thus, refuse to provide care.

Artwork seen in a restaurant in Budapest, Hungary, showing the various levels of comfortability and acceptance of transgender images and cross dressing in different cultures.

Not only do discrimination and bias prevent trans individuals from accessing health care, they also often lack proper treatment when they do gain access. Safer, et al., 2016, identifies a lack of sufficiently knowledgeable health care providers in trans needs as the biggest barrier to proper health care for this community. Transgender treatment is currently not part of conventional medical curricula, thus very few doctors have adequate requisite knowledge and comfort levels when it comes to transgender specific medical care (Safer, et al. 2016). Due to lack of traditional education, doctors must seek outside resources themselves if they wish to provide care for this population. Lack of education can lead to negative, and even dangerous, outcomes for transgender patients. Eliot also experienced this barrier to their personal healthcare, and suffered the consequences of a poorly educated physician. In recent months, the nurse practitioner that had been supervising Eliot’s care left the clinic and was replaced by a new nurse practitioner. This nurse saw that Eliot’s testosterone levels were high (as compared to the average levels for trans men) and immediately reduced their dosage and frequency of injections from every two weeks to every three weeks. Trusting the medical professional, Eliot complied but eventually began having issues with their mood and other health concerns, which lead to them missing work and valuable income needed to pay for their insurance and other medical costs. Although this practitioner was attempting to provide the right treatment, they actually made things worse due to lack of knowledge because they were unaware that testosterone is completely processed by the body within two weeks, thus Eliot was spending one week without medication. Eventually, Eliot was able to get back to a correct dosage and frequency but had to live with inconsistency for six months before this happened. If the nurse had been more educated and knowledgeable about trans care, then Eliot would not have experienced any of these issues.

The three most commonly noted barriers to health care for transgender individuals are financial barriers, discrimination, and lack of knowledgeable health care providers. All three of these barriers have been a lived, and common, experience for my family member, showing not only the prevalence of the issue, but also that no trans individual is immune from these barriers, regardless of being considered a more privileged trans person.

References

CNN Wire. (2018, July 29). Growing homophobia will fuel the HIV epidemic, experts fear. CNN. Retrieved from http://www.kmov.com/story/38758780/growing-homophobia-will-fuel-the-hiv-epidemic-experts-fear

Fiske, S.T. (2015). Intergroup biases: a focus on stereotype content. Current Opinion in Behavioral Sciences, 3, 45-50. doi:10.1016/j.cobeha.2015.01.010

Grant, J.M., Mottet, L.A., Tanis, J., Herman, J.L., Harrison, J., & Keisling, M. (2010). National transgender discrimination survey report on health and health care. National Center for Transgender Equality and the National Gay and Lesbian Task Force. Retrieved from https://cancer-network.org/wp-content/uploads/2017/02/National_Transgender_Discrimination_Survey_Report_on_health_and_health_care.pdf

Lombardi, E. (2010). Transgender Health: A Review and Guidance for Future Research—Proceedings from the Summer Institute at the Center for Research on Health and Sexual Orientation, University of Pittsburgh. International Journal of Transgenderism, 12(4), 211-229, doi: 10.1080/15532739.2010.544232

Safer, J.D., Coleman, E., Feldman, J., Garofalo, R., Wylie, H., Radix, A., Sevelius, J. (2016). Barriers to health care for transgender individuals. Current Opinion Endocrinol Diabetes Obes., 23 (2), 168-171. doi:10.1097/MED.0000000000000227.