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Transgender Health - Eliminating Inequalities and
Strengthening Clinician-Patient Relationships
Christy A. Rentmeester PhD
Associate Professor of Health Policy and Ethics
Creighton University School of Medicine
Omaha, Nebraska USA
Ryan K. Sallans MA
Consultant, Diversity and Inclusion Trainer, Publisher and Author
Omaha, Nebraska USA
Key Words: clinician-patient relationship, disparities, ethics,
health justice, inequalities, physician-patient relationship, standard
of care, transgender health
The term transgender is used to characterize people whose
gender expression—the way a person communicates
their gender—is considered nontraditional for their sex
or gender and to characterize people whose gender identity—a
person’s psychological identi cation of gender—is di erent from
their sex assigned at birth. Importantly, a transgender identity can
di er from a person’s sexual orientation; one can be gay, lesbian,
or heterosexual, for example, and also have a transgender identity.
In 2011, healthcare inequalities for transgender people were
acknowledged as a critical area of research by the Institute of
Medicine (Institute of Medicine of e National Academies,
March 2011, p. 3). In 2014, the Hastings Center Report published a
supplement further documenting these inequalities and analyzing,
from an ethics point of view, some model progress in access and
healthcare infrastructure innovation (Davis & Berlinger, 2014, p.
S45). Also in 2014, the American Journal of Public Health featured
numerous articles illuminating inequalities in health status and
access to healthcare su ered by transgender patients in the United
States’s healthcare system. One of those articles issued “a call to
action” (Conron, Stewart, Reisner, & Sell, 2014, p. 970), citing risks
for suicide, depression, and violence as “commonplace” (Conron
et al., 2014, p. 970) vulnerabilities of transgender people. e
response we contribute here is intended to problematize binary
dominance as a culturally imperialistic expression common
in clinical practices and to motivate deeper understanding of
trends of underservice by focusing on one set of clinical encounter
experiences of transgender patients.
Clinical Encounters as One Micro-
Level Support for Macro-Level
Inequalities
One important question to explore is, How can macro-level,
systems-based inequalities be addressed by focusing on micro-
level clinical encounters? First, we consider that one reason why
transgender people are vulnerable in healthcare settings is that,
for many transgender patients, pursuing, exploring, ful lling and
maintaining physical expressions of authenticity over time demands
deep personal reliance and dependence on healthcare professionals.
Second, clinical standards that promote the clinician’s stance as
the one who surveys and veri es the authenticity of a transgender
person’s identity are ethically problematic. ese standards place
clinicians in positions to reinforce binary dominance and to be the
primary enforcers of this species of cultural imperialism. ese
standards also divert clinical attention away from responding to a
P R
This article considers healthcare experiences of transgender
patients on their transition journeys. One case illuminates
ways in which binary-dominance—the prevailing
assumption that a person must be either male or female
to be normal—is a species of cultural imperialism that
can in uence the quality of clinical encounters. We focus
speci cally on clinicians’ a ective orientation toward a
transgender patient and how it can in uence the patient’s
general and mental healthcare experience. When expressed
in healthcare contexts, binary dominance exacerbates the
vulnerabilities of transgender patients and reinforces trends
of underservice to members of this community. Generally,
clinicians tend to lack knowledge about the medical and
mental health needs of transgender patients, and clinicians
and o ce sta tend to lack cultural humility regarding the
multi-dimensional challenges of being transgender in a
binary-dominant society. We suggest a ve-point model of
foundational clinical and ethical competencies related to
di erent patients’ transition experiences, which can help
clinicians and organizations identify and eliminate binary
dominance expressions from their practices and policies.
A
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patient’s needs, generate anxiety for patients in clinical encounters,
and undermine trust and potential therapeutic capacity of the
clinician-patient relationship (WPATH). Consider the following
case as an example of some of the typical dynamics in transgender
patients’ healthcare experiences.
Aidan, a transgender male (born assigned female,
transitioning to male) is ready to start cross-sex hormones
to induce male secondary sex characteristics, but he is
having di culty nding a physician willing to prescribe
and monitor his hormone therapy regimen. After calling
several o ces, where sta members hang up on him or
ask invasive questions about what his body looks like, he
nally nds a willing physician who has treated transgender
patients in the past.
Ten minutes into Aidan’s rst appointment, he quickly
begins to realize that this physician does not seem familiar
with how to start a transgender patient on hormone
therapy. The physician asks, “So, you’ve already been living
as a man?” Aidan asks why this information is relevant to
beginning a hormone regimen. The physician responds, “I’ve
read that patients seeking hormones should undergo a ‘real
life experience’ before undergoing a medical transition.”
Aidan, mindful of his tone despite his growing feelings of
discomfort, politely reminds the physician that the language
of “the real life experience” does not appear in the recent
literature on transgender clinical care standards. Aidan
o ers to send the physician an article or two documenting
current clinical standards.
The physician seems taken aback by the suggestion that
his practice and protocol need updating. He states curtly,
“Look, if you don’t want to follow my advice, I’d be happy
to refer you to someone else.” Knowing that this physician
is the only one in his area willing to work with transgender
patients, Aidan says, “I’m sorry. I wasn’t trying to o end you.
I just felt like I needed to inform you about this important
change.” The physician ends the medical consult requesting
a letter from a therapist and stating that he would like to
wait three months before Aidan’s next appointment.
A number of things seem to go wrong during this clinical
encounter, some of which seem to stem from the physician’s
a ective orientation to Aidan. A ective orientation can be an
important means of expressing culturally imperialistic tendencies
in clinical contexts; in this case, the clinician’s response to Aidan’s
resistance to binary dominance is key. is physician, for example,
is open to working with transgender patients, but he is threatened
by the patient’s knowledge, has little empathy with the cluster of
stressors Aidan must navigate in his everyday life, and his response
places Aidan in the position of having to capitulate to the advice of
someone he doesn’t trust or go without timely care. Emotionally,
Aidan may not feel like he can speak up or advocate for his health,
due to the fear of being denied care or being subject to delays. ese
feelings might increase his anxiety, frustration, and fears. Not being
able to trust his physician, Aidan might even withhold clinically
relevant information (about depression, thoughts of suicide, fear,
anxiety, and self-injurious behaviors, for example). Aidan leaves
this clinical encounter, perhaps, feeling hopeless about getting
help with his deepest concerns.
Because many transgender patients rely on healthcare professionals
for authentic identity expression, they are particularly vulnerable
to particular experiences of medicine as an enforcer of cultural
imperialism. For example, Jacob Hale’s chapter “Tracing a Ghostly
Memory in My roat” in “You’ve Changed” Sex Reassignment
and Personal Identity (2009) problematize use of the clinical
specialty of psychiatry as the permission-granting authority of
gender transitioning. He argues that placing psychiatry in charge
of certifying transgender patients’ needs can co-opt patients into
self- pathologization and feigning “symptoms” of pathology that
don’t correspond well to transgender patients’ actual needs. He
also argues that placing psychiatry in charge of certi cation of
need relies upon essentialist conceptions of gender that reinforce
binary-dominance.
Also, because so many health professionals lack education and
training in transgender medicine, transgender patients far too
o en are pressed into the stressful triple role of being patient,
advocate, and educator during clinical encounters like the one in
this case. is dynamic can also be awkward and a potential source
of strain and frustration for clinicians, as it upsets “traditional”
distribution of power in clinician-patient relationships, in which
clinicians wield knowledge and power and patients are ill and
objecti ed. Despite that the triple role of transgender patient-
advocate-educators during clinical encounters can be threatening
to some clinicians, it’s important to remember that patients like
Aidan are still far more vulnerable than their clinicians.
Just as this case illustrates the importance of clinicians’ a ective
orientations to transgender patients, it also illuminates micro-level
challenges of their individual clinical encounters and suggests
how macro-level inequalities in health status, access to care, and
quality of care develop and persist.
Common Inequalities
Improving clinical encounters for transgender patients rst
requires healthcare professionals’ cultivation of awareness that
three kinds of inequalities—in health status, in access to care, and
in the quality of care received—matter for transgender patients.
Transgender community members’ self-reports consistently
suggest that health inequalities experienced by these patients are
a function of stigma from broader society expressed within clinical
settings (Poteat, German, & Kerrigan, 2013, p. 22).
Stigmatization is always morally problematic when it reinforces
cultural imperialism, and has special capacity to incur harm in
clinical settings. Stigmatization works via cultural, economic,
political, and social means (Link & Phelan, 2006, p. 528), which,
in clinical settings, is magni ed by healthcare professionals’ social
power and cultural authority. So, processes of discrimination
and marginalization extant in the broader social sphere, such as
“othering, blaming and shaming” (Deacon, 2006, p. 418; Poteat
et al., 2013, p. 27) can be experienced by transgender patients as
especially poignant and damaging expressions of devaluation when
they happen in clinical settings.
“Othering” is, perhaps, most clearly de ned by the philosopher
Iris Marion Young in Justice and the Politics of Di erence (1990).
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“Othering” happens when a group “di erent from the dominant
group” is “de ned by the dominant culture as deviant” (p. 60). For
gender, “othering” is a species of stigma that works by endorsing
binary-dominant identities. It happens in clinical settings, for
example, when a clinician states that she works with patients who
are transgender men, but not with patients who are transgender
women—born assigned male at birth, transitioning to female—
as they are sometimes alleged to be “di cult” or noncompliant
(Poteat et al., 2013, p. 27). When clinicians’ a ective orientations
to transgender patients reinforce this kind of devaluation of
transgender patients, health inequalities are likely to be exacerbated.
Transgender patients who feel that they are viewed with contempt
by healthcare professionals or their o ce sta , for example, can
be unlikely to feel incentivized to return to that environment to
meet their healthcare needs. is is one important link between
macro- and micro-level trends in healthcare service delivery for
members of transgender communities.
Health Status Inequalities
Transgender patients o en present with multiple health concerns
and critical risks including: suicide, depression, anxiety,
posttraumatic stress disorder, increased risk of being a victim
of violence, substance abuse, and sexually transmitted infections
(Conron et al., 2014, p. 970; Grant, Mottet, & Tanis, 2010, p. 1;
HealthyPeople.gov; Liu & Mustanski, 2012, p. 221; Stroumsa, 2014,
p. 32). Transgender women are at high risk for HIV infections,
and black transgender women have the highest risk for new HIV
infections (CDC, 2013). Transgender women of color are also at
the highest risk for being victims of violence (CDC, 2013; Grant,
Mottet, Tanis, Harrison, Herman, Keisling, 2011).
e risk for suicide and substance abuse are also disproportionally
high among transgender patients. According to a survey of almost
6500 transgender respondents, an alarming 41 percent reported
attempting suicide at least once in their past. If we look speci cally
at transgender youth, one study documents that nearly half of
young transgender people have seriously considered suicide and
one quarter report having made a suicide attempt (Grossman
& D’Augelli, 2007, p. 535). Twenty-six percent of transgender
adults reported using drugs or alcohol to cope with stress and
discrimination, which is higher than the general population (Grant
et al., 2010, p. 14).
Inequalities in Access to Care
e numbers just mentioned suggest the obvious need for general
medical and mental health care for transgender patients. As the
case above suggests, members of transgender communities also
experience transition-related health needs that deserve responsive,
professional care. Access to competent transition-related care and
insurance coverage for such care is scarce for this population. For
example, transgender community members are less likely than
members of the general public to have health insurance (Grant et
al., 2010, p. 8). In part, this is due to over-reliance in the United
States’s healthcare system on employer-sponsored healthcare; rates
of unemployment among transgender community members are
also high (Grant et al., 2010, p. 15). Furthermore, state and federal
policy restrictions on name changes and other legal document
amendments can exacerbate battles transgender patients have
to ght with insurers over inclusions and exclusions of services
under a policy’s coverage.
Additionally, transgender patients are frequently denied clinical
services. Such denials can take several forms. For example, in the
experience of one of the authors (Sallans), some clinicians simply
refuse to work with transgender patients. Another expression of
an outright denial was rendered by a receptionist in a medical
o ce, who hung up on a transgender man when he asked to
schedule a pap smear. Transgender patients also experience varying
degrees of verbal abuse—ranging anywhere from rudeness to overt
harassment—in clinical o ces (Grant et al., 2010, p. 76).
Care Quality Inequalities
When transgender patients can access care, they o en receive
substandard care from a professional (Grant et al., 2010, p. 1; Poteat
et al., 2013, p. 23). e physician in the case lacks knowledge about
transgender patients’ needs. Sadly, this lack of knowledge and
training is sometimes a function of some healthcare professionals’
negative attitudes (Dorsen, 2012, p. 18) and ambivalence (Poteat
et al., 2013, p. 25) about learning transgender medicine.
Half of transgender respondents reported having to teach their
medical professionals about how to care for them (Grant et al.,
2010, p. 6). In the case, the physician is uninformed about current
standards of care related to managing a patient’s hormone regimen.
Hormone care, for example, requires knowledge of appropriate
screening techniques, formulations and dosing, and monitoring
lab values over time.
Particularly complex barriers to good care arise when professionals
who do work with transgender patients overemphasize a patient’s
experience of mental illness as a strategy for undermining the
patient’s knowledge or pathologize transgender patients’ desires
(Nelson, 2012, p. 252). For example, a patient with depression
might be questioned about their “real” intent behind transitioning,
as if a person’s desire for gender transition could only be rationally
explained by mental illness. For another example, a patient with a
history of eating disorders might be told that a desire to transition
is a product of their disorder and negative body image, and thus
cannot be addressed until the eating disorder is addressed. In these
cases, mental illnesses are used as diversions from addressing a
transgender patient’s desires about their own identity expression;
this is a fundamental way in which clinical interrogations can
undermine patients’ cultural resistance to binary dominance and
their assertions and explorations of their own conceptions of
authentic realization of what it means to inhabit their bodies.
Ironically, another neglected source of complexity regarding
barriers to good care is revealed in cases in which transgender
patients must present themselves as mentally ill (Nelson, 2012, p.
252) in order to be seen as eligible for transition-related services.
ose unwilling to do so might go without care rather than
capitulate to presenting themselves as mentally ill. So the irony
here, and another byproduct of binary dominance as an expression
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of cultural imperialism, is that transgender patients are pressed
into situations in which they must feign a mental illness they
don’t have while their real mental health issues go unrecognized
and untreated.
Additionally, some transgender patients might feel that they need
to be selective and careful about the information they disclose
to clinicians about their identities. For example, clinicians who
judge transgender patients’ desires to change their physical gender
expressions can sometime impose their own ideas of what it
means to be a man or woman or what it means to assume men’s
or women’s roles. As a result, transgender patients can feel pushed
into tting the labels, constructs, and categories as assumed (rightly
or wrongly) by their clinicians. Speci cally, a transgender patient
who wants to express some of the physical characteristics of an
anatomically typical male, such as facial hair, a more squared jaw,
and prominent shoulders, might not be interested in expressing
all of the physical characteristics of an anatomically typical male,
such as having a penis. Such a patient needs hormones, but
not lower surgery. Clinicians trapped in the cultural norm of
binary-dominant thinking will be ill equipped to be responsive
to transgender patients. e variations of gender expression are
numerous, and many clinicians have never been prepared to think
of these variations before in their professional preparation and
training.
Resisting Cultural Imperialism in
Clinician-Patient Relationships
ough little is known empirically about how discrimination
functions in clinical encounters (Poteat et al., 2013, p. 23), the case
above suggests the multi-dimensional challenges Aidan faces as a
transgender person in a socially and culturally binary-dominant
society. Healthcare professionals’ lack of knowledge, sex and
gender labeling, and a lack of cultural humility, for example, are
three important byproducts of binary dominance and expressions
of cultural imperialism related to gender in society-at-large that
importantly in uence the nature and quality of transgender
patients’ clinical experiences. Transgender patients will have a
sense of the care they will be provided at a clinic immediately when
they walk through the o ce doors. ey will be assessing how they
are treated by the front-desk sta , the presence of gender neutral
or gender segregated restrooms, and how questions are worded
on patient intake forms. Speci cally, forms that reinforce “Male-
Only” and “Female-Only” sections reiterate binary-dominance,
as do forms that have places only to mark whether you are
“male” or “female.” ese features of the clinical environment
express whether and how aware, knowledgeable, and respectful a
healthcare institution is about transgender patients’ needs.
Social and Cultural Situatedness of
Clinical Encounters
Binary dominance in the broader society and culture is expressed as
imperialistic in numerous ways, but two of substantial importance
have to do with common policies and our everyday environments,
both of which are created by and sustained as macro-level social
and cultural structures. First, government policy restrictions on
name changes and other legal document amendments sustain
structural barriers that disproportionately harm transgender
community members. Such policies limit a transgender persons’
moral and legal agency and abilities to direct and exercise control
over their own futures and life paths.
Second, media representations of transgender people and their lives
far too o en endorse public ignorance about the concept around
being transgender and reinforce harmful stories and stereotypes
about transgender people. Misrepresentations are harmful when
they negatively bias our perceptions of transgender people, their
characters, and their strivings. Speci cally, media representations
tend to emphasize transgender people as threatening (as in
transgender adults or students needing to access restrooms that
align with their transgender identity), as dishonorable (as in stories
of transgender members of the military who are discharged due
to their transgender identity), and as victims (as in stories of
transgender individuals being victims of hate crimes).
Finally, transgender community members’ everyday experiences
of microaggressions also deserve consideration here. For example,
transgender patients need protections from employment
discrimination and organizational structural accommodations
that make it di cult or awkward for transgender people to use
facilities that align with their gender identity. Gender-neutral
restrooms, for example, can substantially reduce the frequency, and
perhaps the impact, of everyday microaggressions. In the chapter
“ e Education of Little Cis,” Professor A. Finn Einke relates an
experience of this kind of microaggression when their University
department moved into a new space with new wheelchair accessible
restrooms, which clearly de ned the restrooms as male-only and
female-only spaces. Einke writes, “I go there, braided and bearded,
and am furious to discover the options,” (Einke, 2012, p. 73). If
the building would o er a gender-neutral option, it could easily
avert Einke’s (and fellow non-binary presenting and transgender
individuals’) anger and discomfort.
Another way to reduce microaggression in clinical settings is
by creating more inclusive language in patient intake forms. For
example, e Fenway Institute and the Center for American
Progress (2013) and the Center for Transgender Excellence (Cahill,
2014, p. 37) suggests that all healthcare settings use a “two-step
gender identity and birth sex question” (p. 10). Two questions
include “What is your current gender identity?” and “What sex
were you assigned at birth on your original birth certi cate?” ( e
Fenway Institute, 2013, p. 11). e Centers for Disease Control and
Prevention (CDC) suggests a strategy for clinicians and healthcare
facilities to recognize a patient’s current gender identity while also
honoring their past and potential healthcare needs that might not
align with their current gender. For example, a patient who has a
current gender identity of female, but was assigned male at birth,
might need testicular cancer screenings if they have not undergone
an orchiectomy. Also, a patient that identi es as male, but was
assigned female at birth, requires cervical screenings if they have
a cervix. Having both items listed, and having clinicians educated
on what to be aware of, allows for more comprehensive, better
informed, and more compassionate care of transgender patients.
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Recommendations for Eliminating
Inequalities in Transgender Health: A
Five Point Model
What follows is an example of one set of key transition points—not
necessarily sequential—that could be adapted to clinical work with
a variety of transgender patients.
1.
A patient “comes out” as transgender to a healthcare
professional.
When a patient comes out as transgender, clinicians need to be
sensitive to how the patient is feeling (Mayer et al., 2008, p. 991)
and be able to identify common clinically relevant challenges
such as biological puberty, signs of emotional distress, lack of
social and cultural support, risks of being harassed or abused
in schools, homes, or other community-based environments.
Clinicians should be motivated to and should know how to create
an environment during clinical encounters that is inclusive towards
and supportive of transgender patients. One important feature of
the environment during clinical encounters that can confer caring
and respect is the use of appropriate language. For example, if a
client informs a clinician that they are now going by the name
“John,” the clinician can respond by saying, “ ank you for letting
me know. Are there di erent pronouns that you prefer I use?”
2.
A patient is in need of general healthcare in a medical
setting.
When we discuss transgender medicine, we o en forget to
acknowledge that transgender patients need general medical care
like any other patient, however many transgender patients will
avoid accessing general medical care because of previous negative
experiences in medical settings (Grant et al., 2010, p. 76). Clinicians
should be aware of current risks a ecting transgender community
members. (For example, high rates of depression, anxiety, eating
disorders, substance abuse, and HIV infections were cited earlier
in this article.) Many transgender patients fear disclosing their
own risk behaviors or emotions to clinicians. is can happen
for a number of reasons, including the patient’s distrust of a
clinician who does not appear caring or knowledgeable about the
stressors a ecting transgender community members. Clinicians
have obligations to help patients avoid delaying transition-related
care, particularly in the absence of a medical indication for delay.
3. A patient is ready to begin cross-sex hormone therapy.
It is beyond the scope of this paper to discuss the justi ability of
clinicians’ conscientious objection or “ambivalence” (Poteat et
al., 2013, p. 26) to working with transgender patients; we assume
for sake of exploring the quality of clinical encounters between
clinicians and patients that clinicians have, at the very least, an
obligation to treat all transgender patients with care and respect.
Additionally, clinicians have general obligations to be up-to-date
and versed in current standards of care and practices a ecting
transgender patients. When clinicians are not competent to execute
standards of care themselves, they have obligations to make timely
and actionable referrals to clinicians who can. Standards of Care
from the World Professional Association for Transgender Health
(WPATH), currently in its seventh version (WPATH) are the most
commonly used guidelines for the care of transgender patients. All
clinicians should be prepared to talk with their patients in order
to determine their current transition-related goals and assess any
concerns.
4. A patient requests a physician’s letter to enable changing
legal documents, such as driver’s licenses, birth certi cates,
and passports.
Clinicians should educate themselves on their state’s current
policies related to changing legal documentation. Continuing
education modules for clinicians should be developed to inform
clinicians about the nature and scope of their roles in assisting
patients with these kinds of document changes. One helpful
organization for advocacy and education about current state
and federal laws is the National Center for Transgender Equality
(NCTE) (National Center for Transgender Equality).
5. A patient requests a physician’s referral and/or a letter for
a transition-related surgery.
Clinicians should be able to describe comprehensive clinical care
and treatment options to transgender patients and their loved ones
or provide referrals and additional information when necessary.
One resource for clinicians in need of one-on-one consultation
with someone knowledgeable about transgender medicine is
TransLine through Project Health (TransLine).
Conclusion
Responding well to transgender patients’ general medical
and mental health needs include understanding the patients’
current support systems and fractures in those support systems,
employment status, income streams, and legal protections in
the region or state in which that patient lives. For example, a
transgender patient who has a supportive family or partner, is
steadily employed, and lives in a state where gender identity is
protected by nondiscrimination language in statutes, regulations,
or court holdings, might very well be in a better state of health
than patients who have been kicked out of their homes, unable
to maintain steady employment at an income level that allows
coverage of basic living needs, and lives in a region or state where
marginalization is commonplace and tolerated. Clinicians should
also take into account the additional e ect of “structural and
interpersonal acts of racism” (Harrison-Quintana, Lettman-Hicks,
& Grant, p. 1) on patients of color.
e analysis and recommendations we o er in this article focus
on nourishing the therapeutic capacity of the clinician-patient
relationship and on generating improvements in general and
mental health outcomes for transgender patients. We hope to have
illustrated the numerous ways in which micro- and macro-levels
connect, as quality clinical encounters are critical for eliminating
transgender health inequalities.
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Acknowledgments:
e authors extend their gratitude to nursing student Emma
Wojnicki for her assistance in the assembly of this manuscript.
Competing Interests:
none
Address for Correspondence:
e-mail:
ChristyRentmeester@creighton.edu
rsallans@gmail.com
Date of Publication: June 17, 2015
