When it comes to health, cisgender people have many of the same needs as transgender, non-binary, and gender-nonconforming individuals. Everyone requires basic physical exams, routine preventive care like vaccinations and cancer screenings, and acute care in the face of sickness or injury. While public acceptance of the transgender community is growing, trans healthcare is still largely misunderstood by the general public, due to lack of education, social stigma, or transphobia. According to the 2015 U.S Trangender Survey, for instance, 24% of transgender individuals reported having to teach their healthcare provider about transgender people in order to get the care they needed. Those who are unfamiliar with trans health often mistakenly assume that all transgender people medically transition or that transition-related procedures are elective and cosmetic in nature. Such misconceptions and myths only further harm trans individuals and perpetrate transphobic and discriminatory attitudes. With this in mind, we partnered with Included Health, a comprehensive healthcare platform that connects LGBTQ+ patients to competent care, to highlight some of the key health concerns and needs of the transgender community you should know about.
1. Inclusive, Affirmative Care
Few people look forward to doctor’s appointments, but for transgender and non-binary individuals, especially, the experience is often dreaded. From ill-informed healthcare providers to outright refusal of treatment or harassment, many transgender people face significant barriers to basic healthcare. According to a 2017 survey by the Center for American Progress, (CAP) 29% of transgender respondents reported that a healthcare provider had refused to see them because of their sexual orientation or gender identity. Meanwhile, a study by Lambda Legal found that 70% of transgender and gender nonconforming indivudals have faced serious discrimination in a healthcare setting.
As a result, many transgender patients struggle to be transparent with their provider about their gender identity and even avoid seeking care altogether due to fear of discrimination or hostility. “Trans and nonbinary patients tell us often of the mistreatment, mistrust, and worry that arises from an upcoming doctor's visit” said Cass Wahl from Included Health. “It’s hard to know who you can trust as a trans patient, especially if you’ve had previous negative healthcare interactions and experiences.” One study found that 23% of transgender individuals did not go to the doctor when they needed to because of fear of being mistreated for being transgender.
According to One Medical provider, Travis Sherer PA-C, gender-affirming, nonjudgmental, competent care is crucial to the health and safety of transgender and non-binary individuals. “You need to start with the basic building blocks — a warm, welcoming, affirming environment,” said Sherer. “That doesn’t start or stop at the provider’s door. It can start with how you talk to someone on the phone with someone in billing or a at a lab visit with the phlebotomist. The question ‘Are you male or female’ can tell a transgender patient that a clinic is not welcoming environment before they ever even get in the door.” For transgender and non-binary patients, inclusive care includes everything from asking for someone’s pronouns, to accepting, well-trained staff.
2. Mental Health
Transgender and non-binary individuals are also at increased risk of mental illness. While an estimated one in five U.S. adults will experience mental illness in any given year, transgender people are nearly four times as likely as cisgender individuals to experience a mental heallth issue. Meanwhile, the U.S. Transgender Survey found that 41% of transgender respondents had attempted suicide at some point in their life, nearly nine times the U.S. average.
It’s important to note that being transgender is not a mental health condition itself, said Sherer. Rather, these disparities can largely be attributed to external factors, including a history of discrimination, stigma, and violence against the trans community. “There’s nothing inherently wrong with being transgender,” said Sherer. “There are increased mental health needs in this community because trans persons are so victimized. There are high rates of hate crimes, bullying, and racism, as well as structural transphobia. Society is geared toward cisgender men and women and that’s stressful.”
According to the CDC, the majority of transgender people experience various forms of discrimination, victimization, and harassment in their daily lives. 77% of transgender students, for instance, experience some form of mistreatment between kindergarten and twelfth grade, while 30% of transgender adults reported mistreatment in the workplace, such as verbal harassment or physical assault. Many transgender individuals may be bullied as they transition, feel rejected by family or loved ones, struggle with their own sense of shame due to social stigma, or even fear for their safety at work, school, or public settings. Likewise, the transgender community is one of the largest targets of hate crime and violence. All of these experiences can trigger feelings of loneliness, sadness, anger, worry, self-hate and hopelessness, and increase risk of mental illness like depression or anxiety. Research suggests disproportionately high rates of substance use among transgender individuals is also linked to such challenges.
In addition to societal factors, some transgender individuals suffer from gender dysphoria, a state of pyschological distress over the incongruence between one’s assigned sex at birth and their gender identity. If left untreated, this distress can lead to severe mental illness including depression, anxiety, or suicide. Comprehensive mental health care, as well as gender-affirming surgery or hormone treatments, can help someone through this distress.
3. Sexual and Reproductive Health
Transgender and non-binary individuals also face a distinct set of barriers and have unique needs in terms of sexual and reproductive health. According to the CDC, for example, the rate of HIV infection among transgender people is 4 times that of the U.S. population. A World Health Organization report also found that the risk of cervical, ovarian, and uterine cancer is higher for trans men who retain genitalia they are born with, yet due to stigma, social exclusion, discomfort, and discrimination, these individuals do not often receive the sexual health, cancer, and STI screenings they need. In fact, one survey found that half of transgender men did not receive routine cervical cancer screening, with 40% citing discomfort with the physical exam and 13% listing lack of a medical provider they were comfortable with as the reason. “Transgender men and transmasculine people broadly are also often and repeatedly discouraged from having hysterectomies, without explanations around the procedure and what it entails, forcing them into a double- or triple-bind trying to access care and avoid violation, discrimination, and increased risks,” said Ever Hayward from Included Health.
Given the intimate nature of sexual health and cancer screenings like those for breast, cervical, and prostate cancer, physical examinations can be uncomfortable and traumatizing for many transgender and non-binary individuals, and can even exacerbate gender dysphoria. As a result, these examinations may require a different approach than the traditional physical. “It might mean something like you're not doing a full physical the first time you meet somebody,” said Sherer. “Maybe you're doing a focused physical or split the physical between visits. You need to recognize that the patient may be uncomfortable with a particular part of their anatomy so it’s helpful to build rapport first before doing an exam.” Some transgender patients feel more comfortable by talking through the exam beforehand, using non-medical terms for specific body parts, discussing each step of the exam as it’s happening, or listening to music or reading a book during the exam.
Transgender patients also often struggle to get their sexual health needs met due to provider’s assumptions about their gender identity. For instance, a provider may make assumptions about one’s pronouns, sexual partners, and sexual history based on their appearance, which then informs their care plan. According to Included Health, it’s important that providers challenge the “default” when treating patients. “We need to understand that cisgender bodies are not the only gendered bodies out there in healthcare and recognize our assumptions about an individual’s medical needs based on their gender” said Hayward. “For example, does a trans male patient get excluded from gynecological services? Do trans women receive provider recommendations for prostate cancer screenings?” Physical examinations and cancer screenings for transgender patients should be based on the existing anatomy, not on their gender presentation.
4. Transition-Related Care
One of the biggest misconceptions about transgender people is that all transgender individuals medically transition. The reality, however, is that transitioning looks different for everyone. Some people choose to socially transition —using different pronouns, changing their name, or dressing differently — while others may undergo medical procedures such as hormone treatment or gender-affirming surgery. “Not every trans person needs surgery or even wants surgery,” said Sherer. “It’s important to note that not everybody needs or wants interventions.” There is not one, correct way to transition, and medical procedures do not define who is or isn’t transgender.
For some, however, medically transitioning is an important, necessary step in an authentic, fulfilling life. The 2015 U.S. Transgender Survey found that 78%of transgender individuals wanted to receive hormone therapy, 49% of respondents had received hormone therapy, and 25% had some form of transition-related surgery. It’s important to note that medically transitioning is more than just one simple surgery. It’s a complex process that for many can include several different gender affirming procedures. Some people may choose to undergo other procedures such as facial surgery, hair removal, or speech modification. “Every individual person has their own experiences, level of income, access to community, health needs, and genetic and biological differences,” said Isaac McManus from Included Health. “Healthcare is personal all the time and that’s especially true for the trans community as well.”
How One Medical Can Help
At One Medical, our providers understand the unique health concerns and obstacles members of the trans and non-binary community often face. Knowing that many trans people have had poor healthcare experiences in the past, our team is committed to providing culturally, competent, affirmative care at every visit and creating safe, judgment-free spaces for all. This includes everything from asking for your gender identity, pronouns and preferred name to offering gender-neutral bathrooms whenever possible.
All of our providers adhere to our philosophy toward inclusivity so trans and non-binary patients can expect to be treated with respect, compassion, and professionalism by whoever they see. Trans individuals can also choose to see a provider who specializes in areas like LGBTQ+ family planning, PrEP, hormone therapy, and mental health, as many of our providers are experts in these fields, or identify as a member of LGBTQ community themselves. Likewise, we can refer patients to transgender-friendly specialists as needed.
For more information on our LGBTQ services, see here.
The One Medical blog is published by One Medical, an innovative primary care practice with offices in Atlanta, Boston, Chicago, Los Angeles, New York, Orange County,Phoenix, Portland, San Diego, the San Francisco Bay Area, Seattle, and Washington, DC.
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