The meme of “The Transgender Tipping Point” has been promulgated throughout popular culture and the media since 2014, increasing visibility for transgender and gender nonconforming (TGNC) people. However, TGNC people continue to encounter tremendous health disparities in the United States, perpetuated in part by limited TGNC-related content in medical education and health professions training.1 A 2011 Institute of Medicine report on the health of lesbian, gay, bisexual, and transgender (LGBT) populations commented that TGNC people “face a profound and poorly understood set of additional health risks due largely to social stigma,” and identified transgender-specific health needs as 1 of the 5 most pressing domains of its research agenda.2 Indeed, almost 70% of TGNC patients report discrimination when attempting to access the health care system.3
Unfortunately, despite a recent surge of interest and momentum with respect to integration of health professions' curricula and trainings devoted to LGBT health, there remains a dearth of transgender-specific content.4 Moreover, data indicate that TGNC people experience more discrimination, stigma, and substandard care than their lesbian, gay, and bisexual counterparts.3
Recent developments in health equity research and policy have led health professionals' training institutions to implement curricular changes so that providers are better able to serve the needs of diverse patient populations.5 Understanding basic information about transgender identities, and recognizing patterns of societal and institutionalized bias toward transgender communities, enable health care providers to promote health equity for these historically underserved populations.
Introduction to Transgender and Gender Nonconforming Identities
TGNC people have existed throughout history and across cultures. Albert D. J. Cashier (December 25, 1843–October 10, 1915) was an Irish-born immigrant who served as a male soldier in the Union Army during the American Civil War, and lived as a man his entire adult life. When he was elderly and unable to care for himself, his sex assigned at birth (female) was discovered, and he was forced to wear a dress.6 “Two-Spirit” is a term used by some indigenous North American people to describe gender-variant people in their communities, and has been documented in more than 130 North American tribes.7
The 20th century in Western Europe and North America marked the medicalization of transgender identities, once the capacity to facilitate gender affirmation via medical and surgical interventions emerged. It is in this context that much of the current discourse related to transgender identities, institutionalized bias, marginalization, and access to care takes place.
Many people are familiar with the acronym “LGBT” as an umbrella term referring to lesbian, gay, bisexual, and transgender people. Some clinicians, institutions, and research groups are moving away from this nomenclature toward the use of “sexual and gender minorities,” which is inclusive of LGBT, queer, intersex (or differences of sex development/[DSD]), and other people whose sexualities and gender identities are non-normative.8
The politics underpinning these various lexicons are beyond the scope of this article, and the number of words people use to describe themselves can seem overwhelming. However, it is important to recognize that these words are often part of closely held identities, and a means by which historically marginalized people have reclaimed power and resisted pathologization.
For such groups that have been medically underserved, using appropriate language can improve the chances of a patient disclosing important elements of their history, returning for follow-up care, and adhering to treatment.
Definitions of Terms
Myriad working definitions for the terms that follow have been adopted by institutions, research groups, clinicians, and gender communities. Although such definitions are inherently limited, it is useful to have a common lexicon to provide a framework for discussion. The following working definitions are culled from a combination of specialists in the field of transgender health, patient interactions, and personal experience.
Sex and gender. Sex is assigned to us at birth or in utero, and is based on genotypic, phenotypic, and anatomic characteristics, designated as male or female (see below for a brief discussion of intersex conditions or DSD).
Gender refers to socially and culturally constructed roles, behaviors, activities, and attributes a given society considers appropriate for the sex assigned at birth. In modern Western society, gender is often defined by two polarized roles that correlate with the sex assigned at birth, ie, man and woman.
Sexual orientation and gender identity. Sexual orientation describes a person's emotional, sexual, and/or relational attraction to others, and may encompass desire, behavior, and identity.
Gender identity describes a person's internal sense of gender. Because gender identity is internal, it is not visible to others.
Gender expression and gender presentation refer to how a person conveys gender to the outside world, although gender expression and/or presentation may not be concordant with gender identity. Of note, sexual orientation, gender identity, and gender presentation may be fluid and shift over time.
Transgender, Cisgender, and Gender Nonconforming
Those who identify as transgender generally experience gender dissonance or gender incongruence with the sex assigned at birth. However, it is important to remember that there is no singular transgender identity, community, or culture.
Transsexual is an older term originating in medical and psychiatric communities9,10 used to describe people with a persistent and profound awareness that their assigned sex is inappropriate and who are seeking out a binary transition (male to female or female to male) via hormone therapy and surgical interventions.11 There are people who self-identify as transsexual, although the term is falling out of favor in TGNC communities.
Gender nonconformity refers to the extent to which a person's gender identity, role, or expression differs from societal norms prescribed for the sex assigned at birth. Gender nonconforming people may not identify with the binary of man/woman, male/female, or masculine/feminine. They may identify as both genders, neither, in between; on a spectrum or continuum; or outside of the binary system altogether. Terms that gender nonconforming people may use to signify gender identity include agender, bigender, genderqueer, genderfluid, gender variant, nonbinary, two-spirit, androgynous, pangender, and others. Some gender nonconforming people prefer the gender-neutral pronouns “they” and “their,” constructions such as ze and hir, no pronouns, or different pronouns in different contexts.
Transgender and trans are terms used to describe people whose gender identity is discordant with the sex assigned at birth. A transgender man or trans man refers to a person who identifies as male but was assigned female at birth, and a transgender woman or trans woman refers to a person who identifies as female but was assigned male at birth. Transgender men may refer to themselves as female-to-male, and transgender women may refer to themselves as male-to-female, whereas other trans people may not identify with the binary model of sex and gender at all.
TGNC is an umbrella term used to refer to diverse identities on the transgender spectrum. Cisgender or cis describes people whose gender identity is concordant with their sex assigned at birth. The terms “cis” and “trans” derive from Latin, in which cis means “on this side” and trans means “on the other side” or “across.”
Of note, intersex identities are sometimes included under the TGNC rubric as well, although a robust exploration of issues related to intersex people is beyond the scope of this article. Intersex conditions, also called differences of sex development or DSD, include variations in sex chromosomes, gonads, reproductive ducts, and genitalia.12 Intersex people are nearly always assigned a binary sex at birth (male or female), and some eventually feel that the sex assigned at birth is discordant with their gender identity, and may socially, medically, or surgically transition. There is some overlap between intersex and transgender populations, and some intersex people identify as both intersex and transgender.13 However, other intersex people do not wish to be identified as transgender or gender nonconforming, and find it problematic to be included in acronyms such as LGBTI (lesbian, gay, bisexual, transgender, and intersex).
Transition and Gender Affirmation
There are numerous ways to assert one's gender identity, just as there are a myriad of ways to be trans. Some trans people pursue medical interventions to facilitate bodily and gender identity concordance. Many people refer to this as transitioning. Some prefer the terms gender affirmation or gender assertion, to underscore the pursuit of interventions to affirm or assert identity rather than change from one binary gender to another.
Gender affirming treatments include medical and surgical interventions, as well as interventions such as vocal training and image consulting. Medical interventions include masculinizing or feminizing hormone therapy, electrolysis, and laser hair ablation. Surgical interventions are sometimes described under the rubric of sex reassignment surgery or gender affirming surgery. These include (1) “top surgery,” reconstructive chest surgery for trans men and masculine spectrum people; breast augmentation for trans women and feminine spectrum people, (2) “bottom surgery,” orchiectomy, penectomy, vaginoplasty for trans women; metoidioplasty, scrotoplasty, phalloplasty, hysterectomy, and salpingo-ooperectomy for trans men, and (3) head-and-neck procedures, such as facial feminization surgery, tracheal shave, and hair reconstruction/transplantation for trans women.
Not all trans people desire medical and/or surgical interventions. Additionally, some nonbinary-identified people may still desire certain interventions. For example, a genderqueer person assigned female at birth may not be interested in masculinizing hormone therapy, but may not feel comfortable with their chest; this person might pursue top surgery.
Access to Care
World Professional Association for Transgender Health (WPATH) Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, version 714 are the most widely used evidence-based and expert professional consensus treatment guidelines for transgender care. WPATH provides clinical guidance for health professionals to “assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment,” which may include primary care, hormonal and surgical treatments, gynecologic and urologic care, and mental health care.14
Many TGNC people do not have access to evidence-based primary care, mental health care, and gender-affirming interventions. Determining how many transgender people struggle to obtain health care is challenging because there is a dearth of data about the size of the trans population. Researchers studying the prevalence of TGNC identities have tended to focus on transsexual-identified people, or those who experience gender dysphoria and thus seek transition-related care at gender specialty clinics. In a 2007 review that included 10 studies from eight countries spanning four decades, the prevalence of trans women ranged from 1 in 11,900 to 1 in 45,000, and the prevalence of trans men ranged from 1 in 30,400 to 1 in 200,000.15,16
Scholars have suggested the prevalence is actually much higher, given that many of the studies on TGNC populations are methodologically flawed. A 2011 report from the Williams Institute Gender Identity in US Surveillance Group at the University of California, Los Angeles School of Law estimates the adult trans population in the US to be about 700,000 or 0.3% of the population.17
Unfortunately, US health surveillance systems do not yet routinely include questions designed to identify gender minority respondents, limiting data that can be used to evaluate health disparities in the TGNC population. Moreover, in our culture, and by extension, in many research studies, sex and gender are often conflated, creating further challenges for data gathering.
Although many people in the general US population are uninsured, transgender people are less likely to have insurance than cisgender people. One study showed that 19% of transgender people are uninsured, nearly 25% more than the national average of 15%.18 Most people are insured through an employer, and transgender people are less likely to be employed than cisgender people. Moreover, because trans people have more difficulty obtaining identity documents with the appropriate name and gender, they may have more difficulty applying for public insurance, even if they qualify.19 In most states, Medicaid programs do not cover transgender-related care despite federal statutes requiring they do so.16
For those transgender people who are insured through an employer, the majority of policies exclude transgender care. This is steadily changing, with more and more employers offering inclusive insurance. According to the 2015 Human Rights Campaign's Corporate Equality Index, 418 private companies currently offer at least one transgender-inclusive health care plan.20 In addition, several states including California, Colorado, Oregon, and the District of Columbia have instituted regulations that bar exclusions for transgender care.
Because insurers use the sex or gender indicated on insurance forms to determine medically necessary care, transgender people must decide which designation is most appropriate. For example, if a transgender woman (assigned male at birth) lists “F” (for “female”) on her insurance forms, she may be able to obtain coverage for estrogen prescriptions, but she may be denied prostate care. Likewise, if a transgender man (assigned female at birth) selects “M” (for “male”), his insurance may cover testosterone prescriptions, but not routine gynecologic care, such as a pap smear. Even in the best case scenario in which an insurance company covers transgender-related care, obtaining authorization overrides for care specific to one's sex assigned at birth may delay care and payments.
Discrimination and Stigma
TGNC people frequently experience discrimination in health care, from disrespect and harassment to physical violence and outright denial of services.21,22 For many trans people, simply disrobing for a physical examination, being called from a waiting room by a name and pronoun discordant with one's gender identity, or using a gendered bathroom jeopardizes safety. Prejudice and bias by health care providers is well-documented, leading many TGNC people to avoid health care providers altogether. Many TGNC patients suffer from iatrogenic trauma due to negative interactions within health care systems.
The National Transgender Discrimination Survey,18 the most robust survey to date of discrimination experienced by TGNC people, included a sample of 6,456 respondents from 50 states. Participants reported barriers to care when seeking preventive medicine, routine and emergency care, and transgender-related services, which in turn deterred them from seeking further health care. Nineteen percent of the sample reported being refused care due to their transgender or gender nonconforming status, 28% reported postponing care due to harassment, and 2% reported physical violence in medical settings. Half reported having to educate their medical provider about transgender care.
Moreover, the data showed that racial bias presented a significant, additional risk of discrimination for TGNC people of color in virtually every area of the study, making their health care access and outcomes dramatically worse. Gender-minority status is only one of the social determinants of health, and it is important to examine health outcomes in the context of racial, ethnic, socioeconomic, and geographic diversity.21 To do so will require improved methods for collecting and analyzing data, and increased recruitment of gender and other minorities in public health research.
TGNC people have an equally fraught relationship with psychiatry, which has a long tradition of pathologizing gender variant people. To this day, mental health professionals often act as “gatekeepers” for TGNC people seeking gender-affirming medical and surgical procedures. The growing visibility of people with TGNC identities helped drive the change in category in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision23 from gender identity disorder to gender dysphoria in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition.24 Rather than labeling transgender identity as an illness, gender dysphoria requires the presence of clinically significant distress caused by a discrepancy between gender identity and sex assigned at birth, thus not labeling trans or gender nonconforming identity as inherently pathologic.15
Multiple professional organizations including WPATH, the American Medical Association, the American Psychiatric Association, the American Congress of Obstetricians and Gynecologists, and the Association of American Medical Colleges have now published position statements recognizing that transgender and gender nonconforming people can benefit greatly from medical and surgical treatment as well as advocating for removal of barriers to care.22
Assumptions by Providers
Mental health providers who have no exposure to TGNC people in social or professional communities may have only seen TGNC patients in acute settings. This may lead to a skewed perspective that transgender people always have severe psychopathology, which is assumed to be inherently related to their gender identity. Although it is true that TGNC people are at a heightened risk of certain mental health issues due to stigma and victimization, extrapolating from a narrow sample size to the overall TGNC population is problematic. Providers may presume that fluid gender identity or gender presentation is indicative of the unstable sense of self associated with certain personality disorder diagnoses. However, unless these fluctuations cause clinically significant distress, they are not consistent with pathology.
Furthermore, TGNC people may seek mental health treatment for reasons completely unrelated to their gender identity. For example, a transgender person without gender dysphoria might present to a mental health provider because of increasing generalized anxiety after a promotion to a more demanding job. Cognitive-behavioral therapy for anxiety, with or without pharmacotherapy, would likely be an appropriate intervention for a cis or trans person with this chief concern.
There is also the misperception that trans medical care is exclusively concerned with gender-affirming medical and surgical interventions. However, this overlooks general health maintenance and acute medical needs unrelated to transition. Trans people seek medical health care for many of the same reasons that cis people do—for upper respiratory infections (URI), broken bones, preventive care, and health maintenance.
If a trans or gender nonconforming person presents to the emergency department (ED) with a laceration that requires sutures, the examination and treatment should be identical to that of a cis person. However, many TGNC people report traumatic encounters with providers who are intrusive or voyeuristic about their bodies and any history of trans-related procedures, particularly genital surgeries. For something such as a URI or broken bone, this information is irrelevant. On the other hand, if a trans man comes to the ED with abdominal pain, obtaining a surgical history of hysterectomy or salpingo-oopherectomy is imperative—as it would be for a cisgender woman—to guide the differential diagnosis and examination.
Regardless of the reasons for seeking care, developing trans-affirming clinical settings, providing inclusive intake forms, following the patient's lead in the use of names and pronouns, and expressing humility when uncertainty exists can be invaluable to the patient-provider alliance. Such empathy and cultural humility can ameliorate some of the potential for iatrogenic trauma and encourage follow-up care.
Cultural Humility and Advocacy for Equity
The Declaration of Geneva (Physician's Oath), a declaration of the physician's dedication to the humanitarian goals of medicine, adopted by the World Medical Association in 1948, requires a physician to say the following at the time of being admitted to the medical profession: “I solemnly pledge to consecrate my life to the service of humanity.” It further compels physicians not to permit “considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene” between the duty of the physician toward the patient.25
Exploring transgender identities and examining ways in which these identities are marginalized provides tools to advocate for the most vulnerable patients, and to address the structural sources of health disparities. Implementing curricular changes in training programs for health professionals, accurate epidemiology and public health research, and examination of one's own biases and assumptions are essential to ameliorating health disparities affecting TGNC communities, thereby advancing health equity for all.
Update: After this article was submitted for publication, there was a new development in transgender health care. On May 13, 2016, President Barack Obama announced that any health care provider or health insurance company that receives federal funds, including state Medicaid agencies and insurance plans in the Affordable Care Act exchanges, must guarantee equal treatment of transgender people and may not categorically exclude treatments related to gender transition.