History of Transgender Inequality in Health Care

By Nicole Yee and Monica Gonzalez

(Graphic by The Commonwealth Fund)

Terms

Transgender: Most commonly used as an umbrella term for individuals whose gender identity and/or expression is different from the gender assigned to them at birth. Trans people include individuals who are transsexual, genderqueer, agender, androgyne, demigender, genderfluid, individuals who cross-dress or dress androgynously, and other individuals who cross or go beyond traditional gender categories.

Gender dysphoria: The American Psychiatric Association defines gender dysphoria as “persistent discomfort about one’s assigned sex or a sense of belonging to the other sex…[and]…a desire to be…of the other sex.” It is important to note that not all transgender people experience gender dysphoria.

Gender non-conforming: Denoting or relating to a person whose behavior or appearance does not conform to prevailing cultural and social expectations about what is appropriate to their gender.

Transgender individuals in America have faced a long, uphill battle in gaining the protection and respect that everyone deserves. The history of transgender people has largely been one of struggle and loss, with threads of triump, hope, and a slow but growing acceptance.

Within the medical and psychiatric communities, transgender people have made strides in acceptance and receiving care. As part of the wider LGBTQ+ community, they have faced similar issues of discrimination, prejudice, and legal challenges in order to be recognized and cared for in our society. Although much progress has been made, the fight for federal protections and inclusion of transgender people in our current environment continues today. This article highlights the history of transgender inequality in health care and our call to action for all medical providers and the wider society to progress towards a more inclusive and accepting environment for transgender people.

Historically, there have been various terms referring to transgender people, some being not only out of date, but also offensive. The term transgender, as understood today, is an individual whose gender identity and/or expression is different from the gender assigned to them at birth. They do not identify as the sex they were born as and may not conform to cultural expectations of gender identity.

One of the first recognitions of gender nonconformity in Western medicine appeared in the 1920s. The American Psychiatric Association classified it as gender identity disorder (GID) in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980, where it remained until the most recent edition, the DSM-5. [2] Until recently, gender identity disorder was categorized as a mental pathology and was treated as such. Similar to the status of gay, lesbian, and bisexual identities, these categorizations have changed over time and are no longer a mark of mental illness that needs to be “fixed.”

The most recent edition of the DSM-5 refers to transgender identity as gender dysophoria, emphasizing gender incongruence rather than patholigizing it. [2] This new definition was made to differentiate gender nonconformity from mental illness so that transgender identity would no longer be classified as such. The medical and mental health communities have come to view transgender identity as valid, rather than a pathology that needed to be fixed. These communities have recognized the need for medical transitioning in the form of surgery and hormone therapy for some transgender individuals.

Significant dates in the fight for equality include triumphs from the first sexual reassignment surgery (SRS) to hormone treatment to legal recognition and protections. Listed below are just a few of the many events that have brought transgender people to the forefront of our conversation on medical inclusion and equality. [3]

1932 — Magnus Hirschfeld performs the first ‘documented’ Sexual Reassignment Surgery (SRS) on Dora-R.

1945 — Sir Harold Gillies and his colleague, Ralph Millard, carry out the world’s first change of a woman into a man on the young aristocrat, Michael Dillon.

1949 — Harry Benjamin begins to treat transgender individuals in San Francisco with hormones.

1969 — The First Gender Symposia is held. This develops into the Harry Benjamin International Gender Dysphoria Association. June 27th-28th: Transgender and gender non-conforming people are among those who resist arrest in a routine bar raid on the Stonewall Inn in New York City’s Greenwich Village, thus helping to ignite the modern LGBT rights movement.

1976 — Tennis ace Reneé Richards is outed and barred from competition when she attempts to enter a women’s tennis tournament. Her subsequent legal battle establishes that transsexuals are legally accepted in their new identity after reassignment in the U.S.

1993 — Minnesota passes the first law in the U.S., which prohibits discrimination against transgendered people. The Minnesota statute establishes protections for transgendered people under the rubric of sexual orientation.

2004 — Feburary 10th: The Gender Recognition Act becomes law, allowing transgender persons to legally change their sex and have it recognized for the purposes of marriage and other issues.

Health care issues such as HIV have helped spark improvement in healthcare for transgender individuals. HIV has increased support for transgender people by implementing programs to assist and reach out to vulnerable populations. A clear example of support that has arisen is the Center of Excellence for Transgender Health. [5] This center provides services and conducts research specifically aiming to improve the health of transgender and gender diverse individuals and to bring them into the conversation. By providing a space where transgender and gender diverse individuals have the opportunity to be a part of their health experiences and health issues, this would definitely help improve healthcare for trangender and gender diverse individuals.

Implementing these support programs is just a start, but what healthcare alleviations have been given to transgender and gender diverse individuals federally, if any at all? Under Trump’s Administration, Section 1557 of the Affordable Care Act has had a few changes. Some of the major and applicable ones, regarding transgender and gender diverse individuals, are the following: [4]

• Eliminating the general prohibition on discrimination based on gender identity and sex-stereotyping and specific health insurance coverage protections for transgender individuals.
• Eliminating the provision preventing health insurers from varying benefits in ways that discriminate against certain groups, such as people with HIV or LGBTQ people.
• Eliminating prohibitions against discrimination based on gender identity and sexual orientation in ten other federal health care regulations outside Section 1557.

The Trump Administration’s elimination of transgender civil rights regarding health care can only worsen the stigma and discrimination against transgender and gender diverse individuals. Recently, there has been no federal help for transgender and gender diverse individual healthcare; instead, there has been a stepback by removing prohibition on discrimination.

This will only increase barriers for these individuals, depriving them of the care that they may actually need. Some of the current barriers that transgender and gender diverse people face in health care are the lack of access to providers who are sufficiently knowledgable about transgender issues, the direct lack of insurance coverage, stigma, and discrimination among many others. [1]

Therefore, there is an urge for change regarding transgender and gender diverse individuals’ health care. Firstly, prioritizing research on barriers trangender individuals face and potential solutions will not only help us identify the problems at hand, but also figure out what solutions can be implemented effectively.

There should also be push for the American health care system to provide adequate health care for transgender individuals by citizens, health care providers, and people who are aware of this issue. Furthermore, federal regulation against discrimination should be implemented to prevent the recurrence of discriminatory events that affect these communities at large.

A major issue that should be addressed is the lack of training that physicians are receiving. There should be more transgender-sensitive care incorporated into physician training. In addition, there should be more federal support for funding centers and implementing guidelines to respect individuals by their gender such as normalizing gender-neutral bathrooms, keeping health records with the individual’s names and pronouns, and expanding safety measures such as increasing restroom accessibility for transgender individuals to create a more welcoming environment. [2]

Transgender communities deserve federal protections and greater acceptance and inclusion in health care. Transgender people may rely heavily on medical care and procedures in order to fully reflect their identity. Being so closely tied to and reliant on health care, they are caught in a difficult position, relying on medical procedures and hormones to transition into their identity while finding the field unwelcoming and lacking protection and insurance coverage. Discrimination and prejudice affects not only their physical health, but largely their mental health and ability to present themselves in their identity. Transgender communities deserve federal protections and greater acceptance and inclusion in health care; it’s time to enact new policies and training to ensure this.

Sources:

[1] Barriers to Health Care for Transgender Individuals (Safer et al.)
[2] The State of Transgender Health Care: Policy, Law, and Medical Frameworks (Stroumsa)
[3] Trans History (The Proud Trust)
[4] The Trump Administration’s Final Rule on Section 1557 Non-Discrimination Regulations Under the ACA and Current Status (Musumeci)
[5] The Center of Excellence for Transgender Health (CoE) (UCSF)
[6] Common Transgender Definitions and Terms (Gay Straight Alliance for Safe Schools)

Monica Gonzalez is a third-year Biology major with a minor in Global Health at UCLA. Nicole Yee is a fourth-year Psychobiology major with a minor in Anthropology at UCLA. Monica and Nicole are both THINQ 2020–2021 clinical fellows.

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