Bad Medicine: Failings in Trans Healthcare

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As companies broadcast hollow messages of support on Trans Remembrance Day, many working class LGBT+ people are unable to afford or access adequate healthcare due to high insurance rates and discriminatory medical practices. We need to fight for a truly universal healthcare system that prioritizes health and well-being over profit.

Image: Kelsey Wroten

Twenty thousand LGBT+ teens will be put through conversion therapy in the US before the age of 18, according to Newsweek. This unscientific “therapy” is intended to change a person who is not both cisgender and heterosexual into a person who is. The techniques are often abusive and centered in conservative Christian ideology. They may even include electric shocks and nausea-inducing drugs. While no benefit has ever been scientifically shown for these procedures, its victims are at a much greater risk for depression, suicide, substance abuse, and PTSD. Several states have banned conversion therapy for minors, including those in the Northeast, Illinois, and the West Coast.

While homosexuality and transsexuality were recognized as naturally occurring human variations by the Institute for Sexual Research in Berlin in the 1920s (the institute was destroyed by Nazis in 1933), the US did not acknowledge them until decades later. Many doctors are now against the barbaric practice of conversion therapy, including the American Psychiatric Association, the American Medical Association, the American Psychological Association, and the American Academy of Pediatrics.

Even after officially denouncing conversion therapy, however, the medical community continues to fail queer people, especially trans people, in many ways. Healthcare workers sometimes deny service to trans people – even emergency, life-saving healthcare. If they do see trans patients, the care provided may be woefully substandard. One young trans boy was so traumatized by how a hospital treated him that he was driven to suicide. A trans woman in Michigan was disrespected and laughed at while trying to get important medical imaging. When her doctor called the manager of the facility to advocate for his patient, he only received further hostility. Moments after that, the manager’s boss called the doctor not to apologize, but to attack him for defending his patient! 

These individual cases of transphobia are being increasingly institutionalized by discriminatory legal practices which sanction the refusal of service to LGBT+ people on religious or moral grounds. The Trump administration in particularThe Trump administration has been working to further restrict LGBT+ access to healthcare services with a perversion of religious freedom laws.

Trans people often have to educate their healthcare providers on trans medicine and the biology of trans bodies, even as they pay ridiculous amounts for healthcare in the US. Trans medicine was for many years a predatory market where surgical techniques were kept secret to boost profits for individual surgeons. It often takes great effort to find providers who will even listen to their trans patients. 

Some doctors claim that they are “not comfortable” or “not an expert” enough to prescribe hormone replacement therapy (HRT), even though the information on how to properly manage it is now easily accessible to medical professionals. 

For many trans people, HRT is an important part of transition healthcare. It shifts their sex hormone levels to bring their bodies more into alignment with what they need to physically experience. Exactly what transition changes are needed and desirable often varies from one trans person to the next, but this is nothing that cannot readily be discussed with and managed by a knowledgeable physician. Unfortunately, many doctors have trans-related medical information that is outdated, inaccurate, or simply absent. Many doctors are not taught about trans-specific medicine or much about how the relevant hormones actually work in human bodies.

Problems in Access to Healthcare

As most people know all too well, health insurance is still a major headache in the era of the Affordable Care Act. Insurance prices on exchanges are often prohibitively high, even with the ADA’s pitiful government contributions. For a person getting paid $40,000 in Queens, New York, the cost of healthcare can be $200 per month or more, on top of a deductible of thousands. 

Even Medicaid is not an alternative. In order to qualify for this service in New York, one must often be too poor to afford rent. Many other states have even stricter criteria, allowing Medicaid coverage only if one has a duly diagnosed and “approved” disability. Getting such a diagnosis can take many years, often longer for women. Getting federal disability can take years beyond that. 

Further, many states still do not allow transition healthcare via Medicaid. Even though the Affordable Care Act and certain state regulations made exclusions of parts of transition healthcare illegal, coverage remains sporadic. The effect of these policies is that people end up stuck in dead-end, exploitative jobs just to keep their healthcare access. Finding a new job is not always an option for LGBT+ people, who are often hit by heavy employment discrimination. Reproductive healthcare like surrogacy, artificial insemination, and sperm banking remain inaccessible to many working class people.

Trans teens are often denied physical or mental transition healthcare unless they obtain parental consent. Denying the autonomy and bodily freedom of trans people, these laws make one’s access to healthcare dependent on parents’ judgment. Many minors are ultimately denied access if their parents are transphobic. One woman even sued her trans daughter who became an emancipated minor in order to get transition healthcare. 

Evidence shows how important gender-affirming care is for reducing levels of depression, anxiety, substance abuse, trauma, and suicide among LGBT+ teens and young adults. Many older trans people often wish that they could have accessed transition healthcare as teens. The harms of this systemic injustice are manifold. 

Those who are kept from HRT as teens often need additional healthcare later in life that they otherwise would not, such as hair removal (or scalp hair replacement), voice therapy, and mastectomy or breast augmentation/reconstruction. Different individuals have different needs, but collective data and experiences continue to indicate the great harm done by systemic medical injustice. The effects on a person’s physical appearance due to an incompatible puberty can lead to social exclusion and employment discrimination.

Poor Availability

Many areas, particularly those outside major cities, have few doctors, if any, who are willing and able to provide competent healthcare for LGBT+ patients. Some trans people travel great distances to see a doctor. Hormone shortages are not uncommon, as evidenced by the current Testosterone shortage in the US. Even when doctors are supportive and knowledgeable, long wait times in hospitals keep patients from care. 

In the US, these issues are driven by the enormous cost of healthcare. The hashtag #transcrowdfund on Twitter is always full of poor trans people struggling to get the healthcare they need. American capitalism has not made more doctors available to those who are insured. Countries with some level of socialized medicine like Cuba, North Korea, Sweden, and Iceland (along with many others) all have more doctors per capita than the US. Housing instability and lack of social support can also be barriers to healthcare.

In the UK, a lack of funding and medical gatekeeping prevent many trans people from accessing the care they need. Transition healthcare is seen as a specialty service, only available through a Gender Identity Clinic (GIC). There are only eight of these, and the process of getting a referral from one’s primary doctor and then an appointment with a GIC can take a long time. If something goes wrong with the paperwork, it can take even longer. Many trans people have had to wait years just to start medical transition, while those with money can go to private doctors.

Gaps in Research and Advocacy

Little has been done in trans medical research since the demise of the Institute for Sexual Research in Berlin in 1933. Trans people still rely on “off-label” uses of pharmaceutical products created to serve the needs of cis people. Fertility treatments to help cis women conceive get a fair amount of attention and research, but almost no one in the medical industry is interested in enabling trans women to give birth. When research is done on trans bodies, it is usually carried out with the aim of discovering why they exist at all. 

Outside of medical circles, activism for bodily autonomy is centered on abortion, though this work often leaves out trans men and non-binary people. While there is activism around issues such as ending non-consensual surgeries on infants with “ambiguous” genitalia at birth or ending requirements for surgery before one can correct the gender marker on official ID documents, These efforts are only a small part of the wider struggle to liberate gender, sex, and sexuality minorities.

How We Can Fix It

More than simple policy change, adequate access to and quality of healthcare will require a complete restructuring of society so that it suits the needs of the many over those of the few. Conversion therapy is already banned in several states, but it needs to be ended everywhere. In April 2019, Representative Sean Maloney from New York introduced a national ban on these procedures. But legislative solutions are slow and uncertain. They can be stopped or reversed by political opponents, or simply not enforced. 

Only mass action by workers and young people can make a difference on this issue. Healthcare unions should demand that conversion therapy and other harms against LGBT+ patients not be permitted at their facilities. Protests or boycotts should focus collective pressure against specific providers that engage in harmful practices. Individual doctors can help with this too by pushing back against homophobia and transphobia.

Fully Inclusive Universal Healthcare

Medicare For All has become a popular slogan among the US left, and while it would be a massive improvement, Medicare for All is not actually a complete solution. It is a hodgepodge of multiple parts to cover hospitals, doctors, and prescriptions. However, important things like dental, vision, post-procedure care, and help getting to and from appointments are not among those services covered by Medicare, or by corporate plans. Some will claim that the cost of running a truly universal healthcare system in the US would be too great, yet the ruling class continues to spend hundreds of billions on war and provides many large corporations with billions in tax refunds.

The healthcare system also needs to go beyond merely doing procedures and writing prescriptions. People who are in one or more parts of the queer umbrella are more likely to have little or no family and social support due to society’s bigotry and cissexist beauty standards. These factors can prevent people from getting the healthcare they need because they have no one to pick them up from a procedure or support them during recovery. 

Doctors often will not do important procedures or treatments for patients that do not have this support. One study found that doctors gave less effective treatment to cancer patients who were single than to those who were married, assuming single people lack social support. That is not necessarily the case, but it points to the deeper problem of how the healthcare industry treats people who do lack support. Since we live in a very homo- and transphobic society, this is more likely to happen to queer and trans people than the average person. To be actually inclusive, healthcare needs to provide support for people dealing with serious or chronic illnesses or recovering from a procedure.

Research

Nearly all information on trans people’s physical health is “anecdotal” information compiled by trans people themselves in the midst of their day jobs and surviving systemic oppression. LGBT+ people in general and trans women in particular suffer from chronic physical illnesses at a greater rate than the general population, in addition to being at greater risk for mental illness and substance abuse. These risks do not come from being trans but from systemic oppression. Yet little if any high-quality research on trans people’s physical health is ever done. We need more research on better medical techniques and technology to improve trans health and bodily autonomy. 

Who Does the Medical Industry Really Serve?

Beyond being the targets of oppression, queer and trans people (and disabled people—the two groups overlap more than one might think) are a small and usually poor segment of the population and thus not a big money maker for capitalist healthcare. The industry bosses tend to focus on that which could lead to big profits in a large market, not research on issues affecting a small group that may or may not ever yield a hefty payday. 

Putting the healthcare industry in the democratic control of the working people, with protections for the rights of marginalized people, would allow society’s collective resources and labor to be focused on that which will improve human lives and health (such as better healthcare and housing) instead of destroying them (via war, pollution, etc). We are now living in a time in history when humanity can least afford the recklessness of profit obsession, but a new society that fails to do right by its vulnerable minority groups will be no better than the current one.

Even Medicare For All is insufficient for providing fully inclusive healthcare to everyone. The structure of the healthcare system must be rebuilt to ensure that no one is left out in any way. This new structure also must serve the needs of its patients and its workers, not those of rich executives and stockholders who neither work in nor require the services of clinics and hospitals in poor city neighborhoods and rural areas.

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