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How do you find the balance between Mental Safety and Physical Safety for Transgender Youth?

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How do you find the balance between Mental Safety and Physical Safety for Transgender Youth?

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Danielle and Steven Boyer, from a rural town in Ohio, face significant decisions regarding their 12-year-old daughter, Ryace, who is transitioning from male to female. They are considering whether to allow her to begin treatment with puberty blockers and hormone therapy at Akron Children's Hospital, which could halt undesirable physical changes. Gender-affirming care, such as recognizing a child's chosen name and allowing them to dress according to their gender identity, is essential before any medical intervention. Experts stress the need for further studies to understand the impact of medical transition on suicidal thoughts compared to social transition or delayed treatment. Ultimately, parents must carefully weigh the safety and well-being of their child, striving to achieve a balanced approach to their mental and physical health.

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CHAD TERHUNE, ROBIN RESPAUT, and MICHELLE CONLIN

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As children line up at gender clinics, families confront many unknowns

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Thousands of transgender U.S. youths are medically transitioning. The treatments they receive have little scientific evidence of long-term safety and efficacy.

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Does Discrimination Towards Trans Youth Patients Exist in Healthcare?

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Does Discrimination Towards Trans Youth Patients Exist in Healthcare?

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Every level of antitransgender prejudice is fueled by cultural and institutional cissexism an ideology asserting that cisgender individuals and their lived experiences hold more authenticity and legitimacy than those of transgender individuals. On a societal scale, systemic and personal biases position transgender individuals as frequent victims of discrimination, harassment, violence, and mistreatment across various areas of their lives. The 2015 US Transgender Survey revealed that, overall, transgender individuals experience disturbingly high lifetime incidences of verbal harassment , physical attacks , workplace bias , negative experiences in primary and secondary education , and further issues in undergraduate education , in addition to homelessness within the last year due to their gender identity.

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Journal of Ethics | American Medical Association

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Abstract

Transgender people commonly experience discrimination from clinicians, which directly contributes to worse mental and physical health outcomes among this population. This article describes mechanisms by which stigma perpetuates health inequity among transgender patients and highlights its unique effects on transgender patients of color. The article concludes with recommendations to cisgender clinicians on how to help prevent stigmatizing interactions with transgender patients.

Introduction

People who are transgender experience discrimination in every aspect of their lives, including health care settings. Perceived discrimination by clinicians contributes to health care avoidance, increased substance use, poor general health, and poor mental health among transgender individuals. 1,2,3 Moreover, transgender people of color (TPOC) experience even higher rates of gender-based discrimination by clinicians and have worse health outcomes than their White counterparts. 4,5,6 In this article, we describe mechanisms through which clinicians and health care systems perpetuate stigmatization of transgender patients. We also describe how compounded cissexist and racial discrimination shapes unique health inequities experienced by TPOC. Finally, we offer recommendations that cisgender clinicians can enact to prevent stigmatization of transgender patients.

Antitransgender Stigma

Stigmatization is a social process whereby human differences are identified, labeled, and linked to negative stereotypes, resulting in the social devaluation of labeled groups. 7,8 People who are labeled experience a loss of status, which adversely affects their capacity for upward social mobility, their overall life chances, and their health. ⁹ One widely accepted framework of stigma conceptualizes it as occurring at 3 different levels: structural, interpersonal, and individual. 9,10

Structural stigma refers to the systematic devaluation of people through institutional policies and cultural norms that limit access to important social resources. Interpersonal stigma refers to discriminatory actions carried out against a person due to the perpetrator's conscious or subconscious negative views about a labeled group. Finally, individual stigma refers to the negative beliefs individuals have about themselves due to the internalization of structural and interpersonal stigma. ¹⁰ From a sociocultural perspective, stigma is believed to encourage conformity to social norms by punishing those who display attributes associated with labeled groups. ⁷

Antitransgender stigma at every level is generated by institutional and cultural cissexism-an ideology that holds that cisgender people and their experiences are more natural and legitimate than those of transgender people. 9,11 At a societal level, structural and interpersonal stigma render transgender people targets of discrimination, harassment, violence, and mistreatment in every aspect of their lives. ⁹ The 2015 US Transgender Survey found that, as a whole, transgender people face alarmingly high lifetime rates of verbal harassment (46%), physical assault (9%), workplace discrimination (30%), mistreatment in primary and secondary education (77%), and mistreatment in undergraduate education (24%), as well as homelessness within the past year (12%) because of their gender identity. ¹²

In health care settings, interpersonal stigma against transgender people is common. In fact, participants in the 2005-2006 Virginia Transgender Health Initiative Study reported experiencing health care discrimination more commonly than employment discrimination or housing discrimination. ¹³ One-third of respondents of the 2015 US Transgender Survey who had seen a health care practitioner in the preceding year reported at least one negative health care-associated experience related to being transgender. ¹² Overt acts of discrimination by clinicians include refusal of services because of gender identity, abusive language, physically aggressive treatment, and attempts to stop patients from transitioning gender. 14,15 More insidious displays of interpersonal stigma include misgendering and deadnaming patients. Misgendering is the repeated use of gender pronouns inconsistent with a person's current gender identity (eg, using "he" or "him" when referring to a transgender woman), while deadnaming is the use of a patient's legal or former name rather than their chosen name. 16,17,18 Clinicians also stigmatize transgender patients by asking them intrusive questions about their private lives out of personal curiosity, such as inquiring about their genitals, their sexual partners, or their sexual activity during encounters in which that information is not medically relevant. 16,19

Structural stigma against transgender persons within the health care system is also pervasive. One prominent example is pathologization of transgender experiences in reference works such as the Diagnostic and Statistical Manual of Mental Disorders. ²⁰ For example, gender dysphoria is a miscodification that pathologizes normal gender variance and contributes to delegitimization of transgender individuals' experiences by characterizing transgender persons as mentally disordered. 20,21 Moreover, that transgender people seeking to obtain medical interventions, such as hormone replacement therapy or gender-affirming surgery, are routinely made to undergo psychological evaluation before receiving treatment implies that transgender individuals are not competent enough to make these kinds of medical decisions on their own. ²² Electronic health records that do not allow for accurate documentation of gender identity, gender pronouns, or chosen names also promote erasure of transgender identities and can lead to stigmatizing experiences, such as misgendering or deadnaming. ²³

Minority Stress Among Transgender People

The minority stress model developed by Ilan Meyer provides a framework for conceptualizing how stigma, prejudice, and discrimination create hostile social situations that result in higher prevalence of mental health disorders among sexual and gender minorities. ²⁴ The 3 steps of this model proceed as follows: (1) hostile interpersonal interactions resulting from an individual's transgender identity create overt stress and/or physical harm; (2) the individual then learns to anticipate and watch for situations that may lead to repeated instances of stress or harm; and, eventually, (3) the individual internalizes the negative prejudices and stereotypes held by society, leading to increased psychopathology. ²⁵ In other words, experiencing enacted stigma produces anticipated stigma, and both ultimately contribute to the worsening of individual stigma.

Transgender individuals who experience stigmatizing events in health care settings are more likely to delay or forgo future care out of fear of discrimination. 1,2,13,25,26,27,28 Avoiding health care secondary to anticipated discrimination from clinicians is associated with mental health pathology, including depression, suicidal ideation, and suicide attempts. 25,29,30 Additionally, some transgender people engage in the use of recreational substances such as alcohol, cigarettes, vaping, and marijuana to cope with emotional consequences of discrimination, including health care discrimination. 3,25,31,32,33 New research is beginning to reveal the ways in which minority stress among transgender individuals contributes to physical disease through immune dysregulation, chronic inflammation, and elevated cortisol levels. 34,35,36

Minority Stress Among TPOC

TPOC experience compounded forms of minority stress due to the overlapping effects of cissexism and racism, and they are more likely to face barriers to health care access and to experience worse health outcomes than their cisgender peers of the same race. 5,6,37 Among transgender individuals, those who hold the additional marginalized identity of being a person of color are at increased risk of experiencing overt health care discrimination because of their gender identity. Notably, they are more likely than White transgender people to be discriminated against by physicians in hospitals (26.1% vs 18.5%) and emergency rooms (16.8% vs 10.1%) and by paramedics in ambulances (8.6% vs 3.0%). ⁴ TPOC are also more likely than White transgender individuals to experience discrimination when accessing social services such as mental health clinics (14.1% vs 9.1%), drug treatment centers (5.6% vs 1.9%), domestic violence shelters (9.6% vs 4.1%), and rape crisis centers (7.3% vs 3.9%). ³⁸

Clinicians also stigmatize transgender patients by asking them intrusive questions about their private lives out of personal curiosity.

In interpersonal interactions with clinicians, TPOC are more likely than their White counterparts to experience refusal of physical touch (18.4% vs 14.7%), to be denied medical care (28.7% vs 26.4%), to be subjected to harsh language (25.9% vs 19.7%), and to experience physically rough or abusive treatment (9.6% vs 7.3%). ¹⁵ Consequently, TPOC experience a greater anticipated fear of health care discrimination. ¹ Ultimately, TPOC are more likely than their White counterparts to have concerns that their gender identity will be a significant barrier to obtaining medical care (53.5% vs 51.8%). ¹⁵

Recommendations

Clinicians have a responsibility to recognize the ways in which they directly contribute to the perpetuation of health disparities among transgender patients. Although action at a social and structural level will be necessary to bring about the greatest amount of change in care delivery and overall health for this patient population, clinicians can act at an individual level to prevent the stigmatization of transgender patients. To this end, we present several recommendations that cisgender clinicians can implement.

Signal an inclusive clinical environment. Help ease patients' fear of health care discrimination by openly communicating a commitment to gender-affirming care. Prominently display your clinic's nondiscriminatory policy indicating protection against discrimination based on gender identity. Use visual cues, such as rainbow-colored "safe space" signage on your office door, website, or work badge. Additionally, consider submitting your contact information to online directories of trans-affirming health professionals, such as Trans in the South or GLMA's online provider directory. 39,40

Employ gender sensitivity in communication. Recognize that language can intentionally and unintentionally lead to marginalization and stigmatization of transgender individuals. ⁴¹ Train staff members to avoid using gender-specific language until they know the patient's name and pronouns. ² Use affirming questions on intake paperwork, such as "What is your gender identity?" "What was your designated sex at birth?" "How do you self-identify by name and pronouns?" 42,43,44 Respect patients by using names and pronouns with which they identify. If you use incorrect gender pronouns, offer a brief but sincere apology and correct the mistake. ¹⁷ In addition to preferred name and pronouns, ask patients which words they prefer to use for their body or employ ungendered and neutral language, such as "external genitals" rather than "male genitals" or "penis." ⁴⁵ Familiarize yourself with gender inclusive terminology by referencing a glossary of transgender terms. 11,46,47,48 Avoid asking patients intrusive questions regarding genitals, sexual partners, or sexual activity. Finally, unless medically necessary, refrain from performing a genital exam, as such exams can cause significant anxiety and distress for many transgender people.

Consider multiple marginalized experiences. TPOC experience unique forms of discrimination and have worse health care access and health outcomes than their White transgender and cisgender counterparts. 1,4,5,6,32 When caring for transgender patients with multiple marginalized identities, recognize that unless you share the same set of marginalized identities, you lack a full understanding of their circumstances and experiences. ⁴⁹ Contemplate how your personal biases and lack of shared life experiences may shape your clinical decision making to the patient's detriment. Acknowledge the power differential inherent in the patient-physician relationship and relinquish some of that power by engaging the patient in shared decision making that takes their unique circumstances into account, allowing them to lead the way. ⁴⁹

Engage with the transgender community. Although clinical knowledge regarding biomedical aspects of transgender care is important and necessary, it is equally important to seek out opportunities that increase your exposure to gender minority patients. ¹⁴ One way to do so is by enrolling in a cultural competency training session at a local lesbian, gay, bisexual, transgender (LGBT) resource center or through an online platform such as the National LGBTQIA+ Health Education Center. ⁵⁰ Collaborating with these groups in respectful and supportive ways fosters trust and helps to destigmatize transgender people. ⁵¹ Although less interactive, media-such as documentaries, books, news articles, or scholarly literature that feature transgender narratives-are also easily accessible resources for familiarizing yourself with the experiences of gender minorities. ⁵²

Avoid pathologizing and gatekeeping. Recognize that, according to the World Professional Association for Transgender Health's Standards of Care, a diagnosis of gender dysphoria is not required for adult patients to access transition-related interventions. 20,47 Become familiar with the difference between using gender dysphoria as a diagnostic label and to enable access to gender-affirming care, and only use it when genuinely necessary in order to avoid pathologizing transgender patients. ²⁰ Implement an informed consent model for hormone therapy initiation instead of requiring adult patients to obtain a psychological evaluation before beginning treatment. 22,53

Although these steps alone will not lead to large-scale changes, they can mitigate some of the most common structural barriers that prevent many transgender patients from accessing gender-affirming care. In addition, consider how you can promote broader structural change by wielding the influence you have in positions of power-such as your seat on a medical board, your academic rank, or your connections to policymakers-to amplify the voices of transgender people. Clinicians in any capacity should feel empowered to promote equity for transgender individuals through advocacy in-and that extends beyond-their communities and their institutions. ⁵¹

Conclusion

There is a wealth of evidence demonstrating that clinicians perpetuate the stigmatization of transgender patients, leading to poor health outcomes in this vulnerable population. TPOC are disproportionately affected by health care discrimination and inequity. Large-scale organizational changes that reject structural cissexism and racism, in conjunction with public health initiatives and policy changes, will be necessary to bring about the greatest degree of change for this population. Cisgender clinicians can act on a personal level and on a broader scale to prevent the stigmatization of transgender patients in health care settings.

Editor's Note

Background image by Michaela Chan.

Citation

AMA J Ethics. 2022;24(8):E753-761.

DOI
10.1001/amajethics.2022.753.
Conflict of Interest Disclosure

The author(s) had no conflicts of interest to disclose.

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.

Author Information

Antonio D. Garcia is a third-year medical student at the University of Texas Southwestern Medical Center in Dallas. His research interests include language barriers in health care, racial and ethnic disparities in health care, and gender minority health disparities.

Ximena Lopez, MD is a pediatric endocrinologist and associate professor at the University of Texas Southwestern Medical Center in Dallas. She is the founder of the GENder Education and Care Interdisciplinary Support Program, which provides multidisciplinary care to transgender and gender diverse youth.

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How Cisgender Clinicians Can Help Prevent Harm During Encounters With Transgender Patients

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Transgender people commonly experience discrimination from clinicians, which directly contributes to worse mental and physical health outcomes.

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Transgender Youth Have Rights that need to be Protected before the U.S. Government permanently Takes it Away. 

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Transgender Youth Have Rights that need to be Protected before the U.S. Government permanently Takes it Away. 

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Access to these life-saving gender-affirming healthcare resources is crucial for transgender youth. There exists a significant gap in traditional metrics of quality of life between trans youth experiencing untreated dysphoria and their cisgender counterparts. Numerous empirical studies demonstrate that while it does not completely eliminate this disparity, medical transition significantly reduces it. This section outlines the advantages of gender-affirming care for trans youth across three dimensions: mental health, social acceptance, and legal rights. Although categorized separately for clarity, these dimensions frequently overlap and support each other in practice.

(a) Mental Health. — The experience of untreated dysphoria in transgender youth is linked to profound mental health issues, such as depression, social anxiety, and suicidal ideation and actions. Research on the initial psychological profiles of trans youth indicated that 20% exhibited "moderate to severe" depressive symptoms, with their reported rates of suicidal thoughts and attempts being at least threefold higher than those of the general adolescent demographic. More than half expressed having contemplated suicide, and a third had made at least one attempt.

In contrast, an extensive range of research indicates that transgender youth who receive gender-affirming healthcare to address their dysphoria experience reduced anxiety, depression, suicidal tendencies, and psychological distress, while enjoying improved quality of life. Trans children permitted to socially transition before reaching puberty tend to show relatively normal levels of anxiety and depression, which is "starkly different" from that of non-transitioned trans youth. A longitudinal study tracking trans adolescents before and after they accessed gender-affirming care revealed that their psychological well-being consistently enhanced throughout the treatment period, resulting in overall wellness that was "similar to that of [their] same-age peers."

In early 2020, legislators in fifteen states proposed bills aimed at prohibiting medical professionals from providing gender-affirming healthcare to minors. The specifics and wording of these bills are notably alike. Almost all of them (with some minor variations) prohibit all state medical professionals from administering puberty blockers, HRT, or performing gender-affirming surgeries on individuals under eighteen, with significant exceptions for minors possessing "medically verifiable" developmental disorders or intersex conditions. Most proposed legislation aims to criminalize the provision of gender-affirming care; in Idaho, for instance, a violation of the prohibition may incur a felony charge leading to a life sentence. By hindering any state-licensed medical provider from furnishing gender-affirming care, the bans would effectively deny transgender youth access to necessary services unless they could travel out of state. Consequently, this would disproportionately impact trans youth from marginalized socioeconomic backgrounds and communities of color, who are less likely to have the financial means to travel across state lines or to relocate for necessary care. None of the fifteen bills proposed in early 2020 were enacted into law. Nonetheless, this situation serves as an ominous sign of the trajectory of U.S. government policies concerning the prohibition of transgender healthcare.

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Outlawing Trans Youth: State Legislatures and the Battle over

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As soon as I realized that I was not happy in my body, I went up to my parents to fix it. And it felt as natural as going up and being like, “Hey, I’m hungry.” I was just kind of

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Do the States in America have the right to Deny Mental Health Care to Transgender Youth?

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Do the States in America have the right to Deny Mental Health Care to Transgender Youth?

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The insufficient funding for mental health services in North Carolina is having a profound effect on transgender youth. Numerous transgender adolescents, such as Callum Bradford from Chapel Hill, face challenges in obtaining tailored mental health support. North Carolina stands as one of at least 22 states that have implemented laws to restrict or prohibit gender-affirming medical care for minors.

The deficit of financial resources and trained professionals often results in hospitals being unable to deliver sufficient assistance for transgender adolescents in crisis, occasionally worsening their trauma. Furthermore, a survey indicated that 58% of LGBTQ youth in North Carolina who pursued mental health services in the preceding year were unable to receive it.

This circumstance underscores the critical need for enhanced funding and resources to bolster the mental well-being of transgender youth in the state.

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Lack of mental health funding is impacting transgender youth in North Carolina

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Guidelines can Help Health Care Workers know the parameters to Work Around to Give Equal Rights of Care. 

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Why are Guidelines Important to keep Transgender Youth Safe?

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Why are Guidelines Important to keep Transgender Youth Safe?

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The guidelines’ overall objectives are to support the provision of care to young people without discrimination and to address concerns expressed by families and health professionals regarding attempts to characterize gender-affirming treatment as “abuse”. This post will

demonstrate how the state of Texas attempts to label anyone who supports treatment that is gender-affirming as abusing children. It will discuss the inquiries and legal actions Texas is

bringing against caregivers and parents of young transgender individuals. I will present an overview of gender-affirming care, the OCR’s guidance, section 1557 and section 504, 1557 also HIPPA, and remedies to protect individual rights. Keeping Trans youth safe is very important.

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State bills restricting access of transgender youth to health care, school facilities, and school athletics threaten health and well-being.

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Aren't the Schools Supposed to Advocate for Students?

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Aren't the Schools Supposed to Advocate for Students?

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Recent legislative measures aim to limit healthcare access, school facilities, and participation in athletics for transgender youth. Such restrictions can have detrimental effects on the health and overall well-being of transgender minors. Some of the adverse consequences include:

Blocking access to essential medical treatment
Government-endorsed prejudice and discrimination
Restricting involvement in educational activities unduly harms health and well-being these measures present a dangerously misleading representation of what constitutes evidence-based, medically sound care for transgender children and adolescents.

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The reason I chose Current Healthcare Issue. The LGBTQ+ Community had to fight hard for the same rights as Heterosexuals. The LGBTQ+ men and women were discriminated against, bullied, and Killed because of their sexual orientation. LGBTQ+ now have rights like same-sex marriage. And equal rights to prosecute individuals who assault Gay Men, Gay Women, or transgender. Our Transgender Youth need to have the same rights and protection. Their Mental health needs to be protected and our States and country shouldn't deny Mental Health care from our Transgender Youth.