Transgender patients and their health providers fear worsening discrimination
Kelly Houske was walking her dogs one morning when she developed stabbing pain in her back that brought her to her knees. Houske, who had survived her first heart attack only a year earlier, was worried she was experiencing a second.
When Houske arrived at a local emergency room by ambulance, she hoped for compassionate treatment. Instead, her doctor appeared cold and kept his distance, standing in the doorway without ever entering her room, Houske said.
An imaging technician ignored how much pain she was suffering and shouted at her, Houske said. Rather than help her out of the scanner, the technician barked at her to climb out of the machine herself.
'I was in so much pain I could hardly move,' said Houske, 67, whose back pain was later found to be caused by kidney stones. The technician 'kept saying, 'Come on, come on, come on,'' she recalled. 'He didn't offer to help.'
When Houske tried to stand on her own, she crumpled to the ground.
The tech stood over her impatiently, Houske said, but didn't help her off the floor. 'Eventually, someone else came into the room and helped me get up,' she said.
The 2017 encounter at a Tennessee hospital was one of many instances in which Houske, who is transgender, said she has been mistreated by a health care provider. Surveys show that mistreatment of trans patients is common — including verbal harassment or refusal of care — sometimes leading them to delay or avoid seeking care.
Many advocates for transgender people say they fear treatment of trans patients will suffer further under President Donald Trump, who has issued a slew of executive orders in recent weeks restricting transgender rights, including several that seek to limit access to transition-related health care.
In a report published in Psychiatric News last month, physicians who work with transgender patients said the executive orders have led to widespread distress among their trans patients.
And according to a report released last month from the UCLA School of Law's Williams Institute, an LGBTQ think tank, almost three-quarters of trans patients surveyed after the presidential election said they are concerned that the quality of their health care will decline under Trump. About 80% of respondents, who were surveyed before Trump took office, said they planned to make changes to their behavior, appearance or speech to downplay visibility as transgender people. One-third said they were socially isolating and avoiding public places and activities.
Shawn Reilly, a transgender community organizer in Nashville, Tennessee, said he is concerned that Trump will roll back protections for trans patients established by the Obama and Biden administrations. Reilly said they fear health providers will be allowed to withhold care from trans patients.
'Stripping transgender people and all sexual and gender minorities of protections while they are trying to access a basic human right — health care — is inhumane and unjust,' said Reilly, a former coordinator of the 'trans buddy' program at Vanderbilt University Medical Center in Nashville, which provides trained advocates to accompany transgender patients on medical visits.
Neither the Department of Health and Human Services nor the White House responded to requests for comment about the concerns of transgender people, along with their health care providers and advocates, about their treatment in health care settings.
Targeting transgender people
During his first term in office, Trump issued a policy that reversed an Obama-era nondiscrimination rule for transgender patients.
Although Trump hasn't yet issued a new rule on health care discrimination, a web page created by the Biden administration, which explained legal protections for transgender patients, is now blank.
Trump's actions in the first months of his second term have raised alarms, Reilly said.
In one of his first acts after he was inaugurated, Trump issued an executive order that denies legal recognition to transgender people. The order says that 'it is the policy of the United States to recognize two sexes, male and female. These sexes are not changeable.'
The word 'transgender' has disappeared from government websites, although some deleted web pages have been restored because of a court order. Trump has also canceled research grants for projects related to transgender health.
As part of the effort to fight what Trump calls 'gender ideology,' the Department of Veterans Affairs said last month that it will phase out coverage of gender transition care for veterans.
Through additional executive orders, Trump has tried to restrict access to gender-affirming care for transgender people under age 19, ban trans people from serving openly in the military, ban trans athletes from women's sports, require incarcerated trans women to be held in men's prisons and eliminate protections for trans students in elementary and secondary schools, such as allowing them to use the bathrooms of their choice.
Advocacy groups have challenged many of Trump's executive orders in court. Federal judges have issued temporary restraining orders on the gender-affirming care ban, the prison order and his ban on trans people enlisting or serving in the military.
Legal protections in flux
Legal protections for transgender patients are grounded in the Affordable Care Act, which bans discrimination in medical settings and health insurance based on race, color, national origin, age, disability and sex. People who have faced illegal discrimination can file complaints with the Department of Health and Human Services, which can withhold federal funds from institutions found to have violated the law.
Every president has interpreted the law differently, however. While Presidents Barack Obama and Joe Biden issued rules stating that the ban on sex discrimination also prohibits mistreatment based on sexual orientation or gender identity, Trump's first administration interpreted sex discrimination as applying only to 'the plain meaning of the word 'sex' as male or female and as determined by biology.'
Groups that disagree with those various interpretations have sued, leading judges to place sex discrimination rules issued by Obama, Biden and the first Trump administration on hold.
Anti-discrimination policies still exert powerful effects, said Elana Redfield, federal policy director at the UCLA School of Law's Williams Institute.
The Obama and Biden administrations' policies helped institute 'cultural norms requiring health providers to consider the needs of trans patients, even in places where state-level protections were not in existence yet,' Redfield said.
Trump could also cause harm by rolling back legal protections for transgender patients, Redfield said, because health care providers might feel emboldened to deny them care.
'If the federal government permits, or even condones, discrimination, it is likely that would galvanize those who already don't want to treat trans people,' Redfield said.
Without a federal rule protecting their rights, transgender patients could lose the ability to file complaints against health care providers with the Department of Health and Human Services. They could still sue health care providers or insurance companies in court, but that process is 'much more burdensome' than filing complaints with the federal health agency, Redfield said.
A small number of transgender patients have successfully sued health care providers for discrimination based on the language in the ACA, said David Stacy, vice president of government affairs for the Human Rights Campaign, which advocates for LGBTQ rights.
'It is crucial that we continue to protect transgender patients, who already face immense obstacles when accessing care,' Stacy said. 'Our leaders should be committed to ensuring that everyone can get the health care they need safely and without the fear of being mistreated.'
Some states, such as California, have their own laws protecting transgender patients from discrimination, Redfield said.
But others are already following Trump's example in restricting or trying to restrict the general rights of transgender people. In late February, Iowa struck gender identity from the state's civil rights law, making it the first state to remove civil rights from a previously protected class.
About 0.6% of U.S. adults identify as transgender, according to the Pew Research Center. Transgender patients suffer from worse physical and mental health than other patients and are less likely to have health insurance.
Houske said she can understand why some trans patients delay or avoid care.
'It's a lot of work emotionally' to see a doctor, Houske said. 'If you're doubting yourself at all, it's really hard. It's going to cause you not to seek the care you really need.'
Threats to educational efforts at hospitals
Houske said she sometimes tries to break the ice with new doctors by asking whether she is the first transgender person they have treated.
'I just try to address the elephant in the room,' said Houske, who now lives in Ohio.
Dr. Alison Haddock, president of the American College of Emergency Physicians, said health professionals should 'deliver maximally compassionate care' to all patients, including those who are transgender.
'It is absolutely foundational to emergency medicine that our door is open to anyone,' Haddock said. 'We need to make sure that we are always delivering care that is consistent with that ethos.'
Some medical schools and professional societies, such as the American College of Emergency Physicians, offer training in the health needs of LGBTQ patients, Haddock said.
'I can attest to this being a much stronger part of the curriculum than when I was in medical school,' said Haddock, who is also a dean at Washington State University's medical school.
Yet critics say medical schools aren't adequately educating the next generation of doctors to care for LGBTQ patients. Many practicing doctors say they have had little training in transgender health issues and feel unprepared to treat trans patients.. Of all the state-level medical boards in the country, only the District of Columbia's requires doctors to receive continuing education in treating LGBTQ patients, according to the Federation of State Medical Boards.
And while the American Medical Association and the American Society for Health Care Risk Management offer educational courses about LGBTQ health and reducing bias, some health care leaders say other efforts could be throttled by Trump's campaign against diversity, equity and inclusion, or DEI. Many universities and private companies, for example, are ending DEI programs for fear of losing funding or contracts.
'The political environment is making it really difficult' to include sexual orientation and gender identity in medical school courses, said Dr. Atul Grover, executive director of the Association of American Medical College's Research and Action Institute.
'We have lawmakers at the state and federal level who are convinced that incorporating the concepts of inclusion, health equity and diversity is taking away from the scientific content of what we're teaching,' Grover said. 'But it does not. These concepts aren't mutually exclusive.'
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