Micro Interactions, Macro Harms: Some Thoughts on Improving Health Care for Transgender and Gender Nonbinary Folks

For a variety of reasons, it's difficult to determine, with any accuracy, the number of trans and gender nonbinary folks living in the United States.¹ Data are difficult to obtain since neither the U.S. Census Bureau nor the Centers for Disease Control and Prevention (CDC) survey people's gender identity (Chalabai 2014). But even if they did, responses would likely be unreliable. Many members of these two groups are hesitant to answer such questions for fear of their safety, resulting discrimination, or because they disagree on the definition of what it means to be transgender (Chalabai 2014). It's also difficult to obtain accurate numbers on these groups since most medical forms still rely on a two-sex system of identification (male and female), do not ask about gender identity, and fail to provide the categories "transgender," "transman," and "transwoman." But even if medical forms did provide such options, many trans folks wouldn't check them since they identify as either male or female. The most recent study on this topic (as of September 2017) estimates that one in every 250 adults or almost one million Americans are transgender (Meerwijk and Sevelius 2017). However, it's likely that even this number is lower than the actual number of transgender individuals since many fear outing themselves as transgender for the reasons mentioned above.

Even trickier than obtaining an accurate number of transgender people is obtaining statistical data on people who are gender nonbinary since the category itself is so diverse, and also because, as with trans folks, there are no agencies that track this information (see Eckstrand et al. 2016 for a helpful discussion on this matter²). Moreover, few if any medical forms provide patients with options like "genderqueer," "agender," or "gender nonbinary." Like many trans folks, gender nonbinary folks also tend not to out themselves in public forums, on demographic forms, and, in particular, in medical contexts. In fact, many nonbinary folks choose to identify as either male or female within those contexts precisely to avoid mistreatment, discrimination, and other psychological harms (Harrison et al. 2012; Freeman 2017). Thus, we have no accurate numbers of how many people fall into this group either. Precision aside, it is the case that there are a large number of people who are either transgender or gender nonbinary, and all of them both require and have a right to access high quality health care. Yet, for a variety of reasons, it is the case that many members of these groups do not receive such care.

According to the 2015 U.S. Transgender Survey (Veale et al. 2015), the largest survey of its kind with responses from over 28,000 participants, trans-gender individuals are systematically discriminated against in health care settings. According to the survey, 23 percent avoid seeking necessary health care for fear of negative interactions with health care providers, and 33 percent are unable to afford health care at all. In Canada, where health care is more accessible than in the United States, 20 percent of transgender people surveyed have avoided visiting the emergency department due to fear of negative consequences from providers (Bauer et al. 2009³). For those who were able to access health care services, they reported negative interactions like harassment; others were refused services altogether on account of their being trans. In a more recent survey of transgender youth in Canada, though 70 percent of participants had a family doctor, only 15 percent of them felt "very comfortable" talking with their doctors about their trans status and trans-specific health care needs (Veale et al. 2015, 33). It is also quite common for transgender youth to use walk-in clinics for their health care needs. As one seventeen-year-old participant in British Columbia Canada noted:

I feel uncomfortable [with walk-in clinics] because almost consistently, the older doctors I see looking to get a refill on my [hormone prescription] don't understand what being trans is, and will treat me with skepticism and concern, sometimes refusing to give pills at all...