1. One of my clinical and research interests includes mental health issues for transgender people, which includes getting access to gender-confirming medical services and positive interactions with the medical community.
Four structural issues within healthcare delivery that might be implicated in health care disparities for transgender people include:
1. Whether health insurance covers transgender health care including access to hormone replacement therapy and gender-confirming procedures and surgeries. In addition, transgender people face higher rates of unemployment, which gives them less access to health insurance and less ability to pay for medical care out-of-pocket. This health care is needed to ease gender dysphoria which contributes to depression, anxiety, substance use, and suicidal ideation/attempts, all of which are greatly increased in transgender people compared to the general population. People need a formal diagnosis of "gender dysphoria" which has changed from "gender identity disorder" to receive care, and this can also be a structural block if physicians are not educated enough on trans issues because gender identities can present very differently. The updated DSM-V criteria for gender dysphoria is more inclusive which is an improvement.
2. Even when health insurance is present, not all transgender-related procedures are covered. For example, breast augmentation surgery may not be covered for transgender women (I met a transgender woman who had to fight Kaiser in order to get this procedure covered). Not having access to gender-confirming procedures again increases symptoms such as anxiety, depression, substance use, and suicidality for transgender people.
3. Whether health care systems acknowledge transgender identities within administrative procedures, such as having more than two gender categories in paperwork. Transgender people need specific medical care that cannot be determined by only having 2 cisgender categories - male and female. New systems need to be in place for things like routine reminders for care for transgender people, which may be different than for cisgender people (ie regular pap smears for transgender men). Disparities may occur if transgender people do not get routine care or trans-specific care due to issues like administrative gender identifiers.
4. Many structural issues that lead to micro-aggressions regarding gender identity may occur. For example, in the electronic medical record, there may be no way to indicate preferred name, so every time a client checked in, the front desk would call them by legal name rather than preferred name before it was legally changed. Even when written in patient-specific notes to call them by their preferred name, this would get missed, and the client would have to speak up or feel uncomfortable each time they visited the office. These micro-aggressions, as they add up, can make interactions with the medical system very unpleasant and stressful, decreasing motivation to seek health care.
2. Individual physicians contributing to health care disparities. For transgender people, physicians need to be specifically trained in the latest health recommendations for trans people, as well as trained in cultural competence with gender-nonconforming and transgender people. Many biases exist towards trans people, and physicians would need to be aware what biases they may have and have strategies to work through them. Micro-aggressions (such as calling someone their birth name or the wrong pronoun) are very stressful and can discourage trans people from seeking care. Also subtle interpersonal cues are important - such as eye contact. Patients may be denied the care they need if physicians take too literal a reading of transgender healthcare recommendations. Care should be determined on a case-by-case basis, and physicians should consult with each other. For example, at a transgender health conference, I witnessed a doctor asking for consultation given that she had a teenage patient who identified as agender (not identifying as any particular gender) who was put on hormone blocking therapy, and did not wish to seek any kind of further hormone treatment (estrogen or testosterone). What is the ethical decision in this case, particularly that the patient is not of legal age yet?
As a clinical psychologist, I was given little to no formal training in mental health issues for transgender people. I consulted with supervisors and luckily had some colleagues who were experts in the area. I often was educating my supervisors and peers as I learned more, and I know I wasn't formally prepared to work with transgender people, and may have made some people uncomfortable before I became more educated. Especially when working with mental health issues, trust and comfort are necessary to build a good therapeutic rapport to do deeper work. The medical and psychiatric systems have historically also been roadblocks to trans people getting care they need. The structural system of needing psychological clearance before receiving hormone therapy is one example, and is called "gatekeeping" within the trans community.