Issues in Transgender Health Care
Special Thanks to Shawn O'Neil for his editing and proofreading.
Issues in Transgender Health Care
Miranda Larocque
Northern Michigan University
April 11, 2010
Transgender individuals are an at-risk population that is often overlooked, even by the LGBT (lesbian, gay, bisexual, and transgender) community of which it is a part of. Transgender people serious issues when attempting to receive health care as well as health insurance and monetary support to assist with the formidable expenses of their health care. Transgender individuals are a very small minority, and are also considered a minority within the LGBT community. This paper will focus on the a lack of support in health care for transgender individuals. It will explore the reasons for that lack of support, along with ways transgender people currently attempt to address these issues. A discussion on the importance of social work professionals awareness and advocacy for change for this at-risk population, and some suggestions for steps toward change will also be present.
To understand the lack of support the US health care system gives transgender people, it is important to understand the health care needs of transgender individuals. To do that, it is equally important to discuss the social construct of gender, in which a dichotomy is forced. In our society, as Raine Dozier explains, sex and gender are viewed as synonymous. However a more accurate description of these terms is explained by the example that biological sex can be viewed as the “coat rack” on which gender is formed. Biological sex is the definition for the biological aspect of an individual where as gender is the social construction (Dozier, 2005, p. 298). If we can gain a clear understanding of biological sex and gender we can go beyond the gender binary of male/female and bring into the picture the complete spectrum of gender and the various forms of masculinity, femininity, and anything between or beyond. Transgender individuals are the most poignant example of a need for distinction between the concepts of sex and gender. The word transgender, according to the training guide Teaching Transgender: A Resource from the National Center for Transgender Equality, is defined as “an umbrella term that refers to people who live differently than the gender presentation and roles expected of them by society” (p.15). To clarify, it is not a personal short coming by the transgender individual, but rather a short coming by society's expectations and labeling. This term includes people a continuum of people from those who may occasionally cross-dress to those people who have an intersex condition. Within this definition are people who would like to seek all sexual reassignment surgeries available to them, people who only wish to have certain surgical procedures, and those who do not wish any surgical intervention. It also includes people who would like hormone replacement therapy, as well as those who do not. It is a diverse minority group, and each individual has different needs to feel comfortable in their own body. The potential medical, surgical, and therapeutic procedures to address these needs are expansive and the variety of options available are diverse. On the personal level, there is no defined way to complete a “sex-reassignment,” it is individual to the person based on their needs, wishes, and, in some cases, their socio-economic status.
One central health care issue for transgender individuals is the Gender Identity Disorder (GID) diagnosis. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) is used widely by helping professionals to diagnose and assist in treatment of mental disorders, including GID. Gender Identity Disorder symptoms are defined as a “strong and persistent identification with the opposite gender. There is a sense of discomfort in their own gender and may feel they were ‘born the wrong sex’”(American Psychological Association, 2004). While this description is relatively accurate to the majority of experiences of transgender individuals there is a lack of understanding and awareness for the diversity and complexity of gender both within this definition as well as society at large, therefore many professionals' understanding of a client's perceptions of themselves and their needs is limited or inaccurate.
The prognosis for GID is “Mixed. The goals of treatment are not as clear as in other disorders, as same-sex identification may be very difficult to achieve. More achievable goals may include acceptance of assigned gender and resolution of other difficulties such as depression or anxiety.”(American Psychological Association, 2004) Again,this definition lacks belief in the dignity and worth of the person, which is inherent in the goal of acceptance of their assigned gender. Forcing a transgender person to accept their “assigned gender” because of perceived difficulties in achieving the correct social recognition of their gender identity is a symptom of the belief that sex and gender are the same, and that not being able to change one's sex means that one should instead simply change their gender.
As social workers, we are taught that no one knows the client better then the client themselves. If a client wants assistance in accepting their assigned gender (some do for personal reasons, and some do out of fear of others), then we should assist them with that. However, if a client believes that they were born the wrong biological sex, that their gender identity does not align with that biological sex, we have a duty to assist them in finding adequate resources to help them resolve this disparity between their gender identity and the socially-constructed gender assignment that was based on their biological sex. For some clients, this will mean hormone therapy and perhaps some surgical intervention, for others it may mean extensive surgeries.
There is also the issue of labeling transgender individuals with this diagnosis, as GID and other DSM diagnosis are by nature perceived as dysfunctional. It is unnecessary to label an individual dysfunctional when the symptoms of GID can be resolved with hormone therapy and perhaps surgery. While diagnosing people with GID does not align with the NASW's Code of Ethics, receiving funds from some insurance companies for hormone therapy and sex reassignment surgery requires a GID diagnosis for transgender individuals to receive treatment (if the insurance company covers the treatment at all-many don't). According to Amber Ault and Stephanie Brzuzy, this forced diagnosis “produces the strange outcome of patients having genital surgery as treatment for a mental disorder. Adults seeking sex-reassignment surgery should not be subjected to the diagnosis of a mental illness if they choose body modification, just as genital and other surgeries should not be accepted as appropriate treatments for any mental illness” (Ault, A., Brzuzy, S., 2009). Despite the inherent disconnect between the transgender person's desire for sexual reassignment surgery and their like of the “mental illness” label, the small population this affects often is forced to seek a GID diagnosis, even when they do not feel it is appropriate, as they do not have alternate means for paying the expensive and long-term medical costs of transition. Loren Cameron, a transgender activist and artist who spoke at the Midwest Bisexual Lesbian Gay Transgender Ally College Conference in February 2010 discussed the pros and cons of this diagnosis. He explained that some of the transgender people he has worked with expressed the negative impact of being considered dysfunctional have been outweighed by the positive impacts of receiving the health care they need (Loren Cameron, personal communication, 2010). Even the GID diagnosis itself isn't a guarantee of health care coverage, however. Not all insurance companies will honor a GID diagnosis, and many refuse to assist with the sex-reassignment processes of transgender individuals, some even going so far as to deny any health coverages to people who have been identified as transgender. Even more transgender individuals lack health insurance in the first place, and a GID diagnosis becomes more of a hindrance to their well-being than a help.
Transgender topics are a relatively new field and the research associated with transgender issues is severely limited. There are very few reliable statistics and the tendency for transgender individuals to wish to remain anonymous does not help data collection efforts. As a result, the statistics for illegal hormone use and underground sex-reassignment surgical procedures are unavailable. Because health care is so inaccessible to transgender individuals, due to job loss (transgender people can be fired for their gender identity in many states) or being ineligible for insurance, many anecdotes of transgender people going to great lengths to receive the medical attention they need abound within the community itself. According to a presentation by Addiction Technology Transfer Center, the use of “street hormones,” particularly through injection, leads to a higher likelihood of HIV infection for transgender individuals, and the cost of such procedures, legal or not, leads to a higher incidence of sex work among transgender populations as well. From personal research throughout the last four years at multiple conferences and through personal discussions with transgender friends and acquaintances, the use of illegal means to achieve their desired gender presentation results in fatalities and health complications from using hormones without medical regulation and undergoing surgeries done by unqualified individuals. Many transgender people, who go through professional channels for their treatment, spend most of their life savings for treatments which cost tens of thousands of dollars.
The issues transgender individuals face finding and paying for health care, due to discrimination and oppression, are a significant issue that social workers need to address. The NASW has already taken steps in that direction through a Social Work Speaks Abstract:
“NASW recognizes that there is considerable diversity in gender expression and identity among our population and believes that people of diverse gender - including those sometimes called “transgender” - should be afforded the same respect and rights as any other person. Discrimination and prejudice toward anyone are socially, emotionally, physically, and economically damaging. A nonjudgmental attitude toward gender diversity enables social workers to provide maximum support and services to those whose gender departs from the expected norm. Social workers must encourage the development of supportive practice environments for those struggling with gender expression and identity issues, including both clients and colleagues”(National Association of Social Workers, 2008).
All forms of discrimination and oppression are interconnected. When progress is reached for any at-risk population's effort toward the end of discrimination and oppression, progress is reached for all at-risk populations. The removal of homosexuality from the DSM was a stepping stone for the potential, yet complicated, removal of GID from the DSM-V which is due to be published in 2011. National health care reform this year is a stepping stone toward health care reform for transgender individuals. The National Center for Transgender Equality outlines the positive impact the new reform may have for transgender individuals, which includes increased access to health insurance, protections from being denied coverage or having their coverage dropped, and a ban on some forms of discrimination. It also outlines important aspects of health care, such as the discrimination and distrust the transgender community has for medical professionals because of numerous negative experiences, and a gap in coverage for transgender individuals as well as the risk of denial in coverage (National Center for Transgender Equality, 2010). When progress is made through reform and advocacy in any area, it is important to be aware and conscious of the impact it will have on groups which are not the focus of the advocacy and reform, and to carefully weigh the pros and cons of including them, as there can be strength in numbers.
The suggestions to address the needs of transgender individuals in health care are varying based upon strategies. There is a strong movement to remove the GID diagnosis from the DSM in the fifth edition. I support this, however care needs to be taken to ensure that individuals who benefit from this diagnosis do not lose coverage by their insurance agencies. Input from the transgender community is essential to affect this change in a positive way. According to the Centers for Medicare and Medicaid Services, the NCD (National Coverage Determination) for what they define as “transsexual surgery” is not covered (Department of Health and Human Services, 2000). Medicare and Medicaid are two of the largest insurers in this country. It is unacceptable to have this NCD not have been assigned an effective date, and have this discriminatory practice justified by it being a “longstanding national coverage determination”(Department of Health and Human Services, 2000). This archaic determination needs to be changed and updated. General advocacy and education on transgender issues is also necessary to help alleviate the discrimination and oppression this population faces.
While all of the National Association of Social Worker's Code of Ethics is pertinent to this topic, the Ethical Principals of social justice and dignity and worth of the person(National Association of Social Workers, 2008) are particularly poignant in this issue. Transgender individuals are oppressed and discriminated in a wide variety of ways such as: lack of gender neutral bathrooms, job loss, health care access discrimination, hate crimes, and other acts of physical violence. In addition, transgender people also suffer from higher rates of suicidal ideation, up to 64 percent(National Coalition for LGBT Health, 2004), and higher rates of substance abuse, which made the top five transgender health priorities according to National Coalition for LGBT Health. As social workers, it is our duty to promote social justice for this at-risk population, which includes advocating for adequate health care.
Our society has put far too much emphasis on the false dichotomy inherent in a gender binary, which excludes transgender individuals from leading full and healthy lives as productive members of society, because of oppression and discrimination founded by a fear of difference. They are suffering depression, suicide, substance abuse, violence, and discrimination on an alarming level. The transgender community deserves our attention on this matter. Assisting them in finding the necessary health care to become the self they know they are, rather than the label they have been given by society is an imperative of the social work community, as we are in a unique position to support them, advocate for them, educate people on the issues, and to encourage them through the difficult process of sexual-reassignment. As social workers it is our duty to follow the Code of Ethics and particularly advocate for social justice for this community, and the dignity and worth as a person who is transgender.
References
Ault, Amber, and Stephanie Brzuzy. "Removing gender identity disorder from the Diagnostic and Statistical Manual of Mental Disorders: a call for action."Social Work 54.2 (2009): 187+. General OneFile. Web. 8 Apr. 2010.
American Psychiatric Association. (2004). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.
Department of Health and Human Services, . (2000). Transmittal 131. Medicare coverage issues manual. Retrieved (2010, April 8)
Dozier, R. (2005). Beards, breasts, and bodies: doing sex in a gendered world. Gender & Society, 19(3), 297-316.
National Association of Social Workers. (approved 1996, revised 2008). Code of Ethics of the National Association of Social Workers. Ethical Principals. Retrieved from http://www.naswdc.org/pubs/code/code.asp.
National Association of Social Workers. (2008). Social Work Speaks Abstracts. Transgender and Gender Identity Issues. Retrieved from http://www.socialworkers.org/resources/abstracts/abstracts/transgender.asp.
National Center for Transgender Equality. (2010, March 23). Health care reform and its impact on transgender people. Retrieved from http://www.transequality.org/news.html#hcr
National Coalition for LGBT Health. (2004). An Overview of Trans Health Priorities: A Report by the Eliminating Disparities Working Group. Retrieved from http://www.lgbthealth.net/TransHealthPriorities.pdf.