Trans Healthcare Access in Mass

Literature Review

Defining “Transgender.” The Lambda Legal team within their 2009 study broadly defines Transgender individuals as being: a person who transitions “from one gender to another, and those who may not, including genderqueer people, cross-dressers, androgynous, and those whose gender non-conformity is a part of their identity” (Lambda Legal, 2010). As of 2013, the DSM-V utilizes a diagnosis of gender dysphoria to support transition related medical care, and the American Psychiatric Association defines this as: “a conflict between a person's physical or assigned gender and the gender with which he/she/they identify” (American Psychiatric Association, 2016). People with gender dysphoria may be extremely uncomfortable with the gender they were assigned, sometimes described as being uncomfortable with their body (particularly developments during puberty) or being uncomfortable with the expected roles of their assigned gender (American Psychiatric Association, 2016).”

Trans individuals begin to self-identify as such at a variety of ages and life-stages, often not having a true name for their experience, but still recognizing an internal disconnect from expectations associated with their assigned sex and gender (Steensma, et al., 2013; James, et al., 2016). A 2015 study conducted by the National Center for Transgender Equality found that 60% of the almost 28,000 individuals surveyed experienced some form of disconnection to their assigned gender at birth, as early as age 10 or younger (James, et al., 2016). Further studies have found a correlation with the intensity of gender dysphoria in childhood and persistence of gender dysphoria and gender nonconformity in later adulthood (Steensma, et al., 2013). When it comes to acting on those feelings associated with their gender identity, 43% indicated taking or intending to take actions to medically and/or socially present in the gender they most identified with also known colloquially as transitioning, between age 18-24, and 24% between age 25-34 (James, et al., 2016).

The American Psychiatric Association refers to the use of medical interventions to support biological gender-affirming changes as a form of treatment for gender dysphoria, primarily using hormone replacement therapy and surgery (American Psychiatric Association, 2016). This medical transition strategy is often supplemented by social and legal transitions (American Psychiatric Association, 2016), often with overlapping requirements of medical treatments, such as gender affirming surgeries, as a requirement to obtain changed gender markers on a birth certificate (Movement Advancement Project, 2019). Some advocates for trans reproductive rights claim that this overlap of government regulation of trans bodies is a form of modern coerced sterilization (Nixon, 2013). For the purposes of this study, questions asked of participants were focused not specifically on transition related medical care, but on the experiences of accessing healthcare of any kind through the lens of being a trans-identified person. To develop an effective interview tool, the largest existing data sets on trans discrimination were reviewed:

The 2011 National Center for Transgender Equality study was the first large scale qualitative study focused entirely on identifying the scope, frequency, types, and severity of discrimination faced by trans and GNC individuals across all areas of daily life, including school, work, and family (Grant, et al., 2011). Data shows that the majority of the 6,400 transgender people surveyed felt that most of the time, if ever, people could not “tell” or identify them as transgender without being explicitly told, which was a significant protective factor correlated with lower rates of discrimination (Grant, et al., 2011). Further, 41% of the 2011 respondents indicated that they are not “out” as being a transgender person to anyone on their medical team (Grant, et al., 2011). Often this is due to fear of lost relationships and discriminatory or negative reactions, including concerns over the quality and type of care that would be offered to the patient after disclosing their identity (Grant, et al., 2011).

Of note, an individual’s status as not being out as a transgender person may also indicate that they have either chosen not to or are unable to medically and/or socially transition. Alternately it could also mean that they have pursued a medical and/or social transition and live at least part of the time as the gender they identify as, without publicly declaring that they are doing so (Lambda Legal, 2010; Grant, et al., 2011).  The ability to hide one’s transgender status can only go so far when seeking medical treatment however and can become a complicating factor of seeking medical care.

Among transgender people, studies show that approximately half of transgender individuals were assigned female at birth (AFAB), and half assigned male at birth (AMAB) on their birth certificate (Grant, et al., 2011; James, et al., 2016).  As represented by the most recent data from the 2015 National Center for Transgender Equality study of approximately 28,000 individuals, the transgender population is predominantly White, with 12.6% identifying as Black, 16.6% identifying as Latino/a, 5.1% Asian, 2.5% Multiracial, and 0.7% American Indian and 0.4% Middle Eastern (James, et al., 2016).

When compared against the United States census general population of 2015, geographic distributions of trans individuals are proportionate to population density throughout the United States, with exception of the Southern regions of the US, which have fewer concentrations of trans individuals comparatively (James, et al., 2016).

English as the only language spoken in the home was indicated by 84% of trans households in the American Community Survey of 2015 within the U.S. Census, however in households that spoke a language other than English (either as a secondary or primary language) Spanish was the predominant common language.

Looking at education and professional experiences, according to these data sets, trans adults are likely to be educated beyond high school, with only 2% not completing high school (James, et al., 2016), down from same cohort measured at 4% in 2011 (Grant, et al., 2011). Despite the 47% majority of secondary degree-holders (James, et al., 2016), individual income among transgender survey respondents is significantly lower than the national average, with 55% earning less than a $25k annual income, compared to only 49% of the US adult population (James, et al., 2016). For those individuals who can secure stable employment, and completion of a secondary education, 9% of trans individuals reported annual incomes of $100K or more (James, et al., 2016).

When considering access to healthcare overall, 86% of trans individuals reported being covered by health insurance, however this was slightly less than the average general population of Americans, with trans people of color (POC) reporting much higher rates of being uninsured (James, et al., 2016). Despite having similar access to insurance as the general population, 24% of trans individuals indicated barriers to appropriate care based on their gender identity or status as a trans individual (James, et al., 2016), these services were most often related to name and identification related changes, transition related health care, and reproductive and/or preventative health screenings (James, et al., 2016). When specifically asked about barriers to healthcare, 33% cited cost of receiving care, with significantly higher numbers among trans POC (James, et al., 2016). The second most significant barrier to healthcare access was perceived risk of being disrespected or mistreated as a trans person, which was reported by 23% of study participants in 2015, or 6,440 individuals (James, et al., 2016). Another significant barrier to healthcare access was the availability of trans inclusive providers in a geographic area, with trans individuals more than three times as likely to travel in excess of 50 miles for transition-related care (James, et al., 2016). This information was especially notable when considering the geographic layout of Massachusetts, and the scarcity of high-quality medical care outside of the Boston area, when compared with the availability of accessible public transit.