Transgender people face multiple obstacles to accessing quality health care, include outright discrimination and refusal to treat transgender patients, as well as a lack of relevant clinical and cultural competence among providers. The intimate nature of sexual and reproductive health care—such as screening and treatment for sexually transmitted infections and breast, cervical, and prostate cancers, as well as contraception provision—makes these concerns especially acute.
Transgender patients seeking sexual and reproductive health care often fear that they will be treated in ways that are disrespectful or judgmental because of their gender identities or sexual choices, or because aspects of their bodies may not conform to gender norms. Too often those fears are justified. Many providers assume that transgender patients do not need services such as pelvic exams or contraception, or that treating transgender patients is too complex for their practice. These dynamics contribute to significant disparities in sexual and reproductive health for transgender people.
KEY FACTS ON SEXUAL AND REPRODUCTIVE HEALTH FOR TRANSGENDER PEOPLE
Transgender people may have sexual partners who are men, women, or both.1 A transgender person’s partners or sexual history cannot be assumed from their gender identity or the gender they were assigned at birth.
Transgender people need preventive health screenings. Standard preventive health screenings are generally recommended for the body parts a patient has regardless of that patient’s gender identity, including breast, cervical, and prostate cancer screenings.2
Transgender people are at high risk for HIV and other STI infections. According to the CDC, transgender people experience HIV infection at four times the national population level.3 African-American and Latino/a transgender people are at especially high risk for HIV and other STIs.4
Many transgender men who have sex with men are at risk for unintended pregnancy as well as STIs. Transgender men who have sex with men report high rates of unprotected vaginal and anal intercourse.5 Some transgender men report being more concerned about pregnancy than HIV and other STIs.6
Marginalization and abuse increase health risks for transgender people. Transgender people face high rates of social and economic marginalization, as well as high rates of physical and sexual abuse. Transgender and gender nonconforming youth are particularly at risk for sexual abuse and for engaging in commercial or survival sex.7
Transgender people are often reluctant to seek sexual and reproductive health care. One in three transgender people, and 48% of transgender men, have delayed or avoided preventive health care such as pelvic exams or STI screening out of fear of discrimination or disrespect.8 One survey reported that half of transgender men did not receive annual pelvic exams. Reasons included discomfort with the physical exam due to gender issues (40%), lack of money or insurance (13%), lack of a medical provider they were comfortable with (13%), and thinking they did not need pelvic exams (7%).9 Another survey found that transgender teens, including those at risk for unintended pregnancy, were reluctant to go to a family planning clinic.10
Transgender people lack access to relevant health information. Sexual health education for youth and adults rarely addresses transgender people’s bodies and identities. For example, transgender men who have sex with men report a lack of adequate information about their sexual health at rates as high as 93.8%.11
Providers often lack appropriate clinical knowledge. While treating transgender patients does not require special expertise, providers often lack basic knowledge about transgender people and their health needs. In a nationwide survey, 50% of transgender people reported having to teach a health care provider about providing appropriate care.12
Many providers still turn transgender patients away. In national surveys, 19% to 27% of transgender people report being turned away by health care providers who refused to provide care for them.13 Outright refusals of care occur across all types of providers, including providers of sexual and reproductive health care.
RECOMMENDATIONS TO IMPROVE TRANSGENDER SEXUAL AND REPRODUCTIVE HEALTH CARE
- Follow accepted medical guidelines. Sexual and reproductive health providers should become familiar with clinical guidelines and recommendations for transgender people from the American Congress of Obstetricians and Gynecologists (ACOG) and the World Professional Association for Transgender Health (WPATH).14
- Adopt policies of respect and nondiscrimination. Providers should also adopt a formal policy of nondiscrimination and respect for each patient’s gender identity. One approach is to develop a clinic guide for transgender-inclusive services, as some providers have done.15
- Train staff on cultural competence and nondiscrimination. Clinics should train providers and staff on transgender-appropriate care, nondiscrimination, and inclusivity. The Fenway Institute and the Joint Commission have created materials to support staff training on transgender and LGBT competence.16
- Incorporate transgender inclusion in grant guidelines. The U.S. Department of Health and Human Services should revise program guidelines for Title X family planning grants to prohibit discrimination on the basis of gender identity and sexual orientation and to address the cultural and clinical needs of transgender patients.
- Report discrimination. Federal law prohibits gender-based discrimination by health care providers that accept any form of federal funding. Patients and their advocates should assert their right to receive treatment free from discrimination by filing complaints of discrimination with appropriate authorities. For more on this, see NCTE’s resource, Health Care Rights and Transgender People.
- Eliminate public policies that require sterilizing procedures for trans people. Policies requiring transgender people to undergo sex reassignment surgery before changing their gender marker on government documents violates their reproductive rights and frequently amounts to forced sterilization. Federal, state, and local agencies should update policies to permit gender marker changes without requiring proof of surgery or other invasive medical procedures.
1 K.A. Stieglitz, Development, Risk, and Resilience of Transgender Youth, 21 J. ASSOCIATION NURSES IN AIDS CARE 192, 197 (2010).
2 University of California, San Francisco, Center of Excellence for Transgender Health, Primary Care Protocol for Transgender Patient Care (2011) http://transhealth.ucsf.edu/trans?page=protocol-00-00.
3 Centers for Disease Control and Prevention, HIV Among Transgender People (2011), http://www.cdc.gov/hiv/transgender/pdf/transgender.pdf; J.M. Grant, L.A. Mottet, J. Tanis, J. Harrison, J.L. Herman, M. Keisling, Injusticia a cada paso: un informe de la Encuesta Nacional sobre Discriminación Transgénero 76, 80 (2011).
4 See, e.g., L. Nuttbrock, S. Hwahng, W. Bockting, A. Rosenblum, M. Mason, M. Macri, J. Becker, Lifetime Risk Factors for HIV/Sexually Transmitted Infections Among Male-to-Female Transgender Persons, 52 J. AIDS 417 (2009); R. Garofalo, J. Deleon, E. Osmer, M. Doll, G.W. Harper, Overlooked, Misunderstood and At-Risk: Exploring the Lives and HIV Risk of Ethnic Minority Male-to-Female Transgender Youth, 38 J. ADOLESCENT HEALTH 230 (2006).
5 S. Reisner, B. Perkovich & M.J. Mimiaga, A Mixed Methods Study of the Sexual Health Needs of New England Transmen Who Have Sex with Nontransgender Men, 24 AIDS PATIENT CARE & STDS 501 (2010); J. Sevelius, “There’s No Pamphlet for the Kind of Sex I Have": HIV-Related Risk Factors and Protective Behaviors Among Transgender Men Who Have Sex with Non-Transgender Men, 20 J. ASSOC. NURSES AIDS CARE 398・410 (2009).
6 S. Reisner, B. Perkovich & M.J. Mimiaga, supra note 5, at 510 (reporting a rate of 6% unintended pregnancy in a group of 16 trans men who have sex with nontrans men).
7 See id.; J.M. Grant, L.A. Mottet, J. Tanis, J. Harrison, J.L Herman, M. Keisling, supra note 3, at 65-66, 80; J.H. Herbst, E.D. Jacobs, T.J. Finlayson, V.S. McKleroy, M.S. Neumann, N. Crepaz; HIV/AIDS Prevention Research Synthesis Team, Estimating HIV Prevalence and Risk Behaviors of Transgender Persons in the United States: A Systematic Review, 12 AIDS BEHAV. 1 (2008).
8 J.M. Grant, L.A. Mottet, J. Tanis, J. Harrison, J.L Herman, M. Keisling, supra note 3, at 76. 9 K. Rachlin, J. Green, & E. Lombardi, Utilization of Health Care Among Female-to-Male Transgender Individuals in the United States, 54 J. HOMOSEXUALITY 243, 252-53 (2008).
10 See, e.g., Planned Parenthood Toronto, Toronto Teen Survey Gender Bulletin (2010)
11 S. Reisner, B. Perkovich & M.J. Mimiaga, supra note 5, at 506.
12 J.M. Grant, L.A. Mottet, J. Tanis, J. Harrison, J.L. Herman, M. Keisling, supra note 3, at 76. 13 Id. at 73; Lambda Legal, When Health Care Isn’t Caring: Lambda Legal’s Survey on Discrimination Against LGBT People and People Living with HIV 10 (2010), http://www.lambdalegal.org/publications/when-health-care-isnt-caring.
14 ACOG Committee Op. No. 512: Health Care for Transgender Individuals, 118 OBSTETRICS & GYNECOLOGY 1454 (2011); World Professional Association for Transgender Health, Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (7th ed. 2011), http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1351&pk_association_webpage=3926.
15 Planned Parenthood of the Southern Finger Lakes, Inc., Providing Transgender Inclusive Healthcare Services (2006) http://www.plannedparenthood.org/ppsfl/files/Southern%20Finger%20Lakes/Providing_Transgender_Inclusive_Healthcare_Handbook.pdf
16 Fenway Health, http://www.fenwayhealth.org/site/PageServer?pagename=FCHC_abt_about_home; Joint Commission, Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide (2011), http://www.lgbthealtheducation.org/wp-content/uploads/13-017_TransBestPracticesforFrontlineStaff_v6_02-19-13_FINAL.pdf.