Since June 1st, and the release of the first photos of Caitlyn Jenner in Vanity Fair, it has been very hard to miss all of the media conversation about Caitlyn (née Bruce) Jenner and transgender individuals in America. I’ve been intrigued by the conversation and admit that I registered for a free 30 day trial of Vanity Fair on my Kindle just to read the article. As I read the article, I further realized the potential uniqueness of Caitlyn’s experience compared to other transgender individuals, and a paragraph on the last page of the article further accentuated this point. The paragraph points out that there are an “estimated 700,000 transgender women and men in the country, too many of them suffering from job discrimination and violence.” (Vanity Fair, July 2015, p. 106).
Based on the article and public conversation, I decided to research a bit on public health and health care concerns for transgender individuals. I will readily admit my knowledge of the topic was, and still remains, fairly elementary. However, I was left upset by what I found out, especially with regards to many of the statistics in the Report of the National Transgender Discrimination Survey that reflected negative social determinates of health. The following are some of the relevant facts I discovered:
There are no reliable estimates of the number of trans people in the United States and their health status. Part of the reasoning for the data collection challenges is the reliance on a binary system of gender classification and the need to include gender identity as a demographic category in health studies. (IOM, Current Issues in Transgender Health)
Almost all transition-related medical care is paid for out of pocket, without any insurance reimbursement. (Report of the National Transgender Discrimination Survey). Medicare began covering surgical transitions that are considered “medically necessary” in 2014, and there is a wide variety of Medicaid coverage. More states are beginning to cover surgical transitions through Medicaid, with Oregon, Washington and New York as recent examples, but the number is still well below 50% of states. With regards to private insurance, the Essential Health Benefits in the ACA do not explicitly require coverage for medical or surgical transitions. A simple review of a few private insurance coverage determination guidelines demonstrate that plans are more likely, but not required, to cover medical transitions but that most plans exclude coverage for surgical transitions. The binary notion of gender also creates challenges where, for example, a transgender man receives a pap smear and a health insurance provider denies the claim because a male patient traditionally does not need to receive a pap smear.
Regardless of insurance coverage, respondents to the Survey faced serious hurdles to accessing health care, including providers refusing to provide care due to a respondent’s transgender or gender non-conforming status, experiencing harassment and violence in medical settings, and providers’ lack of knowledge about transgender care. Transgender individuals reported experiencing barriers to care for general care, e.g., an ENT asking about an individual’s genitalia when an individual was seeking care for an ear related issue, or specific traditional gender specific care, e.g., transgender men receiving pap smears.
Transgender individuals have higher rates of extreme poverty and unemployment compared to the general population. The Report of the National Transgender Discrimination Survey found that respondents to the survey were nearly four times more likely to have a household income of less than $10,000 per year compared to the general population and had double the rate of unemployment compared to the general population. Further, one-fifth of Survey respondents reported experiencing homelessness at some points in their lives because they were transgender or gender non-conforming. These negative social determinates of health can reinforce other barriers to care transgender individuals face.
The Report of the National Transgender Discrimination Survey also found that 41% of respondents reported attempting suicide compared to 1.6% of the general population. Over a quarter of respondents misused drugs or alcohol at some point to cope with the mistreatment they received as a result of being transgender or gender non-conforming. Respondents also reported higher rates of smoking compared to the general population.
Respondents to the National Transgender Discrimination Survey reported over four times the national average of HIV infection. Studies have shown that transgender women living with HIV are less likely to adhere to their HIV medications, however, the integration of hormone treatment into HIV care may augment treatment adherence for HIV medications. (Sevelius, Carrico, Johnson (2010); IOM, Current Issues in Transgender Health).
These few facts alone demonstrate the need for further discussion in the public health community as to how to seek further insurance coverage for transition related medical care and confront the various socioeconomic factors that can act as negative social determinates of health for transgender individuals.
The views reflected in this expert column are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.