Commentary Health Systems

‘First, Do No Harm’: Why Anti-Trans Discrimination in Health Care Must End

Dr. Ilana Addis

We often believe that we do not have the training to deal with the complexities of transgender health. This contributes to significant disparities in sexual and reproductive health for transgender people.

Upon being admitted to the medical profession, I took an oath that says, “I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient.”

As a gynecologist who specializes in female pelvic medicine and reconstructive surgery, my average patient is an older woman from a retirement community who leaks urine when she coughs, sneezes, or plays a set of tennis.

The day I saw my medical assistant seat a man in my waiting room for the first time, I was initially confused. I thought there had been a mistake until I learned that my patient wanted a hysterectomy. Assigned female at birth, he was taking testosterone and having the uncommon side effect of irregular and heavy bleeding that often leads to anemia.

At the time, I was unaware of the many difficulties transgender people confront just showing up at the doctor’s office. In its most recent report, the National Center for Transgender Equality found that 23 percent of respondents avoided going to the doctor because they feared discrimination; one-third had at least one negative experience with their provider. Trans people say they often face ignorance or outright prejudice from medical professionals.

Transgender people are consistently discriminated against. Recently, the Trump administration withdrew a federal guidance reiterating protections for transgender students, which enforce their right to use bathrooms and facilities in public schools that correspond with their gender identity. Additionally, the ethical standards that physicians should live by have been weakened by judges and courts with a political agenda under the guise of “religious freedom.”

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Meanwhile, the internet has exploded with reports of a leaked executive order, titled “Establishing a Government-Wide Initiative to Respect Religious Freedom.” The draft order allows individuals and businesses to claim religious objections to abortion, contraception, marriage equality, premarital sex, and transgender identity when “providing social services, education, or healthcare; [or] earning a living, seeking a job, or employing others.”

Rabbi David Saperstein, the former U.S. religious freedom ambassador, told a congressional subcommittee that the proposed executive order could cause “constitutional problems.” The order would give virtually anybody or entity a reason to refuse services to a number of underserved groups of people in the United States, including transgender people.

Transgender individuals face numerous obstacles in accessing quality health care. Health companies may deny coverage of certain treatments or procedures. Moreover, there is a lack of research on transgender health as well as a lack of relevant clinical and cultural competence among providers. Transgender patients seeking sexual and reproductive health care express concern that they will be treated in ways that are disrespectful or judgmental because of their gender identities or partner choices, or because aspects of their bodies may not conform to “gender norms.”

After my first trans patient, who gave positive feedback about his care, I realized that changes were needed in my clinic and hospital system to address some of the systemic issues that transgender people often face. This has started with trans-competent training for health-care providers in our clinic as well as encouraging education in our local medical school.

Providers may assume that transgender patients do not need services such as pelvic exams or contraception. We often believe that we do not have the training to deal with the complexities of transgender health. This contributes to significant disparities in sexual and reproductive health for transgender people.

The assault against transgender medical rights is also being waged on the state level. On December 31, 2016, Federal District Judge Reed O’Connor of Fort Worth, Texas, blocked on a nationwide basis protections specified in the Affordable Care Act (ACA) that prohibit insurers, doctors, or hospitals from discriminating against transgender people or patients with an abortion in their medical history. He stated that Section 1557 of the ACA rule would force providers to violate their religious beliefs and would force states to rescind their rules refusing to provide insurance coverage for abortions and gender-affirming surgery.

Many, including those crafting the nascent executive order, may ask why a transgender person would not just go to a physician explicitly seeking to meet their needs. The truth is, this may be simple in a city with many options, but not so in a small town. And, even in a large city, many options might be available for a primary care practitioner but not for a specialist.

The patient I saw those years ago was fortunate in many ways. He described a supportive family and a close-knit group of friends. He had a relatively knowledgeable primary care physician and was empowered to seek care for his problem. And he had reliable health insurance.

I didn’t hesitate to treat him: He desperately wanted his uterus and ovaries removed, and did not desire to carry a baby in the future, preserve his eggs for future fertility, and or continue having menses in any form. His hysterectomy was uncomplicated. Just imagine what unnecessary suffering would have befallen him had hysterectomy not been an option: to bleed to death from a condition with a simple solution.

I received my medical training in a variety of places across the country, from Tucson to Memphis to San Francisco. In each of these places I had the privilege to learn from physicians with large differences in practice and even larger differences in political beliefs. Medical school teaches us to do what is right for the patient, honor the physician-patient relationship, and keep our personal beliefs separate from our professional lives, and I have seen this in action. Physicians who let politics take precedent over medicine, and fear of the unknown rule over compassion, break the vows that we took when we became doctors: First, do no harm.

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