Analysis Health Systems

Black Femmes’ Needs Are Ignored in Health-Care Debates, Yet They Have Much to Lose

Kiersten Gillette-Pierce

Black people in the United States are among the most discriminated against when it comes to health care—which is further exacerbated when they are not a cisgender man.

If Republicans in Congress have their way and pass their repeal bill to the Affordable Care Act, Black femmes in particular stand to lose.

For this piece, Black femme includes a Black transgender woman, a Black nonbinary person who identifies as a femme, and a Black cisgender woman. (It is important to note that, not all Black individuals with “nonmasculine” gender expressions would classify themselves as a Black femme and some Black individuals with “masculine” identities not listed here would.)

Black femmehood is a recently visible concept used in social justice and Black queer safe-spaces. It acknowledges that Black feminine individuals experience oppressive forces in similar ways and requires social spaces to acknowledge blackness and femmehood in tandem.

Black femmes experience health-care discrimination on arguably two mega levels: anti-Blackness and anti-femmehood. Academia lacks evidence that shows the shared health concerns of Black femmes and consequently lacks the data to express how the Affordable Care Act benefits them—but Black femmes know it does.

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Black people in the United States are among the most discriminated when it comes to health care— which is further exacerbated when they are not a cisgender man. Additional layers of oppression, such as gender expression- and sex-based discrimination, bring to the forefront critical issues for Black femmes that are often ignored in health-care debates, such as:

Black maternal and infant health. The maternal mortality ratio for Black women is nearly three times that of white women during pregnancy, childbirth, and the year immediately following childbirth, according to a 2013 study by the Centers for Disease Control and Prevention. In fact, some statistics show the rate in some areas of Mississippi exceeds sub-Saharan Africa in maternal deaths.

In addition, to the detriment of both mother and child, nearly one-quarter of Black women initiate prenatal care too late, or not at all, which contributes to the disparate health outcomes. Infant mortality rates and low-birth-weight rates are also much higher for Black women compared to other groups.

Data on other Black childbearing bodies is a rarity. Because only a few studies document pregnancy among trans people, trans men and nonbinary folks are left vulnerable without continuous reporting on their health-care experiences and outcomes. 

Unplanned pregnancies. Black women have the highest rates of unintended pregnancy in the country at about two times the rate of white women. In addition, LGBTQ young women are more likely to become pregnant than non-LGBTQ youth. Racial discrimination, if accounted for, adds another barrier to the sexual education and services LGBTQ youth need.

Birth control prevents a plethora of unplanned pregnancies, including pregnancy as a result of rape. Fifty percent of trans people and one in five Black American women will experience sexual assault at some point in their lives. In addition, LGBTQ young women are at a high risk of sexual assault. Thus, without access to birth control, Black femmes are left vulnerable. 

Transition-related care. Many transgender and nonbinary individuals experience gender dysphoria during childhood, which if untreated can lead to thoughts of self-harm or suicide. While the needs of transgender women and nonbinary people are varied, access to reproductive health care is critical for many. Hormone therapy, often the same care provided to patients with endocrine disorders and menopausal symptoms, is imperative to addressing gender dysphoria.

In highlighting dire issues among Black femmes, it is easy to decipher that without health-care reform laws in place this community’s well-being will continue to be at risk.

Since former President Barack Obama enacted the Patient Protection and Affordable Care Act (ACA), the ACA has granted benefits and protections to the U.S. population at large, and bolstered the health of some 19 million Black people. Under the ACA, no-cost sharing benefits—or mandated insurance coverage of screenings and other preventive services—granted Black people access to preventive measures and vital screenings addressing issues such as HIV prevalence, breast cancer, and cervical cancer. In addition, the ACA’s Section 1557 sought to help increase access to a full spectrum of care for LGBTQ people. It was the first federal law in U.S. history to offer comprehensive protection against sex discrimination in health care.

Section 1557, specifically, mandated an end to denying care or charging more for care to individuals because of things such as pregnancy or pregnancy-related conditions, gender identity, or because they do or do not conform to particular sex stereotypes, thus making care more accessible.

These protections, and many others, are extremely important to Black femmes. Without access to the health-care services they need, Black femmes are at risk of suffering long-term health problems, which could translate into lost income and housing instability for those who do not receive paid time off. This is compounded by the fact that about 90 percent of transgender people surveyed reported they have experienced harassment, mistreatment, or discrimination at work. For many Black femmes, their identities are their biggest vulnerability.

The ACA has improved the quality of life for Americans across the board, and has greatly improved the lives of Black femmes. It has afforded many Black femmes better access to life-saving, gender-affirming care, and the larger opportunity to contribute to society, but it has the potential to do so much more.

Despite the large number of insurance enrollees during the Obama administration and the beneficial impact of the ACA on Black Americans, many of the most basic insurance coverage plans are still inaccessible to Black femmes and their families. Moreover, the states that do not participate in Medicaid expansion under the ACA are primarily Republican states and in the South with large Black populations. Thirty-one percent of uninsured adults in the health coverage gap created by a lack of Medicaid expansion are Black. Many are just above the federal poverty level and just below the income needed to qualify for subsidized insurance, making them ineligible for basic Medicaid in non-expansion states. 

It is no coincidence these states also have some of the highest statistics for Black maternal deaths, poor Black maternal and child health, unplanned pregnancies, and alarmingly unsafe conditions for Black trans women and Black gender-nonconforming femmes.

Right now, the move toward policy that safeguards our national health is under attack. Republicans in the White House and Congress are working arduously to repeal the ACA and make it harder for Black femmes to access these benefits and protections that are so desperately need.

“When politicians restrict insurance coverage of abortion care, low-income families, people of color, immigrant women and youth are hit the hardest,” according to the Black Women’s Health Imperative.

Instead of taking away access, it must be expanded.

We must resist these attempts to take away our bodily autonomy by contacting our senators and demanding the policy we need and deserve. Our lives are worth fighting for.

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