1.5 CONTACT HOURS 0.5 CONTACT HOURS Addressing transgender patients’ barriers to access care Abstract: The transgender population faces several barriers to accessing quality medical care in the US healthcare system. This article examines the challenges that prevent this marginalized group from obtaining high-quality healthcare services and discusses how NP advocacy can help create a welcoming environment for transgender patients. By Denise Rowe, DNP, APRN, FNP-BC; Yeow Chye Ng, PhD, CRNP, AAHIVE, CPC; and Louise C. O’Keefe, PhD, CRNP, CNE, FAANP ransgender people have experienced sig- still faces multiple barriers to obtaining quality nificant progress in recent years. Some healthcare. T countries, including the US, have passed Barriers include stigmatization, discrimination in laws to protect the lesbian, gay, bisexual, transgen- insurance coverage, and a lack of experience among der, and queer or questioning (LGBTQ) community medical professionals in treating the unique health- from discrimination.1 Human rights activists have care needs of transgender patients.3 This article led campaigns that helped shift public opinion on examines the effects of healthcare disparities among transgender people toward greater acceptance. Civil the transgender population and the importance of rights organizations have created new forums to creating a welcoming environment for transgender foster societal understanding and equality between patients receiving care, and emphasizes the vital role transgender and other populations.2 Despite these NPs can play in delivering gender-affi rming care, positive steps forward, the transgender population including cross-sex hormone therapy (CSHT). Nito100 / iStock Keywords: advocacy, cancer, cross-sex hormone therapy (CSHT), healthcare disparities, HIV/AIDS, LGBTQ, mental health, stigmatization, transgender 30 The Nurse Practitioner • Vol. 44, No. 6 www.tnpj.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. Addressing transgender patients’ barriers to access care ■ Healthcare disparities The US census and other demographic studies current- ly do not collect data on gender identity, so the exact number of transgender people in the US is unknown. However, studies estimate that transgender individu- needs. Although some may require an uninterrupted als account for 0.3% of the US population.4 In 2011, supply of hormones, others may need regular voice there were about 9 million transgender people in the and communication therapy, mental health care, and US. Given the recent federal antidiscrimination mea- substance use disorder counseling services. Few trans- sures passed to protect the LGBTQ community, more gender individuals who seek these services from pub- transgender people may choose to disclose their sexual lic hospitals attain high satisfaction levels.15 Surveys orientation in the future.5 Thus, the transgender popu- show that many transgender patients do not record lation is expected to rise to over 10 million by 2020.5 satisfactory encounters at their mainstream healthcare Stigmatization and limited research contribute facilities. Roberts and Fantz’s review of barriers to significantly to the healthcare disparity between transgender care concluded that medical practitioners transgender people and other patient populations.6,7 are not adequately trained to deliver the healthcare Recent studies indicate that few health institutions services required by transgender patients.16 Patient collect data on gender identity, making it diffi cult to dissatisfaction included healthcare providers’ use of measure the quality, treatment decisions, and out- inappropriate pronouns. (See Terminology.) The USTS comes of the healthcare provided to transgender also found that 25% of transgender individuals were patients.8-10 Programs such as Healthy People 2020 denied health insurance coverage for gender transition indicate that HIV, STI, psychiatric disorders, victimization, and sui- The US census and other demographic cide prevalence rates are signifi- cantly higher among transgender studies currently do not collect data on individuals than heterosexuals and gender identity. other LGBTQ groups.11 A systematic review and me- ta-analysis found that transgender women (male to care or routine care because of their reported transgen- female) represent approximately 20% of the exist- der status.14 Yehia and colleagues reported that within ing HIV infection rate throughout the world.12 One their retention and health outcomes of people living study conducted in the US found that the three most with HIV, nontransgender men and nontransgender prevalent concerns among more than 1,000 sur- women achieved a better retention in care as compared veyed transgender people were clinical depression with their transgender counterparts.17 (44%), anxiety (33%), and somatization (28%).13 According to the 2011 National Transgender The 2015 US Transgender Survey (USTS) of 27,715 Discrimination Survey conducted by Shires and Jaffee, transgender people noted that 29% of respondents 50% of the 6,450 respondents expressed dissatisfaction consumed illicit drugs, used prescriptions inap- with the healthcare services they received.22 This fi nding propriately, or used drugs prescribed to others, at a was further supported in the 2015 USTS, in which consumption rate three times higher than the gen- 33% of respondents seen by a healthcare provider eral US population.13 Serious psychological distress (HCP) reported a negative experience such as harass- was prevalent among 39% of respondents compared ment or refusal of care because of gender identity.14 with 5% of the general population and resulted in Consequently, 23% reported they declined to seek care a staggering 40% of respondents having attempt- in the year before being surveyed because of fear of ed suicide in their lifetime—almost nine times the mistreatment.14 Nineteen percent of the respondents attempted suicide rate in the US population (4.6%).14 experienced denial of care, while 28% rarely sought healthcare because of the fear of discrimination. Fur- ■ Care access challenges thermore, the USTS revealed that 33% of respondents Transgender patients require customized services to provided teaching on transgender people to their HCP fulfi ll their personal healthcare and gender identity in order to receive care that was appropriate.14 www.tnpj.com The Nurse Practitioner • June 2019 31 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. Addressing transgender patients’ barriers to access care HIV/AIDS. Among the general population with perceptions or discriminative stereotypes targeting HIV, most HIV research has been conducted on trans- transgender patients. The perceived negative environ- gender women.23 A systematic review of available data ment induces stress and promotes unnecessary school in the US and 14 countries from 2000 to 2011 re- or work absenteeism. As a way of coping, many trans- vealed that 19.1% of the world’s transgender people gender people turn to alcohol, drugs, and promiscuous are currently living with HIV/AIDS.12 The median sexual behavior for consolation. Having unprotected HIV prevalence was 3% higher in the US (21.6%) intercourse with multiple partners increases their risk than low- and middle-income countries (17.7%).12 of contracting HIV.20,21 The rate was signifi cantly greater than other vulner- Mental health. Research demonstrates that many able populations such as men who have sex with men transgender people have low self-esteem. Many fac- (MSM), sex workers, and individuals who inject drugs. tors may contribute to these feelings. Given that many Transgender women and MSM account for more than families reject their transgender family members, the half of the people living with HIV/AIDS in the US and individuals are reluctant to protect themselves from exceed the general population’s HIV prevalence rates discrimination or physical abuse and often engage in middle-income countries as well. These vulnerable in self-destructive behaviors.26 The LGBTQ popula- individuals also contribute to 63% and 30% of the tion is two times more likely to smoke and use other syphilis and gonorrhea infection rates, respectively.18,24 harmful substances than the general population.27 Mizuno and colleagues reported that transgen- Ard and Harvey found that the real or expected dis- der women are 40 times more likely to be diagnosed crimination or abuse results in internalized depres- with HIV than the general population.25 Nevertheless, sion, anxiety, and homophobia.28 This may explain most healthcare systems do not systematically record why mental health disorders are signifi cantly higher data concerning transgender patients. The high HIV/ among the transgender population than among mi- AIDS prevalence rates are attributable to the negative nority ethnic groups. Lapinski and colleagues cite that Terminology Cisgender—people whose gender identity is congruent Genderqueer—a gender expression that is not male or with the gender assigned at birth and who perform female but on the gender continuum.17 5 gender roles that society considers appropriate. Sex—a person’s biological status of either male or Gender—the attitudes, feelings, and behaviors a society female. In most cases, biological factors such as sex expects a particular gender to possess.17 Characteristics chromosomes, reproductive organs (penis or vagina), and that are consistent with such cultural expectations are clas- external genitalia determine whether an individual is male sifi ed as gender-normative.