A person in a hospital gown sitting on the edge of bed

Today is Transgender Day of Remembrance, a moment to pause and reflect on the many transgender individuals around the world who have lost their lives to violence as a result of being transgender. That includes at least 37 people in the U.S. just this past year, though many others whose gender may have been misidentified have likely also been killed.

The estimated 1.6 million people in the U.S. who identify with a different gender from the one assigned to them at birth often confront a toxic social environment: discrimination in education and employment, abuse by police, verbal harassment by strangers, as well as physical and sexual assault, according to a recent report by the Commonwealth Fund, a nonprofit health research center. All of this is worse for transgender people of color.

In addition to raising awareness of the dangers transgender people face, Transgender Day of Remembrance also gives us the opportunity to celebrate transgender people and their transition journey, says Rachel Levine, MD, Pennsylvania’s secretary of health, who is also an advocate for the transgender community. And it offers the chance to look more closely at the social supports that transgender people need.

Access to medical care is one of those areas.

More on Access to Healthcare

Nearly one-third of transgender people report being refused medical care or harassed by medical professionals because they are transgender, according to a 2015 survey by the National Center for Transgender Equality. The survey of more than 27,000 transgender individuals is the largest in the U.S., with respondents from all 50 states.

That type of mistreatment could be why a quarter of transgender people in that survey said they avoid going to the doctor altogether.

Lyra Menolloy Smith, 36, is a transgender woman who had her first doctor’s appointment six years ago after living on the street for two decades in Asheville, N.C., and San Francisco. She says she didn’t see a doctor even after being raped behind her high school’s theater in 2001 at the age of 16, or after multiple suicide attempts. “I tried to drug overdose twice,” she says. “And I tried to shoot myself in the mouth.”

On another occasion, she was arrested for attempting to jump off a public parking garage. Instead of being sent to see a doctor, she says, “I spent three days in jail.”

As Smith’s story shows, having limited or no support from family, community, or healthcare providers can be life-threatening. The attempted suicide rate among transgender people in the NCTE survey was a shocking 40 percent, compared with less than 1 percent of the rest of the population.

Many lesbian, gay, bisexual, and transgender individuals are not out to their healthcare providers.

Rachel Levine, MD

Pennsylvania's secretary of health

Along with a high risk of suicide, transgender people face a higher risk for infection, substance abuse, mental health issues, and even some cancers, says Joshua Safer, MD, executive director of the Center for Transgender Medicine and Surgery at the Mount Sinai Health System in New York City. Safer has recently co-authored medical treatment guidelines for physicians providing care to transgender people.

But Levine, the Pennsylvania secretary of health, says that even among people who do have doctors, trust of the medical system is so low that “many lesbian, gay, bisexual, and transgender individuals are not out to their providers.” A third of people in the NCTE survey said they had never come out to their physician.

Over a decade ago Levine, now 63, herself transitioned. She credits her success partly to the fact that she is an educated, white medical professional who had access to top-notch care at an academic medical center and had a supportive community. 

“I consider myself very privileged,” she says, explaining that’s one reason she’s working to help people who aren’t so fortunate. Everybody, she says, “should have a successful transition.”

That has not been the case for many, she says, especially transgender immigrants, Blacks, Latinx, and Native Americans, who have suffered violence, harassment, and discrimination.

Zander Keig, a Latino trans man and activist who twice attempted suicide as a teenager and spent a year in an adolescent psychiatric hospital, says that while he was transitioning he struggled to find a healthcare provider for the OB-GYN care he continued to need because he still had ovaries and a uterus. He was shuffled among mostly female providers who didn’t want to handle his case and who treated him with such disrespect and disregard that he eventually filed a complaint with the medical school that oversaw the clinic he visited. “The entire experience left me feeling dejected,” Keig says.

Here, we look at four obstacles to healthcare transgender people face, and what to do now to avoid these pitfalls.

A photo of Zander Keig
Zander Keig, a trans man, says he had difficulty finding healthcare providers who treated him with respect while he was transitioning.
Photo: Courtesy of Zander Keig

The High Cost of Care

A third of those in the NCTE survey said they’d skipped getting medical care because of cost. Even when transgender people have insurance, transition services might not be covered well or at all, leaving patients on the hook for potentially thousands of dollars.

For many transgender people, transitioning involves hormone replacement therapy, for example, to promote changes in facial hair, voice quality, or muscle mass, says William Powers, DO, who runs a transgender specialty practice in Farmington Hills, Mich. Many transgender people seek only hormone replacement therapy and do not pursue surgical transition measures like breast removal or augmentation, Powers says.

A quarter of people in the NCTE survey who tried to have insurance pay for their hormone replacement therapy were denied coverage, as were over half who sought coverage for transition-related surgery.

Denial of coverage can have a devastating impact.

When Jami Claire, 62, learned that her health insurance from her employer would not cover her medical transition, including hormone replacement therapy, she went into a deep depression and attempted suicide on three occasions, according to a lawsuit that she and two other transgender people, Kathryn Lane and Ahmir Murphy, filed against the University of Florida and two state agencies earlier this year.

The lawsuit charges that the state’s insurance discriminates against transgender people because it specifically excludes coverage for services to meet their unique medical needs, while covering all medically necessary care for nontransgender people, says their attorney, Simone Chriss. “Gender-affirming care constitutes medically necessary and lifesaving care for many transgender people,” she says.

At least for the moment, denying such coverage is illegal, says the National Center for Transgender Equality. Because of the protections in the Affordable Care Act, “health plans aren’t allowed to exclude transition-related care, and healthcare providers are required to treat you with respect and according to your gender identity." A rule change by the Department of Health and Human Services seeks to void this protection, but is being challenged in court (see more below).

What to do if you need free or low-cost services: Sign up for health insurance with Out2Enroll, a nonprofit organization that helps connect transgender, lesbian, gay, and bisexual people with Medicaid or insurance plans offered under the Affordable Care Act.

If you already have insurance but have been denied transition care coverage, you can appeal that decision directly with the insurer; look for instructions on how to do so on the explanation of benefits the company sends you.

There are also low-cost clinics around the U.S. that offer basic healthcare. To find one, search using your ZIP code at the National Association of Free & Charitable Clinics.

Homelessness

After living for more than two decades on the street, Smith was able to walk through the door of her very own apartment this September. She secured housing with the help of a local community organization, the Ritter Center in San Rafael, Calif.

“Just being able to have a door that I can lock, and I don’t have to worry about somebody kicking it in and arresting me, is a level of security that I have never had,” Smith says through tears.

Transgender people often wind up homeless because, whether voluntarily or by force, they leave their family homes as very young people, before they’ve been able to create a financial or educational safety net, says Mark Shotwell, executive director at the Ritter Center, a 40-year-old social services center that specializes in transgender health care.

That’s what happened to Smith—she was thrown out of her house at age 16 shortly after she was raped. She says she went home and found all her things piled up in the front yard. That night, and taking only what she could carry, she found an abandoned gas station and slept on its bathroom floor.

A photo of Lyra Menolloy Smith.
Lyra Menolloy Smith, a transgender woman, was homeless for more than two decades before finding a home of her own.
Photo: Courtesy of Lyra Smith

Almost two-thirds of transgender people don’t live in traditional housing or in a shelter, according to recent figures (PDF) from the National Alliance to End Homelessness, and that number has risen 88 percent since 2016. As concerning: A recent rule proposed by the Department of Housing and Urban Development would allow sex-segregated shelters to turn away transgender people, according to a report by the Center for American Progress.

Homelessness among transgender people is a significant problem that keeps people from getting routine medical care, says Elizabeth Reis, PhD, a professor at Macaulay Honors College at the City University of New York, whose work focuses gender issues, including transgender health.

“Many transgender people are discriminated against in all areas of life, including employment,” Reis says. “And if they can’t work, they don’t have any money for an apartment, or healthcare.”

Forty-two percent of unsheltered transgender people avoid medical care, according to the National Alliance to End Homelessness, compared with 2 percent who have a home. Living on the street also forces a person to engage in risky survival behaviors, according to their report, and exposes transgender people to brutal hate crimes, even murder. In 2019, at least 26 known transgender people were killed in the U.S.—91 percent were Black.

Where to seek help: Check with the nonprofit group 211. Its online counselors can put you in touch with shelters, community centers, food banks, and other social services 24/7 in your area.

Are you a veteran? Contact the National Call Center for Homeless Veterans at its website or by calling 877-424-3838.

Lack of Access to Trained Providers

William Powers, the specialist in transgender healthcare, says that he didn’t receive any special training in transgender medicine while a medical student but that he has been able to teach himself over the years as he met with more and more patients. His practice now has more than 1,000 transgender patients and a waitlist of another 1,000. 

But when he was looking for his first job in medicine, after his residency when he was already caring for 50 transgender patients, he had trouble finding a position. No one was willing to hire him, he says. Or if they were, they weren’t open to letting him bring his patients, citing concerns about difficulty dealing with insurance for transgender people, or worries that managing transgender patients was too tricky.

“I’ve been told, ‘We don’t want those people in our lobby,” Powers recalls.

Meanwhile, Powers’ wife, also a physician who was applying at the same time to many of the same hospitals and practices, did receive calls to be interviewed.

Finding even a self-trained physician like Powers can be difficult. Not all doctors feel confident treating transgender people, possibly because they haven’t met a transgender person before. A 2018 American College of Obstetricians and Gynecologists survey of healthcare providers found three-quarters of clinicians said they had never encountered a transgender person.

And while 86 percent of physicians said they were willing to provide care for transgender patients, only two-thirds said they felt they’d received enough education to do so.

“Most physicians who do not take care of transgender patients report lack of training,” says Safer at Mount Sinai. Even a half-day of training can have a huge impact, according to a 2020 study of 138 medical students.

More medical students are now being introduced to transgender healthcare issues. Almost two-thirds of U.S. medical schools now include some training in transgender medicine, according to the Association of American Medical Colleges.

How to find transgender-friendly medical practices: Look up qualified providers in your area using the database at the World Professional Association for Transgender Health. Don’t find anyone in your area? Consider telemedicine. Powers says he sees patients virtually across the U.S., which has now become the norm since the COVID-19 crisis.

Weak State and Federal Protections

Last June, the HHS made a rule change that, according to the Commonwealth Fund, would no longer guarantee that transgender people receive equal access to medical care or care that is consistent with their gender identity. HHS says the move would save about $2.9 billion. 

But by the agency’s own estimate, the rule change would allow up to half of more than 137,000 hospitals, doctor offices, insurance companies, state Medicaid agencies, and health centers across the U.S. to no longer honor the earlier protections offered to transgender patients. 

The new rule is currently being challenged in several states. 

Meanwhile, at least 20 states, including California, Colorado, Minnesota, and Michigan, specifically protect transgender patients from being discriminated against in receiving medical care, according to the NCTE. (See the NCTE's list of states and links.)

Some states, like Pennsylvania, Levine says, do not have a law that offers clear protections, though cities like Pittsburgh and Philadelphia do.

“No matter what the Trump Administration says, federal and state laws, and, in many cases, the U.S. Constitution, prohibit discrimination in healthcare and insurance because you’re transgender,” according to the NCTE.

Have you been discriminated against? You can file complaints with the HHS and a number of other agencies—the NCTE publishes a list of where to file a complaint. Or, if you want to challenge your insurance company’s decisions, the NCTE suggests hiring an attorney with experience in coverage issues. See the NCTE’s list of expert transgender legal service providers.