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Imagine you are planning a trip next week. The drive will be long, crossing several state borders. The route passes through communities where, you’ve experienced, many folks don’t understand people like you. The key question is: which city and state will let you use the restroom safely?

You are a transgender woman. The mental isolation and anguish you feel is the norm, and it takes its toll. Your safety is a real concern.  All it takes is one traffic stop. One person who tries to stop you from meeting your biological needs. You could find yourself in jail, or worse.

These substantiated fears matter to transgender communities, their allies, and anyone working to advance population health. Two trans women of color were murdered in the first seven days of 2017 alone. Despite resilience, advocacy, and strength among trans communities and allies, interconnected stressors threaten the physical and mental well-being of trans people around the country and the world.

More Than Numbers

The term “transgender” is often used to describe people whose gender identity or expression differs from the gender they were thought to be at birth. The transgender population encompasses all races and ethnicities, socioeconomic classes, and religious faiths. (The National Center for Transgender Equality developed this excellent FAQ). An estimated 1.4 million, or 0.6% of the US adult population, identify as transgender. An estimated 134,500 trans people are veterans or are retired from the Guard or Reserve service, and another 15,500 individuals are serving on active duty or in the Guard or Reserve forces. (See Transgender in the Military Service).

Although 1.4 million is the most up-to-date approximation, there are currently no federal agencies such as the US Census Bureau or the Center for Disease Control and Prevention (CDC) that accurately assess the true number. Stigma and discrimination against the population are two of many factors that prevent individuals from openly identifying and reporting themselves as transgender.

The 297-page U.S. Transgender Survey, published in December 2016, is the most comprehensive survey on the trans population. Thirty-nine percent of transgender respondents experienced serious psychological distress in the month before completing the survey (based on the Kessler 6 Psychological Distress Scale), compared with only 5% of the U.S. population. Forty percent of transgender respondents have attempted suicide in their lifetime, nearly nine times the rate in the U.S. population (4.6%). Seven percent attempted suicide in the past year, nearly twelve times the rate in the U.S. population (0.6%).

Publications Reflect a Growing Awareness within Population Health Fields

While a work of fiction, the quandary about crossing state lines reflects the very real havoc experienced by one Texas nurse who began her transition to identifying openly as female a little over two years ago.

That nurse’s story is described in the Fall 2016 issue of Texas Nursing Magazine, an issue entitled “Cultural Humility: LGBTQ Stories of Transition on Each Side of Nursing.” The article, Gender Transition: One Nurse’s Story (page 10), describes a nurse who, with the support of her community and colleagues, went through a transition process that included changing her name, undertaking hormonal therapy, and facing legal challenges, such as correcting her gender on government documents and a nursing license. When asked to inform over 140 patients about her transition, with only a month to do so, she complied. However, because of patients’ subsequent focus on her personal experience, she chose to change jobs.

The presence of such a story in that magazine reflects a growing awareness and outspokenness among public health and health care leaders and practitioners about the importance of transgender health equity. A June 2016 issue of The Lancet focused on transgender health, as did the February 2017 issue of the American Journal of Public Health.

Given this momentum, and the numbers, what is the role for those of us using public health training and education to advance population health?

Sharing information is a good place to start, but there is more to be done to build a workforce that supports the transgender community. Storytelling is a critical tool for advancing public health. Professionals who can share personal stories, as the Texas Nursing Magazine article demonstrates, offer game-changing insights for the field.

Before we address the role of public health training in transgender health equity, here are three voices with stories, insights, and recommendations about gender-affirming transitioning within health systems.  

Personal Story 1—Transition Woes
Justine Price, MPH, CPH, CIC

When you are transitioning, every daily interaction becomes an exercise in anxiety. You live as a female and—thanks to the hormones your doctor prescribed—you look female. Unfortunately, your ID still bears the resemblance of a bearded man hiding in the closet.

Most jurisdictions won’t allow you to change your gender marker on state-issued documentation until you’ve either lived full-time in your true gender for a certain period of time, or have undergone some form of surgery. Access to transition-related surgeries can be complicated and require wait times as long as two or three years. The decision to have surgery also requires considerable thought, time, effort, and financial capacity.

This leaves most of us in a very awkward place during transition. We’re expected to live as ourselves and integrate, but we have no proper documentation to affirm this identity.

Almost every time you go to the store, you will be outed as transgender. Perhaps you’re simply buying a bottle of wine, or the clerk asks to verify your ID for your credit card. You feel compelled to explain, to apologize as you see their confusion, “Sorry, I’m uh… transgender, and can’t update my license yet.” The clerk looks to you, in your long hair and makeup, then back to the bearded guy on your ID. “I’m gonna have to call the manager.”

This scenario plays out every day, wherever ID is required. Imagine having to reveal personal medical information to strangers, multiple times per day, to complete basic transactions.

The bigger the transaction, the worse the scrutiny. The first time I flew during transition, the TSA employee thought I was trying to pull a fast one. He asked me, “Who is Justin?” (I was still awaiting my court date for a name/gender change.) He kept my ID and made me stand by the side while other TSA agents came over. They looked at my documents and laughed and laughed, then back up at me. More laughter—all while another TSA employee kept coming over and asking me for more documentation.

I am a government employee. I showed her my employee badge, a letter from my therapist, a letter from my attorney, prescription bottles… Eventually, they let me through, parading me between the boarding lines, and frisking me thoroughly. I felt immensely embarrassed and incredibly frustrated.

Not wanting others to experience that, I filed a formal complaint about the incident and an investigation was performed.

Personal Story 2—Gender Transition and Health Professionals
Danielle M. Skidmore, P.E. CFM

I am a 44-year-old civil engineer and parent living in Austin, Texas. I am a proud to call myself a transgender woman. I am finally living one congruent life as my complete self, and it has been profoundly positive to my emotional well-being.

I always knew I was “different,” even at an early age. However, growing up in the 1970s and 1980s without any social context or positive role models, I quickly found myself in a place of shame and guilt whenever I considered how I felt more like a girl than a boy. Long before I had ever heard the word “transgender,” I settled into a life where this disconnect, this dysphoria between my physical body and my brain, was always present. I was always melancholy and lived with near-constant anxiety.

After decades struggling to ignore that I was transgender, followed by years actively trying to find any alternative explanation, I finally accepted that the only real solution was to embrace who I am and move forward with transition.

My personal transition experience with the medical and health community has been largely positive, but, sadly, this is still an exception. For medical and public health professionals working with patients who want to improve people’s experiences, I recommend these key points:

Even if you have zero experience with transgender patients, if a patient comes out to you, immediately recognize them as real and valid. Being transgender has huge implications for mental health, but it is not a disease.  

Since emotional, physical, and legal transition all move on different schedules, immediate recognition of a transgender person’s preferred name and pronouns is enormously helpful to creating a safe, supportive, environment—even if it only shows up in the “nicknames” field of their Electronic Health Record or patient record, while legal names remain where necessary.

Take some time to learn about hormone replacement therapy (HRT). Even if you may not feel professionally comfortable managing a patient’s HRT, reading and understanding the latest research on protocols, risks, and benefits will show that this medical intervention is an amazing tool to help the lives of transgender people. Having expanded access to medically supervised HRT therapy would help reduce the number of people who have no practical choice but to self-medicate.  

The data support the need for the health workforce to support transgender patients.

The U.S. Transgender Survey, discussed earlier, reported 87% of transgender respondents had seen a healthcare provider in 2015.

One-third (33%) reported having at least one negative experience with a doctor or other healthcare provider, related to being transgender. And of those with a negative experience, twenty-four percent had to teach their healthcare provider about transgender people and appropriate care.

Fifteen percent said a healthcare provider asked them unnecessary or invasive questions about their transgender status that were irrelevant to the reason for their visit.

Eight percent said a healthcare provider refused to give them transition-related healthcare.

Six percent reported being verbally abused in a healthcare setting.

Trans people operating in isolation or with a limited support network are at the greatest risk for psychological distress. Transgender individuals are at the extreme among LGBT individuals dealing with psychological distress issues. However, as with other communities, the trans community shows resilience.

Not all trans people transition. However, all trans people benefit from role models and trans peers. These encounters reinforce the positive aspects of their lives. Trans individuals nationally and locally serve as positive role models others can relate to and talk with.

Personal Story 3—Transition Before Internet
Lou Weaver

I grew up in a time before the Internet. There were no role models for guys like me in the TV, films, or magazines I had access to. I tried to come out in 2001, but had no resources and no one to talk to. In 2007, I was finally able to find a community that I could call home. All of a sudden I had access to information, including where to find a doctor and what a trans community looked like.

I discovered my true self while living in Houston, Texas. Some might think that Houston is a horrible place to come out as trans, but for me it was the best place to be. There was a strong, thriving community, with a lot of trans masculine guys with all types of journeys represented. I had insurance when I came out; I was one of the lucky ones. But finding a doctor who was willing to treat me was a different story. I identified only three such doctors in the city. I live within a mile of the world’s largest medical centers, yet the ability to find a doctor trained in care for the trans community was proving to be a daunting task.

I had my hysterectomy at Texas Women’s Hospital in 2010. The surgery was prompted by a complicated medical issue. The hospital also felt like an odd place to go, but that is where my doctor had his surgery privileges. The morning of check-out, the last nurse I called kept calling me “she” and “her” instead of “he” and “him.” After a weekend of affirming care from my doctor and the affirming nurses, I was crushed to leave on this note. I was glad I was going home.

Planning my next trans-related surgery was harder. I could not find a surgeon to perform my top surgery (double mastectomy) in Houston. This is a routine surgery that no doctor in a city of two million people was performing for trans men. It took me years to save up, since the procedure was not covered by my insurance.

Support systems are vital for trans people, not only during transition but also throughout their lives. I had to drive almost 200 miles for the surgery—three hours away from my support system.

Next Steps: It’s in Your Hands

These stories illustrate some of the difficulties trans people have navigating the world.  

It’s not just adults. Trans youth and children, as well as their parents and families, face numerous obstacles in their daily lives. Trans people need a community that cares—a community that accepts them for who they are. A little respect can go a long way in reducing psychological distress. Public health practitioners can take the first steps towards a trans-culturally-competent workforce by being supportive and respectful.

The Public Health Learning Network is uniquely positioned to help develop an LGBT-culturally-competent workforce. This in turn can facilitate the development of an LGBT-culturally-competent healthcare workforce in hospitals, long-term care organizations, and other direct health care delivery providers.

Several regional public health training centers (PHTCs) and local performance sites (LPSs) are already engaged in developing LGBT courses to inform and update public health practitioner knowledge and skills. The Region VI – South Central Public Health Training Center is developing  an overview course entitled “Public Health C.A.R.E.S.––Compassion, Acceptance, Resilience, Equality, Support.” This is the first of a six course learning series with topics on “Culturally Competent Healthcare,” “Behavioral Health Issues,” “The Role of Endocrinology,” and “Post Operative/Surgery Care,” and “Gender Identity, Gender Expression and Workplace Discrimination in Public Health.” The Region 2 Public Health Training Center created a webinar to help public health professionals understand and provide affirmative services to the trans population. Other regions can work with local communities and agencies to develop the training resources their regions need.

Let’s consider an LGBT special interest group within the network, including staff from training centers across all regions. This would enable a more comprehensive and systemic approach to emerge in creating courses to meet the public health practitioner’s needs for LGBT culturally competent training.

The first step is in your hands. If you are interested in helping form such a group, contact John Oeffinger, Director, eLearning and Training at the Texas Health Institute for further information.

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Authors:

John Oeffinger, BA, Director, eLearning and Training, Texas Health Institute

Lou Weaver, Transgender Programs Coordinator, Equality Texas

Justine Price, MPH CPH CIC, Subject Matter Expert Reviewer, Texas Health Institute

Danielle M. Skidmore, P.E. CFM, Vice President, K Friese + Associates

Yoonhwi Cho, MPH Candidate, PHTC Course Author, Texas Health Institute

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See the February 2017 edition of Elevate »