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Transgender-Competent Health Care
By Michael Fitz, MSW, LSW

There is little research on the cultural competency of providers who serve the health care needs of transgender individuals. However, what research does exist shows a great need for ongoing sensitivity training to decrease inherent biases and phobias around transidentities, training regarding appropriate language and terminology to use with transgender individuals, and knowledge of the overall challenges this population faces (Witten & Eyler, 2012).

These needs are important as transgender individuals age and require more visits with culturally competent health care providers or placement in long term care facilities with culturally competent staff.

Health care providers must stay up-to-date through cultural sensitivity and competency workshops, relevant readings from other health care professionals working with transgender individuals, and understanding the political and social issues affecting this population. 

Health Care and the Transgender Community
The growing field of transgender health has evolved from a disease-based identity in the 1950s and 1960s to an identity-based model today (Bockting, 2009). However, according to a 2011 study by the National Gay and Lesbian Task Force and the National Center for Transgender Equality, the transgender community faces discrimination by health care providers, high HIV rates, and lack of access to necessary care (Grant, Mottet, Tanis, Harrison, Herman, & Keisling, 2011).

Approximately 3.5% of the U.S. population identifies as lesbian, gay, bisexual, or transgender (LGBT) (Gates & Newport, 2013). Witten (2008) estimates that there are approximately 1 million transgender-identified individuals in the United States and up to 10 million globally but admits there is no way to fully confirm these figures because of many transgender individuals’ perceived fear of persecution and perceived or real abuse and lack of legal protections.

A study cited in an article by Poteat, German, and Kerrigan (2013) supported Witten’s findings. The study showed that all of the 2,281 respondents who identified as heterosexual reported a high level of bias toward transgender individuals. These findings are consistent with studies among the transgender population, which reports widespread stigma and discrimination.

Furthermore, the NASW Code of Ethics recommends that social workers educate themselves about cultural issues facing their clients from various backgrounds. It also indicates that social workers should not “practice, condone, facilitate, or collaborate with any form of discrimination on the basis of ... gender identity or expression.”

Lastly, the Code of Ethical Responsibilities to the Social Work Professionstates that social workers should monitor and evaluate policies, program implementation, and practice interventions (code 5.02) and engage in social and political action (code 6.04) to expand choices and opportunities for all people.

Key Findings
Findings from the National Gay and Lesbian Task Force and the National Center for Transgender Equality study showed that the more than 6,450 transgender and gender-nonconforming respondents reported very high levels of postponing medical care when sick or injured due to discrimination (28%) or inability to afford care (48%) The study also found that 19% of survey participants were refused medical treatment outright (Grant et al.).

Twenty-eight percent of the study’s respondents were subjected to harassment in medical settings, while 2% were victims of violence in doctor’s offices. Fifty percent reported having to educate their medical providers about transgender care. Respondents also reported more than four times the national average of HIV infection: 2.64% vs. 0.6% of the general population (Grant et al.).

Additionally, if medical providers were aware of a patient’s transgender status, the likelihood of that person experiencing discrimination increased. More than 25% of the respondents reported misusing drugs or alcohol specifically to cope with this mistreatment, and 41% reported attempting suicide.

According to a study conducted by McFarland and Sanders (2003), transgender individuals want adequate access to quality health care and no discrimination from service providers. Therefore, it appears that this issue needs to be addressed as more transgender individuals disclose to their families and support systems about their transgender status and seek health care. 

Regarding abuse from community organizations toward transgender individuals, Witten (2008) wrote, “Community organizations that work with the LGBT communities must be sensitized to the symptoms of various forms of trans-elder abuse and how to approach them. However, it is also important that researchers discard the traditional constructs as the only forms of abuse and begin to explore how transgender abuse may lead to ... unthought-of forms of abuse ... In addition to understanding violence and abuse of the transgender-identified aging population, it is important that researchers and practitioners become acquainted with health care issues for aging Transgender individuals” (p. 14).

Social Work Implications
Social workers must ask themselves about the costs for the transgender clients when there is no mandated transgender competency training for service providers. Many transgender individuals across many age brackets do not have the financial means or motivation to change their natal body to match their gender identity. This requires the medical community to attend ongoing training about transgender issues and challenges so they can treat the individual with dignity and respect while honoring patients’ right to pain-free living and self-determination, as indicated in the Code of Ethics.

Social workers and other health care professionals have an ethical obligation to combat social injustice whenever we come across it in our professional careers. The NASW’s six core values thoroughly address that obligation. It is our duty as social work professionals to serve individuals who need quality health care, whether it is preventive medicine or end-of-life care, no matter what our personal biases are. Barsky (2009) wrote that accountability reflects two NASW principles: integrity and competence.

Since the implementation of the Affordable Care Act, transgender individuals, in theory, have access to affordable health care without fear of discrimination and legal action options if they do encounter discrimination from medical providers.

First, it is theory because not every medical provider receives federal financial assistance, and not every populated area of every state has a low-income or free health clinic. Second, since there are states that have refused to expand Medicaid, there still are individuals ineligible for health subsidies if they want to purchase private insurance but who also do not qualify for Medicaid. Because health insurance can (and does) refuse to pay for transition-related health care, there are transgender individuals who cannot afford to transition, maintain their hormone therapy, or pay for medically necessary surgeries in order to change their assigned-at-birth sex to match their identity (HRC.org, 2011).

As Persson (2009) points out, it is left to transgender individuals to educate service providers regarding their needs because of the lack of knowledge and training about transgender identity and sexuality necessary for service providers to respond adequately to their patients. That is neither ethical nor just in the 21st century.

— Michael Fitz, MSW, LSW, is a recent graduate of the School of Social Work at Temple University in Philadelphia.

References
• Barksy, A. E. (2009). Ethics and values in social work: an integrated approach for a comprehensive curriculum. Oxford: Oxford University Press.

• Bockting, W. O. (2009). Transforming the paradigm of transgender health: A field in transition. Sexual and Relationship Therapy, 24(2), 103-107.

• Gates, G. J., & Newport, F. (2013). LGBT percentage highest in D.C., lowest in North Dakota. Retrieved from http://www.gallup.com/poll/160517/lgbt-percentage-highest-lowest-north-dakota.aspx.

• Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & Keisling, M. (2011). Injustice at every turn: A report of the national transgender discrimination survey. Retrieved from http://issuu.com/lgbtagingcenter/docs/ntds_report.

• McFarland, P. L., & Sanders, S. (2003). A pilot study about the needs of older gays and lesbians. Journal of Gerontological Social Work, 40(3), 67-80.

• Poteat, T., German, D., & Kerrigan, D. (2013). Managing uncertainty: A grounded theory of stigma in transgender health care encounters. Social Science & Medicine, 84, 22-29.

• Witten, T. M. (2008). Graceful exits: Intersections of aging, transgender identities, and the family/community. Journal of GLBT Family Studies, 5(1-2), 35-61.

• Witten, T. M., & Eyler, A. E. (2012). Gay, lesbian, bisexual, and transgender aging: challenges in research, practice, and policy. Baltimore, MD: Johns Hopkins University Press.