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Federal Protections in Health Care at Risk for Transgender Americans

transgender health care rights

The Affordable Care Act (ACA) created many safeguards for consumers of health care. One such protection in Section 1557 of the law prohibits discrimination in health care based on race, color, national origin, sex, age, or disability. In 2016, the federal government released a rule clarifying that the provision also applies to gender identity. This means that, under current law, health providers and insurance companies that receive federal funding may not discriminate against transgender people in health care and must provide the same access to coverage, services, and care to trans people that cisgender people — individuals whose gender identify matches the sex they were assigned at birth — have.

However, recent reports suggest the federal government is considering defining gender as sex at birth. This news comes amid other signals suggesting the federal government will no longer recognize trans people. The definition change could effectively eliminate federal protections of the ACA, bringing us back to a time when trans people could be legally discriminated against and denied care, without recourse.

The move could have devastating implications for the health and health care of transgender and gender nonconforming individuals, placing an already vulnerable population at even greater risk. It also would undermine efforts to ensure everyone has access to affordable care that helps to avoid unnecessary and more expensive care down the line.

One of the Most At-Risk Populations

The approximately 1.7 million trans people in the United States face significant hardships that increase their risk of poor health outcomes. First, two in five (39%) report being low income, or earning less than $30,000 a year per household, which can have negative effects on health. In addition, trans people are more likely than the general population to face discrimination in education and employment; abuse by the police; harassment in public spaces; and physical, verbal, and sexual assault. Nearly all of these issues are even greater for trans people of color.

Percent of trans people reporting...

Harassed in school (K–12)

78%

Harassed in public space like hotel, restaurant, airport, or government agency

53%

Harassed at work

50%

Physically assaulted

26%

Lost a job because of gender identity

26%

Harassed by the police

22%

Refused a home or apartment because of gender identity

19%

Experienced homelessness at some point in life

19%

Sexually assaulted

10%

Data: Jaime M. Grant et al., Injustice at Every Turn: A Report of the National Transgender Discrimination Survey (National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011).

The daily, toxic stress of living as a trans person in America — from poverty to discrimination — can negatively affect the physical and mental well-being of trans people. Trans people are more likely than their cisgender counterparts to report poor physical health, experience mental health issues like anxiety and depression, and have substance abuse problems. A staggering 40 percent have attempted suicide, compared with 4.6 percent of the general population.

Poor Access to Quality Health Care

Transgender people often face barriers to getting the health care they need. One in five transgender adults is uninsured. Trans people often skip health care because of cost: nearly half of trans adults (48%) have postponed medical care when sick or injured and avoided preventive care (50%) because they couldn’t afford it.

Trans people also often hide their gender identities from health providers out of fear of retaliation and harassment. Only 40 percent of trans people report being out to all their medical providers. It’s understandable that many would want to conceal this information: 28 percent of trans people report experiencing verbal harassment in a medical setting and 19 percent report having been refused medical care by providers because of their gender identity. Because of this past stigmatization and harassment, 28 percent of trans people report avoiding care altogether.

Of those who do make it to the doctor and actually disclose their gender identity, half report having to teach their medical providers about transgender individuals’ health care needs and the appropriate medical care required. This unawareness on the part of medical providers — in part because of the lack of training they receive — has serious implications for care quality. Moreover, when people veil their identities in medical settings, their providers miss important information that should inform screening, diagnosis, and care. And having to hide who they are leads trans people to further distrust and avoid the health care system. Why go to the doctor — putting yourself at risk of harassment and discrimination — when they won’t help you anyway?

The Consequences of Erasing Transgender Rights

For trans people, health care settings often add to their distress rather than offer help. The American Medical Association (AMA), in a suite of recommendations for trans health care, has openly opposed policies that could harm trans people, stating that “laws and policies that restrict the use of public facilities based on biological gender can have immediate and lingering physical consequences, as well as severe mental health repercussions.” The AMA recommends equal access to care that corresponds with a person’s gender identity, “to protect the public health and to promote social equality and safe access to public facilities and services.”

If gender is defined only as sex at birth, the current disparities in health and health care for trans people will likely widen, leading to greater harassment, more avoidance of care, and, ultimately, even greater unmet medical and behavioral health needs. Maintaining federal protections for trans people in health care will help ensure that our health system meets the needs of all Americans in an efficient and humane way.

Publication Details

Publication Date: November 8, 2018
Citation:

Corinne Lewis, Yaphet Getachew, and Mekdes Tsega, “Federal Protections in Health Care at Risk for Transgender Americans,” To the Point (blog), Commonwealth Fund, Nov. 8, 2018.

Experts

Corinne Lewis
Research Associate, Delivery System Reform, The Commonwealth Fund
Yaphet Getachew
Program Assistant, Delivery System Reform, The Commonwealth Fund
Mekdes Tsega
Program Associate, The Commonwealth Fund