Transgender Adults & Health Care: A Guide for Reporters
This article is one part of a series on recommendations for reporting on the lives and experiences of transgender people. For an introduction, click here.
For a guide on covering health care for transgender youth, click here.
Access to health care is one of the most consistent and widespread issues faced by transgender people today. When I worked on the Protect Trans Health campaign, we received thousands of comments from transgender people and their loved ones telling stories of humiliation, harassment, and rejection by undertrained medical providers.
Thoughtful and accurate reporting on the health care of transgender people is critical to educate your readers about this growing matter of public health. The topics in this guide include:
Transition-Related Care 101
Health Care Access
Insurance Coverage
HIV
Suicide
Cliches to Avoid
Sources
Transition-Related Care 101
A persistent discomfort with one’s gender expression and identity is called gender dysphoria.
According to the American Psychological Association:
Gender dysphoria involves a conflict between a person’s physical or assigned gender and the gender with which he/she/they identify. People with gender dysphoria may be very uncomfortable with the gender they were assigned, sometimes described as being uncomfortable with their body (particularly developments during puberty) or being uncomfortable with the expected roles of their assigned gender.
People with gender dysphoria may often experience significant distress and/or problems functioning associated with this conflict between the way they feel and think of themselves (referred to as experienced or expressed gender) and their physical or assigned gender.
A transgender adult may pursue mental health care, counseling, hormonal therapy, and transition-related surgery. These interventions are widely-recognized throughout the medical mainstream as safe and effective, including by the American Medical Association, the American Psychological Association, and the American Psychiatric Association.
Guidelines for providing transition-related care are available from the World Professional Association of Transgender Health (WPATH). These guidelines are the result of the decades of research by medical providers and public health experts across the globe.
Like all other forms of medical care, the course of treatment a transgender person takes — if they seek medical care at all — is going to be different for each individual. Access to transition-related care will vary greatly by socioeconomic status and geographic location — transgender people with no-to-low incomes or transgender people in rural areas may struggle to find care.
One of the most common forms of transition-related health care is Hormone Replacement Therapy (HRT), a low-risk regiment of prescription hormones and/or hormone blockers that can help alter secondary sexual characteristics. Estrogen, for example, can help transgender people develop breast tissue, soften hair and skin, and — in combination with suppressing testosterone — reduce muscle mass. Testosterone can deepen one's voice, increase muscle mass, and prompt the growth of facial hair.
Because the risks carried with HRT are relatively low — and the medications involved are available at most pharmacies — it is increasingly being prescribed by primary care providers in lieu of specialists and often on an informed consent basis.
Transition-related surgeries are increasingly available across the United States and offered at many major hospitals. There is no one surgery that a transgender person might pursue — if any at all — and surgery is not always going to be right for a transgender person’s course of treatment.
Health Care Access Among Transgender People
The 2015 US Transgender Survey remains the most thorough and complete study of transgender adults in the US. It contains a thorough section devoted to health care access among transgender people and can most likely answer any questions you might have as well as provide important context for your reporting. Topics include general health care access, access to specific forms of transition-related care, mental health care access, insurance coverage, and costs.
The USTS includes individual reports by state as well as breakout reports focused specifically on trans people within a variety of ethnic groups.
Health care access for transgender people in the southern United States is particularly lacking. In 2019, the Campaign for Southern Equality released a comprehensive survey of southern states and its findings cover a broad array of medical care, ranging from counseling, STI prevention, primary care, transition-related care, and many others.
It is important to remember that transgender people may have particular health needs related to their gender identity, but they likewise need the same level of healthcare any other person who is not transgender would need. Specialist fields ranging from cardiology, oncology, dermatology, gastroenterology, and OB/GYN have all begun to tackle barriers transgender people might face to accessing their services — some of which are related to their identity as a transgender person but most of which are related to other factors including poverty, prejudice, or a lack of medical insurance.
While access to transition-related care is wanting across the country, many issues faced by transgender people occur while accessing the same forms of general care needed by someone who is not transgender. According to a study by the Center for American Progress, one in three transgender people has been refused care by a medical provider — and the vast majority of complaints submitted to the Department of Health and Human Services by transgender people involved barriers and incidents faced while accessing general health care
Insurance Coverage for Transition-Related Care
Before the passage of the Affordable Care Act, a gender dysphoria diagnosis was considered a pre-existing condition by most insurers and disqualified most transgender people from receiving insurance coverage. Since the ACA’s passage in 2010, the market for insurance coverage of transition-related care — in both private and public insurers — has changed dramatically.
Private Insurance
Within the Affordable Care Act is Section 1557, the first federal law prohibiting discrimination on the basis of sex in health care programs and settings. As most courts have read it, this includes anti-transgender discrimination and exclusions against transition-related care.
In 2016, the Obama administration issued a regulation mandating this interpretation for the Department of Health & Human Services. By the end of 2016, a federal judge in Texas had placed a permanent injunction against this regulation and, in the spring of 2019, the Trump administration proposed a full rollback of the regulation. For more on this topic, please consult this resource from the American Academy of Family Physicians.
According to a 2019 analysis by Out2Enroll, 97 percent of Marketplace insurance plans have no exclusion against transition-related care and 47 percent included language explicitly including transition-related care.
Medicaid
The Medicaid Act of 1965 prohibits exclusions on the basis of any particular diagnosis — and that includes gender dysphoria. That said, many state plans still fail to cover transition-related care and such plans are frequently the subject of legal challenges.
As the Center for American Progress reports:
Many of these exclusions date to the early 1980s, when the federal Medicare program adopted a policy excluding transition-related care from coverage on the assumption that it was “cosmetic” and “experimental,” despite a widespread medical consensus deeming health care services related to gender transition medically necessary. Numerous state Medicaid programs, as well as most private insurance plans, quickly followed suit. As a result, Medicaid coverage for transition-related health care has long been available only in a small handful of states on the basis of court rulings requiring these states’ Medicaid programs to consider the medical necessity of transition-related care for transgender individuals on a case-by-case basis.
Medicare ended its exclusions against transition-related care in 2014.
After numerous successful legal challenges, the number of state Medicaid programs with exclusions has been shrinking steadily since. Today, only ten states have explicit exclusions against transition-related care and 21 states (plus DC and Puerto Rico) have explicit inclusion of transition-related care.
Veteran’s Affairs
Clinics operated by the Department for Veteran’s Affairs provide most forms of transition-related care with the exception of surgical care. That exception is the subject of a lawsuit and pending regulation filed in 2018.
A detailed listing of services provided to eligible transgender veterans by VA clinics can be found at the Transgender American Veteran Association’s website.
Prisons and Immigration Detention
For a more thorough discussion of this topic, click here
Health care access for trans people within prisons and/or immigration detention centers is notoriously spotty, if available at all. Few have explicit policies governing such treatment, and even fewer enforce these policies in a fair or transparent manner.
According to the American Medical Association, “Prisoners have a fundamental right to access necessary and effective medical care, and that includes the full range of treatments for gender dysphoria.”
To learn more about treatment of transgender prisoners in your area, consider contacting a local chapter of Black & Pink, an organization providing services and support to LGBTQ people in prison.
HIV and Transgender People
According to a 2017 analysis by the Centers for Disease Control and Prevention, transgender people are three times as likely to contract HIV as the general population. Most alarmingly, the CDC reports half of all Black transgender women are HIV positive.
The CDC contributes this to a range of factors including poverty, lack of access to health care, and prejudice within the health care field against transgender people.
Reporters should consider contacting local sexual health and reproductive health clinics to understand local access to HIV prevention programs — a directory of which is available at HIV.gov.
The Center for Health Journalism at USC-Annenberg offers some helpful tips for reporting on HIV.
Suicide and Transgender People
According to the 2015 US Transgender Survey, transgender adults are nine times as likely as their peers to experience a suicide attempt. Researchers, providers, and public health experts agree this high suicide risk is largely a factor of “minority stress” as well as a lack of access to adequate health care. Nothing about being transgender inherently raises ones risk for suicide.
As with any story focused on suicide, reporters and editors should take care to discuss suicide as a significant concern of public health. Most importantly, suicide must be understood as something that happens to someone, not a choice someone makes.
For more on the risks and considerations to take when covering suicide and self-harm, visit Reporting On Suicide.
Cliches to Avoid
Surgery and Anatomy
Of all the areas of life for transgender people covered by the mainstream US media, none is as sensationalized and misunderstood as our health care. In just the last decade, prominent transgender people in public life have been asked probing, sensitive, and humiliating questions about surgical care — particularly our genitalia.
These questions reduce transgender people to our bodies in a way that distracts from our humanity. It is critical to ask yourself as a reporter whether these details about a trans person’s body hold any relevance to your story because they most likely do not. Unless you are reporting on access to a specific form of treatment, you can and must avoid reporting these details in the interest of privacy and safety. Audience interest in these details is not reason enough to print them.
Sources
Health care for transgender people is often misunderstood, misrepresented, and overly politicized. It is critical to approach the health of transgender people through a public health lens.
To that effect, consider limiting your sourcing to medical providers, researchers, or experts in related fields. Most major medical organizations, for example, have issued previous statements on the health care of transgender people and recognize transition-related care in particular as safe, effective, and necessary. Do not use activists or politicians as medical experts.
Transition-related care is not controversial within the medical field. When reporting on medical treatment and care, be conscious of the dangers that can come with reporting false or misleading information.
