Lauren Denitzio, Untitled (Alex) (2017).

Primary Care

Who decides what being you looks like?

By Ruben Hopwood, MDiv, PhD

A primary concern for many health care providers is how to respond when someone experiencing gender incongruence and mental health concerns seeks out gender affirming hormone treatment (GAHT). Individuals who experience gender incongruence are people who I will categorize for the purposes of this article as trans and non-binary, or more widely as gender diverse people. This means individuals who experience their sex assigned at birth (e.g., typically male or female) as being an inaccurate or incomplete marker of their gender identity. Some may or may not use terms such as trans, non-binary, genderqueer, agender, gender fluid, etc. for self-identity. People may identify their gender in alignment with their assigned sex (cisgender). They may identify with an opposite gender from assigned sex, with two or more genders (non-binary, gender queer, bi-gender, two spirit), with genders that shift at times (gender fluid), or with no gender at all (agender).

In The Report of the 2015 U.S. Transgender Survey, out of nearly 28,000 gender diverse people, 78 percent wanted GAHT, and only 49 percent had ever received this treatment. For many, whether they experience or disclose any mental health issues may determine whether they are given access to medically managed and safe treatment or are left without care. When supported in attaining safe GAHT, the overwhelming majority of gender diverse people report their lives markedly improve in ways that are counterintuitive to mental health and medical predictions and expectations, such as decreased depression and anxiety and increased job performance, life satisfaction, and sexual functioning. According to the Report, as well as a 2016 study, improvements exceeded traditional talk therapy and medication treatment for these symptoms with some reports of 80 percent improvement in overall quality of life. And still, health care remains largely focused on resolving secondary issues such as depression, suicidal thinking, and substance use, prior to treating the primary concern of gender dysphoria (e.g., significant distress brought on by incongruence between sex assigned at birth and socially expected gender identity).

[W]e get it all backwards and treat secondary issues first, believing that the underlying primary issue will just vanish.

I propose this focus on secondary issues is largely rooted in an unfortunate, though unsurprising reaction to gender diverse people breaking cultural expectations and norms. In our US culture that often seems hyper-focused on idealized images of unattainable masculine and feminine perfection, it can be challenging and confusing for most people trying to fit into gendered norms. It is especially challenging and confusing for those who do not identify themselves on a man-woman binary or with their sex assigned at birth.

We know the devastating impact on the health of women and gay men that arises from social images and messages around bodies. Cultural messages of what is “acceptable” masculinity and femininity are not new. As humans we seem to thrive on an inherent drive to have everyone in our groups be similar and look healthy according to our often arbitrary or superstitious markers. For instance, during the Great Depression, thin people were considered unhealthy, ill, unattractive, and to be avoided. Ads in the 1930s-1950s for products like Wate-On, admonished women, girls, men, boys, and convalescents, “If you want to be popular…you can’t afford to be skinny.” How different the 21st-century image of health is! It has turned upside-down.

Socially, we tend to exhibit fear, revulsion, and suspicion of anyone dissimilar to our ideals of health and normalcy. The dissimilarity from dominant cultural norms of gender incongruence engenders rejection, violence, and stigmatizing responses from the majority society. The response by gender diverse people to this stigma is understood through a minority stress model. Minority stress is a state of chronically high levels of stress due to being part of a marginalized group. The stress arises from repeated experiences of stigmatization, discrimination, poor social supports, and access to resources for basic needs. The highest known contributor to minority stress is personal prejudice and discrimination against a minority person or group. Responses to minority stress typically result in mental health concerns (e.g., depression, suicidal thinking, isolation, etc.) and coping strategies that may be debilitating or lead to additional experiences of marginalization and discrimination (e.g., substance use, drinking, cutting, eating issues, etc.).

At times, medicine and mental health practitioners focus on diagnosing and treating minority stress symptoms that make more sense to the provider or reduce clinician discomfort with caring for a gender diverse person. The providers (and family and friends) may blame the gender identity on the symptoms of minority stress. They develop the false belief that if these symptoms of “pathology” can be eliminated, then the person will become “normal” gendered as expected by the society. This process of making someone’s core identity and needs a problem is referred to broadly as pathologizing a person or a group of people. Individuals may end up with multiple diagnoses that interfere with or prevent gender affirming care. It’s a paradoxical situation from which there is little hope of escape. The solution (gender affirming treatment) is denied by the circumstances (bias and discrimination) that also create the problem (symptoms from minority stress that become the focus of treatment instead of gender affirmation).

Marchers in the 2018 Boston Pride Parade urged spectators to vote “yes” to uphold transgender protections, including the right to be free from discrimination in places of public accommodation, such as healthcare facilities.

In simpler terms, we get it all backwards and treat secondary issues first, believing that the underlying primary issue will just vanish. There are endless examples of people being denied gender affirming and other medically necessary treatments, such as routine cancer screenings and reproductive healthcare, or forced to wait until some far-off unattainable day when their lives conform to what someone else has defined for them before they can get care. In over a decade of work in healthcare, providing direct services to hundreds of gender diverse people and helping clinical providers across the country working with thousands of gender diverse people, I have come to understand that the majority of care denials for gender diverse people arise from combinations of bias and misinformation rather than clear conditions that would block anyone from the same care.

This is a bias in health care and society that harms hundreds of thousands of people. It is preventable harm. Addressing this harm involves action, advocacy, and education. Counting gender diverse people in population polls, research, registration forms, and census data increases the visibility of the population and its needs. Integrating gender affirming care into medical and mental health professional education, by use of gender diverse model patients and case examples, teaches the next generation of providers to be aware of, and set better standards for, gender affirming care. Asking every single person who enters care what name they use and what their correct pronouns are demonstrates that you know gender diverse people exist and you want to include them openly in care. Fighting to change the status of gender affirming medical treatments from off-label to federally approved options will improve health care coverage, medical outcomes, and research. Integrating gender diversity into all employee non-discrimination and diversity training instead of making it separate will normalize the expectation to treat everyone equitably. Putting non-discrimination clauses based on gender identity or expression explicitly into corporate policies creates foundations of intent and accountability for fair treatment of individuals. Removing exclusions for medically necessary gender affirming care from health insurance policies enables people to access safe health care from licensed providers. The list goes on.

The most important action is a challenge to cisgender people: willfully learn (more) about gender diverse populations from the people themselves through literature and thoughtful conversations. Ask yourself and others whether you contribute to transphobic bias unconsciously or consciously. Explore and work to change that. Who decides what YOU look like or whether you get to be you at all? How can you be an ally for gender diverse people and not an obstacle? When will you take action?

Art: Lauren Denitzio, Untitled (Alex) (2017).
Photo Insert: Marchers in the 2018 Boston Pride Parade urged spectators to vote “yes” to uphold transgender protections, including the right to be free from discrimination in places of public accommodation, such as healthcare facilities. Credit: Boston Pride.
Ruben Hopwood

Ruben Hopwood

Ruben Hopwood, MDiv, PhD, is Coordinator of the Fenway Health Transgender Health Program and Visiting Researcher at The Danielsen Institute at Boston University. Ruben is Director and Founder of Hopwood Counseling & Consulting in Cambridge, MA. The opinions of the author do not represent any official position, policies, protocols, or practices of Fenway Health, The Danielsen Institute, or Boston University.