Barriers to Health Care for Transgender Individuals

Abstract

Purpose of Review

Transgender persons suffer significant health disparities and may require medical intervention as part of their care. The purpose of this manuscript is to briefly review the literature characterizing barriers to health care for transgender individuals and to propose research priorities to understand mechanisms of those barriers and interventions to overcome them.

Recent Findings

Current research emphasizes sexual minorities’ self report of barriers, rather than using direct methods. The biggest barrier to health care reported by transgender individuals is lack of access due to lack of providers who are sufficiently knowledgeable on the topic. Other barriers include: financial barriers, discrimination, lack of cultural competence by providers, health systems barriers and socioeconomic barriers.

Summary

National research priorities should include rigorous determination of the capacity of the United States health care system to provide adequate care for transgender individuals. Studies should determine knowledge and biases of the medical work force across the spectrum of medical training with regard to transgender medical care; adequacy of sufficient providers for the care required, larger social structural barriers and status of a framework to pay for appropriate care. As well, studies should propose and validate potential solutions to address identified gaps.

Introduction

Transgender persons suffer significant health disparities in multiple arenas (1, 2). Real or perceived stigma and discrimination within biomedicine and the health care provision in general may impact transgender people’s desire and ability to access appropriate care (3, 4). Transgender women (Male to Female, MTF) are internationally recognized as a population group that carries a disproportionate burden of HIV infection, with a worldwide HIV prevalence of 20% (5). A US sample of 1093 transgender persons demonstrated a high prevalence of clinical depression (44.1%), anxiety (33.2%), and somatization (27.5%) (6). In the largest national transgender survey to date (n= 6,456), 30% of the respondents reported current smoking (1.5x the rate of the general population), 26% reported current or former alcohol or drug use to cope with mistreatment, and 41% report having attempted suicide (26x higher than the general population) (7). While some of these health care barriers are faced by other minority groups, many are unique and many are significantly magnified for transgender persons.

In addition to the usual care, transgender patients often require medical interventions such as hormone therapy and/or surgery.. The purpose of this manuscript is to briefly review the current literature characterizing barriers to high quality health care for transgender individuals and to propose research priorities to understand both the mechanisms of those barriers and potential interventions to overcome them.

The biggest barrier both to safe hormonal therapy and to appropriate general medical care for transgender patients is the lack of access to care. Despite both guidelines and data supporting the current transgender medicine treatment paradigm (8–13), transgender patients report that lack of providers with expertise in transgender medicine represents the single largest component inhibiting access (14). Transgender treatment is not taught in conventional medical curricula and too few physicians have the requisite knowledge and comfort level (15–19)

Other reported barriers include: financial barriers (lack of insurance, lack of income), discrimination, lack of cultural competence by health care providers, health systems barriers (inappropriate electronic records, forms, lab references, clinic facilities) and socioeconomic barriers (transportation, housing, mental health). While some of these health care barriers are faced by other minority groups, many are unique and many are significantly magnified for transgender persons.

Review of Research to Date: Challenges, Gaps, Opportunities

Research on barriers to care for transgender individuals consists almost exclusively of data collected through self report by transgender individuals themselves, rather than more direct techniques. The largest study is the National Transgender Discrimination Survey (NTDS), with data collected between September 2008 and March 2009 (7). Other published research consists primarily of local or regional quantitative or qualitative studies.

Factors that interfere with physicians’ delivery of quality care are largely unknown. To understand the disparities, most research has evaluated patients’ perceptions of care (14, 20–23), while the perspective of physicians has been mostly overlooked.

There is one study of medical students and one study of medical residents where subjects in both cases reported substantially less predicted comfort with providing hormone care for transgender individuals than providing the same hormone care to other patients (24, 25).

In addition, some qualitative formative work has focused on understanding physicians’ need for transgender medicine education (26, 27) without a thorough understanding of physicians’ barriers to providing care.

Studies of physician knowledge, attitudes, and barriers that do exist at all reflect LGBT health care broadly without transgender health care specific data (28, 29).

Further, there has been no meaningful attempt either to determine the specific work force needs to provide care nor any attempt to determine the current status of that care. Similarly a comprehensive analysis of 3^rd-party financial support for care is lacking. Finally, reports regarding other barriers are only speculative and based on perceptions rather than validated assessment.

Conclusion and Priorities for Future Research

Although it is clear that transgender patients suffer from a dearth of competent providers for their health care, the specific explanations for that gap remain to be studied.

Therefore an early research priority must be to establish a rigorous determination of the ability of the United States health care system to provide adequate care for transgender individuals along with a careful assessment of causes for deficits (Table 1).

TABLE 1.

Barriers to Transgender Medical and Health Care Research Priorities.

Assess the knowledge and sophistication of the provider workforce to provide transgender medical care – along with barriers to that education. Lack of knowledge may manifest as assumed complexity of knowledge needed along with report of anxiety regarding uncertainty. Identify solutions to overcome the knowledge gap. Assess bias and other barriers to provider care independent of knowledge. The other barriers may include fear of stigma associated with providing transgender medical care. Other barriers may also include bias in the structure of clinics, forms, and electronic medical record systems in addition to gaps in knowledge and bias among support staff. Identify solutions to the gaps which are not solely a lack of knowledge. Determine the degree to which 3rd-party payer policy impedes access. Determine change needed to overcome the financial barrier to care. Evaluate other barriers including societal stigma, mental health issue among patients, and socioeconomic issues that represent barriers to transgender individuals receiving high quality care. Evaluate strategies to overcoming these barriers.

Such studies should include determination of the knowledge and biases of the existing medical work force – medical students, physician trainees, physicians in practice and other health care workers across the spectrum of training; the adequacy of sufficient providers for the care required, and the status of a framework to pay for appropriate care. There is a specific need to determine if providers receive adequate training in transgender medicine and if not, to determine the gap. There is also a specific need to determine the current status of anti-transgender discrimination in the health care system. As well, studies should determine potential solutions to address the gaps (including training for knowledge gaps and policy shifts for financial gaps) along with mechanisms to validate such solutions.

In addition to provider gaps, research should investigate systems gaps including biases in the structure of clinics, forms, and electronic medical record systems. Further, gaps in knowledge and biases among support staff must be determined and then validated tools developed to close those gaps.

Finally, studies are needed to determine and then overcome barriers to care outside of provider and clinic competence. Such studies would include societal stigma for both patients and providers, mental health of patients, and socioeconomic concerns of patients.

Key points.

• There are numerous barriers to health care for transgender individuals with the largest barrier reported by transgender individuals being the paucity of knowledgeable providers.

• Barriers to health care include those that are direct like lack of insurance coverage along with those that are indirect like unfriendly office environments and perceived stigma for both the patients themselves and the providers of transgender health care.

• The priorities for research on barriers to transgender health care must include determination of the gaps in knowledge among the provider workforce across the range of training, potential interventions for those gaps, determination of indirect barriers like environment and stigma, and potential solutions to overcome those barriers.