Discrimination in health care industry common for transgender people

Sept. 13--Jamy Rae Zubich-Hanson wrote her graduate-school paper about developing clinical competency for mental health professionals who want the expertise to serve transgender patients.

About half of the clients she sees in her counseling practice are seeking therapy related to a gender concern or gender dysphoria, the feeling of unease due to cross-gender identification.

Transgender individuals "transition" from their anatomical gender at birth to the one they feel they were intended to be all along. But finding health care to coincide with that transition can be a struggle.

"I do a lot of work just going to random health professionals on my own and asking them about transition views, and I have yet to meet somebody who has said, 'Oh, yeah, I know about this.' Or, 'I'd totally be willing to learn more about this. Please send them my way,' or 'Make sure people know that I'm available and that I'm a safe provider,'" Zubich-Hanson said.

Health professionals and therapists, in general, she said, are not open to treating transgender patients.

Transgender people are often declined medical care simply because they're transgender.

"A trans woman goes in and she has some health issue that she needs to discuss with her doctor and the doctor instantly says 'Well, I don't see trans people,'" Zubich-Hanson said. It's a big problem for individuals who need care for commonplace health concerns and for transgender-related ones.

"I've had families come to me from Iowa to seek therapy with me," said Zubich-Hanson, whose degree is in marriage and family counseling and who serves clients at a Twin Cities private practice. "There are less people who are comfortable than I would hope." Often the problem stems from health professionals being scared of practicing beyond their competency or beyond the scope of their licensure, she said.

Not enough information

People fear transgender individuals and lack information about them, Zubich-Hanson said.

"They don't know enough about them and they think that there's something wrong with them, or they're sick or they have mental health issues," she said. "When people don't know something, or something seems scary, they shut down."

Transgender patients often seek health-care and counseling not directly related to transgender issues, just like the general public, she said. They might seek therapy because they're dealing with dropping out of school due to grades, medical problems with diabetes or relationship issues.

"A lot of the time it's not even about being trans. It's about needing help and support for things that all other cisgender people deal with," Zubich-Hanson said. Cisgender is the term for people who feel their gender assigned at birth matches what they feel their gender is.

Transgender people do indeed seek counseling related to transgender issues, such as depression, rejection, violence, discrimination or harassment.

"There's a very high percentage of time that is true, but it's not always about that," Zubich-Hanson said.

Health professionals, she said, should "let go of everything that you've learned about gender and re-learn it." There's a "gender binary," with a clear male and a clear female category babies are put into based on their body parts. The kids then get labels. But Zubich-Hanson said anybody, but especially health professionals, should rethink that concept of male and female.

She said health professionals should be curious and ask questions without making assumptions about what trans people need.

"What one trans person needs can be extremely different from what another trans person needs," she said.

If, for example, a transgender woman still has a prostate and needs a prostate exam, the doctor should do one, Zubich-Hanson said. But, too often, the patient is declined that health service because she's transgender.

"Because women aren't supposed to have prostates, you instantly go, 'OK, well I can't treat this person,'" Zubich-Hanson said. "But it's the same body part ... you know what to do when any other person needs a prostate exam. So it shouldn't be any different."

"That's an unfortunate thing because primary-care people take care of people who've had heart surgery -- and they don't know how to do heart surgery," said Mayo Clinic endocrinologistDr. Todd Nippoldt, who is leading an effort to start a Transgender and Intersex Specialty Care Clinic at Mayo Clinic.

Health care is tricky

Being turned away from routine medical care that health providers are actually qualified to handle -- but refuse to treat because a patient is transgender -- is more common than one might imagine.

"That, I think, is a big problem and I think it's an under-appreciated problem in the general community," Nippoldt said. "What I hear from the patients I've seen and reading, conferences and things, it's a huge thing."

The discomfort among health care providers may have as much to do with lack of education as it does with philosophical viewpoints.

"Historically there's been no formal training in this. It hasn't been part of primary-care training, officially, endocrinology training, internal-med training," Nippoldt said. "But that's changing. and that's another reason we're getting excited about getting this formalized program here."

Mayo Medical School and the Mayo residency programs will be part of that change, he said.

"That's kind of the rationale for this response of 'you know, I don't know much about this area, so I won't take care of you,'" Nippoldt said.

Few transgender people have access to affordable health care, Zubich-Hanson said. Many don't have insurance at all.

"I think that's probably, hopefully, changing," Zubich-Hanson said. The Minnesota Trangender Health Coalition, for example, provides a directory of transgender-friendly health-related providers from pediatricians to massage therapists.

"A lot of trans people do not want to access health care because they've already tried health care and they've been harassed or discriminated against or rejected by people and so, sometimes, they don't even want to go back and deal with that again," Zubich-Hanson said. "And other times they go and they just kind of have to deal with the harassment or the discrimination."

Nippoldt added that "it is a big problem they face. It's incredible how much discrimination and just overt sorts of things, not to mention all the subtle things, that happen when you don't even realize what you might be saying or doing that's offensive to them -- because you're just not in their shoes."

Treatment is refused

Any psychologist can provide care, Nippoldt said. But many don't feel qualified because they haven't been trained specifically in transgender health. Any endocrinologist can discuss the powerful hormone testosterone and the equally powerful estrogen. Likewise, general practitioners, such as family-practice physicians, can discuss many of the health issues important to transgender individuals.

But, Adelie Bergstrom, a transgender woman and former Rochester resident, said many will refuse to discuss it.

"How many times a day are you reminded of whether you are a man or a woman? That's how society works," said Bergstrom, who now lives in Duluth.

The University of Minnesota Program in Human Sexuality was where she booked her first appointment after learning a doctor there came up with some of the first protocols for standards of care of transgender patients.

"Gatekeeping" can be a problem, for example, said Bergstrom. That can come up when a doctor is deciding how long before a patient can start hormone therapy.

"Shared decision-making can be hard to find," she said.

Outright dismissal from a health provider's practice can have devastating effects.