A Review of Patient Experiences and Provider Education to Improve Transgender Health Inequities in the USA
The research on transgender patients with healthcare providers (HCPs) in the USA has been limited, but recent efforts have focused on understanding these experiences. Two significant national studies, the 2015 United States Transgender Survey and the 2010 National Transgender Discrimination Survey, have been conducted to analyze the data. The 2015 survey, which collected data from 27,715 transgender adults, found that one in three participants reported having at least one negative experience related to gender identity in the past year. This was accompanied by both interpersonal and anticipation barriers to accessing healthcare. When actively seeking healthcare, eight percent of participants reported denial of trans-specific healthcare, and around three percent reported refusal of general healthcare. These negative experiences were more likely to occur for transgender clients of an older age, biracial- or multi-racial-identified individuals, people with disabilities, lower-income, and less-educated individuals. Transgender individuals with other marginalized identities are at a higher risk for healthcare discrimination, receiving lower-quality care, and receiving care from providers with limited competence. The strongest predictors of visiting an HCP were the perception of HCP knowledge, health insurance status, and the costs of healthcare. Stressors associated with healthcare utilization were associated with symptoms of emotional distress and greater odds of physical impairment. Another study using data from the 2015 U.S. Transgender Survey and the PRIDE Study found that 70.1% of transgender, nonbinary, and gender-expansive people who were assigned female or intersex at birth reported at least one negative HCP interaction in the past year. This large-scale study provides valuable information on transgender healthcare experiences and sheds light on the specific challenges that transgender clients face, which could lead to efforts to remedy these issues, including improving provider education. The 2010 National Transgender Discrimination Survey (NTDS) revealed that 30.8% of transgender people in the USA reported delaying or not seeking healthcare, with delays being four times more likely among those who reported having to teach healthcare providers about transgender people. These findings highlight the severity of discrimination faced by transgender people in the USA and the need for healthcare providers to work to better serve them. Small-scale studies on transgender healthcare experiences in the USA have also been conducted, such as the 2014 Colorado Transgender Health Survey, which found that 40% of participants reported delaying healthcare and worse general health. Access to a trans-inclusive primary care provider was a strong indicator for not delaying healthcare. The 2018 Pride Study data found that transgender people were more likely to avoid healthcare when reporting previous mistreatment. This lack of improvement in transgender healthcare experiences calls for a need to critically examine the enforcement of state-level healthcare policies to ensure proper implementation. A study on 18-to-26-year-old transgender people in the USA found that they were less likely to have received a routine check-up compared to the general population. Another small-scale study involved a focus group in Virginia that found barriers to accessing healthcare, such as poor patient-provider relationships, a lack of insurance related to employment discrimination, and issues with identity documentation. Many participants also mentioned hostility, insensitivity, disrespect, and discrimination in their experiences with HCPs. Indirect experiences with HCPs have been found to include issues of gatekeeping, pathologization, stigmatization, misgendering by HCPs, unfamiliarity with transgender people and their health issues, and transphobic practices. Other barriers to care include high costs of medical care and a lack of transgender-friendly providers. An online study of US transgender adults found that mistreatment by providers could be categorized according to six overarching themes: gender insensitivity, displays of discomfort, denied services, substandard care, verbal abuse, and forced care. Despite the numerous issues identified in transgender healthcare in the USA, there have also been some positive findings. For patients who had a provider with some level of knowledge about transgender people, this was found to be beneficial.
The 2015 United States Transgender Survey
The 2015 United States Transgender Survey is one of the most prominent studies on transgender healthcare experiences in the USA thus far [32], and collected data from 27,715 adults who identified as transgender. These data have been analyzed in numerous studies to examine different aspects of healthcare access for transgender individuals. From the survey, one in three participants reported having at least one negative experience in healthcare related to gender identity in the past year [33]; this was found along with both interpersonal (e.g., a lack of provider sensitivity or knowledge, the refusal of care for transgender patients, and harassment) and anticipation barriers (i.e., the avoidance of healthcare due to the anticipation of mistreatment or discrimination from providers) to accessing healthcare. Further, when actively seeking healthcare, eight percent of participants reported denial of trans-specific healthcare, and around three percent reported refusal of general healthcare [34]. These negative experiences were more likely to occur for transgender clients of an older age, biracial- or multi-racial-identified individuals, people with disabilities, and lower-income, and less-educated individuals [34]. Transgender individuals with another marginalized identity are at a higher risk for healthcare discrimination, receiving lower-quality care and receiving care from providers with limited competence [34]. Further, these findings were replicated in additional works by Romanelli & Lindsey 2020 [35] and Seelman et al., 2021 [36].