BREAKING THE BINARY: ADDRESSING HEALTHCARE DISPARITIES WITHIN
SACRAMENTO’S TRANSGENDER COMMUNITY
A Project
Presented to the faculty of the Division of Social Work
California State University, Sacramento
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF SOCIAL WORK
by
Annie Louise Temple
SPRING
2013
BREAKING THE BINARY: ADDRESSING HEALTHCARE DISPARITIES WITHIN
SACRAMENTO’S TRANSGENDER COMMUNITY
A Project
by
Annie Louise Temple
Approved by:
__________________________________, Committee Chair
Serge Lee, Ph.D., M.S.W.
Date
ii
Student: Annie Louise Temple
I certify that this student has met the requirements for format contained in the University
format manual, and that this project is suitable for shelving in the Library and credit is to
be awarded for the project.
, Graduate Coordinator
Dale Russell, Ed.D., L.C.S.W.
Date
Division of Social Work
iii
Abstract
of
BREAKING THE BINARY: ADDRESSING HEALTHCARE DISPARITIES WITHIN
SACRAMENTO’S TRANSGENDER COMMUNITY
by
Annie Louise Temple
Previous research has illuminated the fact that the transgender community faces many
barriers to healthcare (Lombardi, 2001). The purpose of the present study was to determine
the current barriers that the greater Sacramento area transgender community experiences
surrounding the ability to access quality healthcare services. The researcher conducted
interviews with transsexual individuals, health professionals, community advocates and
Social Work professors. The present study, like previous research in other parts of the
country, revealed that medical professionals are not adequately trained in transgender cultural
competency and that more education and training needs to be given to both mental and
physical health providers. The present study also found that Gender Identity Disorder, a
mental disorder that transgender-identified individuals are often diagnosed with, assists
transgender individuals in insurance coverage but also stigmatizes them. Implications for
social work practice in addition to future research recommendations are also discussed.
, Committee Chair
Serge Lee, Ph.D., M.S.W.
Date
iv
ACKNOWLEDGMENTS
My parents have offered invaluable encouragement throughout the writing of this
project. My parents, Nancy and Blake Temple gave me an abundance of emotional
support, helped motivate me to “get to the coffee shop and write!” and answered many
frantic phone calls. My mother, Nancy Temple helped me edit my project and was open
to learning about a topic that she previously knew very little about. Thank you both for
your unwavering support throughout my work on this project and through all of life’s ups
and downs.
My friends and colleagues in this program, Leah Barros, Christine Arneson, and
Heather Valdez have also been amazing throughout this process. Even though they had
projects of their own to work on, each of these women made themselves available to
support me when I needed encouragement. Whether it was reassuring me that I “WILL
FINISH” via text messages, commiserating over drinks and dinner, taking mini trips to
Napa to get a break from the perils of writing or intimate conversations over coffee
(specifically the ones that had NOTHING to do with this project), I CAN’T thank you
ladies enough. Your friendship means the world to me.
I also need to thank my cats, Fall, Stanley and Spring Temple. Spring, thank you
for being so cuddly and cute and keeping me company during the naps that I took to
procrastinate. Thank you also for demanding food with your piercingly loud meows in
the morning so that I got out of bed and got to work. Fall, thank you for being the king of
the neighborhood and keeping me company (on my lap) while I typed away on my
v
laptop. Stanley, thank you for being so youthful and cute, your energy (although
sometimes irritating) reminded me to stay light hearted throughout the stressful times.
Thank you also to Emily Newton for advising me on this project, inspiring me to thank
my cats and for being an amazing and supportive friend.
I also want to thank my advisor, Dr. Serge Lee for his advising and reassurance.
Additionally, thank you to Dr. Andrew Bein and Dr. Chrys Barranti for their mentorship.
Thank you to Dr. David Nylund, the professor who first educated me about the
oppression that the transgender community experiences and inspired the focus of this
project. Thank you for your support throughout the writing process and your dedicated
commitment to the Gender Health Center (GHC). Lastly, I want to thank the Gender
Health Center and Rachael and Ben Hudson for supporting my research and helping me
recruit participants. The amazing work that is done on a daily basis at the GHC inspires
me to be the best social worker that I can be.
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TABLE OF CONTENTS
Page
Acknowledgments................................................................................................................v
Chapter
1. INTRODUCTION .........................................................................................................1
Background of the Research Problem......................................................................2
Study Purpose ..........................................................................................................3
Theoretical Framework ............................................................................................4
Definition of Terms..................................................................................................7
Social Work Research Justification .........................................................................9
Study Limitations ...................................................................................................10
2. REVIEW OF THE LITERATURE .............................................................................12
Transgender Identity ..............................................................................................13
Access to Healthcare ..............................................................................................22
3. METHODS ..................................................................................................................37
Study Objectives ....................................................................................................37
Study Design ..........................................................................................................37
Sampling Procedures .............................................................................................38
Instruments .............................................................................................................40
Data Analysis .........................................................................................................40
Protection of Human Subjects ...............................................................................40
vii
4. STUDY FINDINGS AND DISCUSSIONS ................................................................42
Overall Findings.....................................................................................................42
Specific Findings ...................................................................................................43
Interpretations of the Findings ...............................................................................52
Summary ................................................................................................................54
5. CONCLUSION, SUMMARY, AND RECOMMENDATIONS .................................55
Summary of Study .................................................................................................55
Discussion ..............................................................................................................55
Social Work Implications ......................................................................................60
Future Research .....................................................................................................61
Appendix A. Consent Forms..............................................................................................64
Appendix B. Questionnaires ..............................................................................................68
References ..........................................................................................................................72
viii
1
Chapter 1
INTRODUCTION
Approximately 3%-10% of the population considers themselves transgender (van
Kesteren, Gooren, & Megens, 1996). The transgender community has long been
marginalized when it comes to receiving acceptable healthcare services. There are many
reasons for the subpar healthcare access that transgender individuals are subject to. Fear
of stigma, violence, judgment, prejudice and also a general lack of services specific to
this population are several of the reasons behind the lack of access to quality care
(Alegria, 2011; Lombardi, 2001). The fears that many transgender individuals live with
surrounding seeking healthcare are not unfounded due to pervasive societal stigma. In
one study, 60% of transgendered individuals interviewed reported being the victim of
harassment and/or violence (Lombardi). In another study in Philadelphia, 26% of
respondents from a 182-person sample of transgender individuals, reported to having
been denied healthcare access due to their gender identity (Kenagy, 2005). In addition to
pervasive stigma, many transgender individuals lack insurance coverage or do not have
insurance that covers transition related services. Lack of coverage for necessary
healthcare services, fear of culturally incompetent providers and lack of insurance access
all influence the problem of finding and obtaining quality healthcare (Johnson, Mimiaga,
& Bradford, 2008; Lombardi, 2001). Faced with many barriers to receiving adequate
healthcare services, many transgender individuals go without healthcare (Sanchez,
Nelson, Sanchez, & Danoff, 2009). It is unacceptable for any human being to go without
2
the fundamental right of healthcare and thus, more studies must be done to find out
details about specific barriers that leave transgender individuals without satisfactory
access to superior, culturally competent mental and physical healthcare services.
The current Master’s Project hopes to identify information about the access
transgender individuals currently have to quality mental and physical healthcare services
in the greater Sacramento region. Additionally, the study aims at identifying what the
barriers are for transgender individuals when seeking both psychological and physical
health care services. Lastly, the current study will assess what possible solutions there
are to the barriers discovered and what is already being done to alleviate the identified
barriers to ensure adequate healthcare for the greater Sacramento region’s transgender
community.
Background of the Research Problem
The research problem for the current study is to examine the quality of healthcare
available to the greater Sacramento region’s transgender community. Currently, there are
not enough culturally competent mental and physical healthcare services for the
transgender community in the United States. Furthermore, transgender individuals that
have access to health insurance and healthcare often come across culturally incompetent
doctors and mental health professionals. Although there are guidelines available through
the World Professional Organization of Transgender Health (WPATH), many doctors
and psychotherapists are not educated on culturally appropriate ways to treat transgender
patients. More research needs to be done to reveal the current barriers to obtaining
3
proper healthcare for transgender individuals, brainstorm solutions to these barriers and
assess the cultural competence of health providers in order to get a full picture of what is
going on for the transgender community in the greater Sacramento area when it comes to
receiving quality mental and physical health care.
Study Purpose
The transgender community has been gaining more attention as a legitimate
community who has been marginalized not only within society as a whole but also within
the LGBTQ community. Because the transgender community has been pathologized and
ignored by much of society, few studies have been done to assess the unique needs of the
transgender community when it comes to receiving both physical and mental healthcare
(Alegria, 2011). Since the transgender community has been invisible in many scholarly
studies surrounding LGBTQ access to healthcare, it is important that social workers study
how much access the community currently has to mental, physical and transition related
healthcare. The purposes for this study are to discover the extent that healthcare services
are available to the transgender community in the greater Sacramento area currently,
what kinds of reformations to healthcare need to happen in order to adequately meet the
transgender community’s needs, to discover the reasons behind why adequate healthcare
services may not be available and identify potential solutions. In addition to these
reasons, this study will also seek to find out what local professionals and transgender
individuals think about the Gender Identity Disorder/proposed Gender Dysphoria
diagnosis and how helpful these are in accessing healthcare. Because the transgender
4
community has only recently begun to be recognized as a population that deserves a
voice, it is imperative that these questions be researched so that more information can be
gathered to ensure that transgender individuals in the greater Sacramento area and all
over the world have access to sufficient healthcare.
The author of this Master’s Project expects to find that healthcare services for the
transgender community in the Sacramento area are going to be limited and grossly
inadequate when it comes to cultural competency. It is also expected that most of the
transsexual participants that are interviewed will carry a Gender Identity Disorder (GID)
diagnosis. Because transgender individuals are still pathologized as having a mental
disorder, the assumption is that without this diagnosis, required surgeries and other
medical treatments may be seen as cosmetic and thus, not covered by insurance. This
researcher expects to find that most professionals and transgender participants alike find
the GID diagnosis to be helpful in obtaining healthcare services yet stigmatizing by
nature of it being a mental disorder. Finally this researcher expects to find that mental
health professionals, medical doctors and nurses are going to possess little knowledge
about the unique needs of the transgender community. It is expected that many
healthcare settings will neither have programs nor plans in place to serve the transgender
community and meet the unique needs of this population.
Theoretical Framework
Three main social work theoretical frameworks will be utilized when conducting
this study. The first theoretical framework utilized in this research is the Conflict
5
Perspective (Johnson & Rhodes, 2010). This theory describes how minority populations
are marginalized due to their lower economic and cultural status. The conflict
perspective explains the reasons behind why transgender individuals have not been able
to receive adequate healthcare. According to the Conflict Perspective, the healthcare
system in our society holds the power and because transgender individuals are not a
highly valued and powerful community, they are not valued in our healthcare system
(Johnson & Rhodes, 2010). Through this perspective, research into the discrepancies in
access to and quality of healthcare is extremely important because it is only in actively
fighting the system and demanding rights, that the transgender community is going to
obtain access to quality healthcare services. This study will utilize Conflict theory in the
hope that the present study’s research findings can be a part of the fight for social justice
for the world’s transgender community.
The second theoretical framework used to inform the present study is Queer
Theory (Butler, 1988). Queer Theory suggests the ridding of sexual based binaries,
whether they are related to sexual orientation, sexual practices or gender identity.
Because the transgender community does not fit into the gender binary categories of
“male” or “female” that are seen as essential and fixed identities in much of our society,
transgender individuals are marginalized and pathologized as having a mental disorder
(Sennott, 2011). Following this logic, because the transgender identity is outside of the
socially constructed binary and therefore marginalized by it, the pathologization of the
identity that this creates influences the fact that the transgender community has
6
inadequate healthcare access. Thus, if society were to rid itself of gender binaries and
adopt a more fluid idea of gender and sexuality, the transgender population would no
longer be marginalized and would have more opportunities for equality in society and
better healthcare access and services. The present study will utilize Queer Theory in that
it will study a population that does not fit into the current gender binary. In recognizing
the transgender community as one that deserves equal access to healthcare, Queer Theory
allows research into categories outside of commonly accepted societal gender binaries
and hopefully will enable society to move towards a system that is more inclusive of
different gender identities and sexual orientations (Butler, 1988).
The third theoretical framework that guides this research project is Transgender
theory. In many ways, Transgender theory is a bridge between essentialist theories of
sexuality, Feminist theory and Queer theory. Transgender theory views essentialist
theories of sexuality as being too rigid, as they suggest that a person’s gender and sexual
orientation are fixed traits within an individual. Similarly, Transgender theory views
social constructivist theories such as Queer theory and Feminist theory as discounting a
transgender person’s unique experience and claim of an identity that can assist in
combatting stigma and marginalization. In finding a balance between essentialist
theories, Feminist theory and Queer theory, transgender theory incorporates socially
constructed ideas of gender with transgender individuals’ unique experiences, so as not to
discount identities that can be helpful to a person or the entire transgender community
(Nagoshi & Brzuzy, 2010). The present study will bring awareness to the socially
7
constructed nature of gender and at the same time honor the Transgender identity and the
ways that the gender binary can be helpful to transgender individuals.
Definition of Terms
The following are definitions of terms used in this research project. Without an
understanding of these terms, the review of the literature and present study’s findings
cannot be properly understood.
Cisgender
An individual who is cisgender identifies as the same gender as his/her biological
sex (Hulstein, 2012).
Gender Binary
The Gender Binary reflects common perspectives in contemporary society
surrounding gender norms. People are often referred to as being female or male.
These categorizations stem from a person’s biological sex and other performative
actions such as whether one chooses to wear skirts or pants. Certain behaviors are
socially constructed as being normal and others are pathologized. The Gender
Binary refers to the rigidity surrounding gender categorization in that it only has
two options: male or female. Transgender individuals often fall outside of this
binary (Butler, 1998).
Genderqueer
Transgender individuals and cisgender (individuals whose gender reflects their
biological sex) individuals alike sometimes identify as genderqueer. This
8
category of gender identity can encompass any and all expressions of gender that
do not fit neatly into the gender binary (e.g., a man who prefers to wear women’s
clothes or a female born individual who prefers to express a masculine identity)
(Alegria, 2011).
Intersex
Intersex individuals are born with genitalia and/or chromosomal make up that can
neither be classified as male or female. There is a range of different possibilities
of intersex characteristics. For example, intersex individuals may have male
genitalia and XY chromosomes or ambiguous genitalia (Sax, 2002).
LGBTQ
LGBTQ is an acronym that stands for Lesbian, Gay, Bisexual, Transgender,
Queer. This acronym is often used when talking about entire Queer community
(Sherrif, Hamilston, Wigmore, & Giambrone, 2011).
Gender
Gender is a socially constructed category that in contemporary society is often
looked at as a binary system with only two options: male or female. Because the
term “gender” differs from sex in that it is not referring to biological features, in
reality, there are many more than two expressions of gender (Butler, 1998;
Nagoshi & Brzuzy, 2010).
9
Transgender
The term transgender is an umbrella term that has a range of expressed gender
identities. Transgender identities can include individuals who identify as the
opposite gender from their birth sex, transvestites, cross-dressers and individuals
that express other gender-bending practices (Reis, 2004). While some
transgender individuals readily embrace the gender binary, others may reject it
entirely (Alegria, 2011).
Transsexual
The term transsexual refers to a transgender person who feels that they are a
different gender from their biological sex. Most transsexual persons are in the
process of transitioning to a gender other than their birth sex (Roen, 2001).
Transphobia
Transphobia refers to discomfort and negative feelings towards those who do not
comply with societal gender norms and live out differing expressions of gender
(Lombardi, 2009).
Social Work Research Justification
The transgender population has historically been a marginalized and oppressed
community. As stated in the National Association of Social Workers’ (NASW) Code of
Ethics, it is important for social workers to take action against discrimination towards any
group of people. Because the transgender population is the victim of discrimination in
many realms, it is important that social workers take action (NASW, 2008). In order for
10
social workers to begin action steps at alleviating stigma, fighting discrimination and
advocating for better healthcare services for transgender individuals, more research needs
to be done to find out the specific factors contributing to the transgender population’s
marginalized status. This research examines healthcare disparities among the transgender
community and therefore sheds light on an important topic for social workers to act on.
Social workers are pursuers of social change and advocates of social justice and this
research project reflects both goals. In examining barriers to healthcare for the
transgender community, social workers can begin to advocate with the transgender
community for more comprehensive healthcare services. Without research into the
healthcare services available, accessibility of care, specific barriers and possible
solutions, social workers do not have enough knowledge to fight for social justice for the
transgender community. It is the hope of this researcher that this study will be part of a
broader effort to bring the transgender community out of invisibility and help highlight
this population’s healthcare needs.
Study Limitations
This research project is limited in nature by its small sample size. Because the
researcher cannot afford to provide incentives for participating in the research, all
subjects participated on a volunteer basis. Because the sample size is so small, it is
difficult to generalize findings to the greater Sacramento region’s entire transgender
population or the United States population at large. Additionally, the researcher
composed her own questionnaires and therefore the interviews were unstandardized and
11
may lack validity. An additional limitation is that two of the medical professionals are
connected to the Gender Health Center, a non-profit counseling center specializing in the
transgender community’s needs. Had the researcher interviewed medical professionals
unassociated with the Gender Health Center, different results may have been found.
With that said, the research conducted in this study contains results from interviews done
with experts in the field of transgender healthcare and transsexual participants personal
experiences. Because of this, these results are extremely valuable when looking at the
struggles that this population faces in obtaining respectable healthcare services.
12
Chapter 2
REVIEW OF THE LITERATURE
The transgender community is broad in definition and has only recently begun to
get the recognition it deserves as a population with specific needs. Additionally, only
recently have efforts begun to research the available healthcare services for the
community (Alegria, 2011). For the last several years, many transgender individuals
have been given a psychiatric diagnosis of Gender Identity Disorder (GID) that has been
both helpful and damaging to transgender individuals as it pertains to their access to
healthcare services. The diagnosis can be helpful to transgender individuals getting
certain healthcare services paid for by insurance, but harmful in other scenarios regarding
prejudice and stigma from health care professionals (Sennott, 2011). The current
Diagnostical Statistical Manual on Mental Disorders (DSM-IV) continues to classify the
transgender identity as Gender Identity Disorder although the following edition will
change the diagnosis to Gender Dysphoria (Ford, 2012). Previous research suggests that
health care professionals need further training in transgender physical and mental health
care as well as in the appropriate language to use with transgender individuals to ensure
that professionals respect a transgender person’s preferred gender identity (Lombardi,
2001).
Additionally, education and training for healthcare professionals needs to address
the fear of stigma that currently exists within the transgender community in order to
prevent transgender individuals from avoiding seeking healthcare due to their fears of
13
judgment, violence, and prejudice (Alegria, 2011). The following literature review
explores the research that has been previously conducted pertaining to the transgender
community’s access and barriers to healthcare. It begins by describing the transgender
identity, and then explores the Gender Identity Disorder (GID) diagnosis and its
pertinence to the transgender community when accessing healthcare. The literature
review goes on to discuss the previously identified barriers to both physical and mental
healthcare for transgender individuals and the role that The World Professional
Association for Transgender Health (WPATH) plays in this process.
Transgender Identity
Gender
Gender is considered a socially constructed category that in modern western
society is often split into the binary male or female. Because the term gender differs
from sex in that it is not referring to biological features, in reality, there are many more
than two expressions of gender than the binary system suggests. Queer theorists such as
Judith Butler (1988), view this binary classification of gender as harmful and question the
need for such categorizations as well as the reasons for the categories. Queer theorists
see gender as performative and dramatic and thus, see individuals as acting out a gender
that is historically situated and culturally determined. Queer and Feminist theorists see
these categories of male and female as being harmful to individuals that deviate from said
categories. According to Queer theorists, the gender binary is used to contain and police
individuals who do not fit into one of these categories, and thus, Queer theorists reject
14
these socially constructed systems (Butler, 1988). Opposed to viewing gender as an
essential trait within an individual, Queer theorists see gender as being both socially
constructed and fluid. Although Feminist theory argues that gender is one attribute that
helps humans develop categories to identify and make meaning of relationships with
other people, the gender binary can be extremely harmful to transgender individuals.
When gender is viewed as a fixed essential trait within a person, it can be used as a
justification for prejudice, discrimination, and other forms of oppression similar to other
traits such as race and class when they were viewed as being natural. Because society
expects a culturally specific gender expression that reflects one’s biological sex, the
transgender expression of gender identity is outside of what is considered normal and is
often deemed deviant or abnormal (Grossman & D'Augelli, 2006).
However, viewing gender as entirely socially constructed with no merit
whatsoever can also be problematic for transgender individuals. Without being able to at
least partially identify with constructed ideas of gender, a transgender individual may feel
like s/he is without an identity. If transgender individuals denied all labels of gender
expression, the transgender community could not come together as an oppressed group to
fight marginalization because following this logic, not even the transgender identity could
exist. Because oppression and discrimination towards the transgender population is
pervasive, socially constructed ideas of gender prove somewhat useful to transgender
individuals in claiming an identity (Nagoshi & Brzuzy, 2010).
15
Although some physicians believe that a person whose gender identity differs
from their biological sex is mentally ill and needs to be treated with behavioral therapies
and medication, there is a great deal of research suggesting that gender identity is a
relatively fixed trait. Several studies have been conducted with findings about intersex
patients who are raised as a certain gender and turn out to identify as the opposite gender.
Moreover, chromosomal make up does not predict gender identity. For example, an
intersex person with an XY genotype may not identify as male, even if they are raised as
a boy (Feldman & Safer, 2009).
Transgender
Approximately 3%-10% of the United States population is considered transgender
(Grossman, & D'Augelli, 2006). As stated by Alegria (2011), the term “transgender”
“refers to appearance, behavior, or identity that does not conform to socially constructed
norms for women or men” (p. 176). Transgender as a construct is an umbrella term that
has a range of expressed identities that do not fit within traditional male or female
categories. Although the cause of transgenderism is unknown, one explanation comes
from brain autopsies of transgender individuals. In one study with male-to-female (MTF)
transsexuals, the Bed Nucleus of the Stria Terminalis (BST) in the hypothalamus
contained less staining, a finding that is consistent with genetically female individuals.
Additionally, sexual orientation had no effect on the amount of BST staining shown.
This particular study illustrates an association between the transgender identity and BST
staining in the brain. Although studies like these are small and there isn’t enough
16
research to draw any conclusions, preliminary results portray the fixed nature of gender
identity and the transgender diagnosis. Despite some medical and mental health
professionals’ claims, there is no literature to support the idea that gender identity can be
changed or manipulated by behavioral therapies or other treatments (Feldman & Safer,
2009).
The Transgender identity has a large range of expressions. Transgender
individuals may identify as the opposite gender or as “genderqueer”, connoting that the
gender expression is outside the norms of any categorized gender. Transgender
individuals may dress in what is considered the opposite gender’s clothing; however,
dressing in the opposite gender’s clothing does not necessarily make a person
transgender. Moreover, not all transgender individuals desire to change their physical
body with hormones or surgeries in order to live as their desired gender (Alegria, 2011).
Many transgender individuals view themselves as expressing a fluid portrayal of gender
identity, identify with masculine and feminine aspects of gender and therefore do not fit
in the traditional categorical male/female binary. Recently, more transgender individuals
have embraced a transgender identity instead of trying to fit within the dichotomy of
masculine or feminine or male or female (Bockting, 2009). Transgender individuals may
also be transsexual, defined as a condition that is biological in nature, therefore requiring
surgeries and/or hormones to address the assumingly inherent condition. Typically,
individuals that are transsexual have received medical interventions such as hormones
and/or Sex Reassignment Surgery (SRS) (Nagoshi & Brzuzy, 2010). Moreover, some
17
transsexual or other gender nonconforming individuals don’t identify with the
transgender identity at all and alternatively, even embrace the gender binary. Gender
nonconforming individuals who do not claim a transgender identity will often solely
identify with the opposite gender from their biological sex (Hines, 2007).
In addition to the wide range of different experiences and gender expressions of
transgender individuals, a person’s gender identity, including the transgender identity,
does not indicate their sexual orientation. A person’s sexual orientation is entirely
different than his/her gender identity (Alegria, 2011). A male-to-female (MTF)
transgender individual may identify as a lesbian, bisexual, straight or queer woman, just
as a female-to-male (FTM) transgender individual may identify as a gay, straight,
bisexual or queer man. Gender identity does not dictate what gender or physical
characteristics one is sexually attracted to (Alegria).
The transgender community is a marginalized one, much like other racial, ethnic
and Lesbian, Gay, Bisexual, and Queer (LGBQ) identities. However, in some ways, the
transgender population is a different type of minority group. Unlike women or African
Americans who may grow up in a community of people that look like them, it is very
unlikely that a transgender individual will grow up in a society where they know of other
transgender identified individuals. Therefore, their lack of social status is in part due to
their isolation from each other (Johnson & Rhodes, 2010). Additionally, many other
minority groups do not have a mental disorder attached to their identity. Currently, many
18
transgender individuals are diagnosed as having a mental disorder categorized in the
DSM-IV as Gender Identity Disorder (GID) (Sennott, 2011).
Gender Identity Disorder
Many transgender individuals are diagnosed with what is known in the Diagnostic
and Statistical Manual of Mental Disorders (American Psychiatric Association [APA],
2000) as Gender Identity Disorder (GID). The American Psychological Association
(APA) first presented GID as a diagnosis in 1980 and it continues to exist as a
diagnosable mental disorder today (Byne et al., 2010). According to the DSM-IV, to be
diagnosed with GID as an adolescent or an adult, a person must exhibit these
characteristics:
Frequent passing as the other sex, desire to live or be treated as the other sex, or
the conviction that he or she has the typical feelings and reactions of the other sex,
Persistent discomfort with his or her sex or sense of inappropriateness in the
gender role of that sex, preoccupation with getting rid of primary and secondary
sex characteristics (e.g., request for hormones, surgery, or other procedures to
physically alter sexual characteristics to simulate the other sex) or belief that he or
she was born the wrong sex. (Alegria, 2011, p. 178)
In addition to these qualities, an individual with GID cannot have a “physical intersex
condition” and the “disturbance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning” (APA, 2000, p. 581).
19
Although the DSM-IV categorizes GID as a mental disorder, there are no standardized
mental health treatment guidelines for treating GID.
Currently, most of the guidelines for mental health professionals who are treating
transgender individuals come from patients who report on the care that they are getting.
However, there is a small body of research regarding mental health treatment for
transgender individuals. Evidence suggests that patients with other psychiatric and or
alcohol/drug abuse issues are more likely to be unsatisfied with their treatment.
Additionally, retrospective data describes that adults with GID who undergo sexreassignment surgery (SRS) are more likely to experience satisfaction and well-being.
Even though these outcomes are empirically validated, the APA has not instituted ethical
guidelines for treatment of GID (Byne et al., 2010).
Holding a diagnosis of Gender Identity Disorder (GID) can be both useful and
harmful to transgender individuals. The fact that Gender Identity Disorder labels
transgender individuals as having a mental disorder is pathologizing of the identity.
Critics of the mental disorder diagnosis compare the diagnosis of GID to homosexuality
that was also considered a mental disorder in the DSM-II as late as 1970 (Sennott, 2011).
In addition to this criticism of the diagnosis, because gender nonconforming individuals
have been seen throughout different time periods and various cultures, many people
question whether it is appropriate to categorize transgender individuals as being deviant
at all (Sennott). Gender Identity Disorder is considered a mental disorder with criteria
that includes distress experienced by an individual when living in accordance to his/her
20
biological sex. However, many people feel that this distress is due to social stigma, not
an inherent distress that is located within an individual who is gender nonconforming. A
work group for the World Professional Association for Transgender Health (WPATH,
2011) has recognized that distress among those with GID is alleviated upon living in
accordance to what a transgender person feels is his/her real gender identity. Therefore,
the distress component of the diagnosis is wavering and largely impacted by societal
discrimination and stigma (Bouman, Bauer, Richards, & Coleman, 2010).
Along similar lines, critics of the diagnosis indicate that when something becomes
a disorder in our society, it immediately becomes stigmatized. Many transgender
theorists see the Gender Identity Disorder diagnosis as being a direct link to prejudice and
discrimination against the community (Nagoshi & Brzuzy, 2010). Due to many of these
concerns, the World Professional Association for Transgender Health (WPATH) has
proposed a change for the DSM-V that would change the Gender Identity Disorder
diagnosis to a Gender Dysphoria diagnosis. WPATH believes that because not all
transgender individuals experience distress associated with their identity, the DSM-V’s
Gender Dysphoria diagnosis would only address individuals that experience significant
distress instead of blanketing the entire community under this diagnosis (WPATH, 2010).
Opponents of the GID diagnosis, including WPATH, speculate that the transphobia that
permeates modern American society stems largely from Gender Identity Disorder’s
mentally disordered status (Sennott).
21
However, there are some benefits to having Gender Identity Disorder as a
diagnosis in the Diagnostic and Statistical Manual on Mental Disorders (DSM-IV) (APA,
2000). Supporters of the diagnosis see the fact that GID is a mental disorder as a
justification for insurance companies to cover health care services related to the physical
transition process between genders (Sennott, 2011). Backers of the diagnosis question
whether insurance companies would cover the costs for the medical aspects of the gender
transition process if GID were not labeled as a mental disorder. Many healthcare
providers offering sex reassignment surgery (SRS) require a GID diagnosis before
surgery can be completed (Nagoshi & Brzuzy, 2010).
Those in opposition of the GID diagnosis suggest one possibility that might keep
the financial benefits and eliminate stigma for transgender individuals. As an alternative
to a mental disorder, one suggestion is to transfer the GID diagnosis from a mental
disorder into a medical or physical disorder, therefore eliminating some of the shame and
stigma that currently accompanies having a mental illness (Sennott). In some ways, this
would make sense due to the fact that many transgender individuals require medical
treatment, hormones and/or surgery in order to transition. However, others acknowledge
that although there are similarities between Gender Identity Disorder and homosexuality
in that both were considered mental disorders at one point, homosexuality requires no
medical attention. Some see this distinction as merit for GID continuing to exist in the
DSM-V (Rochman, 2007). Others have suggested that a less stigmatizing DSM
diagnosis would suffice. Ideas for a new diagnosis that is not as pathologizing include
22
the terms “Gender Dysphoria,” “Gender Dissonance,” and “Gender Incongruence.”
Advocates of this type of change have insisted that a new name for the diagnosis would
eliminate the shame that currently exists, while still allowing for the legal and medical
procedures that the diagnosis affirms (Rochman, 2007, pp. 32-35).
In May of 2013, the fifth edition of the Diagnostical Statistical Manual on Mental
Disorders (DSM-V) will be released. In this new edition, Gender Identity Disorder will
be removed as a diagnosis and replaced with Gender Dysphoria. The anticipated change
aims at emphasizing the dysphoric feelings that transgender individuals often carry due to
the incongruence between their biological sex and their preferred gender. Many involved
in the transgender community feel that this new diagnosis will allow access to transition
related healthcare without the stigma that has previously been attached to the Gender
Identity Disorder diagnosis (Ford, 2012).
Access to Healthcare
WPATH
For many transgender individuals seeking medical treatment to aid in their
transition process, The World Professional Association for Transgender Health
(WPATH) is the organization that guides this process (Alegria, 2011). WPATH is
designed to promote “the highest standards of care” for transgender individuals and
provide medical professionals with guidance on how best to help transgender individuals
in their journey (WPATH, 2011, p. 1). WPATH provides many kinds of information to
different types of clinicians including information related to a transgender person’s
23
medical transition in addition to medical issues that are not directly related to
transitioning protocols. Guidelines are released for medical professionals who are
treating the entire Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ) population that
include creating a welcoming environment, utilizing appropriate language and pronouns,
maintaining written confidentiality, and instituting mandated training and educational
programs for staff. Unfortunately, even though these guidelines are available to the
public, several studies show that in many cases, these guidelines are not being followed
(Johnson et al., 2008).
Although WPATH was designed for medical professionals, many transgender
individuals and their family members will consult WPATH’s guidelines when making
decisions regarding their own health needs (WPATH). WPATH provides specific
standards for transgender-identified individuals to abide by when seeking to medically
transition to the opposite gender. These standards also inform medical professionals
about how to begin assisting their patients in their process towards transitioning.
WPATH proposes a transition that happens in stages so that individuals have a chance to
change their mind. Therefore, surgeries and more permanent parts of the transition
process are recommended to come in the later stages (Byne et al., 2012). Although many
transgender individuals never pursue surgery, if the transgender individual does decide to
seek surgery, WPATH recommends that there be a collaborative team approach where
the surgeon, primary care physician and mental health professional work together in
order to best prepare the patient for surgery. Because of this collaborative approach,
24
surgeons who diagnosis/Gender Dysphoria Diagnosis as well as other medical problems
the patient may be facing. Additionally, WPATH recommends that surgeons who are
operating on transgender individuals should agree with the Gender Identity Disorder/
Gender Dysphoria diagnosis for their patient before proceeding with surgery, even if
another medical professional has already made a diagnosis, due to the fact that surgeons
are responsible for all diagnoses justifying the surgical procedures they perform.
Because surgical intervention requires many medical professionals to be on the same
page with treatment goals, in some geographic areas, there are treatment teams of
different medical professionals already set up for transgender individuals seeking
surgery. Unfortunately, treatment teams offering this approach are not available to many
transgender individuals who seek surgery and in these cases; WPATH recommends that a
surgeon communicate directly with all psychiatrists, psychologists and primary care
doctors involved (Schechter, 2009).
Although WPATH can be extremely helpful to medical professionals and
transgender individuals, some critique WPATH in that it gives a medical professional,
who may not be educated on transgender issues, too much power in deciding a
transgender person’s fate (Lev, 2009). Many transgender individuals feel like they
should be the ones to decide whether they are ready for sex-reassignment surgery instead
of a medical professional that may not even be an expert in the area of transgender health
care. Additionally, WPATH puts a lot of the responsibility on medical doctors and
mental health professionals in determining a transgender person’s track. Through
25
charging mental health and medical professionals with diagnosing GID and often times
determining if surgical treatment is appropriate, there is an expectation that these
professionals are competent in transgender related care. This responsibility of medical
professionals causes many transgender individuals to feel even more pathologized due to
the fact that they often need a mental health diagnosis in order to obtain surgery
(Bockting, Robinson, Benner, & Scheltema, 2004).
Barriers to Healthcare
Several empirical studies suggest that enormous disparities exist when it comes to
the transgender community’s access to health care. In the United States, simply falling
outside the norm in one’s sexual orientation or gender identity puts one at greater risk for
developing health problems and for not receiving adequate healthcare (Brockett, McNair,
& Suniewick, 2007). For transgender individuals who fall outside of the male-female
binary paradigm, barriers to healthcare include inadequate care and a lack of services for
both mental and physical health care needs. In one survey of transgender-identified
individuals, only 30%-40% reported regularly seeking healthcare services (Sanchez et al.,
2009). In a similar study (n=154) done with transgender subjects living in Philadelphia,
26% of the sample reported that they had been denied health care access in at least one
instance due to their transgender identity (Kenagy, 2005). Additionally, research looking
into access to health care in the United States among the Lesbian, Gay, Bisexual and
Transgender, Intersex (LGBTI) communities found that the transgender community was
26
the most uninsured group. Within the transgender community, transgender people of
color were the least likely to have insurance (Johnson et al., 2008).
Absence of insurance coverage presents transgender individuals with even more
problems. Lack of access to hormone therapy has created a black market industry for
transgender individuals desiring secondary sex characteristics associated with the
opposite sex. Many transgender youth and adults are getting their hormones outside of a
medical setting, often times on the street, from friends or the internet. Because of this,
the transgender community is at further risk for contracting HIV and other diseases from
contaminated needles (Grossman & D'Augelli, 2006; Sanchez et al., 2009). HIV and
AIDS are major concerns for the transgender community. In one study of 515
transgender individuals living in San Francisco, 25% were HIV positive. Despite this
alarming statistic, literature suggests that transgender individuals are sometimes denied
healthcare services related to the treatment of HIV and AIDS (Kenagy, 2005). Without
health care access and competent health care services, this epidemic can only get worse.
In addition to lack of insurance coverage, there are many other barriers evident
that prevent the transgender community from obtaining adequate healthcare services.
One of the most common barriers to transgender individuals receiving decent medical
care is the ignorance of medical professionals. Many doctors are unfamiliar with
transgender medical needs and are prejudiced towards the community (Lombardi, 2001).
Due to this prejudice, many transgender individuals fear seeking treatment due to the
pervasive stigma that exists in doctors’ offices in addition to previous negative
27
experiences with healthcare professionals (Shipherd, Green, Abramovitz, 2010). The
stigma that the transgender population faces can manifest in physical violence or verbal
attacks and the fear of these real threats prevents many transgender individuals from
seeking healthcare due to fear of emotional violation from providers (Alegria, 2011).
Furthermore, Alegria (2011) explains, “these forms of negative bias have been linked to
greater rates of unemployment and risk of suicide among transgender persons” (p. 177).
One cross-sectional study of 97 Male to Female (MTF) transgender adults found
statistically significant results that a greater proportion of transgender adults had
experienced a traumatic life event than had the rest of the biologically male population.
This study found that transgender females had experienced about the same amount of
trauma as women that were female-born. Additionally, 55% of transgender women
reported being objects of unwanted sexual advances, 54% of transgender women reported
sexual assault, 51% had experienced physical abuse and 33% claimed to have been
harassed due to their gender identity. Moreover, transgender individuals who dressed as
their preferred gender experienced much more exposure to traumatic events than those
who did not (Shipherd, Magnun, Skidmore, & Abromovitz, 2011).
For transgender individuals, the medical realm is not necessarily somewhere to
escape this kind of abuse. In a video made for the California HIV/AIDS hotline about
transgender health care needs, one transwoman describes the humiliation she experienced
at an appointment with her primary care doctor. Having gone in for a bronchial infection,
this transwoman described how she ended up on a table with many doctors curiously
28
examining her vagina, even though this had nothing to do with her reason for seeking
care. Due to this experience, this patient now feels uncomfortable going to doctors that
do not specialize in transgender health care (Transforming health care). Because
transgender individuals experience a high rate of discrimination, stigma and violence in
their lives, the fear of facing more of this treatment from medical professionals often
prevents transgender individuals from seeking healthcare (Shipherd et al., 2010). The
impact of stigma and violence on the transgender community is pervasive and many
healthcare services are not culturally competent enough to make transgender individuals
feel comfortable and safe. Added to the transgender community’s valid fears
surrounding stigma and negative bias among medical professionals, another barrier
identified that impedes the transgender community from seeking medical treatment is
fear that medical professionals will tell a transgender individual’s family about his/her
transgender identity. Because many transgender individuals are not public with their
identity, the threat of being outed by a medical professional often prevents people from
seeking treatment (Alegria, 2011). Lack of insurance coverage coupled with
inadequately trained medical professionals creates enormous roadblocks for transgender
individuals in need of healthcare services.
On a Macro level, the mental and physical healthcare needs of the transgender
community remains largely unknown to policy makers. Unlike other marginalized
communities, the transgender community does not have specific access to publicly
funded mental health care programs. Because of this lack of care, transgender
29
individuals often frequent community-based organizations and self-help or other support
groups. In one study, where interviews were conducted with 30 transgender individuals,
such support groups proved to be incredibly helpful at filling in the gap of what is greatly
lacking in medical care (Hines, 2007).
Healthcare Needs
The transgender community would greatly benefit from medical professionals
becoming trained and further educated on transgender medical care, in addition to
training about appropriate language to use with transgender identified individuals
(Alegria, 2011). When meeting with a transgender identified individual, professionals
need to address the person in a “gender appropriate manner,” referring to the person by
the pronoun with which he/she self identifies. However, many doctors are not aware of
or do not follow this practice (Alegria, 2011, p. 179). Additionally, many of the intake
forms contain only two gender options: male and female. This fact further marginalizes
the transgender community in that there isn’t even a space for the transgender community
to choose their preferred gender when coming to see a medical professional. Similarly,
Dafna Wu, a nurse at a clinic specializing in causes many transgender individuals
discomfort. Wu asserts that having unisex bathrooms is imperative to equalization of
healthcare services for the transgender community (Brockett et al., 2007).
Prior research has shown that nurses need more comprehensive training regarding
Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ) cultural competence. Specific to
the transgender population, it is essential that nurses receive more training about allowing
30
transgender persons to self-identify when it comes to picking a gender on an intake form
(Cavender, 2011). In one study, only 10% of nurses had adequate knowledge about the
LGBTQ community (Lombardi, 2001). In another similar study, when given a
questionnaire regarding LGBTQ issues, only 13% of the nursing students interviewed got
90% of the questions correct (Chapman, Watkins, Zappia, Nicol, & Shields, 2011).
Transgender individuals are aware of the fact that medical professionals do not
understand their needs. In a study where researchers interviewed 30 transgender
individuals about their access to healthcare, participants identified lack of understanding
among general practitioners of medicine as one of the top reasons for the existing
disparities (Hines, 2007). The results from these studies illustrate that the medical
community in general lacks knowledge pertaining to the transgender population’s
healthcare needs.
Additionally, physical examinations for transgender individuals should be tailored
to individual needs and based on the person’s physical anatomy, hormone regimen,
possible medications, and potential surgeries instead of doctors and nurses solely relying
on a person’s sex assigned at birth or their current gender presentation.
Physical and laboratory examination of the MTF who has had sex reassignment
surgery should include pelvic examination with Papanicolau (Pap) smear, prostate
exam, prostate specific antigen (PSA), and mammograms. Examination of the
FTM with a vagina should include pelvic examination with Pap smear, clinical
breast exam, and if breast tissue is present, mammogram. (Alegria, 2011, p. 180)
31
Currently, transgender individuals are often denied healthcare examinations based on
their birth sex after they have transitioned despite continuing to need these procedures.
In one study of 122 female-to-male (FTM) men, nearly 50% of them did not receive
annual pelvic examinations and only 7% had a diagnosis of polycystic ovarian syndrome,
18% less than what the general population reports (Johnson et al., 2008). Without proper
exams, many of the individuals in this study may have had PCOS and were simply not
aware of it. Lori Kohler, a family practitioner specializing in transgender healthcare
described the fact that many doctors are uneducated about transgender individuals who
take hormones. Many doctors, Kohler describes, wrongly assume that the health
problems that transgender individuals are experiencing are related to the hormones that
the person is taking (Brockton et al., 2007). Unfortunately, doctors are not the only ones
who are largely uneducated about transgender health care needs. Because transgender
individuals have healthcare needs that differ from some healthcare needs of biological
males and females, many insurance companies will not cover certain sex-specific exams
that transgender individuals may need. Medical professionals and insurance companies
alike are not well versed in medical services that are unique to this community and the
lack of education greatly impacts the quality of care for the transgender community
(Alegria).
Additionally, many transgender adults first seek mental health treatment for a
secondary condition such as substance abuse, depression or another mental health
problem that is really related to their gender dysphoria (Byne et al., 2010). The pervasive
32
social stigma towards the transgender community causes a myriad of mental health
problems for transgender individuals. Many transgender individuals experience shame,
self-hatred, anxiety and depression and may suffer from substance abuse and other
harmful coping mechanisms as a result of the stigma and discrimination that is pervasive
in contemporary society (Johnson et al., 2008). Because of the psychological impact that
stigma and discrimination have on the transgender community, clinicians need to be
aware of other mental health issues that often manifest in transgender individuals.
Transition Related Healthcare
Even though GID is considered a mental disorder and evidence shows that SexReassignment Surgery and hormones are effective ways to eliminate distress for
transgendered individuals, many transgender-identified individuals struggle with getting
their treatment paid for. Mental health services, hormones and surgical procedures are
often denied coverage because they are seen as cosmetic rather than medically necessary
(Byne et al., 2010). In a study conducted with over 2,000 patients who had undergone
hormonal and/or surgical treatment to assist in their gender transition process, 87% of the
MTF and 97% of the FTM participants reported improved psychosocial outcomes.
Additionally, in another study of 325 subjects who had undergone Sex-Reassignment
surgery, only 2% regretted having the procedure. Overall, both studies resulted in
patients with less gender dysphoria and better psychological functioning (Feldman &
Safer, 2009). However, even though medical transition procedures are shown to improve
the well-being of transgender individuals, transition related costs are often extremely
33
expensive without insurance coverage and many transgender individuals go without
transition related medical care (Johnson et al., 2008).
With that said, for employed transgender individuals with insurance, there are
some companies that will pay for transition related procedures. As of 2001, the city of
San Francisco offers its city employees coverage for hormones and surgical procedures
with a 15-50% copayment and maximum benefit of $50,000 (Penn, 2001). In 2007, the
Human Rights Campaign reported that 67 firms are offering coverage for SexReassignment surgery including Wells Fargo, Johnson and Johnson and Toyota (Some
Big Companies, 2007; Trans Rights, 2011). Moreover, the Veterans Administration has
some of the most generous coverage for transition related care. The Veterans
Administration provides health care for eligible transgender veterans, including SexReassignment surgery when it is deemed medically necessary. Additionally, a diagnosis
of GID or Gender Dysphoria is not required in order for transgender veterans to receive
services (VHA Directive, 2011). Unfortunately, even if surgical procedures are covered
through certain companies, transgender individuals experience more unemployment and
discrimination at work compared to the national average and thus, may have more trouble
obtaining employment with decent transition related benefits. Furthermore, the work
environment for employed transgender individuals may be toxic. In a national survey of
the transgender community (n=6,450), 97% of respondents reported having experienced
on the job harassment related to being transgender (Harmon, 2009). This shocking
statistic suggests that even though there are some occupations that allow for transgender
34
individuals to receive transition related care; this does not make up for the gross
inadequacies in other systems or for the rampant discrimination and stigma in the
workplace.
Mental Health and Transition Related Care
The American Psychological Association (APA) plays a major role in transgender
individuals receiving transition related healthcare. The APA has historically increased
stigma for transgender individuals through asserting the GID diagnosis as valid and
lacking solid guidelines for treatment. Both of these factors inadvertently support many
insurance companies’ opinions that surgical procedures are in fact cosmetic. However, a
recent APA Task force that was formed to investigate GID, concluded that APA needs to
take a stance on effective treatment measures of care and issue a resolution that declares
that hormonal and surgical treatments are medically necessary. Moreover, the APA
acknowledged in their report, that their own silence coupled with the GID diagnosis has
been stigmatizing to transgender individuals and therefore impedes their access to care.
The APA declared the transgender community as one that is in the midst of a fight for
civil rights and that treatment must not aim to make the community conform to standard
care as it exists today (Byne et al., 2012).
Additionally, the APA Task Force recommended that mental health professionals
be given training in the area of transgender mental health care so that there are more
competent service providers who are better prepared to work with the transgender
community. In one study (n=93) of patient satisfaction amongst transgender individuals
35
receiving psychotherapy, there was a strong correlation between patients who were
satisfied with their treatment and their psychotherapist possessing cultural competence
pertaining to the transgender community (Bockting et al., 2004). Because most
counseling treatments currently available further the concept of the gender binary and
exclude transgender identities, these counselors are missing key information in
successfully treating transgender individuals (Sanger, 2008). Currently, the APA
recognizes that there are very few mental health professionals who are educated and
therefore qualified to treat people with GID and Gender Dysphoria and even fewer who
have direct clinical experience with transgender individuals (Byne et al., 2012). In order
for transgender individuals to receive competent mental health services, mental health
professionals must be trained specifically on the many societal and institutional issues
that transgender individuals face.
Although the World Professional Association for Transgender Health (WPATH)
Standards of Care do not specify that psychotherapy is a mandatory part of a transgender
individual’s path to surgery, it is a recommended part of the process when there is mental
illness present. If there are co-morbid mental illnesses present such as a psychotic
disorder, eating disorder or substance abuse, WPATH recommends that the individual
seek treatment and show improvement before having Sex-Reassignment surgery.
Treatment for co-morbid disorders may be obtained through the therapeutic process as
well as through psychotropic medications. Additionally, if a transgender individual has a
personality disorder, psychotherapy becomes one of the eligible criteria for surgery (De
36
Cuypere & Vercruysse, 2009). Some professionals see pre-operative psychotherapy as a
way to lessen the chance of post-surgical regret experienced by some transgender
individuals. Several studies show that transgender individuals who experience postsurgical regret are more likely to have not gone through the therapeutic process than
those who are happy with their decision to pursue surgery. Additionally, some
professionals suggest that post-operative patients can benefit from psychotherapy to assist
them in their psychological and social adjustment after surgery (De Cuypere &
Vercruysse, 2009).
However, not everyone agrees with the current standards of care that designate a
great deal of responsibility to mental health professionals. Some advocates for civil rights
feel that mental health professionals sometimes act as “gatekeepers” who can too easily
block a transgender person’s ability to seek medical transition related treatment (Lev,
2009, p. 75). Critics of mental health professionals’ involvement in the decision process
question why transgender individuals cannot go directly to their primary care doctor for
treatment (Lev, 2009). In response to this criticism, a current movement in the
transgender community is evolving aimed at moving away from this authoritative way of
providing healthcare into a more equal relationship between a provider and a consumer of
care (Blockting, 2009).
37
Chapter 3
METHODS
Study Objectives
The present study sought to discover the availability of healthcare access and
quality of healthcare services available to the transgender community living in the greater
Sacramento area. The present study also sought to determine what barriers the
transgender community faces when seeking general healthcare in addition to healthcare
related to the process of transitioning medically. Past research has addressed healthcare
disparities and barriers to healthcare faced by the transgender community in obtaining
adequate healthcare in other parts of the country. The current study sought to determine
what barriers exist and how to improve healthcare access for transgender individuals
living in the greater Sacramento region. The current study utilized data from live
interviews and was analyzed through a qualitative analysis of the data.
Study Design
The research design for this Master’s project was predominantly exploratoryqualitative. The researcher found participants through the Gender Health Center, a nonprofit counseling agency that specializes in treating transgender-identified individuals.
Several transgender-identified individuals who are also transsexual (post medical
transition), medical professionals Social Work professors who are experts in the field and
community advocates were interviewed about their perceptions of healthcare disparities
within the community. The interview questions sought to address how much access to
38
healthcare there is in the greater Sacramento area and what barriers exist for transgender
individuals such as insurance/MediCal coverage, access to the medical transitioning
process and possible solutions to identified barriers. Additionally, these same individuals
were interviewed regarding their perceptions of how competent medical professionals are
in working with the transgender community and how healthcare access and healthcare
quality could be improved for transgender individuals in the greater Sacramento area.
The researcher also interviewed participants regarding their experiences and opinions of
the Gender Identity Diagnosis and how helpful this is in accessing healthcare. The
researcher sought diversity in participants in order to provide many different
perspectives, thus illustrating the full scope of what is currently going on in the greater
Sacramento region in regards to transgender related healthcare.
Sampling Procedures
The researcher used settings to interview participants that were comfortable and
in a public place such as a coffee shop or public park. Participants who self-identified as
transgender and transsexual (post medical transition) in addition to several experts in the
field (social workers, medical doctors, community advocates, nurses) were selected
through the researcher’s internship at the Gender Health Center, a non-profit mental
health agency that specializes in transgender concerns and serves the entire Lesbian, Gay,
Bisexual, Transgender, Queer (LGBTQ) community. The researcher interviewed three
transgender and transsexual self-identified individuals, two Social Work Professors with
specific knowledge about this community, two medical doctors, one registered nurse and
39
four community advocates, all located within the greater Sacramento area to discover
how much healthcare access the transgender community has and how adequate healthcare
services are. The Gender Health Center assisted the researcher in finding potential
research participants. The researcher approached the potential participants at the Gender
Health Center by asking them if they would be interested in participating in her research.
After the participants expressed interest, the researcher met with each participant
individually at public locations in Sacramento. The researcher went over the consent
forms with each individual research participant and had each person sign and date the
consent form (see Appendix A). After obtaining consent, the researcher asked the
participants detailed questions about access to healthcare, barriers to healthcare and
possible solutions to these barriers and recorded the answers on a tape recorder. The
consent form informed participants of their right not to be recorded. Interviews were
conducted at the participants’ convenience, at a public location that was convenient to the
participant. The only people who had access to the recorded interviews as well as all
other data for this research project were the researcher and her faculty advisor, Dr. Serge
Lee. After the research project was complete, all data, including notes and voice
recordings were destroyed so that there was no potential leakage of confidential data.
The data were destroyed on May 19, 2013. All subjects were informed of these
procedures upon signing the consent form.
40
Instruments
The researcher composed the questionnaires prior to meeting with participants.
The interviews differed based on the population being interviewed. The interview for
Social Work Professors and Community advocates consisted of eight questions. The
interview for Medical Doctors and Nurses consisted of nine questions. The interview for
transgender and transsexual-identified individuals contained 22 questions. The
interviews all contained questions regarding perceived access to transition related and
non-transition related healthcare, mental and physical healthcare accessed in the past
year, insurance coverage, perceptions of medical and mental health professionals
competence in caring for transgender-identified individuals and perceptions of the
Gender Identity Disorder (DID) diagnosis as a key tool in getting transition related health
care paid for by insurance companies (see Appendix B). The interview also sought basic
demographic information from transsexual participants such as education level, age,
socio-economic status, racial background and type of employment.
Data Analysis
The data for this research project were gathered from the interviews conducted
with voluntary participants. The researcher performed a qualitative analysis of the data.
Protection of Human Subjects
The researcher submitted a Human Subjects Protocol Application to the
Institutional Review Board (IRB) that discussed the research purpose and proposed
methods. Before submitting her application to the IRB board, the researcher first
41
submitted her Human Subjects Protocol Application to her advisor to review. Her
advisor, Dr. Serge Lee, suggested some modifications to the researcher’s consent forms
including the approximate duration of the interview on the consent form as well as
modifying her formatting. After modifying her application, the researcher submitted her
application to the IRB on October 26, 2012. On November 8, 2012, the researcher
received her application back with the status of approved with minimal risk with
conditions. The conditions were to indicate that participants had the right not to be audio
taped, to delete information regarding medical care in the consent form and to delete age,
ethnicity, education level, and income level for social workers, medical doctors, and
nurses or provide reason for their inclusion. After receiving approval with conditions, the
researcher removed the demographic questions from the questionnaires for social
workers, community advocates, and medical professionals and added a clause in the
consent form about participants being able to decline being audiotaped. The researcher
also removed the medical contacts from the consent form. The researcher submitted her
modified application for full approval to the IRB on December 7, 2012. The researcher
was granted full approval to begin conducting her research on February 1, 2013. The
research project was approved as minimal risk with the protocol number 12-13-029.
42
Chapter 4
STUDY FINDINGS AND DISCUSSIONS
The transgender community has been marginalized when it comes to receiving
adequate healthcare (Brockett et al., 2007). The researcher sought to interview a variety
of health professionals, transsexual individuals and community advocates in order to get
a full picture of how much access the Sacramento area transgender community has to
health care services and the quality of care available.
Overall Findings
The researcher interviewed two Social Work Professors at Sacramento State
University who have knowledge regarding the transgender community as well as four
Sacramento area community advocates for the transgender community. The researcher
also interviewed two family practice medical residents who volunteer at a local hormone
clinic run by the Gender Health Center for transgender individuals in Sacramento and one
registered nurse who works in the Emergency department of a busy Sacramento hospital.
Additionally, three transsexual, (post-transition) transgender identified individuals
living in the Sacramento area were interviewed regarding their own personal experiences
in accessing healthcare. Demographic information was collected for each transsexual
participant. All three transsexual participants were Caucasian male to female (MTF)
transgender identified individuals. There was a range in age of transsexual participants
and included one 42-year-old, one 31-year-old and one 46-year-old. Education level also
varied and included one participant with her bachelor’s degree, one participant with her
43
master’s degree and one participant with her General Education Diploma (GED). Two
participants reported making less than $11,000 a year and one participant reported a
yearly income of $95,000. Two participants were currently unemployed and the third
stated her occupation as a “Software Engineer.” Two of the transsexual participants had
accessed physical health care services within the last year and one had not. All three of
these participants had accessed mental health services within the last year. Additionally,
all three of these participants reported to feeling comfortable when seeking medical care
and mental health services.
Specific Findings
Medical Professionals
Two family practice resident physicians who volunteer at the Gender Health
Center’s hormone clinic were interviewed for this research project. Additionally, one
registered nurse who is employed in an emergency department in the Sacramento area
was interviewed for the present study. All three professionals reported to having had
contact with transgender individuals in their work setting. The two medical doctors had a
lot of contact with transgender individuals in their work as volunteer physicians at the
hormone clinic. Each physician had seen a transgender individual diagnosed with
Gender Identity Disorder (GID) within the last year and one reported to diagnosing a
person as having GID for “insurance purposes.” The registered nurse reported that the
single transgender patient that she had seen in the last year did not have a GID diagnosis.
Both physicians mentioned being opposed to the Gender Identity Disorder diagnosis.
44
Statements included “we’re fighting to get rid of the disorder and embrace the gender
identity part” and “I’ll write in a diagnosis for GID but I don’t put it in their chart.” The
nurse stated that diagnosing patients is outside of her scope of practice.
Three open-ended questions were asked regarding these medical professionals’
perceived competence in treating transgender individuals for their medical and
psychological needs. Additionally, one open-ended question was asked that sought to
find out how each professional felt she could increase competency. Both doctors
reported to feeling very competent in treating the transgender population’s medical needs,
although less competent at treating and understanding the transgender community’s
psychological needs. The registered nurse reported to feeling competent in treating the
transgender community’s non-transition related medical needs but incompetent in
treating transition related medical needs. Additionally, the registered nurse stated that
she could use more education surrounding the biopsychosocial needs of the transgender
community. Responses for perceived competence in medical needs included “I feel
competent,” “I feel I’m comfortable treating them” and “very competent in medical needs
but not so much for transition related needs.” Responses to perceived competence
regarding psychological needs included “I think that’s a little bit trickier,” “on a scale of
one to five I’d be a three if competent was a three and extremely competent was a five”
and “I don’t remember studying their biopsychosocial needs in nursing school.” All three
medical professionals were also asked what they would need to feel more competent in
treating transgender individuals. Both doctors and the registered nurse responded that
45
they needed more training on the needs of the transgender community. Responses
included “more training in the social aspects,” “more data and studies,” “class or reading
material addressing transition related medical complaints” and “more experience.”
Two open-ended questions were asked regarding imagined or observed barriers
for transgender individuals seeking healthcare and potential solutions to these barriers.
Both doctors cited lack of education among medical professionals as a barrier to
healthcare access. The registered nurse reported that lack of training amongst providers
in addition to gender segregated hospital rooms could be barriers for transgender patients.
Specific responses to identified barriers included “there’s a lot of physicians out there
that have no idea what’s going on,” “the physician is completely ignorant or
unwelcoming of transgender patients,” “confusion among providers” and “rooms are
usually shared by two females or two males. Transgender individuals would most likely
be given a private room”. Additionally, one physician described how many physicians
“weren’t familiar with continuing screening and combining services for [transgender
individuals’] birth sex if they still have those organs.” The same physician cited
“prejudice and not knowing how to respond to patients” as being a barrier to healthcare
access. When asked about solutions to these identified barriers, both doctors and the
registered nurse cited education efforts as being key. Responses included “education,
cultural change and general awareness of transgender issues and transgender people,”
“awareness and sensitivity training” and “more staff education on transition related
medical complaints and on the biopsychosocial needs of the transgender community.”
46
Social Work Professors and Community Advocates
Two Social Work Professors who have experience working with the transgender
community as well as four community advocates were interviewed about the potential
barriers to proper healthcare access that transgender individuals face. One open-ended
question was asked regarding what barriers the transgender community faces when
seeking healthcare. Several participants cited incompetent providers as being one of the
main concerns. Responses included “incompetent providers,” “lack of competent
professionals,” “[transgender individuals] are pathologized or turned down by their
doctors, turned away and not even treated,” “physicians either don’t have enough
knowledge of transgender issues or they don’t want to know about it” and “they’re
(medical doctors) just not educated.” Other barriers identified included societal
transphobia and lack of insurance coverage. Responses included “transphobia,” “access
to health insurance,” “insurance companies don’t cover a lot of things transgender people
need,” “a lot of procedures and surgery are not covered by insurance,” “the private
insurance based system,” and “transphobia in our culture and society.”
Two open-ended questions were asked regarding what knowledge each
participant had on insurance company policies pertaining to transgender related health
care. All participants agreed that insurance companies do not cover most transition
related health care and that the services that are covered are hard to navigate and actually
obtain for transgender individuals. Responses included “in general, there’s not a lot of
coverage for it,” “it’s a difficult process,” “there’s a lot of things the insurance company
47
does cover but they don’t tell you they cover it,” “each person attempting to receive
transgender-related care is going to have a different experience” and “Medical and
Medicare have been quite a challenge to deal with.” One participant talked about certain
insurance companies that do cover transition related healthcare. This participant stated
that companies such as UC Davis, Hewlett Packard and the Veterans Administration
covered most transition related care.
Two open-ended questions inquired into each participant’s opinion of perceived
competence among medical and mental health professionals when it comes to working
with the transgender community. Many participants described that medical professionals
and mental health professionals are largely incompetent when it comes to treating
transgender individuals. Responses for perceived competence among medical doctors
included “not very [competent] at all unless they are hormone specialists,” “if you see a
general physician because you have a cough and they see that you’re taking these
hormones, they won’t know what they do,” “not very competent,” “not competent,” “they
need more training on it” and “95% of doctors have no idea or awareness about the
issues.” Responses for perceived competence among mental health professionals
included “you hear stories from folks who tried to access therapy and it didn’t go well,”
“on average, not very” and “as a whole, they’re not very competent” and “they’re not
competent because there isn’t any training in graduate schools about mental health work
with transgender folks.”
48
One open-ended question asked each participant to give their opinion about the
Gender Identity Disorder (GID) diagnosis and proposed Gender Dysphoria diagnosis and
how helpful or unhelpful it is for transgender individuals seeking healthcare. Almost all
of the participants acknowledged that having a diagnosis assists transgender individuals
in getting transition related care covered but also hurts individuals with the stigma such
labels perpetuate. Responses included “you need a label in order to get assistance in
insurance coverage but the label can be a very real and painful aspect of one’s life,” “It’s
a double edged sword. It’s good to have a label so you can get the services that you need
but…it leaves people feeling like something is wrong with them,” “it’s good for
insurance but it doesn’t make them feel good that just because they’re trans, they have a
disorder,” “I understand they need a code to write down but transgender folks should be
covered without needing a mental health diagnosis,” and “I strongly oppose the GID
diagnosis because it says in black and white that it’s a disorder just to cross identify. I
think ideally, it should be a medical condition, not a psychiatric condition.” One
participant did not agree that the diagnoses are helpful for transgender people at all. This
participant’s response to the question stated, “I’m glad they are getting rid of Gender
Identity Disorder. People internalize the diagnosis as a disorder and this will help people
realize that they are not crazy.”
One open-ended question asked participants what solutions they proposed in order
to ensure that the Sacramento area transgender community has access to satisfactory
healthcare. Proposed solutions were varied and included educating professionals,
49
creating more transgender focused community health clinics and advocating and
empowering those in the transgender community. Specific responses included “changing
healthcare and insurance policies,” “more clinics and health centers like the Gender
Health Center,” “physicians to become more aware,” “advocacy,” “train professionals
and empower individuals,” “education and legislative advocacy,” and “community clinics
where we are modeling our care after transgender specific needs because when you’re
able to provide for the most marginalized community within a marginalized community,
you end up providing for a wider, regional community.”
Transsexual Identified Individuals
Four open-ended questions were asked regarding what barriers each participant
had experienced in finding and receiving adequate transition and non-transition related
mental and physical healthcare and what potential solutions to these barriers could be.
Barriers that participants faced when seeking transition related care included not knowing
where to access services, not having insurance coverage and experiencing a lack of
professionals that are educated about the transgender community’s needs. Responses
included “I don’t have any insurance,” “it wasn’t easy to gain access to hormones,” “I
haven’t seen a general practitioner in 6 years” and “the biggest hurdle was finding people
that have the knowledge to help, especially [with] psychological help.”
In seeking non-transition related medical care, respondents reported that money
and lack of insurance coverage was the largest barrier that they faced. One participant
reported having insurance coverage through Kaiser Permanente; however, the other two
50
participants reported having no insurance coverage. Responses about the barriers to
accessing non-transition related care included “no insurance” and “it’s a lot of money,”
third participant’s response (with insurance). In responding to what solutions could help
alleviate these barriers, participants identified educating medical doctors and mental
health professionals about transgender related health care and requiring that doctors treat
transgender patients. Responses included “they need to start educating and they need to
help people despite how they feel about their lifestyle” and “more education for doctors
and providers.” Other identified solutions included “more community agencies
specializing in transgender issues” and “a national insurance program.” Since two
participants were uninsured, only one participant could answer the question about how
helpful insurance has been in covering transition related care. This participant answered,
“they covered hormones but that’s it.”
Four open-ended questions were asked in regards to personal experiences that
informed each participant’s opinion about mental health professionals and medical
doctors’ competence in treating transgender individuals. Each participant described
personal experiences with medical doctors who they felt were incompetent in treating
transgender individuals. Responses included “they’re not [competent] at all unless they
have been doing it for a while” and “not competent.” One participant, who accessed the
hormone clinic that the Gender Health Center provides, stated that the doctors were
“quite competent.” The participants’ experiences with mental health professionals
varied. Participants who sought mental health services through the Gender Health Center
51
found mental health professionals to be more competent than the participant who went
outside of the center for therapy. Responses from participants who saw someone from
the Gender Health Center included “not competent but open to learning” and “this was
the first time I ever had a counselor who I don’t have to educate.” The third participant
described seeing a mental health professional who was not affiliated with the Gender
Health Center. This participant described this particular mental health professional as
being “not competent” when it came to issues of gender identity.
One open-ended question inquired into participant’s opinions of the Gender
Identity Disorder (GID) diagnosis/ proposed Gender Dysphoria diagnosis. One
participant reported liking the diagnosis and feeling that there needs to be stronger
gateways to getting hormones and beginning a medical transition due to her personal
experience in seeing “lives ruined” from transitioning. Her response included “I think the
gateways are there for a reason and need to stay there. I think they could be a little bit
tighter even.” Another participant had opposite feelings about the diagnoses. This
participant responded, “I don’t like the disorder diagnosis…it has nothing to do with my
mind.” The third participant acknowledged both the harmful and helpful aspects of the
diagnoses. This participant responded, “It’s a double edged sword. I feel like I don't want
it in there, I don't feel it's a disorder, but I know that the medical community needs
something on paper in order for them to really provide services.”
The last question asked participants what they feel needs to happen for the
transgender community to receive adequate healthcare. All three participants agreed
52
professionals need more training and education. Responses included “training,”
“educate” and “awareness.” Other responses included “people need to change their
attitude,” “more affordable services” and “easier access to information about the process
to receive services.”
Interpretations of the Findings
The results portray certain themes throughout the interviews with a variety of
individuals involved in the Sacramento region’s transgender community. These themes
offer a lens into the availability of healthcare access and quality of care for the
transgender community in the Sacramento region. Most of the interview participants
cited lack of competent and knowledgeable medical and mental health professionals as
one of the key barriers that exists for transgender individuals seeking adequate
healthcare. Additionally, many participants identified transphobia and ignorance among
health professionals as another common barrier to accessing good healthcare. All
participants identified education, training and spreading awareness as being key tools to
addressing these barriers that currently exist for transgender patients.
The opinions of the participants about the Gender Identify Disorder (GID) and
proposed Gender Dysphoria diagnoses varied somewhat. The views varied among each
group of participants interviewed. Opinions varied greatly from one participant agreeing
with the diagnosis and believing there needs to be stricter gateways to accessing
hormones and surgeries, to a the diagnosis becoming a medical one instead of a mental
health disorder, to wanting to get rid of a diagnosis for transgender individuals entirely.
53
Many participants saw the diagnoses as having benefits in that the diagnosis merits
medical coverage for transition related care and negative consequences pertaining to the
stigma and pathologizing of the transgender identity that the diagnoses help further. Both
medical doctors admitted that the GID diagnosis is helpful in getting insurance
companies to cover transition related medical needs; however, the nurse reported to
seeing a transgender patient that did not possess the diagnosis. The nurse was unaware of
the individual’s insurance situation and so one cannot know if the GID diagnosis was
needed for potential coverage for treatment.
The results about how much insurance coverage there is for transgender-identified
individuals also varied. Two of the transsexual participants interviewed had no health
insurance whereas the third possessed a high paying job and reported having good health
insurance. However, the one transsexual participant interviewed who possessed health
insurance coverage, reported that insurance only covered hormones and no other medical
interventions related to her medical transition. Several participants identified lack of
access to insurance in addition to lack of coverage for medical procedures for those who
are insured as major barriers to healthcare for the transgender community. Additionally,
several participants cited a confusing insurance system where it is unclear what is
covered and what is not as being another barrier to healthcare. Several participants
mentioned a change in our health care system as well as National Health Insurance
program as being solutions to barriers to healthcare access. Furthermore, many
participants described needing more community health agencies specializing in the needs
54
of transgender individuals such as the Gender Health Center as a solution to the lack of
access to care.
Summary
In examining results from interviews with health professionals, transsexual
individuals, Social Work professors with knowledge about the transgender community
and other community advocates, we see a clearer picture of what is getting in the way of
transgender individuals seeking and obtaining adequate healthcare, in addition to some
possible solutions to these barriers. Incompetent and ignorant medical and mental health
professionals and the need for more training and education about the medical and
psychological needs of the community are barriers to the transgender community when it
comes to receiving adequate care. Additionally, transphobia in our society as well as
stigmatization related to the Gender Identity Disorder/proposed Gender Dysphoria
diagnoses perpetuate and create barriers that exist for transgender individuals. Lastly,
lack of insurance access in addition to confusing policies and lack of insurance coverage
for transition related medical needs prevents many transgender individuals from
obtaining both transition and non-transition related medical care. National Health Care
programs as well as more community health centers specializing in the transgender
community were identified as solutions to the barriers with health insurance companies.
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Chapter 5
CONCLUSION, SUMMARY, AND RECOMMENDATIONS
Summary of Study
The present study sought to examine the availability and quality of healthcare for
transgender individuals in the greater Sacramento region. In this chapter, I first identify
evidence from the present study that did or did not support the research hypothesis and
discuss possible reasons for these results as related to the review of the literature.
Following, I present the limitations of the present study in addition to the implications for
Micro and Macro Social Work practice. Lastly, I make suggestions for future research.
Discussion
The researcher expected to find that healthcare access for the transgender
community in the Sacramento region was going to be grossly inadequate. This
hypothesis was largely validated through the present study’s results. Past research shows
that transgender individuals are the largest uninsured group in the LGBTQ community.
Additionally, the transgender community experiences high rates of denials to proper
treatment whether from insurance or providers due to their gender identity (Johnson et
al., 2008, Kenagy, 2005). The present study indicated that lack of insurance access and
coverage is a major barrier for transgender individuals in the Sacramento region. Two of
the transsexual participants interviewed did not currently possess health insurance and the
other participant with insurance coverage reported that insurance only covered hormones.
Additionally, such as the researcher suspected, several participants identified better
56
insurance access and coverage as well as a National health insurance program as
solutions to these barriers. Insurance access and transition related coverage appear to be
two of the main factors that need to be addressed in order for transgender individuals to
receive proper healthcare.
Supplemental to the results from the interviews with participants is the
researcher’s perusing of local private insurance plans in the Northern California area as
well as looking into what MediCal covers. Two local private health insurance plans
stated that the transgender patient would be denied a private insurance policy simply
based on their Gender Identity Disorder (GID) diagnosis. When looking into MediCal
coverage, the researcher found a complicated web where it was unclear what was covered
and what was not. In looking at a group plan through a local University, the researcher
found through this insurance plan, every transgender patient has access to transition
related medical care up to a lifetime limit of 75,000 dollars. However, one has to be an
employee of the University to access these benefits.
Several participants in the current study mentioned that insurance coverage is a
confusing network to navigate and often times it is unclear what is covered and what is
not covered. Additionally, the one transsexual participant who reported having health
insurance described that her insurance company solely covered her prescribed hormones
and nothing else transition related. It appears that insurance coverage for transition
related medical needs differ between different group insurance policies and that private
plans may not even take a transgender patient in the first place. Because the participant
57
that possessed insurance coverage was employed with a salary of $95,000 annually, she
was able to sign up for a group plan through her work that provided some transition
related coverage. However, the two other transsexual individuals who reported annual
incomes below $11,000 had no insurance coverage. It appears from the present study and
independent research into local health insurance policies, that private insurance policies
are difficult for transgender individuals to be approved for, especially if they have a GID
diagnosis and that many insurance companies are confusing to navigate when it comes to
transition related medical coverage.
The researcher also sought to determine the consensus on whether the Gender
Identity Disorder (GID) diagnosis/proposed Gender Dysphoria diagnosis was helpful or
harmful to the transgender community when seeking satisfactory healthcare services.
Previous research shows that critics of the diagnosis view the fact that transgender
individuals are labeled with a mental disorder, as feeding the stigma and discrimination
that exists towards the transgender community. However, previous research indicates
that the GID diagnosis can be also be extremely helpful in getting insurance companies to
cover transition related health care services (Sennott, 2011). The present study found
varied opinions of the diagnoses and how helpful or harmful they can be, similarly to
previous research done on the subject. One interesting finding is related to the
transsexual participant who reported liking the GID diagnosis and desiring even further
“gateways” for individuals seeking to transition. Because this participant is Caucasian,
upper-middle class and possesses adequate health insurance and resources to pay for
58
procedures that aren’t covered, she may not see the negative effects of the diagnoses or
experience the stigmatizing nature of the diagnoses as other transgender individuals who
are less financially stable might experience. However, even though this participant had a
view that differed from the rest of the participants on the GID/Gender Dysphoria
diagnoses, this participant still reported to having personally experienced both mental
health professionals and medical professionals who were incompetent and ignorant about
the medical and psychological needs of transgender individuals.
Previous research shows that both medical professionals and mental health
professionals are lacking in knowledge about the transgender community (Lombardi,
2001). Likewise, almost all of the participants in the present study identified education,
training and efforts towards awareness for health professionals as being key to
transgender individuals obtaining proper healthcare. Furthermore, many participants
mentioned that community health centers like the Gender Health Center in Sacramento
that specialize in transgender needs could also be a solution to the lack of quality
healthcare available for transgender individuals. One community advocate discussed
how community health centers such as the Gender Health Center focus on the most
marginalized community within the LGBTQ community and therefore are able to serve
the entire community. Because of this, medical and mental health clinics that specialize
in the needs of the transgender community could be part of the solution towards greater
healthcare access and better services for transgender individuals. In addition to health
clinics, the results make clear that there needs to be more training and educational efforts
59
aimed towards health professionals in the Sacramento region surrounding cultural
competency.
The overwhelming mention of incompetent professionals in the current study
from transsexual participants, community advocates and health professionals suggests the
lack of culturally competent professionals in the Sacramento region, not unlike previous
research done in other parts of the country. Previous literature identified gender
segregated bathrooms as a barrier to healthcare for transgender individuals. Similarly,
the Registered Nurse who was interviewed for the present study reported that transgender
patients would be given a private room in a hospital due to their gender identity.
Previous research and the Nurse’s report make clear that health professionals are largely
uneducated surrounding the needs of transgender community. With this said, all three
transsexual participants interviewed reported being comfortable seeking mental health
and physical health care. This could be due to the fact that Sacramento has the Gender
Health Center that provides mental health services as well as a hormone clinic for
transgender individuals and specializes in the needs of the transgender community. Had
the researcher interviewed transsexual participants that were unfamiliar with the Gender
Health Center, she could have seen different results with transsexual individuals that
reported feeling uncomfortable seeking healthcare services. Additionally, had the
researcher interviewed transgender individuals prior to their medical transition, the
comfort levels in accessing care could have been different.
60
Social Work Implications
The present study contains many useful implications for social workers that are
employed in both micro and macro level positions. Social workers, like medical
professionals, need to be educated about transgender issues in order to be culturally
competent in their practice. The present study portrays the fact that many clinicians
remain ignorant about the psychosocial needs of the transgender community. Social
workers in the clinical realm need to be aware of the stigma and prejudice that the
transgender community faces and the psychological impacts on individuals and on the
community as a whole. Additionally, clinical social workers need to learn about what
language to use with transgender-identified individuals, such as using a transgender
person’s preferred pronoun when addressing a client. Moreover, social workers that
diagnose clients need to be careful when diagnosing a transgender person with Gender
Identity Disorder/ Gender Dysphoria and not use these diagnoses in a pathologizing
manner. Through the interviews done with transsexual participants, a wide range of
opinions emerged about the use of the GID diagnosis; however, most of the participants
agreed that the fact that the diagnosis is considered a mental illness is inherently
stigmatizing. With that said, as many participants pointed out in the present study, it may
be necessary to utilize the diagnoses for insurance coverage purposes.
Macro level social workers that are working in advocacy and policy positions
need to be aware of the transgender community’s marginalized status, even within the
LGBTQ community. When social workers fight for social justice for the LGBTQ
61
community, they should keep the transgender community’s needs in mind instead of
solely sticking them under the umbrella of LGBTQ and subsequently forgetting about the
unique issues that this community faces with problems in accessing healthcare, stigma
and discrimination. Social workers that are employed in policy design and
implementation should make sure that the policies that they create are transgender
friendly and do not further marginalize the community.
Future Research
The present study also provides several ideas for future research in this area.
Because training, education and awareness were identified as potential solutions to
incompetent health care providers, the researcher recommends that future research
studies focus on the best ways are to educate and train mental and medical health
professionals in the needs of the transgender community. Once education and training
efforts have been implemented, the researcher recommends that these programs be
analyzed for their effectiveness and whether increased knowledge decreases the
marginalization of the transgender community and increases the quality of and access to
healthcare. Another recommendation for future research is to determine the impact on
the transgender population once Gender Identity Disorder is taken out of the next edition
of the Diagnostical and Statistical Manual on Mental Disorders and replaced with Gender
Dysphoria. Because the new diagnosis could theoretically be less stigmatizing, it has the
potential to decrease discrimination and pathologization of the community. It will also be
interesting to see how the new diagnosis affects insurance coverage for transition related
62
care. Additionally, with the Affordable Care Act being instituted in 2014, the researcher
recommends that further research be done on how the new health care system impacts the
transgender community’s access to health care. Lastly, this researcher recommends that
future researchers study how culturally accepted binaries of gender are impacted by
increased awareness and education about the transgender identity. It is the hope of this
researcher that through lessening the grip on socially constructed ideologies of gender
and breaking through these binaries, the transgender community will experience less
discrimination, stigma and greater access to healthcare.
63
APPENDICES
64
APPENDIX A
Consent Forms
Consent to Participate in Research: Medical Professional/Mental Health
Professional/Expert in the Field/ Community Advocate
Purpose of the research
You are being asked to participate in research that will be conducted by Annie Temple, a
graduate student in the Division of Social Work at California State University,
Sacramento. The purpose of the study is to investigate the current access and barriers to
healthcare available to the transgender community in Sacramento.
Research procedures
Upon written consent, you will be given an interview regarding your perceptions of
questions related to the availability, quality, barriers, and general access to healthcare for
transgender individuals in Sacramento. The interview will be audiotaped and will require
approximately 30 minutes of your time.
Risks
I want to inform you that some of the questions in the interview may seem personal, but
you don’t have to answer any if you don’t want to. You have the right to not be audio
taped and the interview will not be taped if you don’t want it to be. You may participate
as much or as little in the interview as you wish. In addition, I want to let you know that
you can stop the interview at any time with no explanation required.
Benefits
You may not personally benefit from participating in this research. However, it is hoped
that the results of the study will be beneficial to the Transgender community in
identifying current barriers in healthcare access and proposing potential solutions to these
barriers.
Confidentiality
I want you to know that your responses to the questionnaires will be anonymous. A
pseudonym will be used when reporting the data to protect your privacy. With your
permission, the interview conducted will be audio taped. Those tapes will be destroyed as
65
soon as the interviews have been transcribed, and in any event no later than one year after
they were made. Until that time, they will be stored in a secure location. All results
reported will be completely confidential.
Compensation
Unfortunately, you will not receive any compensation for participating in this research.
If you have any questions about this research, you may contact the researcher, Annie
Temple at 530-219-6703 or by email at annielouisetemple@gmail.com. You may also
contact her faculty advisor, Dr. Serge Lee at 916-278-5820 or by e-mail at
lees@saclink.csus.edu. You may decline to be a participant in this study without any
consequences. Your signature below indicates that you have read this page and agree to
participate in the research.
________________________________
Signature of Participant
____________________
Date
66
Consent to Participate in Research: Transsexual Participants
Purpose of the research
You are being asked to participate in research that will be conducted by Annie Temple, a
graduate student in the Division of Social Work at California State University,
Sacramento. The purpose of the study is to investigate the current access and barriers to
healthcare available to the transgender community in Sacramento.
Research procedures
Upon written consent, you will be given an interview regarding your perceptions of
questions related to the availability, quality, barriers, and general access to healthcare for
transgender individuals in Sacramento. The interview will be audiotaped and will require
approximately 30 minutes of your time.
Risks
I want to inform you that some of the questions in the interview may seem personal, but
you don’t have to answer any if you don’t want to. You have the right to not be audio
taped and the interview will not be taped if you don’t want it to be. You may participate
as much or as little in the interview as you wish. In addition, I want to let you know that
you can stop the interview at any time with no explanation required.
Benefits
You may not personally benefit from participating in this research. However, it is hoped
that the results of the study will be beneficial to the transgender community in identifying
current barriers in healthcare access and proposing potential solutions to these barriers.
Confidentiality
I want you to know that your responses to the questionnaires will be anonymous. A
pseudonym will be used when reporting the data to protect your privacy. With your
permission, the interview conducted will be audiotaped. Those tapes will be destroyed as
soon as the interviews have been transcribed, and in any event no later than one year after
they were made. Until that time, they will be stored in a secure location. All results
reported will be completely confidential.
Compensation
67
Unfortunately, you will not receive any compensation for participating in this research. If
you are interested in talking more about these issues or desire counseling services, you
may contact Ben Hudson, Executive Director of the Gender Health Center at 916-4552391.
If you have any questions about this research, you may contact the researcher, Annie
Temple at 530-219-6703 or by email at annielouisetemple@gmail.com. You may also
contact her faculty advisor, Dr. Serge Lee at 916-278-5820 or by e-mail at
lees@saclink.csus.edu. You may decline to be a participant in this study without any
consequences. Your signature below indicates that you have read this page and agree to
participate in the research.
________________________________
Signature of Participant
____________________
Date
68
APPENDIX B
Questionnaires
Interview for Social Work Professors who are Experts in the Field/Community
Advocates
Occupation:
In your opinion, what are the current barriers that the greater Sacramento area
transgender community faces when seeking adequate physical and mental health care?
In your opinion, what needs to happen for the reduction/elimination of these barriers?
Do you have any knowledge about insurance company policies on the coverage of
transition related health care? What has your experience been with clients/acquaintances
who attempt to seek coverage for transition related care?
In your opinion, how competent do you think medical doctors are in transgender related
health care? Please explain your opinion.
In your opinion, how competent do you think mental health professionals are in
transgender related mental health care?
Please explain your opinion.
What is your personal opinion about the Gender Identity Disorder/ proposed Gender
Dysphoria diagnosis? How helpful/unhelpful do you feel these are for transgender
individuals in receiving proper mental/physical healthcare?
What solutions do you propose to ensure that the Sacramento area transgender
community has access to satisfactory healthcare?
69
Interview for Medical Doctors/Nurses
Occupation:
How competent do you feel you are when it comes to treating transgender patients for
non-transition related medical needs?
How competent do you feel you are when it comes to treating transgender patients for
transition related medical needs?
How comfortable/competent/educated do you consider yourself when it comes to the
bio/psycho/social needs of the transgender community?
What would you need in order to feel more competent/comfortable as a medical service
provider to transgender individuals?
How much contact have you had with transgender individuals in the last year of your
practice? How many patients have you seen with a Gender Identity Disorder (GID)
diagnosis?
How many times during the last year have you diagnosed someone as having GID?
What barriers have you observed or imagine exist for transgender individuals when
seeking sufficient healthcare?
In your opinion, what are the potential solutions to these identified barriers?
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Interview for Transsexual Individuals
Age:
Ethnicity:
Occupation:
Education Level:
Income Level:
What kinds of barriers have you personally experienced in finding/receiving adequate
transition related mental and physical healthcare?
In your opinion, what needs to happen for the reduction/elimination of these barriers?
What kinds of barriers have you personally experienced in finding/obtaining adequate
non-transition related mental and physical healthcare?
In your opinion, what needs to happen for the reduction/elimination of these barriers?
Are you insured? If so, who is your insurance company?
If you do have health insurance, how helpful has insurance been in obtaining/getting
coverage for adequate mental/physical healthcare?
If you do have health insurance, how helpful has insurance been in obtaining/getting
coverage for transition related healthcare?
How competent do you feel medical doctors are when it comes to transgender related
health care?
What personal experiences do you have with doctors’ competence/incompetence when
treating transgender individuals?
What is your personal opinion about the Gender Identity Disorder (GID)/ proposed
Gender Dysphoria diagnosis? How helpful/unhelpful do you feel it is for you when trying
to obtain proper mental/physical healthcare?
Have you utilized mental health services in the last year?
If yes, how competent were these mental health professionals in transgender related care?
Have you utilized physical health care services in the last year?
71
If yes, how competent were these medical professionals in transgender related care? If
not, what is your reason behind not utilizing these services?
How comfortable do you/would you feel in seeking mental health care?
How comfortable do you feel in seeking physical health care?
In your opinion, what needs to happen for transgender identified individuals to receive
satisfactory healthcare?
72
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