The issue of LGBTQ rights has long been a source of heated debate both nationally and abroad. While the United States has undoubtedly moved towards greater inclusivity with the expansion of certain legal protections for the LGBTQ community and with increasing societal acceptance of and engagement in LGBTQ-inclusive discourse, the LGBTQ community continues to suffer from discrimination in the workplace, in education, and in healthcare.
Discrimination against LGBTQ individuals has become particularly visible in the healthcare setting in recent years. According to a review of anti-LGBTQ discrimination in US healthcare by the Human Rights Watch, patients reported a multitude of experiences with discrimination, including being denied fertility treatment, counseling, routine screening, and even pediatric care for their children.1 A study published by the Center of American Progress in 2020 showed that 15% of 1,528 self-identified LGBTQ respondents endorsed postponing or avoiding medical treatment due to fear of discrimination. The transgender population, in particular, was shown to suffer from even more pervasive discrimination. Of the transgender respondents, 3 in 10 endorsed postponing or avoiding medical treatment due to discrimination, and 1 in 3 reported the need to teach providers about their sexual identity in order to receive adequate care.2
The problem of discrimination against the transgender patient population and the LGBTQ community at large begins at the federal level. In January 2021, the US Department of Health and Human Services under the Trump Administration published a final rule rescinding Obama-era protections barring providers receiving federal funding from discrimination on the basis of gender identity or sexual orientation.3 This policy change is particularly damaging to the LGBTQ community, as it allows providers to deny patients access to important services, including sexual health screenings, opioid treatment, detoxification programs, and health professional training.
While this policy change was addressed by the Biden administration’s recent executive order reaffirming anti-discrimination protections based on the Supreme Court case Bostock v. Clayton County, it ultimately falls short in the security it offers to the LGBTQ community.4 Executive orders, however, are limited in their durability and longevity. In contrast to federal statutory law, which is passed by the US Congress and signed by the president, executive orders are limited in their jurisdiction and can only dictate federal government operations within the boundaries outlined by the Congress. In addition, executive orders are not permanent and subject to alterations with changes in administrations. These limitations ultimately reduce the ability of the Biden administration’s executive order to offer a lasting solution to the problem of discrimination for this population.
The lack of federal protections for transgender patients is further exacerbated by discrimination at the individual provider level. However, physician discrimination against the transgender patient population seems to stem more often from a deficit of knowledge than from a deficit of tolerance.5 Even the most well-intentioned providers may fall short in their ability to provide adequate care to transgender patients without sufficient training in healthcare issues unique to these patients, such as hormone therapy, sex-reassignment surgery, and transition care.6 In a recent study published in the Annals of Family Medicine, only about 69% of surveyed physicians felt adequately prepared to provide care to transgender individuals, although 86% of surveyed physicians were willing to provide care to these individuals.7
Underlying the discrimination faced by transgender patients in the healthcare setting is a fundamental lack of provider competency in transgender care. The failure to understand the transgender patient experience may not only contribute to healthcare practice perceived as discriminatory by patients, but may even perpetuate discrimination, as providers lacking adequate training in transgender healthcare issues may be more likely to perceive being transgender as deviant. Increasing provider education on the psychosocial aspects of being transgender as well as on healthcare screening, diagnoses, and treatments unique to this population may reduce the barriers faced by transgender patients in receiving quality care.8
Ultimately, increased training in transgender healthcare must also be accompanied by the enactment of lasting legal protections against discrimination in the healthcare setting for transgender and other LGBTQ patients. While this process has been initiated by the recent passage of the Equality Act by the House of Representatives, the bill’s ability to withstand pushback from the Senate remains to be seen.9 Regardless of this outcome, legislation that expands LGBTQ access to quality healthcare, secures insurance coverage for transition-related treatments, and emphasizes anti-discrimination policy is crucial for ensuring more equitable healthcare for the LGBTQ community.
Alexandria Lee is a third year medical student at Loma Linda University School of Medicine. She graduated from UCLA with a degree in Ecology and Evolutionary Biology and has always been interested in intersectionality in medicine. When she’s not studying, she can be found at a coffee shop in LA.