Alabama, Arizona and Texas have recently passed legislative efforts to ban gender-affirming health care to transgender adolescents. This is highly concerning and relevant, as 2% of younger Americans identify as transgender, a term that refers to people whose gender identity (an internal sense of self) does not align with the sex they were assigned at birth.
A gender transition, or the process a transgender person undergoes to express their gender more in line with their internal identity, is a critical component of maintaining their mental health. Research shows that transitioning in affirming environments is life-saving for many transgender people; supportive communities, culturally competent health care and choosing a new name and gender pronouns improves mental health outcomes, including suicidality (which transgender people are significantly more at risk for).
Conversely, non-affirming environments and systemic barriers to health care result in higher rates of depression, suicidality and substance misuse in the transgender community, as compared to their cisgender peers. Therefore, we have reason to believe that this anti-LGBTQ+ legislation will worsen the mental health of our transgender youth and adolescents, in addition to increasing the stigma experienced by an already vulnerable population.
This challenge is compounded by a shortage of affirming health care providers for the transgender community. As a transgender physician living with mental illness, I understand the fear and pain that the stigma of transgender identity and mental illness can bear when receiving health care services. I am often left feeling unseen or ignored by the health care system at times of my greatest need.
Unpacking The Reality in Numbers
In 2015, the National Center for Transgender Equality performed the largest survey of adult transgender community members living within the U.S. The results are eye-opening and point to largescale systemic barriers preventing transgender people from receiving medically-necessary health care services of adequate quality and cultural competence.
- At least one in four (25%) of the survey respondents reported issues with health insurance coverage, including the denial of medically necessary gender-affirming services, such as hormone therapy or transition-related surgeries.
- One-third (33%) had at least one negative experience with a health care provider related to being transgender, such as verbal harassment, refusal of treatment or having to educate the provider to receive the standard care for transgender patients.
- Approximately one in five (23%) respondents did not see a doctor when they needed to because of fear of being mistreated as a transgender person.
These findings demonstrate an unaddressed public health issue, but also, they are impacting real people in their everyday lives.
While my experience does not represent the full diversity of the gender expansive community, my hope is that sharing my experience will help other transgender people with mental illness feel less alone and have hope for recovery in their journeys.
My Experience in the Health Care Field
Since coming out and transitioning, I have faced unexpected discrimination within the health care system, even as a physician myself. On multiple occasions, I have been refused medically necessary health care specifically due to my gender identity. This discrimination worsened when I began openly identifying to my providers as a patient experiencing a serious mental illness. Even living in New York City, there are few mental health providers who understand and are affirming of transgender patients. There are even fewer who are transgender themselves or willing to disclose they have lived experience with a serious mental illness.
I would have more trust in a mental health provider who is my peer: that is, someone who has lived experience with mental illness and the resulting stigma. As a result, I often need to teach my mental health providers about what it is like to live as a transgender person in recovery from serious mental illness. And professionally, I am left with a small number of colleagues who openly share my identities.
When I do find affirming providers, my commercial health care insurance has not covered their services on multiple occasions. I am privileged to be a physician, and therefore, can pay for many of these transition-related expenses out of pocket. This in turn buys me further “passing” privilege, meaning I have undergone a medical and surgical transition, which allows me to appear cisgender. However, there are many others who cannot afford to undergo a medical or surgical transition, or do not wish to do so.
Navigating Patient-Doctor Relationships
I often ask my treating physicians if they have experienced serious mental illness. This is most often met with, “that is none of your business,” when, in fact, I believe it is highly relevant. In these moments, my provider made me feel like they believed mental illness was something shameful. In many stigmatized and shame-based mental illnesses, disclosing a shared identity with a patient can be healing and increase trust in the relationship between patient and physician. Conversely, acknowledging potential awareness gaps and implicit bias is also an important practice for all health care providers.
For me, once experiencing the societal sting of transphobia, any other stigmas I hold are no longer worth hiding. I proudly share my identities as a transgender physician living with mental illness, and I believe these experiences have increased my value to society as I can better understand my patients’ perspective and their place within the full range of humanity. This understanding is the basis for a cultural awareness which can improve the healing environment of our offices and the social well-being of our patients.
In recent years, I have met many adolescents who boldly identify as neurodivergent, transgender community members. I have faith this generation can help teach physicians to holistically treat their patients and the environmental factors impacting the health of their brains and bodies. I hope some of these adolescents will say, “I can become a doctor, too.” Because they can, and we can do better to make room for them.
If you are transgender and have symptoms of mental illness, please contact a provider experienced in gender-affirming therapy at the World Professional Association of Transgender Health: https://www.wpath.org/provider/search.
The Trevor Project has free, confidential, 24/7 support services for LGBTQ+ youth: https://www.thetrevorproject.org/.
The following are resources from the Human Rights Campaign on LGBTQ+ youth: https://www.hrc.org/resources/lgbtq-youth.
The following are educator resources from the Gay and Lesbian & Straight Education Network: https://www.glsen.org/resources/educator-resources.
Pledge to take the 2022 US Trans Survey and increase transgender representation in health care policies, research, education and practice: https://www.ustranssurvey.org/.
Z. Paige Lerario, MD (@MPLerario) is a board-certified neurologist and graduate student of social service at Fordham University where they perform activism and research for the transgender community. Dr. Lerario holds New York State provisional peer certifications in mental health and addiction recovery. Their work has been published in “Neurology: Clinical Practice,” the Journal of Speech Language and Hearing Research and the Harvard Public Health Review Journal, among others. Their blog can be found at greenburghpride.org.