Gender-affirming care is important for all transgender patients—including transgender physicians.
This article was first published on the National Alliance on Mental Illness Blog, and can be found here.
Alabama, Arizona, and Texas have recently passed legislative efforts to ban gender-affirming health care to transgender adolescents.1-3 This is highly relevant as 2% of younger Americans identify as transgender.4 Transgender 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 is the process a transgender person undergoes to express their gender more in line with their internal identity. Transitioning in affirming environments is life-saving for many transgender people and improves mental health outcomes including suicidality.5,6 Nonaffirming environments and systemic barriers to health care result in higher rates of depression, suicidality, and substance addiction in the transgender community as compared to their cisgender peers.7-11 Therefore, anti-LGBTQ+ legislation will likely worsen the mental health of our transgender youth and adolescents and increase the stigma experienced by an already vulnerable population.
The United States has a shortage of affirming health care providers for the transgender community.12,13 Because mental illness is already stigmatized in the United States, a lack of accessible mental health services further marginalizes those within the transgender community who experience mental illness.14-16 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. This issue traces back for centuries, as the medical model of health care has historically pathologized mental and neurological functioning outside of societal standards of what is typical in a specific culture at a specific time and place. Neurodivergence is an alternative health care model describing the mental and neurological functions that is outside of what is typical and accepts these functions as part of biological diversity.
In 2015, the National Center for Transgender Equality performed the largest survey of adult transgender community members living within the United States.11 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 competency. At least 1 in 4 (25%) of the survey respondents reported issues with health insurance coverage, including the denial of medically-necessary gender-affirming services, such as hormones or transition-related surgeries. One-third (33%) had at least 1 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 1 in 5 (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.
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 bold journeys to find authenticity. I do need to stress that this is only 1 person’s experience, and my experience should not represent the full diversity of the gender expansive community. Many transgender people do not have mental illness or disability. And I acknowledge the difficult work that many transgender people previously accomplished to provide me the privilege to exist as a neurodivergent, transgender physician within the United States.
So here goes:
I can confirm that physicians often provide professional courtesies to each other. These are little perks like priority scheduling or extra attention. It is reminiscent of being first-class on a commercial airliner. I will admit I have previously enjoyed these niceties.
However, since coming out and transitioning, I have faced unexpected discrimination within the health care system, even as someone who is a physician. 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 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 and are willing to disclose they have lived experience with a serious mental illness. I know I personally would have more trust of a mental health provider who is my peer:that is, someone who has experienced the stigma of having more psychotropic pill bottles in their medicine cabinet than letters in their name, or who has experienced the persistent pain of surviving an involuntary psychiatric admission. 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 a serious mental illness. 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 my pocket. This in turn buys me further “passing” privilege, meaning I have undergone a medical and surgical transition which allows me to appear cisgender; that is, not transgender. However, there are many others who cannot afford to undergo a medical or surgical transition, or do not wish to do so, for that matter.
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 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 wellbeing 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 sociocultural 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/
Dr Lerario (@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. 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.
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