7.2: Medicine and the History of Transgender Care

The celebrity of Christine Jorgensen (figure 7.2), who began her physical transition from male to female in the early 1950s and who led a bold public life as a writer, lecturer, and entertainer, brought the transgender experience to wide attention.^[13] Beginning in 1965, Johns Hopkins University in Baltimore was the first American medical school to study and perform what was called sex reassignment surgery (now more aptly known as gender-affirming surgery), or in popular parlance, sex change operations. However, despite this pioneering role, the Johns Hopkins clinic ended the practice in 1978, in part because of flawed transphobic follow-up research. Only recently has it resumed its transgender and gender-affirming care.^[14] In the first decade and a half of the twenty-first century, almost forty thousand patients sought transgender care, with 11 percent of them seeking gender-affirming surgery and an increasing percentage using health insurance rather than out-of-pocket payments as had been typical in the past.^[15]

Figure 7.2. Christine Jorgensen. (Public domain, Maurice Seymour.)

Medicine’s relationship to LGBTQ+ people has been complicated enough over the last century and a half, but considering a person’s place in the human lifespan and intersectional identities makes it even more so. We explore these considerations next.

Vulnerabilities across the Lifespan and across Intersectional Identities

Decades of research have indicated that LGBTQ+ populations face a disproportionate burden of health problems and stigma, including higher levels of depression, lower self-esteem, compromised academic achievement, and more substance use.^[16] These disparities are documented across the lifespan, from childhood to young adulthood and even into late adulthood.^[17] Researchers have identified minority stress, or sexuality- and gender-related stressors, as the mechanism through which these health problems can be explained.^[18]

Minority Stress Model

Being a marginalized or minority person in a society produces personal and group stress, sometimes invisible but always with both psychological and physiological effects. The Institute of Medicine report proposed the minority stress model as a strong framework to understand health disparities among LGBTQ+ populations. In particular, the report highlights how minority stress has been found to affect the day-to-day lives and health of LGBTQ+ individuals across the lifespan.^[19] This minority stress can be distal (e.g., victimization from others because of a sexual minority identity) or proximal (e.g., concealment of sexual identity, internalized homophobia). Therefore, strategies to promote health and well-being should consider multiple types of stressors.

Intersecting Identities

In addition to minority stress, the Institute of Medicine recommended a focus on intersectionality as an imperative consideration for researchers, clinicians, and other stakeholders invested in LGBTQ+ health.^[20] Intersectionality at its broadest meaning proposes that race, ethnicity, ability status, and other oppressed identities can amplify LGBTQ+ health issues.^[21] In addition to being aware how oppressed and intersecting identities can compound health outcomes, researchers are increasingly measuring and considering all demographic characteristics among LGBTQ+ youth to better understand how multiple identities (e.g., being Black, gay, and residing in the U.S. South) might be related to the holistic LGBTQ+ experience. For example, a study collected data from 17,112 LGBTQ+ youth across the United States and documented twenty-six distinct sexual and gender identities.^[22] Additionally, youth who were transgender and nonbinary were more likely than cisgender youth to identify with an “emerging sexual identity label,” such as pansexual (figure 7.3). These patterns also differed by ethnoracial identity, suggesting that youth of color are using different terms, compared with their white counterparts, to describe their sexual attractions and gender identities. The next step is to better understand how intersecting identities may be uniquely associated with health outcomes, given that a large focus of research has focused on disease prevention and health promotion among LGBTQ+ populations. The Institute of Medicine also points out that LGBTQ+ couples and their children are less likely to have adequate health insurance, which is usually provided through employers, especially when they are unemployed or underemployed.^[23]

Figure 7.3. The pansexual pride flag. (Public domain, kiwineko14.)

Disease Prevention and Health Promotion

Recent research on health disparities finds that the gap in disparities between some LGBTQ+ and heterosexual youth continues to grow across a number of outcomes.^[24] Emerging research has moved beyond documenting these disparities to examining the risk and protective factors that may help prevent disease and promote health among LGBTQ+ people.

With respect to LGBTQ+ youth, research has consistently documented family and parent support to be the strongest buffer against negative health experiences, above and beyond other support systems. In addition to families, a number of other support systems are known to protect against negative health (and thus disease later in life), such as school-based clubs, supportive peers, and supportive policies and laws.^[25] The protective role of these support systems extends into young adulthood and across a lifespan, but the magnitude by which certain supports (e.g., school peers) affect LGBTQ+ health may change.

Among older LGBTQ+ adults, there has been a strong focus on sexually transmitted disease and HIV prevention. Given HIV’s disproportionate burdens on the LGBTQ+ community, and in particular the disproportionate impact on African American men who have sex with men, research funding and attention have focused on reducing this stark disparity (figure 7.4). Medical advancements in preventing HIV have proliferated in the recent past, and one method in particular, pre-exposure prophylaxis (PrEP), has been the focus of many studies. However, a vexing dilemma exists: although there is a drug that can prevent HIV infection, why aren’t more men who have sex with men (and LGBTQ+ individuals) taking the drug? After all, Tony Kirby and Michelle Thornber-Dunwell find that the rates of HIV acquisition in the United States are still high and similar to the rates in other countries. Researchers continue to consider how stigma, a history of medical mistrust, and other factors might thwart the uptake of lifesaving drugs that prevent HIV among LGBTQ+ populations.^[26]

Figure 7.4. Diagnoses of HIV infection in the United States and dependent areas, 2015. Subpopulations representing 2 percent or less of HIV diagnoses are not reflected in this chart. MSM = men who have sex with men. (Public domain, Centers for Disease Control and Prevention.)

See table 7.1 for a summary of the critical health concerns over the life course.

Table 7.1 Health concerns across the lifespan

Life stage	Health concerns
Adolescence	HIV infection, particularly among Black or Latino men who have sex with men; depression, suicidal ideation, suicide attempts; smoking, alcohol, substance use; homelessness; violence, bullying, harassment
Early to middle adulthood	Mood and anxiety disorders; using preventive health resources less frequently; smoking, alcohol, substance use
Later adulthood	Long-term hormone use among transgender people; HIV infection; stigma, discrimination, violence in health care institutions (e.g., nursing homes). The research literature also suggests that older LGBTQ+ adults may possess a high degree of resilience, having weathered the difficulties of adolescence and earlier adulthood

Source: Institute of Medicine, The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding (Washington, DC: National Academies Press, 2011).

A long history of health professionals’ insensitivity or even hostility to LGBTQ+ people, as described in the beginning of this chapter, continues to have real-life consequences. Disparities are particularly evident among transgender people, who are a uniquely vulnerable population and whose health and wellness concerns we discuss next.

Transgender and Gender-Nonconforming Health Care

The transgender and gender-nonconforming community has suffered, often in silence. Numerous studies have depicted the barriers these patients face with respect to health care, which include mistreatment by health care providers and providers’ discomfort or inexperience regarding patient’s health care needs, as well as patients’ lack of adequate insurance coverage for health care services.^[27] Owing to these barriers, transgender and gender-nonconforming patients are often left to navigate health care on their own.

For example, the National Center for Transgender Equality reported that 33 percent of respondents who had seen a health care provider in the preceding year suffered at least one negative experience related to being transgender, and 23 percent of respondents did not even seek a medical provider when they needed one for fear of being mistreated. Additionally, a staggering 39 percent of respondents experienced psychological distress, and 40 percent have attempted suicide in their lifetimes, which is nearly nine times the 4.6 percent rate of the general population.^[28] Seeking routine or preventive physical and mental health care, let alone transition-related services for those who seek to transition, is difficult.

Incidence and Prevalence

Several attempts have been made to determine how many Americans identify as transgender.^[29] A 2016 estimate postulates that 0.6 percent of the population, or 1.4 million Americans, are transgender.^[30] However, the gender construct is complex, and more rigorous epidemiological studies are needed on a global scale to delineate the incidence (percentage of the population) and prevalence (total number of people) of this experience. Historically, transgender and gender-nonconforming individuals have been marginalized, and the disparities discussed earlier in this chapter may instill a sense of fear within the community, thus leading to greater difficulty in obtaining an accurate estimate. Additionally, cultural differences among societies shape the behavioral expressions of gender identities, masking gender dysphoria.^[31] For instance, certain cultures may revere and consider as sacred such gender-nonbinary behaviors, leading to less stigmatization.^[32]

Watch Angelica Ross Explains the History of the Word Transgender

In a video in the InQueery series, Angelica Ross maps out the history of the word transgender, tracing its origins from the words transvestite and transsexual to the contemporary term transgender. (https://www.them.us/video/watch/ange...rd-transgender).

• Why is understanding the difference between sex and gender important when learning about the history of the word transgender?
• What different identities fall under the transgender umbrella? Why is there debate about whether some identities do or do not belong?
• What information was new or surprising to you in the video? How does it affect your understanding of transgender needs in health care?

Moreover, as the literature suggests, the prevalence of gender dysphoria is unknown. There has been great controversy within the transgender and gender-nonconforming community regarding this diagnosis because in earlier years the phenomenon was deemed psychopathological.^[33] On the one hand, gender nonconformity refers to “the extent to which a person’s gender identity, expression, or role differs from the cultural norms that designate for people of a particular sex.”^[34] On the other hand, gender dysphoria, first described by N. M. Fisk in 1974, is the “discomfort or distress that is caused by a discrepancy or incongruence with a person’s gender identity and that very same person’s sex that was assigned at birth.”^[35] Therefore, not every transgender and gender-nonconforming individual experiences gender dysphoria. As a result, the World Professional Association of Transgender Health released a statement in 2010 that urged the depsychopathologization of gender nonconformity worldwide.^[36] The goal of the health care professional is thus to assist transgender and gender-nonconforming patients who suffer from gender dysphoria by affirming their gender identity and collaboratively investigating the array of options that are at their disposal for expression of their gender identity.

Check Your Knowledge

Contributed by Has Arakelyan, Rio Hondo College

Multiple-Choice Questions

1. Who was Christine Jorgensen and why is she significant in transgender history?
A) The first American to undergo gender-affirming surgery and a public figure who brought attention to transgender experiences
B) The founder of the first LGBTQ+ health clinic
C) A psychologist who developed the minority stress model
D) The first openly gay politician in the U.S.

2. What is the minority stress model?
A) A theory that only economic status affects health
B) A framework explaining that chronic stress from being a minority leads to health disparities
C) A model for health insurance coverage
D) A method for measuring academic achievement

3. What does intersectionality mean in the context of LGBTQ+ health?
A) Only sexual identity matters for health
B) Multiple oppressed identities (race, gender, ability, etc.) can amplify health issues
C) Intersectionality is not relevant to health
D) It refers to the intersection of two roads

4. According to research, what percentage of transgender people have attempted suicide in their lifetimes?
A) 4.6%
B) 10%
C) 40%
D) 75%

5. What is a major barrier to health care for transgender and gender-nonconforming people?
A) Too many health care providers
B) Lack of interest in health care
C) Overabundance of insurance options
D) Mistreatment and lack of provider experience, as well as inadequate insurance coverage

Discussion Questions

1. How did Christine Jorgensen’s public life help change perceptions of transgender people in the United States?
2. In what ways does the minority stress model help us understand health disparities among LGBTQ+ populations?
3. Why is it important to consider intersectionality when studying the health of LGBTQ+ individuals?
4. What are some specific challenges transgender and gender-nonconforming people face when seeking health care?
5. How might cultural differences influence the experiences and visibility of transgender and gender-nonconforming individuals around the world

Multiple-Choice Questions - Answers

1. A) The first American to undergo gender-affirming surgery and a public figure who brought attention to transgender experiences
2. B) A framework explaining that chronic stress from being a minority leads to health disparities
3. B) Multiple oppressed identities (race, gender, ability, etc.) can amplify health issues
4. C) 40%
5. D) Mistreatment and lack of provider experience, as well as inadequate insurance coverage