“What are you?” asks the medical assistant as he checks me in for my COVID-19 swab. As a medical student, I am routinely tested for COVID-19.
“What do you mean?” My chest tightens, warning me of what’s to come.
He looks exasperated, hands hovering over his keyboard.
“Look. Are you a man or woman? I have to enter it into the computer.”
I explain that I am neither a man nor a woman. That while I was assigned female at birth, I am non-binary. He ignores me and returns his gaze to the monitor, where I can see him check off the “F” box. He averts further eye contact as if my non-binary gender were an aberration stopping him from efficiently accomplishing his job.
Weeks later, I walk into a surgery center for care related to my chronic health conditions and introduce myself with my current name. I repeatedly state my pronouns — they/them — to the front-desk staff, my nurses, my gastroenterologist who is the primary doctor for the procedure, and the anesthesiologist, attempting to save myself from later discomfort.
As I am wheeled into the surgery suite, providers check my vitals and draw up medications that will lead me to fully surrender myself to their care. The anesthesiologist turns to my gastroenterologist — the doctor I’ve known for years and who knows I am non-binary — and asks, “Has she signed the consent form?”
My doctor begins to reply, but I interrupt. “My pronouns are they/them.”
“What?” says my doctor.
I repeat myself but am greeted with more silence.
“Can you sign the consent form?” asks my doctor.
I sign the legal name that I no longer use and have asked not to be called in medical settings. I feel alone and my heart begins to race.
“OK, we’re ready for her to go under,” states the anesthesiologist.
No one corrects her. I fall unconscious in fear. Feeling unimportant, unseen, and unheard by these physicians whom I have just consented to give my mind and body up to. When my sex assignment at birth — and the genitalia I have — are prioritized as representing a picture of my identity, it is a denial of my complete personhood. When my gender is ignored in healthcare visits, deemed irrelevant, invalid, or simply too much bother, the experience is, at its core, dehumanizing. And this repeats across healthcare encounters.
I am a transgender, non-binary patient living in San Francisco. I am also a medical student in a city believed to be one of the most progressive cities in the world — a city assumed to be at the forefront of transgender rights. Here and nationally, trans patients — including transgender men, transgender women, and non-binary patients — face unique health challenges and health disparities driven by clinicians’ ignorance, stigma, discrimination, and a lack of access to quality care. One in five trans patients report being refused medical care due to their trans or gender non-conforming status, and over half of trans people report having to teach their healthcare providers about trans health issues. For those living in the intersection of multiple marginalized identities — those experiencing racism and ableism on top of transphobia — the experiences of dehumanization in healthcare are amplified.
“You would think that in San Francisco things would be better…”
I hear these words uttered daily whenever I share my experiences of dehumanization in healthcare settings with cisgender people. Things won’t get better within San Francisco — or be good enough anywhere — until we first acknowledge that we, as physicians, need to do better to support our trans patients.
The Gap in Training and Research
Clinicians are undertrained in trans care. Though my medical school classmates are generally respectful of my identity, our curriculum hardly touches on transgender health. In this city, many clinics won’t refer to transgender patients by their preferred name and will write transgender identity on the problem list. In other parts of the country, there is overt harassment toward trans patients. Clinicians lack expertise in the fundamentals of transgender care including prescribing hormones and giving basic recommendations for chest binding or genital packing (safe techniques that modify gender expression and reduce gender dysphoria). In addition, there is a fundamental lack of research as most clinical trials exclude or misrepresent trans patients.
The Gap in Political Advocacy
Most physicians are unaware that there are more anti-trans bills being legislated right now than at any other time in our nation’s history. This year, there are 144 bills aiming to restrict the rights and opportunities of transgender people. Transgender people deserve to not be harassed by genital inspections, as in Florida’s bill allowing genital inspections of athletes accused of being transgender. Trans people also deserve not to have their parents accused of child abuse, as in Texas and New Hampshire bills allowing age-appropriate transition-related medical care to be deemed child abuse. Beyond disrupting the well-being and safety of transgender people and their families, 40 of these bills aim to directly disrupt trans healthcare delivery. Many bills ban gender-affirming care for youth, including hormone blockers for endogenous puberty suppression in trans youth, despite it being a safe and well-supported practice that has been shown to reduce depression and suicidality in transgender youth.
There is much we can do as medical providers to meet the needs of the trans community, including improving our clinical care and our teaching of clinical care, and politically advocating to protect the rights of trans patients. To improve clinical care, we can read the relevant literature and take steps at our clinics to reduce mistreatment of transgender patients, and support research projects that aim to better characterize healthcare disparities. To improve our teaching, we can encourage medical schools and national organizations to fund experts in trans health to provide guidance on integrating trans health curriculum. And politically, we, individually and as institutions, can collectively work to prevent the passage of more legislation restricting the rights of transgender people. The statements of support made by the American Medical Association and American Academy of Pediatrics are an important start to fighting this wave of legislation. However, transphobic lawmakers are making headway, and tangible change will require political opposition from providers at every institution.
Like many trans patients across the U.S., I have repeatedly felt dehumanized by the healthcare system. This is not surprising; trans people experience discrimination and marginalization across all sectors of society. It is time that clinicians engage in the movement to eliminate the dehumanization of trans people in healthcare and society at large. Right now, we need non-trans health professionals to serve as our allies. This is not a pipe dream. As I have become more activated in disseminating vital knowledge and skills related to the care of trans patients, I have witnessed dozens of clinicians and clinicians-in-training grow from being unaware of and disengaged from the needs of transgender patients, to becoming both experts in, and active allies for reshaping clinical practice, medical education, and legislation. While this work can seem challenging, it is vital, and it is well within our abilities and obligations as healthcare professionals. As individuals and as a field, it is time we step forward to truly meet the needs of this diverse, beautiful, and underserved community.
Jay Bindman is a third-year medical student at the University of California San Francisco School of Medicine.