Francesca Maria Lorenzini

There were times when Samson Winsor, 29, felt like ‘an animal in a cage’ while seeking medical care. This happened a lot when doctors pulled in medical students to assist.
“It’s great that they’re getting educated on men like me,” he said. But it also “still adds to that kind of circus effect where you kind of feel like you’re ‘the bearded lady’.”

Winsor is a transgender man who was assigned female at birth. The poor treatment in the medical community led him to avoid gynecological visits for some years, from age 19 to 23, as it felt more like a gendered experience than just a medical checkup.
“It was an uncomfortable conversation for me,” he said. “It would cause huge anxiety breakdowns.”

This is not unusual within the transgender community. In a 2021 report, the Center for American Progress, a public policy research and advocacy organization, showed that 28% of transgender people avoided or postponed medically necessary care due to providers’ discriminatory attitudes. These span from refusal to provide care to transgender patients to engaging in abusive behavior towards them, the research says.
And experts see this not so much as a problem of prejudice, but of lack of knowledge and training about the world that transgender patients inhabit.

A transgender or trans individual is someone whose gender identity differs from their sex assigned at birth. This mismatch is called gender dysphoria. A person whose gender identity matches their sex at birth, meanwhile, is called cisgender.
Some trans people identify as trans men or trans women, while others describe themselves as non-binary, meaning they don’t identify with any gender. Other nuances of gender identities exist too. Transgender individuals may require hormone treatments or surgery to transition, while others may simply change their pronouns or outside physical appearance.

The Williams Institute, a think tank at UCLA School of Law, reported in a 2022 study that 1.6 million people – 0.6% of the population – identify as transgender in the United States. And according to Samantha Glass, a physician affiliated with Physicians for Reproductive Health, an organization that advocates for sexual and reproductive rights, a high number of transgender and non-binary individuals face numerous obstacles when accessing medical care regardless of their needs.
“Whether that’s just a wellness visit or a heart condition,” she said. “Any of it is just difficult because of the amount of transphobia that they face.”

In its most recent national survey, the National Center for Transgender Equality found that 33% of trans patients reported they were denied medical care or harassed by medical professionals due to their gender identity. This is the largest survey in the country on the topic, with more than 27,000 respondents across all 50 states.

Grayson Schultz is a 35-year-old trans man who did get the care he sought when he visited a medical provider in Madison, Wis. in 2016. He received an intrauterine device —a sex-specific birth control treatment for those who are biologically female. But he says he also got something else at the clinic—a dose of hostility. Schulz says medical staff reactions to his gender identity made him feel uncomfortable.
“Providers seemed to think that my gender identity had to do with seeking attention,” he said.

Hostility or simple ignorance is just one of the hurdles that transgender patients must clear on their route to adequate healthcare. Finding a doctor who understands them can be difficult, and so can getting care. Misgendering – referring to an individual using a pronoun that does not reflect their gender identity – and inappropriate comments are among the most common forms of discrimination transgender people face.
“They misgendered me in person and in their notes,” Schultz said. It happened even though he says he told providers he identified as trans.

Medical staff’s lack of training to deal with transgender people can contribute to creating an unsafe environment for such patients.
“Doctors often don’t get cultural competency training for providing care for transgender and gender non-conforming individuals,” said Lindsay Mahowald, research data analyst at the UCLA Williams Institute who uses gender neutral pronouns. “It’s much broader than an issue of simply doctors being discriminatory people.”

One factor is training, or, rather, the lack of it. The Kaiser Family Foundation, a non-profit organization for health policy research, published a brief in 2018 that showed that more than half of medical school curricula do not cover unique health issues faced by the LGBTQ community beyond HIV prevention and medical care.
Some medical students agree. “I do not think that the school gives us the means to adequately refer to trans or nonbinary patients,” said Matthew Raft, a 26-year-old medical student at Columbia University.

Lack of research on this population in the medical field is among the reasons doctors don’t get adequate training, according to Mandi Pratt-Chapman, associate center director for Community Outreach, Engagement and Equity for the George Washington (GW) Cancer Center. As clinically appropriate care is tailored to the specific conditions of a person, it’s challenging to train providers about transgender patients when there’s a lack of data on their medical experiences.
“We haven’t captured sexual orientation and gender identity data in research on an ongoing basis,” she said. “The clinical research data that we have to inform practice is minimal.”

Alex Keuroghlian, associate professor of psychiatry at Harvard Medical School and director of the Division of Education and Training at The Fenway Institute, agrees on this stance. He adds that more transgender and gender diverse individuals in medical schools is crucial to inform research.
“This does change how health systems are designed and how research is conducted,” he said.

Mikiko Galpin is a 30-year-old trans man who lives in Philadelphia, and says he was lucky enough not to encounter major barriers while navigating the U.S. healthcare system, unlike fellow transgender individuals. But he did witness a lack of knowledge about gender dysphoria among medical providers.
“It’s not necessarily an animosity towards me,” he said. “But it’s just like they don’t understand.”

Stevie Singleton, a 33-year-old trans man – Stevie is not his legal name – felt similarly when he got ready for a hysterectomy – the surgical removal of the uterus and cervix – in Idaho, where providers referred to him with female pronouns.
“I definitely don’t look feminine very much anymore,” he continued. “So, it kind of makes me laugh when that happens because even by mistake, it would be kind of a silly mistake.”

While getting ready for the procedure, he also had to deal with personal questions about his gender transition that were not relevant to what he came for, as the surgery was for medical reasons that were not really related to his gender dysphoria. The Center for American Progress 2021 survey found that 15% of transgender people reported they were invasively or unnecessarily questioned about being transgender without any rationale.

In 2019, Grayson Schultz went to urgent care for a knee injury. When the nurse who took care of him read he was trans on his medical records, she asked if he “already had the surgery.” She was referring to the bottom surgery, a type of gender affirmation procedure that involves altering the genitals to match one’s gender identity.
“I was like ‘How that’s relevant to my knee injury?’,” Schultz said.

The same study showed that a third of transgender people taught their doctors about gender dysphoria so that they could get appropriate care. That’s what happened to Nikolai Poloney – that is not his legal name – a 30-year-old trans man in Maryland. When he went to a mental health provider some years ago, a nurse practitioner thought that gender dysphoria was a sexual problem.
“I had to describe to her that there’s an actual biological thing behind it,” he said.

UCLA Williams Institute Researcher Lindsay Mahowald believes that a larger segment of cultural competency training for doctors to deal with transgender people may make such patients feel more comfortable when going to the doctor’s offices. Keuroghlian agrees: “It’s important to train everybody on implicit bias,” he said.

According to Keuroghlian, as physicians internalize societal bias about transgender individuals, medical schools should teach how not to make assumptions about patients’ gender identity to improve the quality of care.
“Everybody with a cervix needs a cervical path test, regardless of their gender identity,” he said. “We can design a health system [where] everybody feels included and welcome within the setting.”

As a medical student, Raft believes it’s important for doctors to understand how these people feel and want to be treated.
“A huge part of working in the medical field is developing trust and relationships with the patients,” he said.

Some medical schools have already integrated transgender care into their curricula. Harvard, most notably, established training on LGBTQ+ inclusive care that goes beyond sexually transmitted diseases. Stanford, Vanderbilt and Boston University have made similar efforts.
“There is a learning curve to making the systems trans friendly,” said Joshua Safer, executive director of the Mount Sinai Center for Transgender Medicine and Surgery. But, he acknowledged, “that is clearly a work in progress.”

But, for transgender patients, the constant concern is finding a provider that they can trust.
 “You never really know what you’re going to get,” Singleton said.

*This story was part of my master’s project at Columbia Graduate School of Journalism.