2022 California Council of Community Behavioral Health Agencies (CBHA) Conference

Transgender and HIV: Stigma and Discrimination Can No Longer Have a Place in Healthcare

In the past five or six years, I was privileged to be invited by several non-profit organizations and universities to deliver cultural humility trainings and presentations about transgender identities and experiences, and how to improve services to meet the needs of the transgender community. As a Filipino, transgender man and a clinical social worker, providing these trainings are personally and professionally meaningful and important to me. I empathize with the struggles that the transgender community face, with having their healthcare needs met, and I am committed to supporting providers and agencies that truly meet the needs of this community.

While in these presentations, I tried to observe as many audience members’ facial reactions, gestures and body language, as they are non-verbal forms of communication about an individual’s openness, interest or defensiveness about an issue. Being observant of non-verbal language also helps me identify how effectively I may or may not be communicating with them. People’s level of knowledge, familiarity and skills, as well as beliefs and attitudes about the transgender community, vary or overlap. Sadly, I have encountered many current (as well as future) providers in the healthcare field who hold prejudice and stereotypical beliefs and attitudes about transgender individuals. However, because transgender women and men are highly stigmatized and marginalized members of society and need an array of healthcare services, I believe that it is incumbent upon providers to learn information and to practice skills that treat transgender clients with respect, sensitivity and dignity.

“Transgender” is an umbrella term to describe persons whose gender identity do not match the sex that they were assigned at birth. A transgender woman is an individual who was assigned male at birth and lives and/or identifies as a woman or female. A transgender man is an individual who was assigned female at birth and lives and/or identifies as a man or male. It is important to note that not every person uses the word “transgender” to describe their gender identity. Persons may also identify as “male” or “female.” Transgender people have a range of choices when it comes to transitioning. Some may decide to transition medically and/or socially, or not at all. Medical transition includes hormone therapy, gender affirming surgery, chest or breast surgery, and electrolysis, just to name a few. Social transition involves a legal name change, gender marker change, disclosure of their transgender identity to others, change in presentation (i.e., dress, hairstyle, etc.) and so on. Transitioning is a personal choice and not every transgender person decides to do so. For many, transitioning changes their lives in positive ways. For example, their anxiety, depression, and isolation related to gender dysphoria might be alleviated. For others, the costs and risks of transitioning are too high. They might jeopardize their employment, housing, social relationships and status within their social networks.

There have been significant gains for transgender healthcare in the past few years. For example, Medicare and several states’ Medicaid now cover medically necessary hormone therapy and gender affirming surgery. Many provider agencies and organizations now provide all-gender restrooms and have updated their program forms to include different identities. Despite these achievements, transgender women and men continue to face stigma, harassment and discrimination in healthcare settings and social service agencies that include lack of well-trained and informed providers, harassment in waiting rooms and bathrooms and denial of services. Negative experiences contribute to avoidance of healthcare services, poor medical and mental health conditions and distrust of providers.

One glaring example of a healthcare services gap is that transgender people are among the groups at highest risk for HIV and AIDS. According to the Center for Disease Control and Prevention (CDC), “Among the 3.3 million HIV testing events reported to the CDC in 2013, the highest percentages of newly identified HIV-positive persons were among transgender persons, and that Black/African-American transgender women were most likely to test HIV positive, compared to those of other races/ethnicities: 56% of Black/African-American transgender women had positive HIV test results compared to 17% of white or 16% of Hispanic/Latina transgender women” (www.cdc.gov/hiv/group/gender/transgender/). The prevalence of HIV and AIDS among transgender men have been reportedly low, but this might be due to lack of research and understanding about their sexual behaviors and healthcare needs.

Better anti-retroviral treatments and pre-exposure prophylaxis, or PrEP, are available, and adherence to treatment is vital to achieve and maintain an undetectable viral load and good physical health. The effects of stigma and discrimination, however, can make it difficult for transgender persons to be adherent to their medical care. According to a study on the connection between treatment adherence and viral load levels of transgender women of color, “Transgender women on ART were less likely to report 90% adherence rates or higher and reported less confidence in their abilities to integrate treatment regimens into their daily lives. Transgender women reported significantly fewer positive interactions with their health care providers. Training for providers and integration of hormone therapy into HIV care is recommended” (Sevelius JM, etal., Antiretroviral Therapy Adherence Among Transgender Women Living with HIV. The Journal of the Association of Nurses in AIDS Care, 2010). Other factors also influence treatment adherence. Many transgender women may prioritize: 1) hormone treatment because it affirms their gender identity, 2) income-generating work (e.g., sex work, part-time jobs, etc.) to support their living expenses, and 3) concerns about the possible drug interactions between their hormone treatment and ARV medications. More research needs to be funded and conducted about this issue in order to gain a better understanding of factors that affect treatment adherence.

Healthcare providers have a vital role in improving the health outcomes of transgender people living with HIV and AIDS. Stigma and discrimination serve as barriers and cause harm to transgender clients who need HIV-related healthcare urgently. To serve this community, providers need to prioritize the development of effective medical and social service interventions that “not only address and improve health, but also promote health equity…” (Reisner, S. etal. Global Health Burden and Needs of Transgender Populations: A Review,” The Lancet, 2016).

Since 2012, I have worked proudly at Gay Men’s Health Crisis (GMHC) as a mental health counselor. GMHC is the nation’s foremost advocate and leader in HIV and AIDS prevention, advocacy and comprehensive care services. The agency exemplifies an organization that has taken seriously the healthcare concerns of transgender clients and the professional development needs of its staff. In 2014, GMHC established a committee whose primary purpose is to meet programmatic needs and to improve the quality of life for transgender and gender non-conforming individuals by developing and supporting a safe and non-judgmental culture. To this end, orientations for new hires and regular staff trainings include cultural humility trainings, two “All-Gender” restrooms are available, agency forms are inclusive of different identities, and participation and collaboration with community-based organizations at transgender-specific events have increased. Additionally, there are several full-time staff who identify as transgender and a support group for transgender people is led by a transgender woman of color. The total number of transgender clients in 2015 was 68, and although this number is low currently, this was an amazing increase compared to previous years. GMHC is hopeful that the number of transgender individuals served by the agency will multiply and obtain life-saving services and care.

The Collaborative Mental Health program in which I work provides individual, couple and family counseling services as well as support groups for long-term survivors, people in substance use recovery and those newly diagnosed with HIV. In the coming months, GMHC will open an Article 31 mental health clinic licensed by the New York State Office of Mental Health (OMH) and an Article 32 substance use treatment program licensed by the Office of Alcoholism and Substance Abuse Services (OASAS). Because the transgender community face a high risk of mental health conditions and substance use, often as a consequence of stigma and discrimination, the expansion of services designed specifically to address these issues attest to GMHC’s commitment to the healthcare needs of transgender people.

Finally, cultural humility skills and practices do effect positive changes. Skills and practices that can help providers include, but are not limited to, the following list:

  • Understand basic terms, definitions and health risks;
  • Use appropriate gender pronouns and names;
  • Discuss hormone, PrEP and ARV treatments with clients;
  • Provide safe bathrooms;
  • Arrange regular staff trainings about transgender health issues;
  • Collect accurate demographic data;
  • Employ transgender staff in all levels of the agency;
  • Team up with community partners to advocate for housing, jobs, and healthcare; and,
  • Understand the interconnections among stigma, discrimination, misinformation, and poor health outcomes

(New York State Department of Health, Care of the HIV-infected transgender patient, 2012; Center of Excellence for Transgender Health, 8 best practices for HIV prevention among trans people, http://transhealth.ucsf.edu; National LGBT Health Education Center, Affirmative care for transgender and gender non-conforming people: Best practices for front-line health care staff, February 2013; San Francisco Dept. of Public Health, Transgender HIV/AIDS health services best practices guidelines, July 2007).

When transgender clients feel welcomed and are treated with respect, sensitivity and dignity, their engagement in treatment and their investment in their health can improve. Establishing cultural humility skills and practices may involve hurdles and challenges, but the outcome can increase access and retention to care. Stigma and discrimination can no longer have a place in healthcare.

If you are interested in learning more about GMHC’s programs and services described above, please visit www.gmhc.org.

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