EXECUTIVE SUMMARY

Transgender patients face daunting health challenges due to violence, discrimination, and stress. Case managers can help them navigate barriers to care and find providers who are knowledgeable and friendly to LGBTQ patients.

  • On average, transgender women of color live less than half as long as other women of color.
  • Stress from discrimination often results in transgender individuals engaging in unhealthy coping methods, including substance use.
  • Health disparities can be addressed through better provider training and education.

The average life expectancy of a transgender woman of color is around 35 years. It is an astonishing statistic, but the sad result of violence, discrimination, and stress — all of which contribute to negative health effects. (For more information, visit: http://bit.ly/2lyKRdY.)

Violence, stress, and poor health conditions all contribute to these early deaths, which are less than half the expected lifespan of the average woman of color.

“There is greater suicidal ideation and a lot more violence against transgender individuals,” says Michael Garrett, MS, CCM, principal at Mercer in Seattle. “There are challenges with employment, particularly for those going through transitions. There are a lot of challenges that transgender individuals face.”

Society marginalizes sexual minorities and contributes to their overall stress levels, says Carl Streed, Jr., MD, MPH, FACP, an assistant professor of medicine, section of general internal medicine at Boston University School of Medicine, and research lead for the Center for Transgender Medicine and Surgery at Boston Medical Center.

“There are a number of stressors in the way our society treats those individuals,” he says. “This experience of discrimination in society leads to stress, which becomes internalized and leads to worse health outcomes.”

People under stress often engage in unhealthy coping mechanisms, such as substance use and poor eating habits. Substance use also results from people hanging out in bars and clubs that encourage smoking and drinking, Streed says. Alcohol and cigarette advertisers target people who attend bars, particularly places where sexual minorities congregate, he adds.

“They recognize that bars are large, safe spaces for targeted individuals, and so they target them, [suggesting their products] are mechanisms for coping with stress,” Streed says. “We’ve ostracized these individuals to where their safest place is where they might be tempted to use tobacco and excess alcohol.”

The medical profession would argue that marginalized groups often make poor choices, but the truth might be that they do not have many choices to begin with, he says. “The poor choices are among the few accessible to them,” Streed says.

Transgender individuals suffer from health disparities due to real or perceived stigma and discrimination within the healthcare profession. Transgender women also contract HIV infections in disproportionate numbers. The transgender population suffers a high prevalence of clinical depression (44%) and anxiety (33%).1 Healthcare barriers include financial issues, discrimination, lack of cultural competency among healthcare providers, inappropriate electronic records and other healthcare system barriers, and socioeconomic issues.

Case managers working with transgender patients should remember that this population often has faced challenges and discrimination in the healthcare system, Garrett says. Some transgender patients might be distrustful of their providers because of their past negative experiences.2

Case managers should know how to communicate with transgender individuals. They also should know how to help transgender patients find providers and community resources welcoming to this population, Garrett says. “Case managers should understand how to identify transgender-friendly providers that have competency,” he explains.

For instance, providers should understand the differences between male to female and female to male. “The kind of providers you refer a transgender patient to for female to male is different than from male to female,” Garrett explains.

Case managers also can get to know transgender patients to learn about the people they consider family or their main support, Streed suggests. “Sexual and gender minorities might be rejected or ostracized by their families,” he says. “Who is their family of choice now? How do they access community support?”

Many cities offer community resources for people who identify as sexual and gender minorities, Streed adds. The case manager should know where those resources are and recommend them when needed. For example, there are LGBTQ sports leagues for people who want to be physically active, but who are not comfortable in other ones, he says.

“There are homeless shelters that are receptive to LGBTQ,” Streed adds. “I’ve made a point of knowing what those resources are.”

Healthcare professionals can find some resources, including LGBTQ-friendly providers, online through the GLMA, Health Professionals Advancing LGBTQ Equality, website at: http://www.glma.org/. The American Medical Association also offers resources about transgender and LGBTQ patients at: http://bit.ly/2n1fQzN.

Streed’s research into internal medicine residents’ preparedness to care for LGBTQ patients found that residents demonstrated an improvement after receiving information about the population through a didactic online module. The study also suggests that health disparities in LGBTQ communities may improve with improved physician training on clinical care of this population.3

“A large number of associations have begun to adopt LGBTQ health training,” Streed says.

One health message that providers need to know is that transgender women of color face the most discrimination and violence, he says. “The degree of violence against them is high, and their life expectancy is in the mid-30s,” Streed says. “It’s not just that they’re trans and women and people of color; it’s the intersection of those identities that leads to violence and discrimination.”

REFERENCES

  1. Safer JD, Coleman E, Feldman J, et al. Barriers to health care for transgender individuals. Curr Opin Endocrin Diabetes Obes 2016;23:168-171.
  2. Garrett MB. Working with transgender individuals in case management practice. Prof Case Manag 2018;23:19-24.
  3. Streed CG, Hedian HF, Bertram A, et al. Assessment of internal medicine resident preparedness to care for lesbian, gay, bisexual, transgender, and queer/questioning patients. J Gen Intern Med 2019;34:893-898.