In my first year of practicum as a therapist in a mental health clinic, I met a young trans woman who was terrified of psychiatrists.
“That’s okay,” I reassured her. “I’m not a psychiatrist. And I want you to know that I want to be on your side.”
Though I didn’t say it aloud, I knew that a part of me was trying to send her a more covert message: “I’m a trans woman, too. I’m not like the others here.”
She just looked at me with frightened eyes and said simply, “People like you are never on the same side as people like me.”
As a transgender woman practicing social work and therapy in a public hospital, I most often feel like an infiltrator behind enemy lines.
For many trans people – not to mention a lot of other oppressed and marginalized folks – hospitals and doctors’ offices are not places of healing. Instead, they are vastly complicated cultural war zones, battlegrounds on which the fight for transgender human rights is fought.
In attempting to access basic healthcare, be it related or unrelated to gender transition, many trans people find themselves denied, insulted, or outright harmed by doctors, therapists, and other medical professionals.
Trans folks who are racialized, undocumented migrants, and/or disabled face even greater barriers to finding competent and compassionate care.
Even those of us who are lucky enough to actually find healthcare providers who are willing to treat us often find ourselves in compromising situations: We may be repeatedly misgendered and pathologized, and our bodies may be exploited for research purposes.
In situations like this, advocating for ourselves is complicated and anxiety-provoking – because offending the medical professional in question poses a risk to our already precarious access to care.
Working behind the scenes as a mental healthcare provider myself, I can’t even count the number of times I’ve heard ignorant and even hateful ideas about trans people expressed in clinical meetings and professional presentations (often, but not always, when my colleagues are unaware that I am trans).
This would be disturbing in any situation, but in our line of work, ignorance becomes more than offensive: It is dangerous and profoundly violent.
While times are undeniably changing in terms of transgender “awareness” among the mainstream population, this increased visibility is rarely accompanied by concrete change in medical practice.
At this point, I should probably also take a moment to acknowledge the advocacy being done by some doctors, psychologists, and social workers toward the creation of better standards for trans healthcare. I’ve personally met quite a few who have been strong allies and mentors to me.
But I’m not just talking about work of individual healthcare practitioners here. This is not a question of “good or bad apples” practicing medicine. The problem is much wider and deeper than that.
The problem is a medical culture that holds power over transgender health, and uses that power to take our bodies hostage and silence our voices.
The problem is, simply put, a culture of abuse: the medical abuse of trans people.
Trans people are trapped in an abusive relationship with the healthcare industry that we cannot afford to get out of.
The following are five of the most common ways in which this abuse happens – and needs to stop.
1. Denying Our Right to Healthcare
The first barrier that most trans people face in trying to access the health system is the outright rejection of our right to care.
The majority of insurance plans – whether public or private – refuse to cover gender transition-related care such as counseling, hormone therapy, and gender affirmation surgery.
For many trans people, these forms of care are crucial to survival because for some, not being able to transition can actually trigger suicidality and other mental health issues. For others, medically transitioning allows a greater degree of public safety and employment opportunity.
In some cases, medical professionals may even refuse to provide basic healthcare to trans people.
In a now-infamous case, trans woman Tyra Hunter was refused emergency care by a paramedic and emergency room staff after being injured in a car accident – and died as a result.
Denying trans people the right to care not only endangers our lives, it sends us a clear message from health care institutions: Our bodies are not worth treatment, and our lives are not worth saving.
2. Erasing Our Bodies in Medical Science and Education
Even when healthcare professionals want to provide care to trans folks, they very often lack the training and experience to do so competently and compassionately.
Medical and psychological education is based almost entirely on cisgender bodies and mental health, meaning that the vast majority of graduates in healthcare fields have little-to-no knowledge about our needs.
In the case of physicians, the most highly trained practitioners in all of medicine, education in the entire field of LGBTQIA+ health can amount to as little as an hour-long workshop – or nothing at all. (Full disclosure: The linked blog post is written by my sister, a psychiatry resident at Harvard.)
This is because trans people are vastly under-represented in the field of medical science – only a tiny amount of scientific literature on trans health exists, and a lot of it is more harmful than helpful.
What does mean for trans folks in day-to-day terms?
It means that when we finally make it through all the social barriers and into healthcare, we’re told that we are “too complicated.” That trans men are excluded from pregnancy care protocols and trans women from breast cancer research. That we do not exist.
3. Reducing Our Identities to Mental Illness
A lot of the hostility towards trans people in medical culture is rooted in psychiatry’s historic role in creating and reinforcing the popular opinion that being transgender is a “mental illness.”
Professional associations of psychiatrists and psychologists were largely responsible for creating diagnostic terms such as “transvestic fetishism,” “gender identity disorder,” and “gender dysphoria” to describe trans individuals.
These diagnoses were used to label us as “crazy,” and until the recent past, were legal grounds to subject trans individuals to medical treatments like electroshock therapy and incarceration against their will.
While things are not quite so bad in most healthcare institutions today, the medical understanding of trans identities as a kind of sickness still exists and is prevalent among many professionals.
This idea directly impacts and greatly limits the kind of treatment that trans people receive – and worse, can affect our own self-perception.
If the professionals we are supposed to trust with the health of our bodies and minds think that our gender identity is a disease, what are we supposed to think about ourselves?
4. Making Access to Transition Contingent on Physical Dysphoria
A central aspect of abusive relationships is causing the victim or survivor of abuse to feel hatred for the self. Many of the medical systems that “treat” trans people explicitly engage in this same practice.
In order to prescribe hormone therapy or gender-affirming surgery, doctors usually require that patients first be given a formal diagnosis of gender dysphoria. Although the criteria for this diagnosis have, thankfully, become much more flexible over time, many health professionals still practice using outmoded standards.
What this means is that in order to transition, trans people have to convince psychologists, social workers, psychiatrists, and sexologists that we are “really” transgender.
This usually involves repeating, over and over, that we feel “trapped in the wrong body,” and that we hate or feel disgusted by our genitalia – whether or not this is true.
Body dysphoria is a very real experience, and some trans people definitely do go through it. However, many trans people are not dysphoric, and want to transition for other – equally important – reasons, such as the increased public safety that comes with “passing” as cis.
Forcing trans people to say that we feel dysphoria when we don’t has serious consequences: First of all, it dishonors the stories of those who really are dysphoric.
Second, it erases the vast diversity of trans experiences and can psychologically traumatize individuals who feel cornered into “lying” about it – because if you’re forced to say that you hate your body enough times, a part you will inevitably start to believe it.
5. Dismissing All of Our Medical Concerns as Being Related to Being Trans
Many of my trans clients tell me that they worry about going to see mental health professionals because any concern they have is immediately assumed to be related to their trans identities.
While it’s true that trans folks are at greater risk for certain mental health issues like anxiety, depression, and PTSD (likely because we’re exposed to higher levels of social violence), we’re also real humans with real, complex lives.
This should go without saying, but we often have to remind healthcare providers that not everything that happens to us happens because we are trans!
We can get sick or injured, feel depressed or anxious, and experience the negative sides of life for pretty much the same reasons anyone else on the planet.
When therapists refuse to accept our own perspectives on our mental health, they are actually engaging in a form of gaslighting: destabilizing someone’s confidence in their own grasp on reality.
Worse, they send the message, once again, that being transgender is a source of illness and bad fortune – that anything bad that happens to us is the result of being trans.
6. Exploiting Our Bodies and Health for Research
Remember how I said in point #2 that trans people need to be included in medical research?
There’s a big caveat to this, which is that said research needs to actually benefit trans folks and not just the researcher.
A few weeks ago, I was hanging out with some trans friends, and we started joking about how many of us have been invited to participate in a psych study, take part in a documentary, or fill out a survey on HIV/AIDS.
Such studies are almost always run by cis people, rarely ask us for our opinion on how the research should be done, and almost never come back to us with any concrete benefits.
This becomes a lot more serious when we consider the fact that a lot of trans folks who can’t afford healthcare get access to it by agreeing to take part in experimental research.
While participation in scientific research technically must always be consensual, the truth is that informed consent is not always possible when trans people feel that refusing might jeopardize the quality of their care.
Meanwhile, entire scientific careers have been made off of the exploitation of trans folks and gender-variant children.
In one particularly infamous study, the UCLA Gender Identity Project, a doctor named George Rekers performed an experimental behavior therapy on hundreds of “effeminate” boys in an attempt to make them more “masculine.” Rekers became established as a leading psychiatrist in the field, while at least one of Rekers’ patients later died by suicide.
There is something repulsive and infuriating about reading much of the early (and some of the current) medical research on trans people. It treats us as experimental subjects, scientific curiosities, anomalies to be catalogued and dissected.
How can the knowledge created by research like this help us when it doesn’t even see us as fully human?
As a trans woman who is also a therapist, I feel like an infiltrator behind enemy lines most of the time. On my worst days, I feel like a traitor.
Days like those, I wonder what I’m doing participating in an industry that has historically shamed, pathologized, gaslighted, and exploited my trans siblings, and in many ways, continues to do so today.
But I do believe – have to believe – that a better paradigm of trans healthcare is possible – is on its way. Behind enemy lines, I have found more than a few strong and surprising allies.
Even better, I have met other trans people breaking into this field to change it, just like I’m trying to.
And someday, I will no longer need the language of enemies and allies, infiltrators and war zones, to describe trans folks’ relationship with healthcare.
Someday, we will all have the care that we deserve.
Kai Cheng Thom is a Contributing Writer for Everyday Feminism. She is a Chinese trans woman writer, poet, and performance artist based in Montreal. She also holds a Master’s degree in clinical social work, and is working toward creating accessible, politically conscious mental health care for marginalized youth in her community. You can find out more about her work on her website and at Monster Academy.