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  • Human Rights Research Center

The Shortcomings of Transgender Healthcare in the United States

December 11, 2023


Transgender individuals in the United States encounter significant discrimination, with some instances being overt and others constituting less-known human rights violations. At least 21 states have legal restrictions on the rights of transgender individuals (Blazina and Baronavski, 2022); however, there are other hidden discriminations that they face as well, such as gaps in quality healthcare. The American College of Obstetricians and Gynecologists (ACOG) published a guide for healthcare providers to better serve transgender individuals in 2021, but they note that there are also evident absences in research that have caused issues in the care provided to transgender people. Some of these gaps include limited contraceptives, unreliable pap smears, and under-researched breast cancer screening.


Contraception in female-to-male (FTM) transgender individuals is a neglected area of healthcare by providers and patients alike. Light (2018) explains that 16.4% of participants believed that testosterone was a form of contraception and 5.5% reported that this belief was due to their providers’ advice. Whether this is due to miscommunication or a lack of knowledge, this inaccuracy is leading to unwanted pregnancies in a high quantity of FTM individuals. Healthcare providers lack knowledge surrounding transgender patients’ needs (ACOG, 2021), and since ACOG’s guidelines have only been published for 2 years, many providers haven’t received formal education on their application.


In addition to the scarce education on the topic, there is also a lack of contraceptive choices that appeal to transgender people. FTM individuals often favor non-estrogen-containing products (ACOG, 2021) due to concerns involving the feminizing effects of estrogen. Further research demonstrating the absence of these effects may help FTM individuals feel more comfortable using estrogen-containing contraceptive methods. Without estrogen, transgender individuals have limited contraceptive options, and some of these may not be suitable for the patient. Ruling out a majority of these products would not be ideal.


Pap smears for FTM individuals have a higher rate of resulting as unsatisfactory for evaluation compared to cisgender individuals by 10-fold (ACOG, 2021). This can be due to either an insufficient quantity of cells in the sample or too high a quantity of blood in the sample. One study showed that 50.5% of FTM individuals were not up to date on their pap smears and 57.1% preferred self-sampling over provider sampling (Seay, 2017). An exploratory study in Canada showed that the majority of PCPs and OBGYNs would prefer to offer HPV self-sampling for cases where providers can’t collect samples, despite some of their concerns surrounding the accuracy of the method (Zelli, 2022). One study showed that, of the 21 participants who tested HPV positive from provider-collected samples,15 self-samples showed the same result (Reisner, 2018). Currently, there is no FDA-approved self-sampling HPV test readily available for patient use (ACOG, 2021). Cervical cancer is going undetected in FTM individuals because these patients face difficulties staying up to date on their pap smears, and many of these tests won't yield reliable results anyway. The lack of options for transgender patients is a human rights violation and can be easily fixed by making self-sampling a feasible option. Though further research should be done to improve this testing method, a standardized method should be approved for medical providers to use in practice. Receiving adequate healthcare is a human right and there are not enough resources that exist to ensure that transgender individuals are receiving the minimum standard that everyone is entitled to.


81% of radiologists believe that the evidence base for breast cancer in transgender patients is incomplete (Sonnenblick, 2022); however, there isn’t a lot being done to improve this. Breast imaging for transgender patients is treated synonymously to that of cisgender patients, yet research has not been done to determine if their healthcare needs related to breast cancer are different. Such research is vital, as breast cancer is related to hormones, and transgender individuals are sometimes on hormone replacement therapy that could alter their risk of developing cancer. Additionally, 73.4% of radiology facilities do not have explicit policies demonstrating how workers should care for transgender patients (Goldberg, 2018). Healthcare for transgender patients should not be up to the complete discretion of each individual radiology facility. There is not enough data to determine the best practices to implement, and transgender individuals are suffering because of this.


There needs to be further research on contraceptives, pap smears, and breast cancer screening tests as applicable to transgender individuals. Healthcare for transgender people, as it stands today, is not adequate. The novel guidelines from ACOG for healthcare providers to better care for transgender individuals are helpful but incomplete due to insufficient research. Systematically ignoring the health needs of transgender people is a human rights violation, and better research and education must be implemented.


 

Glossary


American College of Obstetricians and Gynecology: A membership of obstetricians and gynecologists who publish guidelines for providers who focus on women’s health and childbirth


Cisgender: Of, relating to, or being a person whose gender identity corresponds with the sex the person was identified as having at birth


Contraceptive: A method to prevent pregnancy, often using hormones


Estrogen: A hormone that develops and maintains female reproductive systems


Hormone: A signaling molecule that regulates physiological functions


Hormone Replacement Therapy: A method of treating symptoms using sex hormones and can be used to help a person's physical characteristics match their gender identity


Pap smear: A test to check cervical cells for abnormality that can indicate cervical cancer


Testosterone: A hormone that develops and maintains male reproductive systems


Transgender: Of, relating to, or being a person whose gender identity differs from the sex the person was identified as having at birth

 

Sources


  1. Blazina C, Baronavski C. How Americans view policy proposals on transgender and gender identity issues, and where such policies exist. Pew Research Center. 2022 Sept 15.https://www.pewresearch.org/short-reads/2022/09/15/how-americans-view-policy-proposals-on-transgender-and-gender-identity-issues-and-where-such-policies-exist/

  2. Goldberg JE, Moy L, Rosenkrantz AB. Assessing Transgender Patient Care and Gender Inclusivity of Breast Imaging Facilities Across the United States. J Am Coll Radiol. 2018 Aug;15(8):1164-1172. doi: 10.1016/j.jacr.2018.05.007. Epub 2018 Jun 20. PMID: 29933975. https://pubmed.ncbi.nlm.nih.gov/29933975/

  3. Light A, Wang LF, Zeymo A, Gomez-Lobo V. Family planning and contraception use in transgender men. Contraception. 2018 Oct;98(4):266-269. doi: 10.1016/j.contraception.2018.06.006. Epub 2018 Jun 23. PMID: 29944875. https://pubmed.ncbi.nlm.nih.gov/29944875/

  4. Reisner SL, Deutsch M, Peitzmeier S, Hughto JW, Cavanaugh T, Pardee D, McLean S, Panther L, Gelman M, Mimiaga M, Potter J. Comparing Clinician-Collected and Self-Collected Tests for Detecting High-Risk HPV Infection among Female-to-Male Transgender Adults [Internet]. Washington (DC): Patient-Centered Outcomes Research Institute (PCORI); 2018 Sep. PMID: 37844157. https://pubmed.ncbi.nlm.nih.gov/37844157/

  5. Seay J, Ranck A, Weiss R, Salgado C, Fein L, Kobetz E. Understanding Transgender Men's Experiences with and Preferences for Cervical Cancer Screening: A Rapid Assessment Survey. LGBT Health. 2017 Aug;4(4):304-309. doi: 10.1089/lgbt.2016.0143. Epub 2017 Apr 19. PMID: 28422558. https://pubmed.ncbi.nlm.nih.gov/28422558/

  6. Sonnenblick EB, Lebron-Zapata L, Yang R, Dodelzon K, Sevilimedu V, Milch H, Dialani V, Dontchos BN, Destounis S, Grimm L. Breast Imaging for Transgender Individuals: Assessment of Current Practice and Needs. J Am Coll Radiol. 2022 Feb;19(2 Pt A):221-231. doi: 10.1016/j.jacr.2021.09.047. Epub 2021 Dec 11. PMID: 34902332. https://pubmed.ncbi.nlm.nih.gov/34902332/

  7. The American College of Obstetricians and Gynecologists. Healthcare for Transgender and Gender Diverse Individuals. 2021 Mar; 137:e75–88. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2021/03/health-care-for-transgender-and-gender-diverse-individuals

  8. Zelli J, Hum S, Lofters A, Dunn S. Canadian Family Physician. 2022 Feb, 68 (2) e31-e38; DOI: https://doi.org/10.46747/cfp.6802e31 https://www.cfp.ca/content/68/2/e31


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