‘Unaware’ and ‘willfully ignorant’: Transgender patients struggle for respect in health care

Mikki Hatfield did not feel comfortable being truthful with their doctor. Hatfield hoped to be prescribed medication to facilitate a gender transition, but feared denial if truthful.

It is a predicament many transgender people face: By not fitting into a health care provider’s preconception regarding who a transgender person can be, hormone therapy and other gender-affirming care could be kept from them.

“Providers need to take a step back and really recognize that because there has been so much stigma and discrimination against trans people … opening up to a doctor can be really scary,” said MultiCare Rockwood clinic physician Dr. Rachel Safran, who treats transgender people in Spokane. “One of the most important things I think we can do in the medical community is just make sure that there’s a safe and welcoming place for people to share their concerns and ask their questions and get care.”

The World Professional Association for Transgender Health, which releases guidelines followed by physicians providing gender-affirming care, recommends educational institutions provide training to health care professionals about how to treat transgender individuals. According to WPATH, the average physician’s lack of knowledge in this subject negatively affects transgender people in attempts “to obtain appropriate, medically necessary care.”

In an initial appointment in Boise, Hatfield told their doctor that they were a transgender woman even though that was not quite the case. Hatfield is transgender but also nonbinary.

That is an important distinction and could affect their care. But Hatfield worried disclosure of their nonbinary identity might dissuade the doctor from prescribing hormone therapy.

“I felt afraid to say anything other than what they wanted to hear. I had a subtle feeling that if I had answered anything other what they wanted, I might not have gotten the care I needed,” Hatfield said.

A nonbinary gender can encompass many different gender expressions. An individual can see themselves as in between man and woman, completely outside of the gender binary or just uncomfortable with the societal expectations placed upon them by their sex at birth.

A nonbinary individual may or may not consider themselves a member of the transgender community. Depending upon their goals, they may or may not seek gender-affirming care and hormone therapy.

Asked to describe their gender, Mikki Hatfield said “if I express myself as a boy, it’s with overbearing femininity. And when I express myself as a woman, it’s with an overbearing but nontoxic kind of masculinity.”

Hatfield believes many health care providers are ill-equipped to provide for the nuances of care required those who seek medical transition but do not necessarily wish to transition to the other end of the gender binary.

Despite having grown up in conservative and rural Idaho, Hatfield knew from an early age that they did not fit into a traditional gender.

“I never really wanted to fully be seen as a woman or like transition all the way through. But I had a sense when I was really young that I wasn’t a boy. And my mom had to convince me I was,” Hatfield said.

Upon seeking gender-affirming care in 2018, Hatfield’s Idaho physician did not ask them to describe their gender identity.

“They really just assumed that it was a given I was a trans woman if I wanted to transition,” Hatfield said.

Care provided to the transgender community is generally geared towards those who want a binary transition from one gender to another. Even though nonbinary individuals make up a plurality of the transgender community, they are comparatively less visible. According to WPATH, nonbinary individuals comprise between 25% and 50% of the transgender community.

“Many nonbinary people report having experiences with health care professionals who were not affirming of their nonbinary gender, including experiences where health care professionals convey beliefs that their gender is not valid, or they are fundamentally more difficult to provide care for,” reads the WPATH standards of care.

Compared to binary transgender individuals, nonbinary persons are more likely to experience fear of prejudice from health care providers and are less likely to disclose their nonbinary identity.

A 2020 study cited by WPATH found 62.7% of nonbinary individuals do not disclose their gender identity all or some of the time. In comparison, only 26.8% of transgender women and 23.5% of transgender men do not disclose their identity all or some of the time.

Another study cited by the organization found nonbinary persons experience “more fear of prejudice from health care providers, less confidence in the services provided and greater difficulty knowing where to go for care” compared to their binary transgender counterparts.

In their first appointment, Hatfield was given a packet explaining the benefits and risks of hormone replacement therapy – called HRT – and did not begin therapy until after a second appointment a month later. After beginning HRT, Hatfield’s hormone levels were checked every three months, but they described care after that point to be “fairly hands-off.”

While largely satisfied with the physical changes and the care received in Boise, Hatfield’s gender-affirming care deteriorated upon moving to Moscow, Idaho. The providers there had little experience treating transgender patients of any kind and were “so hostile to the point it seemed like they wanted me to stop showing up,” Hatfield said. “They were just completely unaware of trans care and willfully ignorant of it.”

Hatfield did not feel comfortable disclosing their nonbinary identity to a health care provider until moving to Spokane last year. Seeing a provider at CHAS Health, Hatfield believes the clinic is “open and willing to cater” to the needs of nonbinary people.

“I feel like I’ll actually be listened to, which is not always the case,” Hatfield said.

Transgender identity and intersex variation

Chandler Wheeler is transgender and nonbinary but also has an intersex variation that has complicated the ability to receive gender-affirming care.

An individual whose reproductive or sexual anatomy does not fit into the binary sex assignments of male and female is considered intersex. There are many ways to be intersex and while an intersex condition may be present from birth, it commonly is not. Even if it is, infants are typically still assigned a sex at birth.

According to data cited by WPATH, approximately 1.7% of the population have an intersex variation and one in 4,500 infants are born with ambiguous genitalia.

Intersex individuals are not necessarily transgender. They may still identify with the sex they were assigned at birth, or they may not. For Wheeler, the discovery of their intersex condition validated their experience.

“I was always a little uncomfortable with the idea of being a woman. That never felt right to me,” Wheeler said of their upbringing in North Idaho. “I did not understand why I needed to be labeled as male or female and why I just couldn’t be me.”

Congenital adrenal hyperplasia is a condition that impacts production of hormones in the body. For Wheeler, it means their body naturally produces relatively high levels of testosterone and cannot produce estrogen despite their body being assigned female at birth. The condition can be diagnosed in infancy in some cases, but Wheeler’s condition was only discovered as they began to develop some male secondary sexual characteristics at the onset of puberty.

“I just remember so much dysphoria around being female as a kid and how that sort of abated when I began growing facial hair and body hair. But that was replaced with a sense of dread as I realized my female peers didn’t have and didn’t want facial hair,” Wheeler said.

Wheeler began identifying as nonbinary after moving to Spokane in early adulthood. Wheeler also wants top surgery or a chest reduction. Despite seeing many gender-affirming care providers in Spokane, they have been unable to begin hormone replacement therapy.

“No one seems to know how to treat me as both a trans and intersex person in Spokane. They all refer me to specialists who are all in Seattle. And that is not really accessible for me at this point in my life,” Wheeler said.

Wheeler has difficulty in receiving generalized health care as well because many doctors seem uncomfortable about Wheeler’s identity and biology. One provider confused the terms nonbinary and asexual – leading to a misdiagnosis. Another told them that it “wasn’t that important” for Wheeler to learn more about their intersex condition. These experiences have left Wheeler occasionally reticent to seek medical care.

“Being told that finding out how my body works is not important is just really frustrating,” Wheeler said.

Because of difficult experiences many transgender people experience in health care settings, Safran has seen many patients go without necessary care unrelated to their gender identity. When a gender variant identity is not disclosed or a provider does not inquire, certain sex-dependent cancer screenings and other preventive measures may not be done.

According to Safran, that is why health care professionals should educate themselves about the LGBTQ+ community and be as inclusive in their practice as possible.

“Unfortunately I’ve heard from many patients that something as simple as using a person’s incorrect name or pronouns or asking very intrusive or hurtful questions about their sexual practices … can be very damaging,” she said. “We need to be a welcoming environment because in many clinics, trans people do not feel comfortably sharing their concerns.”