Advancing health equity for transgender people

Anti-transgender violence and legislation are urgent public health issues

Over the past several months, we have decried specific instances of gun violence, abusive policing, anti-Black racism, anti-Asian racism, and the policies, laws, institutions, beliefs and behaviors that perpetuate them. We are disturbed by the recent wave of anti-transgender violence and by legislation being promoted in state houses across the United States. Today, 40 states have pending or passed anti-transgender legislation, including North Carolina. This comes at a time when two Black transgender women were murdered in Charlotte recently. We unequivocally condemn this violence, and we condemn the beliefs, behaviors and legislation that perpetuate these injustices.

These are critically important public health issues. As emphasized in a recent White House proclamation:

In spite of our progress in advancing civil rights for LGBTQ+ Americans, too many transgender people – adults and youth alike – still face systemic barriers to freedom and equality. Transgender Americans of all ages face high rates of violence, harassment, and discrimination. Nearly one in three transgender Americans have experienced homelessness at some point in life. Transgender Americans continue to face discrimination in employment, housing, health care, and public accommodations. The crisis of violence against transgender women, especially transgender women of color, is a stain on our Nation’s conscience.

As evidence of crisis, a recent study showed that 51% of transgender people who had experienced four instances of discrimination and violence in the past year attempted suicide in that year. Transgender and non-binary individuals often experience discrimination from clinicians and also are confronted with health insurance plans that deny payment for surgery and other services.

The types of anti-transgender legislation being proposed and passed across the U.S. may escalate negative health and other outcomes in profound ways. In their 2018 analysis of impacts of two such North Carolina laws*, Gillings students in the Department of Health Behavior found far-reaching deleterious health effects to transgender people, including spikes in violence perpetrated on LGBTQ+, and especially transgender, people (MPH Capstone Project, 2018).

Many years ago, I audited a medical school (not UNC) class that focused on patients preparing for gender-confirming surgery. All these years later, I recall the poignancy with which patients described feelings that their bodies did not match their gender identities. They were willing to undergo counseling, painful surgeries, substantial out-of-pocket costs and difficult conversations with loved ones to achieve gender confirmation. Accumulating research shows that transgender people who want gender-confirming surgery and undergo it have better mental health than those who want surgery but do not have it. For these and many other reasons described above, the American Public Health Association advocates for inclusive policies and practices and has stated that laws should not discriminate against transgender individuals, and health care services should not be denied to them.

In North Carolina, there is no longer State Health Plan coverage for gender-confirming surgery. This should change, and we can help create that change. Membership on the Governor’s Commission on Inclusion for the past three years has given me a window into how important the issues are. Addressing transgender concerns, including in healthcare coverage, has been one of the Commission’s top priorities.

We support actions by the Biden administration to protect the civil rights of transgender individuals, as described in their March 31 proclamation:

To more fully protect the civil rights of transgender Americans, we must pass the Equality Act and provide long overdue Federal civil rights protections on the basis of sexual orientation and gender identity. The Equality Act will deliver legal protections for LGBTQ+ Americans in our housing, education, public services, and lending systems. It will serve as a lasting legacy to the bravery and fortitude of the LGBTQ+ movement.

Vice President Harris and I affirm that transgender Americans make our Nation more prosperous, vibrant, and strong. I urge my fellow Americans to join us in uplifting the worth and dignity of every transgender person.

Actions we can take. We are thankful to the many Gillings people who are shining a light on, and helping to dismantle, the corrosive systems and beliefs that lead to violence and discrimination against transgender people. Thanks especially to leaders in Health Behavior who recently shared a strong  statement (PDF) against anti-transgender laws and policies, together with students and alumni of the Master of Public Health  concentrations in  Epidemiology; Global Health; Health Equity, Social Justice and Human Rights; Health Behavior and Nutrition, who communicated their strong desire for me to write a statement about transgender issues and proposed N.C. legislation. A special thank you to Paula Kohut, JD, who is a transgender woman and fellow member of the Governor’s Commission on Inclusion, for sharing her knowledge, experiences and insights with me as I developed this statement.

I encourage readers to learn more about transgender issues, including actions we can take. A one- Emergency Preparedness, Equity and Ethics webinar from June 11, 2020, on Elevating and Recentering LGBTQ+ Health during the COVID-19 Pandemic, sponsored by Gillings Inclusive Excellence, features several Gillings faculty and is an excellent resource for understanding and advocacy.

Read and learn more about proposed legislation in North Carolina and other states that would deny healthcare and other services to transgender individuals. (“N.C. General Assembly’s three anti-trans bills follow a recent nationwide trend,” was posted April 20 in the Daily Tar Heel.) If you are uncomfortable with denying services to people who identify as transgender, let your legislators know how you feel (following N.C. employee policies about lobbying as you do so, if you’re a state employee). In your workplaces, religious institutions, and other places you go, be an ally for transgender people. In your families, work toward understanding. Resist attempts to use conversion therapy to change the gender orientation of LGBTQ+ adolescents; it can have serious negative effects on depression and other conditions. If you see situations in which someone is being harassed or bullied, do not be a bystander. Act — or find someone who can. I intend to work with the N.C. Commission on Inclusion to do what we can to achieve the goals stated in the White House proclamation and by N.C. leaders.

At Gillings, we work every day to achieve a world in which everyone thrives; a world in which health, economic and other inequities are eliminated.
Barbara