Promoting Transgender and Gender Minority Health through Inclusive Policies and Practices

Abstract

Policies and practices that exclude transgender and gender-nonconforming people have a negative impact on gender minority health by permitting discrimination and reinforcing stigma. APHA advocates for the adoption and application of inclusive policies and practices that recognize and address the needs of people and communities identifying as transgender or gender nonconforming. Inclusive policies and practices are those that recognize transgender and gender-nonconforming identities as valid and deserving of equal consideration and treatment. Inclusive policies and practices are critical to reduce health inequities experienced by transgender and gender-nonconforming people. Transgender is an umbrella term that refers to individuals who do not conform to binary gender norms that correspond with their assigned sex at birth. This term includes a wide spectrum of individuals, including but not limited to people whose gender identity differs from the gender typically associated with the sex they were assigned at birth, those who embrace gender fluidity, and those who do not identify as either men or women. The term gender nonconforming is also used in this policy statement to describe those with nonbinary gender identities. Although transgender and gender-nonconforming people may experience similar gender-related bias and discrimination, they are diverse in terms of factors such as age, race, ethnicity, ability, income, sexual orientation, socioeconomic status, and immigration status. APHA urges Congress, state legislatures, and other public and private entities to ensure that policies and practices across all sectors are explicitly inclusive of transgender and gender-nonconforming people.

Relationship to Existing APHA Policy Statements

Relevant APHA policy statements include the following:

• APHA Policy Statement 20142: Reduction of Bullying to Address Health Disparities Among LGBT Youth
• APHA Policy Statement 9933: The Need for Acknowledging Transgendered Individuals within Research and Clinical Practice
• APHA Policy Statement 9819: The Need for Public Health Research on Gender Identity and Sexual Orientation
• APHA Policy Statement 200410: Proposed Resolution Condemning Actions Against LGBT and HIV Related Research and Service Delivery
• APHA Policy Statement 201116: Highlighting the Health of Men Who Have Sex With Men in the Global HIV/AIDS Response 

The above policy statements lay the groundwork for this statement, which is additive and does not replace, replicate, or modify any of the existing statements.   

Problem Statement 

Policies and practices that exclude transgender and gender-nonconforming populations have a negative impact on transgender and gender minority health by permitting discrimination and reinforcing stigma.[1–12] The development and implementation of more inclusive public health promotion policies and practices will benefit transgender and gender-nonconforming populations.[13]

It is well established that discrimination, and perceptions of discrimination, have a negative impact on mental and physical health outcomes.[14] The minority stress theory, a prominent theoretical framework for health risks of sexual minorities, proposes that health disparities can be explained by stressors induced by hostile and homophobic environments. These stressors manifest in the form of harassment, discrimination, and victimization. The theory assumes that stressors are “unique (not experienced by other populations), chronic (related to social and cultural structures) and socially-based (embedded within institutions and structures as well as processes).”[15] Although this theoretical framework focuses on sexual minorities, research in which the theory is used suggests that gender minorities may experience minority stress as a result of discrimination based on the nonconformity of their gender expression and/or their ascribed gender identity, in addition to their sexual orientation. Gender expression that is nonconforming as a contributing factor suggests that the minority stress theory could be used to measure the impact of discrimination on transgender and gender-nonconforming people.[16]

Transphobia is defined as the individual, interpersonal, societal, and institutional-level discrimination, as well as systemic exclusion and oppression, experienced by transgender individuals. Additional terms that refer to this discrimination are transnegativity and transantagonism, while transmisogyny refers to the unique experiences of discrimination faced by transgender women, feminine-of-center people, and gender-nonconforming people.[17] According to the 2011 National Transgender Discrimination Survey, respondents who expressed a transgender identity or gender nonconformity reported staggeringly high rates of discrimination while interacting and engaging with a variety of public and private sectors.[18] This discrimination can manifest in the form of housing and employment discrimination, bullying in school, rejection from family and friends, lack of health insurance, inability to obtain needed health care, and sexual, emotional, physical, partner, and other violence.[9–11,19] In the same survey, student respondents in grades K–12 reported high rates of harassment (78%), physical assault (35%), and sexual violence (12%). In addition, 90% of those surveyed reported experiencing harassment, mistreatment, or discrimination at their places of work. Fifty-three percent of respondents reported being verbally harassed or disrespected in places of public accommodation, including hotels, restaurants, buses, airports, and government agencies.[18]

Discrimination against transgender and gender-nonconforming people increases the likelihood of social alienation, homelessness, financial instability, substance use (as a coping mechanism for transphobic discrimination and mistreatment), HIV vulnerability, incarceration, psychological distress, suicidal ideation, suicide attempts, suicide, and homicide.[18,20–23] In particular, transgender and gender-nonconforming youths are significantly overrepresented in the juvenile justice system due to rejection of transgender identity, discrimination, and victimization. These risk factors and negative health outcomes do not occur in isolation from each other; rather, numerous correlations exist among experiences of victimization, substance use behaviors, mental health issues, homelessness, and other factors.[24] For example, transgender and gender-nonconforming people who experience homelessness are more likely to be incarcerated, to engage in sex work and substance use, to be vulnerable to HIV, and to attempt suicide.[18]

Several studies have demonstrated strong correlations between exposure to discrimination and psychological distress (particularly depression) among transgender people.[25–27] An Internet-based study of more than 1,000 transgender men and women revealed significant rates of psychological distress, including clinical depression (44.1%), anxiety (33.2%), and somatization (27.5%).[25] In a prospective study of racially diverse transgender women, the prevalence of major depression was 28%, five times that of the general population. Fifty-three percent of these women reported exposure to psychological abuse related to their gender identity in the preceding 6 months. Transgender women exposed to persistent gender-based psychological abuse were nearly six times more likely than those with no history of abuse to experience major depression, indicating a strong correlation between gender-based oppression and psychological distress.[27]

Many of these negative health outcomes could be reduced by access to affordable, culturally competent, and reliable health care. However, discrimination—and fear of discrimination—also exists in health care settings. Research suggests that racial disparities in the health care system stem largely from institutional prejudice and discrimination rather than overt discrimination by health care providers. The same may be true in the case of gender identity.[28] That said, 19% of those who responded to the National Transgender Discrimination Survey reported that they had been refused health care because of their gender identity, 28% of respondents had postponed medical care because of discrimination, and 28% reported verbal harassment in a doctor’s office, emergency room, or other medical setting.[18] 

Studies examining how race-based discrimination affects engagement with the health care system reveal that perceived discrimination lowers rates of compliance, reduces trust in physicians, and delays medical care seeking.[28] The same concepts can be applied to transgender and gender-nonconforming people. Many of these individuals cannot report their gender identity on medical forms due to limited binary options, which can lead to miscommunication and distrust between patients and their health care providers.[11] Some transgender and gender-nonconforming people report educating their physicians about their gender identities. Others report feeling uncomfortable discussing their health care needs with medical providers.[21] This has kept many transgender and gender-nonconforming people disengaged from the health care system, which has likely compounded the disparities in their health outcomes. Laws that permit health care providers to refuse treatment to LGBT (lesbian, gay, bisexual, transgender) patients based on religious objections will only increase the barriers that these individuals already experience in seeking health care. These laws also threaten to undermine the many ongoing efforts at the state and federal levels to reduce LGBT health disparities. In addition, inequities due to discrimination in one setting can shape expectations of treatment in other settings. In turn, members of minority groups may develop negative attitudes toward establishments such as the health care system in response to past incidents of discrimination.[28]

While policies that protect transgender people exist in some states, historically they have not always been enforced to their full extent, if at all.[29] Federal civil rights legislation does not protect transgender individuals from discrimination, so this responsibility is left to the states.[30] Because there are no explicit protections for transgender and gender-nonconforming people in federal legislation, courts must interpret existing protections based on “gender.” Overwhelmingly, courts decide not to extend protections to transgender and gender-nonconforming people.[31] These unequal protections lead to inconsistent regulations and uncertainty among transgender communities about where they are protected and can go to feel safe. In addition to denying recognition of gender identity as a class for protection, some states have even passed anti-transgender discrimination laws in order to invalidate local nondiscrimination ordinances that included gender identity and gender expression as protected classes.[32]

The most prominent example linking inclusive policies and practices to improved health is the 1964 Civil Rights Act, which prohibits segregation and discrimination on the basis of race, color, religion, sex, or national origin. This legislation resulted in large reductions in the gap in infant mortality rates between Black Americans and White Americans.[33,34] The Black-White ratio dropped from 19 in 1964 to 11 in 1971.[34] The Black infant mortality rate was 16% lower in the 5 years following the Civil Rights Act (1965–1969) than in the previous 5 years (1960–1964).[35] This legislation also had long-term effects on maternal health, with Black mothers born between 1968 and 1970 having a 30% lower incidence of very-low-birthweight infants than Black mothers born between 1960 and 1962.[34] Economists also agree that, by prohibiting employment discrimination, the Civil Rights Act was a significant contributor to the considerable reductions in the Black-White wage gap that occurred from 1965 to 1975.[36,37] 

Despite this legislation not including protections for transgender and gender-nonconforming people, it can be hypothesized that improvements in health among these individuals would follow the same patterns as improvements for other marginalized identities if protections were extended. For example, the passage of inclusive policies has had a positive impact on sexual minorities. Research suggests that passage of marriage equality legislation will have positive health implications for same-sex couples. Research regarding minority stress suggests that prior marriage bans had negative health effects by facilitating chronic stress. Affirming marriage rights affirms equality while improving mental and physical health outcomes among many same-sex couples. Same-sex spouses who need access to health-related benefits and insurance can also now invoke important rights that can improve their health and well-being.[3]

As of 2016, there was no federal nondiscrimination legislation passed by Congress with protections that included gender identity. Although few states have adopted statewide policies and practices that are inclusive of gender identity, inclusion of gender identity in housing and employment nondiscrimination policies is associated with reduced levels of perceived community stigma and lower reported discrimination and victimization among transgender and gender-nonconforming individuals relative to individuals living in states without nondiscrimination protections.[9] In addition, state employment nondiscrimination laws that include gender identity have been associated with 26% lower odds of a medical visit for a mood disorder and 43% lower odds of a medical visit for a self-harm injury among transgender veterans.[38] Lower levels of structural stigma have been associated with fewer lifetime suicide attempts.[2]

This APHA policy is responsive to values of the Public Health Code of Ethics, particularly to values that announce concern for the protection of human dignity, that declare the necessity of developing scientific knowledge in order to improve and ensure the public’s health, and that describe the essential role of trust in public health among citizens.[39] Based on the principles of equity and human rights, this policy seeks equal opportunities for health for populations that have experienced marginalization and discrimination, namely transgender and gender-nonconforming populations.[40]

Evidence-Based Strategies to Address the Problem

From outward discrimination to subtle microaggressions, there are many ways in which our current political climate affects transgender and gender-nonconforming people. Researchers suggest that interventions are needed to reduce stigma toward transgender and gender-nonconforming people at the individual, interpersonal, and structural levels. That said, such multilevel interventions warrant future development.[41] When looking at the prevalent health risks facing transgender and gender-nonconforming individuals, inclusive policies are of the utmost importance to guide behavior, protect those at risk, and combat discrimination and stigma. Acknowledging systemic oppression that targets transgender and gender-nonconforming communities, researchers have linked inclusive policies and practices, including nondiscrimination laws, to improved health outcomes.[31,32,42–44] Examples of this evidence come from across sectors.

Inclusive health care services: The widespread discrimination, mistreatment, and outright denial of care that transgender and gender-nonconforming individuals face in the health care system can begin to be alleviated by gender-inclusive language in patient nondiscrimination policies. Patient nondiscrimination policies that are inclusive of transgender and other gender identities ensure that patients are not refused medical care on the basis of their gender identity or expression. In addition, hospitals have begun to critically assess standardized language across medical forms for inclusivity of transgender and gender-nonconforming people. For example, in some medical settings, health insurance and intake paperwork asks patients for “sex assigned at birth” and gender identity, as well as “preferred name” or “name in use” in addition to their legal name.[45] Researchers also advocate for utilizing consultants who are knowledgeable about and sensitive to LGBT patient care needs and for promoting and collaborating with LGBT community resources to improve health systems and health care services. Such inclusive actions are essential for ensuring positive health outcomes.[46] Researchers suggest that those who engage with members of the transgender and gender-nonconforming communities be aware of prior health care discrepancies and discriminatory practices. Health care settings can collect patient satisfaction data as a way to empower transgender and gender-nonconforming people to provide feedback to and improve health care systems.[47]

While transgender-specific health programs and centers exist as places where transgender and gender-nonconforming people can receive medical services, the majority of these individuals receive health care services in settings that are not tailored to their health needs. In turn, the lack of gender-inclusive institutional protocols, practices, and policies creates a health care system that furthers the social marginalization of transgender and gender-nonconforming individuals.[48] However, resources exist to facilitate affirming, competent care for all. Researchers suggest that health care spaces provide at least one gender-inclusive restroom, subscribe to LGBT magazines or newspapers, display posters showing diverse transgender and gender-nonconforming people or LGBT and transgender-specific organizations, post a nondiscrimination statement regarding gender identity and expression, and offer brochures detailing LGBT health concerns and health risks.[49] By displaying posters, flyers, and additional community-specific materials to create a more inclusive environment, providers can encourage transgender and gender-nonconforming people to be more willing to seek medical care and feel safer vocalizing their needs.[50] In addition to creating a welcoming and inclusive environment, it is essential that providers and practitioners in all health care settings receive LGBT and transgender-specific training that allows them to provide inclusive care to their patients.[51]

Inclusive work and school environments: Noninclusive, heteronormative, and cisnormative workplaces can silence employee voices, which can lead to an atmosphere of fear and silence.[52] This can have a negative impact on the psychological well-being of all employees, including those who self-identify as transgender or gender nonconforming.[53] Alternatively, supportive and inclusive workplace environments, grounded in gender-inclusive work policies, not only give employees a voice but can increase their contributions, job satisfaction, and commitment.[54,55]

Inclusive policies and practices beyond the work environment can help protect transgender youths.[56] Examples of protective factors unique to transgender youths include school environments with anti-bullying policies inclusive of transgender and gender-nonconforming students, gender-inclusive language in student event communications (e.g., proms, formals), gender-neutral restrooms, and peer support from other students who identify as LGBT.[57] When inclusive language is included in school anti-bullying policies, the risk of suicide among LGBT youths is reduced.[58] In addition, creating “safe spaces” through policy reform and encouraging teachers to correct transnegative, transmisogynist, and transphobic language, as well as homonegative and homophobic language, in school and extracurricular settings lessens the psychological stress and bullying that transgender and gender-nonconforming students experience from peers.[59] Anti-bullying measures are addressed at length in APHA Policy 20142.

Invariably, inclusive work and school environments are affected by policies at the state level. The states of New York and California provide evidence of how inclusive state policies can effectively create inclusive work and school environments. In 2002, New York State updated legislation to outline what constitutes gender identity and gender discrimination. These protections include mandating landlords, employers, and business owners to observe pronouns in use (also called “preferred pronouns”); ensure the availability of single-stall, gender-inclusive bathrooms; prohibit gender-specific dress codes; and ensure health insurance coverage and accommodation surrounding gender transition. California legislation ensures transgender youth inclusion in all school activities, facilities, and programs.[60] Unfortunately, few states have nondiscrimination laws that include gender identity and gender expression as protected classes, despite the evidence of improvements in the health of transgender and gender-nonconforming people and communities when these laws are enacted.

Inclusive sex education coursework: Mandatory sex education classes that are inclusive of a variety of gender identities allow transgender and gender-nonconforming students to feel included, welcomed, and affirmed. Currently, the federally funded Personal Responsibility Education Program (PREP) aims to bring more culturally sensitive, science-based sex education programs into schools.[61] While it is designed to target marginalized communities, PREP excludes LGBTQ-specific education. Despite the rise in programs similar to PREP, they continue to focus mainly on pregnancy prevention. While this is an important component of sex education, studies of transgender and gender-nonconforming students show that sex education programs would be more meaningful if they focused on fostering healthy relationships and preventing sexually transmitted infections (STIs).[62] In addition, inclusive coursework on safer sex practices for identities beyond the gender binary can reduce transgender and gender-nonconforming students’ and their partners’ risk of acquiring STIs.[63,64] Focus groups of LGBT high school students have shown that, even in abstinence-only classroom settings, the use of inclusive language creates a greater understanding of different sexualities, raises awareness about transgender communities, and decreases stigma.[62]

Inclusive justice environments: Policies governing the criminal and juvenile justice systems also warrant serious reform. Perpetrators of violence against transgender and gender-nonconforming people often avoid appropriate penalties because gender identity is excluded from hate crime laws in numerous states. Data indicate the need for gender identity to be included in hate crime laws, for both reporting of hate crimes and criminal cases.[65] The National Coalition of Anti-Violence Programs, which monitors violent crimes committed against transgender individuals, recommends gender-inclusive policies within the criminal justice system to reduce hate crimes against this population.[66] In addition, violence against transgender and gender-nonconforming individuals is often underreported due to negative interactions with police. Forty-two percent of transgender individuals who have had an encounter with law enforcement officials report experiencing police brutality and/or misconduct, and half report feeling uncomfortable seeking out a law enforcement official for help.[67] These alarming statistics signal a need for explicit inclusive changes to the educational training received by law enforcement officials. 

Current juvenile justice system policies and practices fail to address the unique needs of transgender youths, leading to discriminatory and harmful treatment including segregation, abuse, and unsafe reparative or conversion therapy. The National Council on Crime and Delinquency and the Equity Project recommend the development and implementation of policies and procedures in the juvenile justice system that will foster a better understanding of transgender needs and reduce harmful treatment.[68] States and local jurisdictions should implement nondiscrimination policies, hormone treatment and other medical guidelines, and inclusive staff training related to serving the transgender population.[69] In a system that utilizes binary, gender-segregated facilities and often does not recognize transgender identity as valid, transgender and gender-nonconforming individuals are classified according to their perceived anatomical sex. Changing the classification system from one based on the prisoner’s perceived anatomical sex to self-selection into the facility corresponding with one’s gender identity is an example of such a policy to reduce violence against transgender individuals in these settings.[70]

Opposing Arguments

Some may claim that noninclusive policies and practices have no impact on overall well-being. Research shows that health disparities among minority groups can be explained to a large extent by stressors induced by a hostile and homophobic culture, which often results in a lifetime of harassment, maltreatment, discrimination, and victimization. Data from the National Transgender Discrimination Survey highlight the negative effects of noninclusive policies and practices on the transgender population. The survey results showed a significant relationship between policies that denied people access to facilities matching their gender identity and lifetime suicide attempts.[18] Even more, the effects of statewide nondiscrimination laws on community-level stigma, and its relationship to psychosocial stressors and mental health outcomes, have been documented among transgender and gender-nonconforming individuals. Analyses suggest that statewide nondiscrimination laws are associated with lower rates of perceived stigma at the community level, which, in turn, are associated with lower rates of discrimination, victimization, and anxiety and a reduced risk of attempted suicide.[9] 

There may be opposition to this policy from those who believe that gender nonconformity is an illness or claim that supporting transgender communities is contrary to their religious and moral beliefs. These reasons have been used to pass discriminatory legislation. In 2015, religious refusal bills accounted for the largest number of anti-LGBT bills introduced. In more than a dozen states, policymakers introduced bills allowing all individuals and businesses to cite religion as a legally permissible reason to discriminate against LGBT individuals.[71] Discriminatory “bathroom bills” serve as an example of this religious and moral reasoning. Proponents of these laws have cited “basic community norms” and “basic privacy and etiquette” as justification for the discriminatory legislation.[72] Arguments against inclusive public accommodations include claims that they will allow nontransgender individuals to cross dress to commit sexual harassment.[73] Despite these assertions, criminal behavior is not protected by gender identity nondiscrimination laws. In addition, there are no data showing that allowing transgender and gender-nonconforming people to use public facilities in line with their gender identity leads to an increase in sexual harassment or abuse of other people using the facilities.[74] Instead, transgender individuals are more often the victims of sexual assault. Research has shown that 50% of transgender individuals experience sexual violence at some point in their lifetime.[75]

General lack of support for transgender rights likely derives from misunderstandings and stereotyping. Since the mid-19th century, medical professionals have been documenting cases in which patients describe feeling disconnected from their assigned sex. Through the 1950s, this disconnection fell under the same umbrella as fetishism, pedophilia, and conditions classified as sexual deviancies at the time. Not only were these conditions considered ethical deviations, but they were also regarded with fear. In 1980, medical professionals declared this experience a psychological disorder, “gender identity disorder” (GID). GID diagnoses have been used against transgender people in court cases, as the diagnosis legally establishes “severe and chronic mental illness.” The medical community has begun to recognize the biological basis of gender identity and the errors of incorrectly classifying the transgender population as “deviant” and “mentally ill.” Instead, the term “gender dysphoria” is now used to describe transgender and gender-nonconforming people’s symptomatic experiences.[76] A study examining public attitudes about transgender rights in the United States showed that as respondents report being more informed about transgender people, they tend to have more supportive attitudes.[77] Inclusive policies and practices need to be adopted and implemented to change attitudes and challenge oppression and misinformation.

Lastly, because gender identity is typically coupled with sexual orientation, some may believe that advances made for sexual minorities have ended the need to fight for LGBT equality. However, transgender and gender-nonconforming people continue to be systematically excluded from the legal, political, cultural, and social progress made for the broad and diverse LGBT communities. For example, the legal and political gains from the repeal of military policies barring openly lesbian, gay, and bisexual individuals from military service and the legalization of same-sex marriage are not inclusive of the experiences and needs of transgender communities.[78,79] Even more, there is a significant gap in the extent to which society accepts LGB communities relative to transgender communities.[80] Transgender and gender-nonconforming people, particularly transgender women of color, are plagued by discrimination, harassment, and violence.[66] At the same time, the public and private spheres continue to enact policies that perpetuate discrimination against transgender identity and expression.[9]

As stated above, policies and practices have a negative impact on transgender and gender minority health[44] by permitting discrimination and reinforcing stigma.[1–11] Furthermore, it is well established that discrimination and perceptions of discrimination negatively affect mental and physical health.[14] The development and implementation of more inclusive public health promotion policies will benefit transgender and gender-nonconforming populations.[12] APHA advocates for the adoption and application of inclusive policies and practices because of the importance of protecting the rights of all individuals. 

Action Steps

Namely, APHA:

• Urges Congress and state legislatures to enact legislation to protect the rights, legal benefits, and access to services of people of all gender identities and expressions.
• Urges Congress and state legislatures to incorporate into legislation language that is clearly inclusive of transgender and gender-nonconforming people, that does not interpret gender as a binary, and that protects the right of transgender and gender-nonconforming people to use facilities that match their gender identity. 
• Urges Congress and state legislatures to fund research to better understand and promote transgender and gender minority health, including research that monitors the effects of policies and practices on health.
• Urges public and private workplaces to institute nondiscriminatory policies and practices inclusive of transgender and gender-nonconforming people.
• Encourages public and private research entities to actively include transgender and gender-nonconforming people in research studies, including clinical trials and observational studies, in order to build a stronger evidence base for transgender and gender minority health.
• Encourages public and private education systems to foster academic cultures grounded in nondiscrimination policies and practices inclusive of transgender and gender-nonconforming people.
• Encourages juvenile justice and criminal justice policies and practices inclusive of transgender and gender-nonconforming people.
• Encourages public health and health care practices that are inclusive of transgender and gender-nonconforming people.
• Encourages public and private entities to adopt policies and practices inclusive of transgender and gender-nonconforming people in different settings and across all sectors.

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