At a time when leadership is needed to address the current COVID-19 pandemic and to tackle racial inequality and police brutality, the federal government is making changes that gamble with the lives of LGBTQ patients. Last week, the Trump administration finalized a rule to remove non-discrimination protections in health care and health insurance for LGBTQ persons, flying in the face of our ethical obligations as physicians to “do no harm.”
The prior rules outlined in Section 1557 of the Affordable Care Act established that it is illegal to discriminate on the basis of “race, color, national origin, sex, age or disability in certain health programs and activities.” Subsequent rules in 2016 expanded those protections regarding “sex” to ensure they encompass gender identity, thus providing for coverage of medically appropriate care for transgender individuals. These 2016 rules ensured that the law reflected the established science and policies of professional health organizations, including the American Medical Association and American Psychological Association.
This latest attempt by the Trump administration to eliminate protections for LGBTQ people relies on the false notion that sex is binary and immutable again demonstrates hostility towards LGBTQ persons, established science, and the practice of medicine. Under this new rule, a transgender person risks being refused routine preventive care, such as prostate cancer screening for a transgender woman and pap smears for a transgender man. Moreover, it threatens insurance coverage for needed gender affirming care such as hormone therapy and facial feminization surgery that research demonstrates can improve the health and well-being of transgender persons. As primary care physicians and providers of gender affirming care, we know that the risk of being denied these services or losing insurance coverage will cause significant harm to our patients.
If this discriminatory rule moves forward, it will also impact reproductive health care protections for individuals experiencing pregnancy and in need of termination, if the procedure violates the beliefs of the provider. Loss of these protections represents a barrier to care, and will lead to higher costs, and more importantly, a loss of dignity.
Transgender, non-binary, and gender diverse people already experience high rates of discrimination in health care. In the largest survey of transgender persons in 2015, 33 percent had at least one negative experience in a health care setting relating to their gender identity in the past year, and 23 percent did not seek care when needed, due to fear of being disrespected or mistreated as a transgender person. These experiences occur even more often for individuals of color and people with disabilities.
In a review of discrimination complaints submitted to the US Department of Health and Human Services, the most common issues involved individuals being denied care or insurance coverage because of gender identity or transgender status. These poor experiences include a transgender woman being denied a mammogram, a transgender man being refused screening for a urinary tract infection, an insurer not covering reproductive health care due to gender identity, and a transgender man being denied coverage for breast cancer genetic testing, despite the recommendation of his physician. These instances of discrimination are a stain on our profession and represent a failure to meet the needs of our patients. Ensuring access to health care and striving for optimal health for all persons are fundamental values of the medical profession and are long reflected in our ethics. The government should work to make it easier for all people to access health care, not more difficult.
This rule legitimizes unequal treatment of patients by clinicians, health care organizations, and insurers. In particular, it harms transgender individuals by providing cover for denial of needed care, and it represents a brutal blow to transgender persons of color, who already face greater health inequities related to the intersecting impact of racism and the anti-transgender sentiment expressed repeatedly by this administration. Such policy should not be permitted by the government, let alone proposed by it.
The administration claims to be protecting the moral and religious beliefs of health care professionals. But if providing care for LGBTQ persons violates health professionals’ beliefs, they are in the wrong profession.
Dr. Carl G. Streed Jr. is the research lead at the Center for Transgender Medicine and Surgery at Boston Medical Center. Dr. Jenny R. Siegel the medical director at the Center for Transgender Medicine and Surgery at Boston Medical Center.