Transgender / Transsexual

For three years, Jesse Brace avoided getting care for their seizures after they experienced discrimination at an emergency room near their home in Lawrence, Kansas, in 2017. 

They said they told the staff that they are transgender and nonbinary, that their name is different from their legal name and that they use gender-neutral pronouns.

“They refused to even so much as acknowledge this information, and not only did they not use [my pronouns], but they also sent me home without treating me for what I went in for,” said Brace, 25. 

When they tried to get care elsewhere after that, they said, they had similar experiences, so they avoided care entirely. 

In 2018, they began having seizures every day, so they started living in their car outside the Amazon facility where they were an assistant operations manager, because they couldn’t drive themself to work anymore. 

In November 2018, they lost their job. “I lost my car soon after and ended up on the streets in the winter,” they said. “I was having hundreds [of seizures] a day and wasn’t even leaving where I was laying.”

They were homeless, living out of their car or on the streets, for over three years. 

Brace’s experience in the ER — and the impact that health care discrimination had on their life — is something many trans people face and fear when they try to get care, according to a report released Wednesday by the Center for American Progress, or CAP, a liberal think tank. 

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Discrimination, among other factors, prevents trans people from seeking necessary care, which leads to health disparities that can affect many other areas of their lives, the report found.

The authors outline a road map of solutions, including legislative protections for LGBTQ people and better competency training for medical providers.

“The onus should not be on individuals,” said one of the report’s authors, Sharita Gruberg, vice president of the center’s LGBTQ Research and Communications Project. “It really should be on these institutions to do the right thing, and the resources and guidance is out there.”

Forgoing routine care after trauma

CAP’s report found that nearly half of transgender people — and 68 percent of transgender people of color — reported having experienced mistreatment at the hands of a medical provider, including refusal of care and verbal or physical abuse, in the year before the survey, which took place in June 2020. 

Discrimination can then prevent people from seeking future care, the survey found: 28 percent of transgender people, including 22 percent of transgender people of color, reported having postponed or not gotten necessary medical care for fear of discrimination.

Brace got another job in May 2019, but they said they weren’t able to get consistent care again until May of this year. They said doctors in the area repeatedly told them that they were unable to take on new patients. It wasn’t until Brace was referred to a doctor who has a transgender child that they were finally able to obtain a primary care physician.

“I get panic attacks just making appointments,” they said. “I have no support whatsoever. Unfortunately, all health care around here is like this. There is no support for trans people, and so most avoid seeking care.”

Dallas Ducar, a psychiatric nurse practitioner, opened Transhealth Northampton, a trans-led organization that provides health care to trans and gender diverse patients in western Massachusetts, in May. Ducar said that as a health care provider and a trans woman, she knows there’s a dearth of affirming care for trans people across the country.

She said many of Transhealth’s patients have gone without medical care for long periods of time. A patient who came in a couple of months ago had abnormal vital signs and had to be quickly taken to an emergency room because they were so sick, she added.

“It’s unfortunately not uncommon to see people who have experienced such high levels of discrimination and then forgo the routine visits, then perhaps even forgo an urgent care visit, which then turns into an emergency care visit,” she said.

The CAP report said harassment and discrimination “contribute to high rates of stress,” and — along with social determinants of health — make trans people “more likely to experience poor health outcomes.” 

People will read about health disparities among trans people “and just think of that as something that, horribly, is associated with just like being trans, but actually a lot of these experiences have to do with being trans in a world that is constantly oppressing you and where you’re experiencing discrimination both interpersonally but also institutionally and in these broader systems,” said one of the report’s authors, Caroline Medina, a policy analyst at CAP.

The report cites the 2019 Behavioral Risk Factor Surveillance System data collected by the Centers for Disease Control and Prevention, which found that trans people were more than twice as likely as cisgender adults to be told they had depressive disorders. 

Fifty-four percent also reported poor physical health at least one day in the previous month, compared to 36 percent of cisgender respondents, according to the CDC data. Trans people also have an increased likelihood of having asthma and developing cardiovascular disease, according to the CAP report.

The Covid-19 pandemic has also aggravated the health disparities trans people face: 1 in 3 reported having had suicidal thoughts during the pandemic, and 1 in 2 reported that their access to gender-affirming health care was curtailed significantly during the pandemic. 

Ducar said barriers to care, particularly gender-affirming care like hormones, is “really, really harmful, and they add to the layers of discrimination that exists within the trans community.” 

“On the mental health side, we are seeing folks with really complex issues — tons and tons of trauma — that’s coming to our doorstep,” she said. “We’re just seeing a lot of not only trauma, but complex PTSD specifically. These are people that have just been consistently burdened with the symptoms of PTSD, trauma just recurring. It’s really been terrible.”

A lack of cultural competency

When trans people do try to seek health care, they can face discrimination or outright refusal of care, as CAP found. But even when they don’t experience discrimination, they are likely to see providers who don’t have the cultural competency to provide them with affirming care.

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CAP’s survey last year found that 1 in 3 transgender people reported having had to teach their doctors about transgender people to get appropriate care, and 15 percent reported having been asked “invasive or unnecessary questions about being transgender” not related to their reasons for visiting. 

The report cited a 2018 brief from the Kaiser Family Foundation that found that more than half of medical school curriculums lack information about unique health issues the LGBTQ community faces and don’t cover treatment beyond HIV prevention and care, “likely contributing to transgender people’s inability to access affirming care,” CAP wrote. 

Alex Petrovnia, 24, a writer and scientific researcher living in central Pennsylvania, said that last fall, he had to report a primary care physician after a negative experience. 

He was worried about how testosterone would affect a joint problem he was having, and he asked the doctor, who was still a medical resident, whether there was a form of physical therapy to help the problem. After a tense exchange, he said, the doctor told him, “I don’t know anything about this, because I’ve never had a patient like you.” 

“I was trying to keep this interaction peaceable, and I replied with: ‘Yeah, I know. It’s really unfortunate that you’re not taught anything about trans people in medical school, and it’s just not a very well-known issue,’” he said. “And she looked me right in the eyes and she said: ‘I don’t think it’s that important. There aren’t many of you.’”

When he left, he tweeted about the visit so other trans people in the area would know not to see that doctor.

The medical practice reached out to him a few days later and asked what it could do better, Petrovnia said. When he returned to see a new, supportive primary care physician, “they told me that they sent the resident back to trans-inclusivity training and that they had instituted that for all of their residents going forward,” he said. “So that was very positive. … Being the squeaky wheel really actually made an impact and actually improved the situation theoretically for others.”

Petrovnia acknowledged that not everyone is able or willing to spark such teachable moments. 

Mel Groves, 25, visited a primary care office in Montgomery, Alabama, in January when he had a cough, fever and lower body pains. When he was taken back for a full-body CT scan, he said, he had a decent conversation with the attendant who was pushing his chair. Groves said that when the procedure was over, however, the attendant’s tone changed. The attendant had apparently seen Groves’ chart and made a comment about his genitals, Groves said. 

“I was taken aback,” he said. “It was shocking, to say the least.” 

Groves said that he wanted to report it but that he was feeling too ill and overwhelmed, as he was working in the area temporarily. “I knew that that’s what I should have done, but at the time, I had a lot of stuff going on,” he said.

The health care system that oversees the primary care office where Groves was treated could not confirm his story, citing patient confidentiality.

‘The role falls on society’

CAP’s report outlines a number of policy recommendations that the authors said would help address health care discrimination against trans people.

One in particular is among the most pressing, the authors said: They recommend that the federal government create a rule to strengthen Section 1557 of the Affordable Care Act, which prohibits discrimination on the basis of sex and has protected trans people from discrimination in federally funded health care facilities. 

“The protections in Section 1557 are so critical but are also a floor that we need to firmly establish and strengthen,” said Gruberg of CAP. She said it was great that the Department of Health and Human Services’ Office of Civil Rights had announced that it would enforceSection 1557 to cover sexual orientation and gender identity, “but we’re also very worried about what that looks like, how strong these protections are going to be and the potential for religious exemptions to undermine them.” 

U.S. District Judge Reed O’Connor issued a permanent injunction last week against the nondiscrimination protections in the Affordable Care Act, ruling in favor of religious health care providers who said the rules would force them to perform abortions or provide gender-affirming treatment against their religious beliefs. While Gruberg expects the decision to be overturned, she said “that threat is still there.”

The report’s authors also recommended that Congress and state and local governments increase funding for LGBTQ community health centers, which often fill the health care gaps that trans people face.

Groves was connected with an affirming primary care physician through the Knights and Orchids Society, a grassroots organization in Selma, Alabama, led by Black trans people. He drives about 4½ hours from his home in Jackson, Mississippi, to Auburn, Alabama, when he needs care. 

Although groups like the Knights and Orchids Society have provided what Groves described as “life-changing” support, he said it’s ultimately up to the medical system and society to address pervasive issues like discrimination.

“We’ve always been here,” he said. “So I think that now the role falls on society and the medical professionals to educate themselves more. If that means more fellowships, more trainings, more professional development … I feel like that is single-handedly the best thing that we can do to foster better health care for trans people, is helping people to understand how to be inclusive, and then going forward from there.”

Britton Hamilton said, as a trans man, he wanted to become a police officer to help promote change from the inside.

He applied to the New Orleans Police Department in June 2020, and after several exams and a panel interview, he received a conditional job offer in December.

“It was like a dream job,” Hamilton said. “I want to be able to help the community and help people to view police officers differently than how they are feeling now.”

The offer was conditional on him passing a routine medical and psychological evaluation, during which he said the psychologist asked him questions about his transition.

On Jan. 26, he received an email from the police department rescinding the conditional offer “based on a psychological assessment” of his “emotional and behavioral” characteristics.

“It was super, super disappointing, because I prepared myself physically, emotionally for this job,” Hamilton said. “This is the foundation for me and my family.”

In May, Hamilton filed a federal complaint with the Equal Employment Opportunity Commission alleging hiring discrimination. His attorney, Chelsea Cusimano, said the EEOC has since opened an investigation.

The New Orleans Police Department issued a statement in May.

“The decision not to move forward with the applicant in question did not involve any discrimination against the individual as a member of a protected group,” the statement read in full.

The department declined additional comment.

Hamilton’s experience isn’t unique, said Julie Callahan, a former law enforcement officer in San Jose, California, and the founder of the Transgender Community of Police and Sheriffs, a peer support group for trans law enforcement officers. Trans people face disproportionate employment discrimination generally, and she said law enforcement, which she described as a relatively conservative field, is no exception.

TCOPS is trying to do its part by providing training and policy templates to departments in the hopes that this educational material can help address the biases and misinformation that lead to discrimination. But outside of that, it’s incredibly difficult for trans people to prove they’ve faced hiring discrimination. Even if they can, many can’t afford to take legal action.

Complicating matters is the historically fraught relationship between law enforcement and the LGBTQ community. This has caused some transgender officers — many of whom are trying to address inequities from within — to face pressure from both sides.

“It’s an ongoing issue that we have to address as a society,” Callahan said of the hiring discrimination trans law enforcement officers face. “We’re starting to see agencies that are developing transgender interaction policies with the public, but they’re not developing policies like this for their employees, and we find that ridiculous. You should be doing both, because you’re going to have people from the community working or at least trying to get jobs at your agency.”

‘That’s not equal protection of the law’

Hamilton alleged that the psychologist who did his evaluation asked him questions like, “What were the names of your doctors that performed your surgery? How does your family feel about you being transgender? How does your wife feel about you being transgender?”

“I felt like it was kind of weird because … it doesn’t pertain to the duties of being a police officer at all,” Hamilton said. The psychologist, who is named in Hamilton’s complaint, has not returned a request for comment.

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As part of standard procedure, the department asked Hamilton for information about his employment over the last 10 years.

After the psychological evaluation, Hamilton said the department asked for documentation outside of the standard 10-year window related to his honorable discharge from the Army 12 years ago due to medical issues, according to his EEOC complaint. Hamilton provided part of the medical discharge records signed by himself, his commanding officer and a physician stating why he was discharged. The department asked for his complete Army medical record, which Hamilton requested from the National Personnel Records Center for military personnel, according to his complaint. The documents were delayed due to the Covid-19 pandemic, so Hamilton also provided the department with the tracking number for his request.

The department rescinded the conditional offer the day after it requested additional documentation related to his honorable discharge, according to Hamilton’s complaint.

After the department rescinded the offer, Hamilton said he contacted his uncle, who has been a police officer for more than 30 years in Chicago.

“The first thing he said was, ‘That doesn’t even sound right; something definitely is up,’” Hamilton recalled.

After hearing Hamilton’s story, Cusimano said the questions that the psychologist allegedly asked him were red flags.

“I just don’t see, at the end of the day, under any reasonable standard, how you get to ask these questions of protected class members when you’re not asking them of members of the straight community applying for the same positions,” Cusimano said. “That’s not equal protection of the law.”

She also noted that Hamilton applied for the job just a few days after the Supreme Court ruled in June 2020 that LGBTQ people are protected from employment discrimination under federal law. Hamilton’s case, she said, is an evolution of that Supreme Court decision.

“Now that the LGBTQ community is a protected class, what are those protections?” she said. “Acting reasonably, should an employer have understood — and I say, certainly — that those protections extend to the equal hiring process, as well as all processes related to employment?”

‘The phone call never came’

Patrick Callahan, Julie Callahan’s husband, a member of TCOPS and a criminology consultant for the federal government and political groups in Washington, D.C., said he had a similar experience to Hamilton’s.

In 2006, he had a promising interview with an agency outside of Boston. The person he interviewed with “was thrilled” and said he’d call him back that Monday, Patrick Callahan recalled.

“Well, the phone call never came,” he said. “So Tuesday I gave him a call. He wouldn’t take my call. In fact, I was never able to get in contact with him again.”

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He said he found out through a friend who knew officers who worked for the department that he wasn’t hired because he’s trans.

“As soon as they got my background check back and saw those female names,” they changed their minds, he said. His friend told him it was “a joke around the department, that some ‘it thing’ wanted to work there.”

Officer Kathryn Winters, the LGBTQ liaison at the San Francisco Police Department, suspects she was the victim of a similar instance of anti-trans employment discrimination, though she was never able to confirm this.

In 2014, she applied to the Denton Police Department in Texas and took its written exam.

“I think I scored in like the top five on the written exam,” she said, noting that the scores are posted publicly. “And then a couple weeks later, [I] received a letter from the Denton Police Department stating that my military discharge form, my DD 214, wasn’t in my background packet. And for that reason, I was being completely disqualified for further consideration.”

She said she and her wife both double- and triple-checked to make sure everything was included in the application packet, including the DD Form 214, prior to its submission. She said “there’s nothing specific to indicate” that she was rejected because she’s trans, but she believes someone may have removed the form from her packet “and that was the reason they gave for not continuing with my consideration.”

A request for comment from the Denton Police Department has not been returned.

There have also been other high-profile cases of alleged anti-trans discrimination by law enforcement agencies. In 2012, Mia Macy, represented by the Transgender Law Center, successfully sued the Bureau of Alcohol, Tobacco, Firearms and Explosives after the agency offered her a job as a ballistics technician and then rescinded the job offer after she told them she was trans.

Clinicians ‘may lack the competency’

As lawsuits slowly accumulate and more people transition on the job, the culture within agencies is slowly changing, Julie Callahan said. Throughout its existence, TCOPS has seen more than 500 officers transition, she added. Trans officers have also made headlines over the last few years for being among the first in their agencies.

But supportive policies for current officers and applicants aren’t growing equally across the country. Agencies in bigger cities are more likely to have better policies, Julie Callahan said, meaning more conservative or rural areas might lack basic information about trans people, which can affect whether they’ll hire them at all.

There also aren’t clear, consistent standards across the country for how clinicians conduct psychological evaluations for law enforcement. Michael Roberts and Ryan Roberts, co-owners of Law Enforcement Psychological Services Inc., have evaluated many LGBTQ law enforcement applicants in San Francisco. They said the guidance, regulations and required continuing education for clinicians who conduct evaluations differs by state. California is among the most well-regulated states, they said.

“Police and public safety psychological assessment is a component of a specialty practice as recognized by the APA,” Michael Roberts said, referring to the American Psychological Association, “so this isn’t something that any clinician should be doing without training specific to this.”

There are laws interwoven into the process of doing psychological assessments for law enforcement candidates, such as the Americans With Disabilities Act, which someone could “run afoul of” while evaluating a trans candidate’s medical records, for example, he said.

“It is the case that people are out there — they’re probably not doing it correctly. They may be doing it without specialized training, which they shouldn’t be doing. They might lack the competency to perform the specialty function,” Ryan Roberts said.

A transgender applicant shouldn’t be disqualified simply for having been diagnosed in the past with gender dysphoria — a diagnosis that is often necessary to receive certain medical treatment, according to Michael Roberts.

“You cannot use just the fact that they had gender dysphoria or they attempted suicide five years ago or something like that. That wouldn’t cut it; they have to dig down deeper,” he said.

Given the allegations in Hamilton’s case, he said, it sounds like that’s what the psychologist did.

Julie Callahan said she knows of trans law enforcement candidates who were disqualified for past suicidal ideation, which 81 percent of trans adults have reported experiencing, according to the 2015 U.S. Transgender Survey.

Many therapists who are evaluating law enforcement candidates “don’t understand that once you’ve dealt with your gender issues, any kind of suicidal ideation has gone away, because you’ve removed the impetus for it,” she said.

‘We’re in an untenable position as transgender cops’

Another barrier to better policy for trans officers and prospective officers is the broader conversation about criminal justice reform, which is happening alongside recent efforts to ban law enforcement at Pride parades, Patrick Callahan said.

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Trans people disproportionately face violence and mistreatment from law enforcement, leading advocates to push for reform or, in some cases, for replacing law enforcement agencies with social support services and other community-led, violence-prevention efforts.

According to a 2011 report from the National Center for Transgender Equality, nearly half of trans people reported they are uncomfortable seeking police assistance. More than one-fifth (22 percent) of trans people who had interacted with police reported police harassment, and 6 percent of trans individuals reported they experienced bias-motivated assault by officers. Those rates were higher for Black transgender people: 38 percent reported that they faced biased harassment, and 15 percent reported assault motivated by bias.

Patrick Callahan said most LGBTQ rights groups see trans officers as the “enemy,” and they “don’t speak to us at all,” even though trans officers face the same discrimination and harassment as trans people in other fields.

“They shut us out automatically, because we’ve crossed a line somewhere,” he said. “We are not trans enough anymore. We are not LGBTQ enough anymore … and we get the same from people within the law enforcement community. Right now, we’re in an untenable position as transgender cops. Actually, anybody in the LGBTQ community who is law enforcement, we’re just in a position where we can’t affect change, because we aren’t being allowed to even by the very people that we would most like to help.”

For Hamilton, things are also moving slowly. Cusimano said it could take up to a year for the Louisiana EEOC to complete its investigation. But Hamilton said the experience hasn’t affected his goals.

“I still want to work in law enforcement,” he said. “At the beginning, I’m not going to lie, I was super, super disappointed, especially disappointed with NOPD. But this is still a dream of mine.”