Research Question
My research question was as follows: How has being trans impacted young adults’ healthcare experiences at Purdue?
I knew from my own experiences that coming out in a medical environment can be overly complicated and result in discrimination, but I had never asked my trans friends before about what their experiences had been. This whole journey started when I was at OutFest, Lafayette's version of pride, and walked by the IU Health booth. The nurses were asking me and the people I was with about our identities and other fairly basic questions. But it made me realize how little they knew about the LGBTQ+ community, and I decided to learn more about LBGTQ+ healthcare when I got back to Purdue. I looked up the website and patient portal of PUSH, Purdue's student clinic, and I saw that there was significant room for improvement. Alongside a friend of mine, I began working with PUSH, presenting to their leadership, about what other schools were doing and how Purdue compared. PUSH agreed to make some changes to their patient portal, although these changes have been put on hold due to the global pandemic. I then wanted to learn about the students' experiences with the healthcare services prior to making the changes, which is where this project came in.
I knew from my own experiences that coming out in a medical environment can be overly complicated and result in discrimination, but I had never asked my trans friends before about what their experiences had been. This whole journey started when I was at OutFest, Lafayette's version of pride, and walked by the IU Health booth. The nurses were asking me and the people I was with about our identities and other fairly basic questions. But it made me realize how little they knew about the LGBTQ+ community, and I decided to learn more about LBGTQ+ healthcare when I got back to Purdue. I looked up the website and patient portal of PUSH, Purdue's student clinic, and I saw that there was significant room for improvement. Alongside a friend of mine, I began working with PUSH, presenting to their leadership, about what other schools were doing and how Purdue compared. PUSH agreed to make some changes to their patient portal, although these changes have been put on hold due to the global pandemic. I then wanted to learn about the students' experiences with the healthcare services prior to making the changes, which is where this project came in.
Introducing the Interviewees
I interviewed four different individuals. Under pseudonyms, here are brief descriptions and a quote from each individual.
Logan: Agender, AMAB, African-American and originally from California but moved around frequently. Panromantic and gray-ace. Recently graduated from Purdue.
"...in some places it says male and in some places it says female. And that's crazy. The dichotomy of, of weirdness of being trans where you're listed as and labeled... so like from the VA they send me stuff like, Oh, are you doing like monthly breast exams and like are you checking or have you been checked for like ovarian cysts, I'm like, 'I don't have any of those parts.'"
Zara: Trans Female, AMAB, White, and from Indiana, pansexual; still a student.
"I get weird looks from the lab people in the basement of PUSH. Not all of them, but some of them. CVS's mobile app doesn't like me and it won't let me find my prescriptions because some parts of the CVS system have me marked as male and some of them have me marked as female. And I can't seem to figure out how to remedy that."
Malik: Genderqueer, AFAB, Mixed-race (African-American and White). From Indiana, bisexual, and about to graduate.
"So, I was just like, you know, this is how I identify. And she was like... 'Cool. You have a fever.'"
Alex: Transmasculine, AFAB, White, from Northern Texas. Queer, and is no longer a student, but was a grad student at Purdue and now works at Purdue.
"We were making small talk and she asked me, my last menstrual cycle was, and I laughed. I said, 'Oh, it's been awhile.' And she just stared at me like she just stopped and was like, 'why?'"
Logan: Agender, AMAB, African-American and originally from California but moved around frequently. Panromantic and gray-ace. Recently graduated from Purdue.
"...in some places it says male and in some places it says female. And that's crazy. The dichotomy of, of weirdness of being trans where you're listed as and labeled... so like from the VA they send me stuff like, Oh, are you doing like monthly breast exams and like are you checking or have you been checked for like ovarian cysts, I'm like, 'I don't have any of those parts.'"
Zara: Trans Female, AMAB, White, and from Indiana, pansexual; still a student.
"I get weird looks from the lab people in the basement of PUSH. Not all of them, but some of them. CVS's mobile app doesn't like me and it won't let me find my prescriptions because some parts of the CVS system have me marked as male and some of them have me marked as female. And I can't seem to figure out how to remedy that."
Malik: Genderqueer, AFAB, Mixed-race (African-American and White). From Indiana, bisexual, and about to graduate.
"So, I was just like, you know, this is how I identify. And she was like... 'Cool. You have a fever.'"
Alex: Transmasculine, AFAB, White, from Northern Texas. Queer, and is no longer a student, but was a grad student at Purdue and now works at Purdue.
"We were making small talk and she asked me, my last menstrual cycle was, and I laughed. I said, 'Oh, it's been awhile.' And she just stared at me like she just stopped and was like, 'why?'"
Main Interview Themes & Significance
As I begin this analysis of the primary themes that emerged from the anthropological interviews, I will start with a brief background of the development of some of the primary ideas that I encountered. In order to appreciate and understand the identities of those interviewed as well as the identity of the author, one must first acknowledge that gender is a social construct. Gender is constructed by our societies - by our languages and by our cultures. There is a distinct difference between one’s gender and one’s sex, and even sex is not binary. These are conclusions that have emerged from decades of research on Queer Theory, Anthropology, and Sociology; and as a result, are presented as tenants of theory on gender and are seen to thoroughly disprove the social construct of the gender binary, which claims that there are only two categories, male and female. As for a few definitions: Transgender refers to individuals whose gender identity differs from their sex assigned at birth, whereas cisgender individuals’ sex assigned at birth and their gender align. These will be referred to as “trans” and “cis” throughout this project (Fenway Health 2010). AFAB is assigned female at birth, while AMAB is assigned male at birth. Nonbinary or genderqueer individuals are often seen as falling under the transgender umbrella, as nonbinary and genderqueer individuals do not identify with their sex assigned at birth, but rather fall outside of the traditional binary. To give an idea of the scale of this specific subgroup, nonbinary individuals made up over one third of the respondents of the 2015 US Transgender Survey (USTS) (James et al., 2016).
It is important to note that within the LGBTQ+ community, there are different dimensions of inequality which can be noted. This project is focused on individuals who self-identified as minorities of both gender and sexual orientation, some of whom are also minorities in the form of their race. This specific analysis will not delve into race-based differences in healthcare, as that was not a specific line of questioning. However, it must be noted that trans people of color are clearly facing greater disparities than white and white-passing trans individuals, with the 2015 USTS stating, “transgender people of color experience deeper and broader patterns of discrimination than white respondents” (James et al., 2016). This analysis will be focused on individuals from the US who are either African-American, White, or a mix of the two, and therefore will not discuss the “third gender” categories present in many cultures (including Native American cultures). The person who conducted the interviews is also a part of the trans community, and therefore cannot be entirely unbiased.
One of the main themes that emerged from the interviews was that medical professionals hold bias, sometimes unconsciously, that leads them to be surprised when a transgender patient appears in their office. The expectation in our society is that people are cisgender, and this bias can be called cisgender bias, or cisnormativity. This terminology emerged first from the concept of heteronormativity, which can be described as transforming “heterosexuality from a naturalized and unmarked identity into an object of analysis” (Compton, Meadow, & Schilt 2018). This is key to thinking anthropologically - making the strange familiar and making the familiar strange. Interrogating the concept of heteronormativity led to the ideas of sexuality best summed up by Vivian Namaste, arguing, “if we focus only on the ‘subculture’ of homosexuality, and if we never interrogate the conditions which engender its marginalization, we shall remain trapped within a theoretical framework which refuses to acknowledge its own complicity in constructing its objects (and subjects) of study” (Compton, Meadow, & Schilt 2018). This is the ideology which must be brought forward and analyzed, in that action must come from research. The goal of this research is to bring attention to specific challenges that trans people are experiencing in the healthcare setting through cisgender bias, the invasive nature of some questions, and mental illness being equated with transness; ultimately resulting in action in the local communities to improve their cultures and systems.
Returning to the concept of cisgender bias - one of the interviewees, under the pseudonym of Alex, summed up the emotional side of this concept fairly well. He stated, “I always joke that like, I wish I could warn [the providers] - not ‘cause I feel like I need a warning label before someone sees me. But, ‘cause I think it unfortunately, providers assume that their patients are going to be straight and cisgender. They don't even have language for that, right? They don't even acknowledge often that that is an assumption that they have because they don't know that that's an assumption that they're making.” This concept was repeated throughout the interviews in the form of general surprise and confusion by providers.
Another concept which was consistent throughout the interviews was the feeling that certain questions and requirements were overly invasive. While the individuals’ opinions on these experiences differed, there was a consensus that certain lines of questioning were not appreciated. Malik, who is genderqueer and bisexual as well as a person of color, experienced lines of questioning regarding their bisexuality, which they found is often equated to promiscuity. The emotional impact of these questions was evident, and they stated that the medical professionals have asked, “‘What's your sexual history? How many people have you had sex with?’ These are not authorized questions. You do not ask these questions, especially if you're not a gynecologist, you do not ask these questions.” Zara had similar difficulties, and had a similar reaction to questions regarding identity. Her opinion was that “the letter from the therapist and the physical are both incredibly unnecessary and invasive and should not be part of the process.” Overall, the consensus is that trans individuals are more aware of certain boundaries being crossed in part due to previous negative experiences. Another example of this is with Alex, who needed an injection in a tendon of his leg. The doctor proceeded to ask about “sexual reassignment surgeries,” (now referred to as gender affirming surgeries) and, “before I could say anything else, he was like, ‘have you had any, are you planning to?’” There was no reason for a cortisone shot in a tendon to turn into a conversation about Alex’s transition, and asking about someone’s genitalia is never appropriate. As a result of experiences like these, the natural inclination is to become wary and reluctant about allowing individuals access to one’s body. Malik, who is AFAB and genderqueer, echoed this, stating that, “I think one of the biggest concerns I have is gynecology with being trans.” These concerns are valid, and they are also backed up by the statistics. In K-12 school alone, 77% of individuals surveyed in the US Transgender Survey reported that they were mistreated in some way (such as being harassed or assaulted) because people thought they were transgender. This does not account for the entirety of one’s life beyond this stage.
Because of reasons like this, many trans people struggle to picture a life beyond their current state. While I did not ask specifically about mental health experiences, many of the individuals interviewed mentioned their mental health treatment. One person I interviewed stated that they were treated in an inpatient facility for their mental health conditions, stating that they, “had to be very roundabout or vague with [their] gender identity.” It is quite common for trans people to experience mental health conditions and the associated distress - according to the 2015 US Transgender Survey, “40% [of respondents] have attempted suicide in their lifetime, nearly nine times the rate in the US population (4.6%)” (James et al., 2016). It is important to not equate being transgender with being mentally ill, however. Malik had an instance in which a medical provider claimed that their [gender] dysphoria was linked to their depression because they are confused about their gender, to which they told me, “No, shut up. I know my gender.” With gender dysphoria still listed as a disorder in the DSM-V, having one’s dysphoria equated with being just a mental illness is not uncommon. In fact, the author of this was diagnosed with “transsexualism” according to the ICD-10, which is the 2019-2020 version.
As stated earlier, The goal of this research is to bring attention to specific challenges that trans people are experiencing in the healthcare setting through the lenses of cisgender bias, the invasive nature of certain questions, and mental illness being equated with transness, with the ultimate result being action in the local communities to improve the cultures and systems. There were far more relevant examples and excellent quotations which should have been included in this analysis, however for the sake of brevity and staying somewhat close to word count, they have not been included.
It is important to note that within the LGBTQ+ community, there are different dimensions of inequality which can be noted. This project is focused on individuals who self-identified as minorities of both gender and sexual orientation, some of whom are also minorities in the form of their race. This specific analysis will not delve into race-based differences in healthcare, as that was not a specific line of questioning. However, it must be noted that trans people of color are clearly facing greater disparities than white and white-passing trans individuals, with the 2015 USTS stating, “transgender people of color experience deeper and broader patterns of discrimination than white respondents” (James et al., 2016). This analysis will be focused on individuals from the US who are either African-American, White, or a mix of the two, and therefore will not discuss the “third gender” categories present in many cultures (including Native American cultures). The person who conducted the interviews is also a part of the trans community, and therefore cannot be entirely unbiased.
One of the main themes that emerged from the interviews was that medical professionals hold bias, sometimes unconsciously, that leads them to be surprised when a transgender patient appears in their office. The expectation in our society is that people are cisgender, and this bias can be called cisgender bias, or cisnormativity. This terminology emerged first from the concept of heteronormativity, which can be described as transforming “heterosexuality from a naturalized and unmarked identity into an object of analysis” (Compton, Meadow, & Schilt 2018). This is key to thinking anthropologically - making the strange familiar and making the familiar strange. Interrogating the concept of heteronormativity led to the ideas of sexuality best summed up by Vivian Namaste, arguing, “if we focus only on the ‘subculture’ of homosexuality, and if we never interrogate the conditions which engender its marginalization, we shall remain trapped within a theoretical framework which refuses to acknowledge its own complicity in constructing its objects (and subjects) of study” (Compton, Meadow, & Schilt 2018). This is the ideology which must be brought forward and analyzed, in that action must come from research. The goal of this research is to bring attention to specific challenges that trans people are experiencing in the healthcare setting through cisgender bias, the invasive nature of some questions, and mental illness being equated with transness; ultimately resulting in action in the local communities to improve their cultures and systems.
Returning to the concept of cisgender bias - one of the interviewees, under the pseudonym of Alex, summed up the emotional side of this concept fairly well. He stated, “I always joke that like, I wish I could warn [the providers] - not ‘cause I feel like I need a warning label before someone sees me. But, ‘cause I think it unfortunately, providers assume that their patients are going to be straight and cisgender. They don't even have language for that, right? They don't even acknowledge often that that is an assumption that they have because they don't know that that's an assumption that they're making.” This concept was repeated throughout the interviews in the form of general surprise and confusion by providers.
Another concept which was consistent throughout the interviews was the feeling that certain questions and requirements were overly invasive. While the individuals’ opinions on these experiences differed, there was a consensus that certain lines of questioning were not appreciated. Malik, who is genderqueer and bisexual as well as a person of color, experienced lines of questioning regarding their bisexuality, which they found is often equated to promiscuity. The emotional impact of these questions was evident, and they stated that the medical professionals have asked, “‘What's your sexual history? How many people have you had sex with?’ These are not authorized questions. You do not ask these questions, especially if you're not a gynecologist, you do not ask these questions.” Zara had similar difficulties, and had a similar reaction to questions regarding identity. Her opinion was that “the letter from the therapist and the physical are both incredibly unnecessary and invasive and should not be part of the process.” Overall, the consensus is that trans individuals are more aware of certain boundaries being crossed in part due to previous negative experiences. Another example of this is with Alex, who needed an injection in a tendon of his leg. The doctor proceeded to ask about “sexual reassignment surgeries,” (now referred to as gender affirming surgeries) and, “before I could say anything else, he was like, ‘have you had any, are you planning to?’” There was no reason for a cortisone shot in a tendon to turn into a conversation about Alex’s transition, and asking about someone’s genitalia is never appropriate. As a result of experiences like these, the natural inclination is to become wary and reluctant about allowing individuals access to one’s body. Malik, who is AFAB and genderqueer, echoed this, stating that, “I think one of the biggest concerns I have is gynecology with being trans.” These concerns are valid, and they are also backed up by the statistics. In K-12 school alone, 77% of individuals surveyed in the US Transgender Survey reported that they were mistreated in some way (such as being harassed or assaulted) because people thought they were transgender. This does not account for the entirety of one’s life beyond this stage.
Because of reasons like this, many trans people struggle to picture a life beyond their current state. While I did not ask specifically about mental health experiences, many of the individuals interviewed mentioned their mental health treatment. One person I interviewed stated that they were treated in an inpatient facility for their mental health conditions, stating that they, “had to be very roundabout or vague with [their] gender identity.” It is quite common for trans people to experience mental health conditions and the associated distress - according to the 2015 US Transgender Survey, “40% [of respondents] have attempted suicide in their lifetime, nearly nine times the rate in the US population (4.6%)” (James et al., 2016). It is important to not equate being transgender with being mentally ill, however. Malik had an instance in which a medical provider claimed that their [gender] dysphoria was linked to their depression because they are confused about their gender, to which they told me, “No, shut up. I know my gender.” With gender dysphoria still listed as a disorder in the DSM-V, having one’s dysphoria equated with being just a mental illness is not uncommon. In fact, the author of this was diagnosed with “transsexualism” according to the ICD-10, which is the 2019-2020 version.
As stated earlier, The goal of this research is to bring attention to specific challenges that trans people are experiencing in the healthcare setting through the lenses of cisgender bias, the invasive nature of certain questions, and mental illness being equated with transness, with the ultimate result being action in the local communities to improve the cultures and systems. There were far more relevant examples and excellent quotations which should have been included in this analysis, however for the sake of brevity and staying somewhat close to word count, they have not been included.
Reflection
This project was highly interesting to me. In a sense, I felt a sense of understanding by hearing the stories of others in that I know I’m not alone. Without delving too much into the details, I have been a subject of fascination by doctors regarding my natural hormone levels and resulting changes as I was hitting puberty. I am technically and officially AFAB, but I never quite fit into the binary. This assignment has left me wanting to know so much more about what can be done to adapt the systems (cistems) that we have to fit the more modern understanding of individuals beyond the gender binary. I was also “diagnosed” with transsexualism by a psychiatrist, and recognize that as our medical systems adapt, our mental health systems are just as important, if not more important, as our physical health facilities. I, too, have my own stories about overly curious and invasive doctors. I found it surprising that, as I was interviewing, the stories did not impact me as much as I expected, but then transcribing them was when the impact of the stories really hit me. Perhaps it was a matter of location - I was alone in my childhood bedroom as I was transcribing. That aspect of it was challenging, but worth it. I hope to be able to use an amalgamation of the stories to continue to work to persuade PUSH to make the changes I suggested at the end of the Fall Semester.
I want to expand my research to include more interviews, as well as into other medical experiences such as blood donation, as a cis gay male mentor of mine led me to look up the specific rules and regulations of The Red Cross, regarding trans people as well, and I lack the vocabulary to describe how disappointed I was with what I found. Overall, though, I thoroughly enjoyed working on this project.
I want to expand my research to include more interviews, as well as into other medical experiences such as blood donation, as a cis gay male mentor of mine led me to look up the specific rules and regulations of The Red Cross, regarding trans people as well, and I lack the vocabulary to describe how disappointed I was with what I found. Overall, though, I thoroughly enjoyed working on this project.
References
Compton, D’Lane R., Meadow, Tey, Schilt, Kristen. (2018). “Other, Please Specify: Queer Methods in Sociology.” Print.
Fenway Health. 2010. Retrieved from: https://fenwayhealth.org/documents/the-fenway-institute/handouts/Handout_7-C_Glossary_of_Gender_and_Transgender_Terms__fi.pdf
James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). Executive Summary of the Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality. Retrieved from: https://transequality.org/sites/default/files/docs/usts/USTS-Executive-Summary-Dec17.pdf
Fenway Health. 2010. Retrieved from: https://fenwayhealth.org/documents/the-fenway-institute/handouts/Handout_7-C_Glossary_of_Gender_and_Transgender_Terms__fi.pdf
James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). Executive Summary of the Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality. Retrieved from: https://transequality.org/sites/default/files/docs/usts/USTS-Executive-Summary-Dec17.pdf