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The Trump Administration’s Hateful Message on Health Care for Transgender Americans - The New Yorker

Protestors outside of the White House
Demonstrators gather in front of the White House in October, 2018, for a #WontBeErased rally to defend transgender equality.Photograph by Carolyn Kaster / AP / Shutterstock

On Friday, the Trump Administration released a set of guidelines dictating that discrimination against L.G.B.T. people in health care is not forbidden. It was the fourth anniversary of the Pulse massacre, when forty-nine people were murdered in a gay night club in Orlando, Florida. It was three months and one day since the World Health Organization declared the coronavirus a global pandemic. It was days, perhaps a week or two, before the Supreme Court is expected to release its ruling on whether discrimination on the basis of sexual orientation or gender identity is illegal under Title VII of the Civil Rights Act.

The timing is conspicuous. The new document reverses a rule, put in place by the Obama Administration, in 2016, that banned health-care providers from discriminating on the basis of gender identity or whether a patient had sought an abortion. The Obama-era rule was immediately challenged in court and still hasn’t taken effect, so the new rule serves only to put an end to that particular legal battle—and to draw attention to the issue. The new document claims that the Department of Health and Human Services lacked the authority to try to implement the old rule in the first place.

If the Supreme Court, in its forthcoming decision, rules that discrimination on the basis of sexual orientation or gender identity, or both, constitutes discrimination on the basis of sex, which is banned by Title VII, then the three-hundred-page document published, on Friday, by Health and Human Services will be rendered legally irrelevant: the discrimination it encourages will be banned. That the Administration decided to speak now suggests that it was rushing to raise its voice in favor of discrimination before the Supreme Court either preëmpted or weakened the rhetorical impact of the rule. The H.H.S. document is a statement not of policy but of hatred. Its message is amplified by its appearance on the anniversary of the largest mass murder of queer people in U.S. history. This was the day the Administration chose to try to inhibit L.G.B.T. people’s access to health care—in the middle of a deadly pandemic.

The document contains a long list of comments submitted by members of the public in response to the original draft of the rule, and detailed responses from H.H.S. One such response reads, in part, “A healthcare provider is not impermissibly stereotyping biological males (notwithstanding their internal sense of gender) on the basis of sex if it uses pronouns such as ‘him’; limits access to lactation rooms and gynecological practices to female users and patients; or lists a male’s sex as ‘male’ on medical forms. Similarly, a covered health care entity is not impermissibly stereotyping biological females (notwithstanding their internal sense of gender) on the basis of sex if it uses pronouns such as ‘her’; warns females that heart-attack symptoms are likely to be quite different than those a man may experience; advises women that certain medications tend to affect women differently than men; or lists a female’s sex as ‘female’ on medical forms. Finally, it is not stereotyping for covered entities to have bathrooms or changing rooms designated by reference to sex, or to group patients in shared hospital rooms by sex.”

As innocuous as that quote might read to someone who has not spent time thinking about issues that transgender people face when seeking health care, it is certain to send shivers down the spine of any trans person, because it conjures a specific series of images: a transgender woman, in a doctor’s waiting room, being referred to as “he”; a trans man being refused access to a gynecologist’s office; transgender people receiving inappropriate medical advice and pharmacological guidance based solely on the sex indicated in their medical records, without regard for surgeries and hormonal treatments that change their physiology; and, of course, trans people unable to use the bathroom in a health-care facility. All of this, the document says, is all right—indeed, it seems to indicate that this is the desirable state of affairs.

The H.H.S. rule cannot force doctors to start discriminating against trans patients; it can only broadcast the Administration’s attitudes. In fact, trans people as a group are at once unusually dependent on the health-care system—for many of us, trans care that may include hormonal treatments or surgeries is vital—and accustomed to facing casual, systematic discrimination. I have written about my own experience of landing in a New York City emergency room with a broken jaw and being compelled to take a pregnancy test in order to have a CT scan—despite being transgender, being on testosterone, having undergone a radical hysterectomy, and being past child-bearing age, but solely because my medical records indicated that I had been born female. As a well-insured privileged white person in New York City, I was able to win that fairly inconsequential battle (if I’d lost, I would have had to pee in a cup), but it was an example of the sort of obstacles health-care providers unthinkingly and automatically throw up in front of trans patients. For many people, the stakes are much higher than they were for me. On trans men’s online forums, I frequently read accounts of being unable to obtain gynecological care. Trans care is often illegally carved out of insurance coverage, forcing people to crowdfund their surgeries or buy hormones on the black market. Lack of access to trans care leads to another important health concern: the risk of suicide, which is far higher for trans people than it is for other Americans.

In April, the Williams Institute, an L.G.B.T. policy think tank at the U.C.L.A. School of Law, released a report on vulnerabilities to COVID-19 that are specific to transgender adults in the United States. The report estimates that nearly half a million people—a third of all adult transgender Americans—“feel concerned that if they express their gender identity, they could be denied good medical care.” Nearly as many reported that they had not gone to the doctor within the past year because they could not afford it. Trans people are more likely to be homeless, and L.G.B.T. people are more likely to be regular smokers than other Americans—two more factors that translate into a higher risk of dying from a coronavirus infection. The new H.H.S. rule may not have an immediate effect on trans people’s experience of health care, because legally, it changes nothing, but at this moment in time, it broadcasts a clear message from the Trump Administration to trans Americans. That message is that they want us dead.

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