Hate Crime, Medical Care, and Mental Health Care for Transgender Individuals

Frequently over the past few months, prominent transgender individuals were featured in U.S. news media, portrayed somewhat more sympathetically than in the past. Celebrities have been applauded for their courage in transitioning to their authentic selves, assisted in their transition by hormonal and/or surgical treatment. These portrayals in the popular press might suggest that transphobia and discrimination against the transgender population is declining. The headline of a recent article in JAMA proclaims that “transgender care moves into the mainstream” (Buchholz, 2015, p. E1). Yet another headline, in the latest issue of Intelligence Report, proclaims that “murder of trans women this year hits new high” (Potok & Terry, 2015, p. 3). According to the article, the murder victims ranged in age from 17 to 66 and lived in locations as diverse as California, Missouri, and Florida. Gruesome details of the violent deaths of both trans men and women, including beating and throat slashing, were provided in the article.

I remember an editorial I wrote more than a decade ago about hate crime against transgendered individuals (Thomas, 2004). My research for that editorial had introduced me to the deeply disturbing world of harassment and physical attacks against transgendered people. The compelling question, “Why did Stephanie Thomas have to die?” was posed on the cover of a 2003 issue of Intelligence Report. Stephanie's story, vividly told by Moser (2003), prompted my editorial and stayed in my mind afterward, perhaps because of the similarity of our names. Stephanie was shot to death in Washington, DC, simply because she was living as a woman despite being born with a man's anatomy. Obviously, this kind of hatred is still with us, and I do not have the prescription for extinguishing it, but I want to devote this editorial to what we health care professionals can do.

When we speak of trans people, we are talking about 700,000 human beings in the United States (Buchholz, 2015). Not only do they deserve the chance to live their lives without fear of violent crime, but also to receive comprehensive and respectful psychological and medical treatment. Yet, a national survey showed that 28% of transgender and gender-nonforming respondents had been harassed in a medical setting and 19% had been refused medical care (2011 National Center for Transgender Equality/National Gay and Lesbian Task Force Report, cited in Buchholz, 2015). In another study, health care was the most common arena in which discrimination was reported by transgender individuals, and 25% of participants reported inability to obtain needed counseling or psychotherapy (Bradford, Reisner, Honnold, & Xavier, 2013). A participant in a qualitative study stated that her local psychiatrist refused to see transgender patients; another interviewee spoke of an aversion therapist who called her “a freak of nature… a pervert… sexually immature” (McCann, 2015, p. 78).

Guidelines for clinical practice (based on consensus of experts rather than research) have been published by the World Professional Association for Transgender Health (http://bit.ly/1HZ7Mjk), but it is unclear how widely the guidelines have been adopted. An Institute of Medicine Report issued in 2011, titled “The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding” noted that the research base on transgender-specific issues was “so thin that the word ‘gap’ wasn't applicable” (cited in Buchholz, 2015, p. E1). A few researchers have begun to conduct studies using community-based participatory research principles, in which transgender people themselves are involved in study design, data collection, and other aspects of the research (Bradford et al., 2013). But, my foray into the literature while writing this editorial still suggests insufficient focus on transgender. In most articles, transgender people were always grouped with lesbian, gay, and bisexual people as though LGBT people were a homogeneous group. (I did not conduct a formal, systematic literature review; in fact, I invite submission of such a review to the journal.)

High rates of substance abuse and suicide attempts in this population mandate attention of psychiatric-mental health care providers. Transgender people have higher suicide rates than lesbian, gay, and bisexual people (Moody, Fuks, Pelaez, & Smith, 2015), mandating particular attention to suicide prevention efforts. Moody et al. conducted a qualitative study exploring suicide protective factors, as identified by a sample of Canadian trans adults participating in an internet listserve. Among findings that would be consistent with suicide protective factors in other populations (e.g., social support), a unique deterrent to suicide reported by the trans individuals was a felt responsibility to be a positive role model for their community:

I cannot steal other people's hope, and I wouldn't want to take others with me by killing myself!

Knowing that dead trans folk cannot change the world keeps me from doing it. (Moody et al., 2015, p. 275).

My challenge to readers is for all of us to make a commitment to be compassionate, trans-affirmative role models for other providers of psychiatric-mental health and medical care. As recommended by Moody et al. (2015), all of us “can advocate for trans-affirmative cultural competency trainings in [our] places of work and can advocate for trans rights generally, in broader society” (p. 277). We can broaden our knowledge of transgender issues and the community resources, such a peer support groups that may be available to them. We can participate in the accumulation of empirical evidence regarding psychological interventions that can be critical in deterring suicides and instilling hope. The transformative power of one sentence by a therapist is illustrated in the following excerpt from McCann's (2015) qualitative data:

The one thing that he did say, I’ll never forget it…’You’ve such hope.’ …That sentence just…made me feel like a human being. I was elated because it wasn't my fault.I was born this way. I’d spent 43 years blaming myself. It was a powerful moment. (p. 78)

Your manuscripts about clinical interventions and community advocacy will be welcomed in this journal.

Declaration of Interest

Declaration of Interest: The author reports no conflict of interest. The author alone is responsible for the content and writing of this paper.