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Gabrielle Beck is a high school student at Tenafly High School in New Jersey. She is an avid analog photographer and hopes to combine her love for activism with photography. She started a research initiative with the City College of San Francisco studying trans-affirming and non-binary inclusive care needs and plans to pursue public health and public policy.

Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) populations are disproportionately affected by limited health care access, poor health outcomes, and mistreatment in health care settings. Despite these disparities, comprehensive approaches to improve the quality of health care of LGBTQ patient populations are currently lacking. In addition, numerous states have passed a series of unprecedented legislation aimed at the trans community, such as Arkansas which has banned critical, gender-affirming medical care for transgender children, and Tennessee which has prohibited hormone treatments for transgender youth. 

Publication fellow Gabrielle Beck (she/her/hers) recently sat down with Professor Pau Crego Walters (he/him/his), Deputy Director & Director of Policy and Program at the Office of Transgender Initiatives at City and County of San Francisco, Professor at the City College of San Francisco, former Lecturer at UC Berkeley School of Public Health, and trans/queer activist based in San Francisco, California, to discuss the state of healthcare for LGBTQ communities and the future for reform. 

What are the current disparities for LGBTQ communities in healthcare?

There are too many to list exhaustively, but the main point I want to make is that there's a lot of health inequities experienced by LGBTQ communities as a whole compared to the general population. In addition, there are also a lot of inequities within the LGBTQ community. For instance, it's not the same to be a Black LGBTQ person and a white LGBTQ person. There's a lot of inequities between the trans community and the rest of the LGBTQ community, or even women who are LGBTQ versus men who are LGBTQ. It is very different based on the sub-population, but we know that if we look at LGBTQ communities as a whole, we experienced higher rates of mental health issues, substance use, including tobacco use, HIV, sexually transmitted infections, cancer, hepatitis C, and many more. 

The reason for that, at least in part, has to do with social determinants of health, which are the economic and social conditions that influence differences in health status. While there are some disparities in health status for LGBTQ people compared to the general population that may have to do with different kinds of practices, the inequities we see are really about the history of oppression and the current oppression that the LGBTQ community experiences, such as barriers around immigration, the criminal justice, racism, trauma, poverty, homelessness, lack of family, and community acceptance, etc. It's a really important piece to highlight because the common misconception is that LGBTQ people are just more unhealthy, but it really is all these factors that can lead members of the LGBTQ community to sometimes engage in coping mechanisms that can be harmful to health like smoking, using substances, or engaging in behaviors that may put someone at higher risk for HIV and STIs. 

According to the Trevor Project, 42% of LGBTQ youth seriously considered attempting suicide in the past year, including more than half of transgender and nonbinary youth. In addition, more than 80% of LGBTQ youth stated that COVID-19 made their living situation more stressful — and only 1 in 3 LGBTQ youth found their home to be LGBTQ-affirming. How has the pandemic exacerbated health disparities for the LGBTQ community?    

For LGBTQ youth, a big source of stress and negative mental health issues can be a lack of acceptance in their families. I could see how COVID-19 has made young people's living situations more stressful because often families of origin, or birth families, are not accepting of LGBTQ identities, or at least not at first, but it's hard to be in a space when families are not accepting. When it's not a global pandemic and we don't have to be stuck at home, we can find other communities that feel more validating and safe. For young people as a whole, isolation and loss of community has been detrimental, but it's really key for communities like LGBTQ communities because we sometimes don't have those family-of-origin relationships to fall back on.

There are other ways in which the pandemic has exacerbated health disparities. For example, many LGBTQ people work in industries that have been affected by COVID-19, like retail, restaurants, healthcare, or education, which can lead to more exposure to COVID-19.  We also know that LGBTQ people are poorer than the general population, especially Black, Indigenous, Latinx, immigrants, and trans people. COVID-19 has impacted these vulnerable sub-populations significantly because the landscape of the economy has completely changed, and folks who did not have a safety net financially before were left with even less of a safety net due to COVID-19. Not having the minimum resources to survive significantly affects your mental and physical health. There's a lot of research showing how our mental health changes the chemistry of our body, making us more vulnerable to physical health problems. Moreover, if someone has fewer economic resources, then they have fewer resources to go and get health care, even if they overcome distrust towards the system, which is particularly prominent among LGBTQ sub-populations. 

On April 6, the Arkansas state legislature passed HB 1570, the first bill in the U.S. that effectively bans trans youth from transitioning. Specifically, it bans gender-affirming care for trans youth, making it illegal for clinicians to provide hormone therapy and puberty blockers. In addition, The Human Rights Campaign has called 2021 the worst year for anti-LGBTQ legislation in recent history. What are the repercussions of the current political climate hostile to gender-affirming healthcare for the trans community? 

The repercussions are devastating. Accessing gender-affirming health care for trans people is a medical necessity. For a lot of us, it really is a life or death situation, not only for mental health reasons but also in terms of our ability to navigate spaces like school, work, and our daily lives. Sometimes people are just outright violent towards us if they perceive us as trans, but even when people have good intentions when they just don't see us for who we are, that has a devastating effect on mental health and our ability to be resilient.

The current legislation, like the one that you mentioned that has passed, but also all the proposed bills that have been popping up throughout the country, are devastating for trans people everywhere in terms of mental health to see that so many places are actually considering and wanting to take away our basic health care. It adds to our lack of safety and sense of alienation in the world. It demonstrates how tenuous trans people's basic rights are.  If we think about what would happen to communities that have dominant cultural power — this would never happen to cis, white, straight men since they would never get their rights taken away. It just speaks to the transphobia that is still present in our legal and healthcare system. 

What is the future of policy reform for the health system to provide better gender-affirming and adequate care? 

My ideal future policy reform for the healthcare system would be universal health care, because we know that when we live in communities where there is inequity, it actually impacts the entire health of the community, not just the people who have the worst outcomes. For example, we know that when there's a huge economic imbalance within a community that affects the health of everyone in that community, even the rich people. Universal healthcare is a way to equalize the current state of health to also make sure that everyone's basic needs are met. 

But beyond that, the future of gender-affirming care would be mandatory training for medical providers on trans and LGBTQ health issues and needs, as well as cultural humility on how to actually provide that care. In addition, our healthcare system is deeply infused with assumptions about bodies, gender, and sexuality. For example, why do we call certain types of services women's health when not all women have those body parts and people who are not women also have those body parts, or how we talk about how babies develop in utero, in terms of sex assigned at birth and gender identity. In addition, the current healthcare system makes assumptions about people's sexualities, not just in terms of sexual orientation, but also sexual practices that could actually be related to what care somebody needs. This is all to say that there needs to be a revamping of the health system addressing those assumptions from the ground up. 

In terms of gender-affirming transition level treatment, the US still has a long way to go in terms of making transition-related treatment based on self-determination and not based on gatekeeping. Currently, most places in the US have a system that requires trans people to get letters from therapists to get medical transition care to show that we are truly trans. Even after that, there are still a lot of assumptions in the process of accessing gender-affirming treatment. For example, you have to first take hormones, then have to have surgery, but there’s no research to back that rigid process up. It really is about how cis people who control our healthcare system have designed it in a way that makes them feel comfortable. The last piece I'll say about transition-related treatment is there's still a lot of rhetoric around medical transition being about “fixing” something or addressing suffering. I know that some trans people do suffer with the ways in which they want to have gender-affirming care and can't access that, but I wish that it were more based on self-determination and what someone wants and needs versus having to prove that they're suffering in order to receive treatment.

What are the benefits and drawbacks of different policy reforms at the local, state, or federal level?

The US is very piecemeal in terms of policy. In some ways this has some benefits because policy reform can happen at the local level where it's easier to pass legislation, and then it can go to the state level, then it can go to other states and eventually federal level. That's a really cool avenue for change, but it also has some drawbacks because individual experiences of people vary a lot based on where they live, for example, a trans person's experience in San Francisco is not the same compared to a trans person's experience in Arkansas. That is a result of the patchwork of policy differences. I wish there was a standard of basic humanity, safety, and social justice for everyone and not imply that if you're trans in this place, you're worth more than if you're trans in another place.

How do you see change taking place in San Francisco specifically?

San Francisco has a really inspiring and rich history of LGBTQ organizing and advocacy. Some of that developed during the HIV epidemic when San Francisco became a leader in health care for HIV and guided a lot of other parts of the country and in the world. It wasn't just the medical community, the communities who lived here also advocated for that care. That is the case with a lot of our history; we have a really strong trans organizing history here, which shines in our current work. For example, we're lucky to have the first trans cultural district in the world, and it was founded by some of our local Black trans heroes.

We have a lot of inspirational and innovative programs and policies like our sexual orientation and gender identity collection policy, all gender restroom policy, the trans housing program, and the guaranteed income pilot program for trans people, which my own office has worked to establish and continue. It’s also important to note that the things that we do in San Francisco can have ramifications beyond San Francisco. We have the ability to set a precedent for other parts of California and other states, especially when our policies are successful. 

There's still a lot of work to do, though. In San Francisco, we still see really high rates of homelessness, mental health issues, substance use, and poverty for LGBTQ communities, especially Black, immigrant, Latinx, and trans folks. There are also inequities for young LGBTQ people. A high proportion of our young homeless people in San Francisco identify as LGBTQ. In addition, we know that there's still a lot of work to do around older LGBTQ people and addressing their isolation, poverty, and lack of health access. I’m super grateful to see that there's a lot of change that happens here and it can be a source of hope for many other places, but I still think we need to do better. It's just an ongoing, ever-evolving process.