Editor’s Note: Aliza Norwood, MD, is an internal medicine physician and Medical Director at Vivent Health in Austin. She is also a Public Voices Fellow of The OpEd Project. The opinions expressed in this commentary are her own. View more opinion on CNN.
One week before President Joe Biden signed a proclamation honoring Transgender Day of Visibility, Dr. Rachel Levine became the first openly transgender federal official to be confirmed by the Senate. As a physician who cares for transgender patients and the sister of a transgender man, I have celebrated these important milestones. But I also know that the freedom to be visible cannot be equally shared across the transgender community until it is equally protected. The privilege of visibility depends on how safe you will be – in your job, in your housing, even in your person – once you come out.
When transgender patients tell me stories of trauma – of being spit on by strangers on the street, of tuning out slurs hurled at them on the bus, of being raped – I wonder how we can expect them to speak out. Anti-trans hate runs deep in this country, and visibility becomes dangerous when our laws make it easier, rather than harder, to punish people for living as their true selves. Until we enact federal legislation that protects transgender people, everywhere, in every aspect of their lives, many in the transgender community will be forced to remain invisible.
On Wednesday the state Senate in Texas, where I live, voted to pass SB 29 which bans transgender athletes from competing in sports teams that align with their gender identity. That same week, the Texas House of Representatives heard bills that would punish doctors for providing evidence-based gender-affirming care by revoking their license (HB 2693/ SB 1311) or prohibit liability insurance from covering doctors who provide gender-affirming care to youth (HB 1399), and many others. These laws are in conflict with the current medical guidelines and expert recommendations of all major medical organizations.
While at the state Capitol that week, I met physicians who canceled their clinic days to drive across the state to testify against these bills. A pediatric endocrinologist who waited for over 10 hours to give her testimony on HB 1399 described the complex science of puberty blockers, hormone therapy, and the interdisciplinary team of psychologists, social workers, and physician experts that make these individualized decisions. When one lawmaker commented on how little they all knew about the science, she remarked “that is because this is a complex decision that should not be decided in a blanket fashion.” In other words, lawmakers should not be legislating from a place of ignorance and should certainly not be superseding best-practice medical guidelines. I listened as parents of trans kids spoke, their voices trembling with emotion, about the lifesaving effects of this care on their kids. “I didn’t know how much of my daughter I didn’t know before,” said one mom of a trans girl, “and how happy she could be.”
When we speak of transgender people being “invisible” we don’t mean there isn’t awareness of transgender people in America. In fact, hate crimes and anti-trans legislation are surging across the country, not just in Texas. In 2016, 0.6% of American adults identified as transgender (for comparison, it is estimated that about 2-6% of Americans have red hair). But when people don’t know (or are unaware that they know) transgender people, it is easier to create boogeyman specters of who they are. Real people are reduced to stereotypes and falsehoods – the reality of transgender lives is invisible.
I know ignorance doesn’t always mean malintent. When my brother first started transitioning, I didn’t understand his reasons. I thought he might be confused because he didn’t dress like a tomboy and didn’t fit the stereotypes I had seen. My family was scared he would be unhealthy or unsafe. But we supported him because we love him, and we educated ourselves. Most importantly, as he transitioned, we saw him become happy for the first time in his life, enjoy a broad circle of friends, and marry the love of his life.
As I progressed through my medical training, I wanted to learn more about transgender health care, but soon realized that I would have to teach myself. There is no requirement to teach medical students about health related to the entire umbrella of LGBTQI+ communities, much less transgender people specifically.
In San Francisco, where I did my residency, transgender patients were invisible to many, even though the city has been at the forefront of LGBTQ advocacy. After I gave a presentation on gender-affirming care as part of my final year, one of the attending senior physicians asked me why I would bother to focus on such a tiny population. The fact that I had just come from a packed lecture on an exceedingly rare condition called adult hemophagocytic lymphohistiocytosis was not lost on me. The truth is that we all likely have friends, family, and colleagues who identify as a transgender or gender-nonconforming – they just may not feel safe or welcome to disclose who they are.
If this was my experience in the liberal bastion of San Francisco, it shouldn’t be surprising that according to a national survey, one in two transgender people say they have had to teach their health care providers about their care. One in five reports having been denied health care outright, and the same proportion delays or avoids health care because of fear of discrimination.
In the South, where state legislatures are advancing anti-transgender bills, over half of LGBTQ individuals feel that being in the South makes it always or often harder to access medical care. Health care is hard enough to access, especially in the midst of a pandemic – what happens when your doctor refuses to treat you?”
My brother didn’t initially disclose his transgender identity outside of a small circle of family and friends. When I asked him why he came out, he tells me it was the example set by his boss, himself an openly transgender man. He wanted to be a support to others and to share that his happiness and success is because, and not in spite, of his identity.
In this way, he adds to the diversity of stories about transgender life. But he also lives in New York, where he cannot be fired or denied health care because he is transgender, and he tells me that he would not have come out in Texas, where the rest of our family lives, because he does not feel safe here. He will never move back, even though he loves us, and we love him.
The problem is not who transgender people are – it’s the bigotry they face. That bigotry is bred of ignorance, and that ignorance will last until transgender people, in all their diversity, can be visible. But until laws that protect rather than attack transgender people are passed on a national level, many will not be safe, and they will stay hidden. In this way, discriminatory legislation acts as the engine of ignorance. To reverse that, and to make transgender visibility a reality, we must pass bills that protect the transgender community, such as the Equality Act; and fight bills that attack it, such as the avalanche of bills passed or pending in state legislatures across the country.
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Until the protections that allow all transgender people to be visible are in place, friends, family, and colleagues of transgender people can help by making ourselves visible advocates. We can ask our transgender friends how they want to be supported to ensure we are lifting their voices without trivializing or endangering them. Private companies can support transgender workers by making public statements that affirm and increase trans visibility without putting the burden on the shoulders of transgender individuals.
Every transgender patient I see in my clinic is unique, but I also see a bit of my brother in each of them. I am so grateful that he was able to get the care he needs, and that I was able to see him blossom from a deeply unhappy child to the person he is today, so full of life and light and love. I am painfully aware of siblings with different experiences, where families are torn apart when loved ones are forced into the closet. As a society, we must ask ourselves if the desire to categorize people into two different boxes based on their genitals is so important that we are willing to sacrifice the health and happiness of those we love. Will we try to silence and hide them, or will we let them come out and be seen?
