First They Came for Us All: Responding to Anti-Transgender Structural Violence With Collective,Community-Engaged,and Intersectional Health Equity Research and Advocacy

Abstract

This article is a call for collective action across health equity researchers and advocates to build a more just world. We attempt to make sense of senseless structural and interpersonal brutality in the context of the current political climate across the United States, whereby the spectrum of gender nonconformity has been and continues to be stigmatized. From drag performance to transgender identities to gender-affirming health care, extremists have instrumentalized primary levers of democracy—the courts, legislatures, and social media—to attempt to outlaw and eradicate gender expansiveness and those who provide forms of support and care, including gender-affirming medical care, to transgender, nonbinary, and gender-expansive (TNBGE) individuals.

We are scholars, scientists, policy advocates, and health system leaders who center gender-affirming care in our work. As transgender, nonbinary, and gender-expansive (TNBGE) individuals, our paths to this work were challenging and diverse, shaped by unique career disciplines and personal trajectories that brought us to this critical intersection. More than 30 years ago, Dr. Kimberlé Crenshaw conceptualized intersectionality as a legal, analytical framework to untangle layers of discrimination, originally showing how economic, gender and racial discrimination is experienced disproportionately by Black women, compared to Black men (Crenshaw, 1989, 1994). We recognize that the most recent wave of legal assaults on bodily autonomy, sexual and reproductive health, and access to health care differentially impact those with multiple marginalized identities and who are living in shifting geographical, legal terrain. The recent and ongoing targets of hostile legal intervention and criminalization also include Black, Brown, Asian American, Indigenous peoples and many communities of color, cisgender women, intersex people, cisgender lesbian, gay, bisexual, and queer people, interracial couples, immigrant people, and people with disabilities.

There is urgency to make this broader appeal to scholars and practitioners across the health professions. Our primary objectives here are threefold: (1) to highlight the policy trends and its impact on TNBGE health equity research, gender-affirming care, and TNBGE lives and deaths, (2) to demonstrate solidarity and create space for collaboration in health equity research and advocacy, and (3) to offer clear pathways for TNBGE health equity research at this critical moment.

Policy and Advocacy

Although criminalizing TNBGE identities is nothing new, the 2023 legislative session has seen a record-breaking surge of discriminatory bills and policies aimed specifically at eroding the rights of TNBGE people—with over 520 anti-LGBTQI+ bills that have been introduced across US states at the time of this writing, of which over 220 bills specifically targeting TNB people (Peele, 2023). At least 70 of these bills have been signed into law. These legislative attacks are particularly concentrated in the South and Midwest, with Texas alone introducing 53 anti-LGBTQ+ bills this year (ACLU, 2023). At the federal level, similar bills targeting TNBGE people have been introduced by conservative extremists in Congress, and the Supreme Court also recently ruled in 303 Creative vs Elenis that certain businesses can refuse to serve LGBTQI+ customers. This legislative and legal assault spans all aspects of life for TNBGE people, including the use of public accommodations, participation in sports, access to accurate IDs, freedom of gender expression, access to accurate and inclusive school curricula, and access to necessary and life-saving healthcare.

This weaponization of state and federal policy is a coordinated strategy to erode the rights and overall health and well-being of TNBGE people for political gain. These bills are not based on fact or science, nor do they address legitimate issues. In describing Florida’s gender-affirming care ban, US District Judge Robert Hinkle stated that such legislation was a political decision rooted in bigotry and, therefore, not a “legitimate state interest” (“Jane Doe et al., Plaintiffs v. Joseph A. Ladapo et al., Defendants,” 2023). Extremists claim that gender-affirming care is experimental and harmful, and some go so far as to compare it to child abuse. In reality, limiting access to medically necessary care is what is actually harmful. Gender-affirming care is evidence-based, with numerous proven health benefits, especially for mental health and overall quality of life. A 2023 peer-reviewed, longitudinal study (Chen et al., 2023) published in the New England Journal of Medicine found that gender-affirming hormone therapy decreased anxiety and depression symptoms and improved overall life satisfaction and body image for TNB youth and young adults. Gender-affirming care is also supported by medical experts, with the American Medical Association recently passing a resolution to oppose all state and federal legislation restricting access to gender-affirming care (Endocrine Society, 2023).

Because their positions are not supported by facts and evidence, politicians often rely on fearmongering and misinformation to push their legislation and appeal to voters inclined to oppose trans rights. This coordinated political strategy to demonize TNBGE people is especially apparent with well-documented transphobic hate groups, like the Alliance Defending Freedom, providing model legislation and legal support to help introduce, enact, and defend these policies across the nation. This all comes at the expense of TNBGE people, who are losing access to necessary services while also facing increased rates of discrimination and violence (Borah et al., 2023). The Anti-Defamation League and GLADD documented at least 356 instances of anti-LGBTQI+ hate and extremism between June 2022 and April 2023, and at least 191 incidents were explicitly tied to baseless “groomer” conspiracy theories often employed to promote anti-LGBTQI+ legislation (Anti-Defamation League, Center on Extremism, & GLADD, 2023).

This well-coordinated, extremist strategy has had a chilling effect. The recent Editor’s Statement in Transgender Health (Garofalo, 2023) cites social media as a significant source of misinformation that has ginned up threats of violence against physicians who provide gender-affirming care, silencing not only them but also the medical institutions that employ them. Vanderbilt University Medical Center (VUMC), one of the nation’s top academic health centers and the first in the South to establish gender-affirming care with an innovative transgender patient navigation program, Trans Buddies, exemplifies this chilling effect. In late 2022, VUMC paused gender-affirming surgeries for minors in response to the introduction of a Tennessee legislative bill to ban gender-affirming surgeries and care for minors. At the same time, in response to an inquiry by the Tennessee Attorney General’s office (Brown & Puente, 2023), VUMC turned over all medical records of its transgender patients dating back to the beginning of 2018, when the Transgender Health Clinic was formally established. VUMC is now facing civil litigation filed by its transgender patients as well as a federal investigation over civil rights violations regarding this release of medical records (Kruesi & Matisse, 2023). The combination of political threats and lack of institutional support places health professionals, affiliated practices, and scientific research in constant fear of penalization. There is also a chilling effect on TNBGE patients, whereby increasing fear and mistrust deters them from seeking care, including basic primary care (Gordon, 2022).

Research

Beginning with Kristin Clements-Nolle and her TNBGE community-engaged research (Clements-Nolle & Bachrach, 2003; Clements-Nolle et al., 2006), the associations between discrimination, transgender stigma, and poor health outcomes are well established (Abreu et al., 2022; Hereth et al., 2021; Klemmer et al., 2021; Nemoto et al., 2011; Operario et al., 2014). A limited number of more recent studies have identified these associations as highest in southern, western, and republican-voting states (Hughto et al., 2021, 2022; Sinnard et al., 2016; White Hughto et al., 2016). However, these studies focused primarily on mental and behavioral health outcomes and are based on data that predates this new wave of anti-TNBGE legislation that criminalizes gender-affirming care, caregivers, and care providers as well as gender-expansive expression itself. Research delineating the impact of this current hostile policy environment on health and well-being of trans people and their care providers is a critical investment priority. More salient, given the urgent public health crisis of high suicide rates among TNBGE youth (The Trevor Project, 2023), and that, to our team’s knowledge, there are currently no evidence-based suicide prevention interventions specific to these young people, federal agencies must prioritize TNBGE suicide prevention research.

In addition to mental and behavioral health, further research is required to comprehensively understand the broader health consequences and health care access implications as a result of anti-LGBTQ+ and anti-trans policies, particularly acute illness and chronic disease outcomes. Recent efforts to expand and improve health outcomes research with the inclusion of gender identity as a data element in electronic health records as well as survey instruments may fail due to the chilling effect that the growing stigma, criminalization, and/or violence has on identity disclosure. For example, a newly registered transgender patient at VUMC may refuse to disclose a TNBGE gender identity within their medical record or disclose off-record their gender identity to their provider. This time-worn practice among TNBGE patients, which may hinder care pathways, is well documented, at least since “Agnes,” a patient described in Dr. Harold Garfinkel’s case files for research conducted in the 1950s at UCLA’s gender clinic (Joynt, 2022). Rather than risk denial of gender-affirming treatments, Agnes had convinced her team of physicians that she had an intersex condition that required exogenous estrogen to live fully as a woman.

Even less clear is the impact that these sweeping policy changes are having on the production of TNBGE health equity research itself. In the realm of HIV prevention and implementation science research, studies have already established the dearth of and the critical need for expanded TNBGE community engagement at every stage of the process (Restar et al., 2023; Thompson et al., 2022). Investments in community-engaged research with, for, and by trans communities as study investigators and key personnel are essential to ensure that research directly benefits TNBGE communities (Minalga et al., 2022).

On the industry-sponsored side of health equity research, from 2000 to 2014, zero industry-sponsored clinical trials specified transgender inclusion. Researchers implementing clinical trials have called for gender-inclusive and gender-specific approaches to clinical trial research (e.g., COVID trials)—acknowledging a plethora of gender identities and valuing transgender and nonbinary people as participants and key research personnel across all stages of the trial (Babu et al., 2023; Restar et al., 2021). The Food and Drug Administration (FDA) formally recognized this inequity and, between 2015 and 2021, transgender representation continuously increased in trials. In 2022, however, the number of trials specifying transgender inclusion decreased by more than 50% (Beaney & Maragkou, 2023). Analysts of clinical trials believe that the trend toward criminalizing gender-affirming care and medical interventions will certainly discourage TNBGE disclosure or participation in trials and perhaps drug companies from running the studies at all. Nonetheless, the FDA’s ongoing Diversity Plan upholds equitable representation of a drug or intervention’s priority population in trials.

Implications and Recommendations

During the time of this writing, on the evening of July 29, 2023, 28-year-old O’Shae Sibley and his friends stopped at a gas station in the Midwood neighborhood of Brooklyn on their way back home from New Jersey (Cramer & Parnell, 2023). While filling up the tank, O’Shae and his friends were listening to Beyonce and voguing around the car. Voguing is a type of dance that is not only celebrated in Black gay and trans communities but often forms the foundation for refuge and chosen families, also known as Houses. Some teens nearby responded to the dancing with harassment, racist and homophobic slurs, and demanded that the dancing stop. O’Shae Sibley was stabbed in the chest, murdered by a 17-year-old, ostensibly for expressing himself and his Black, gay, and gender nonconforming joy in public.

Two weeks prior, Jacob Willamson, an 18-year-old White, transgender man, was killed in North Carolina by a cisgender man whom he had met on the internet for what he thought was going to be a date at an amusement park (Valade, 2023). According to news reports, Williamson had recently come out as transgender and, due to some familial rejection after his disclosure, had moved out of his parents’ home in Laurens, South Carolina. At the time, Williamson was the 15th documented murder of a transgender person in the United States in 2023.

While difficult to measure the direct impact that anti-TNBGE legislation and court rulings are having on health equity research, we know these two physically violent losses of Black, White, gay, and trans lives cannot be understood outside of this structural violence. There is an urgency for coalition building—across research, advocacy, and grant-making silos and fully engaged with marginalized communities—to create new channels for dialogue and new space to imagine and create interventions on these pervasive forms of anti-TNBGE and anti-LGBTQ+ violence. On a global scale, progressive grantmakers have coordinated their efforts over the last 5 years in response to anti-gender, anti-LGBTQ+ movements, particularly in the Global South and East. We endorse the kind of cross pollination that emerged from a four-month long Global Rights Summit, convened to build shared analyses and models across funding networks (Nepon, 2022).

In addition to expanded TNBGE community engagement and coalition building, we emphasize the importance of intersectional frameworks for scientific inquiry but also for these coalitional infrastructures. That is, bringing racial, gender, and economic justice praxis to our research such that research processes are intentionally inclusive, broad-based, and in closer conversation with TNBGE and intersecting marginalized communities and policy stakeholders. Many have cited ACT UP as an exemplary community-based coalition, followed by the Treatment Advisory Group, that drove more effective, though not especially intersectional, HIV research and policy. Lisa Bowleg and Greta Bauer’s Intersectionality Training Institute fosters new pathways to intersectional, health equity research and policy and may serve as a model type of hub of coordination. We highly recommend meaningful and sustainable public and private investments in the inclusion, training, and retention of Black, Indigenous, and other trans scholars of color in the health equity workforce, given current racial/ethnic inequities in this field. As displayed by us, our authorship team is no exception and a reflection of this systemic issue. While trans-led, we recognize that that it is currently made up of majority white scholars and practitioners—a vital reflection that we are continuing to strive to address and practice as we continue the work of health equity.

Although the power of super-PAC money to legislate away our bodily autonomy and enact hate is ominous, the power of broad-based, collaborative relationships within and across targeted institutions and communities cannot be underestimated and should be centered in our respective research, policy, and funding agendas. We need to foster cross-sector coordination and collaboration to undo the knots of structural discrimination, interpersonal violence, and the impacts on health equity and health outcomes across gender identities, racial and ethnic identities, and class formations.