Abstract
Using in-depth interviews with transgender and non-binary (TGNB) young adults in the Southeastern US, I examine TGNB young people’s healthcare experiences and strategies for resisting and reducing inequality in healthcare settings. My analysis draws on sociological conceptualizations of accountability structures in TGNB healthcare and specifically the conceptualization of cisnormative accountability. In this article, I demonstrate how TGNB patients are held accountable to the institutional and interpersonal maintenance of (a) cisnormativity and (b) the medical model of transgender identity in US healthcare systems. Such instances of cisnormative accountability, regardless of cisgender people’s intentions, contribute to the reproduction of gender inequality among TGNB communities. Further, I explain how TGNB young patients engage in strategies to resist and reduce inequality in healthcare through (a) avoidance of health services and (b) selective disclosure of TGNB identities. I draw out implications for understanding TGNB young people’s strategies to minimize inequality in healthcare, and the consequences cisnormative accountability has for the reproduction of gender inequality.
Introduction
Transgender and non-binary (TGNB) communities face significant health and healthcare disparities in the United States, relative to their cisgender counterparts (Lampe, 2022; Hsieh and shuster, 2021; James et al., 2016). Prior sociological research notes how these disparities derive from existing sociopolitical conditions whereby TGNB Americans endure widespread stigma, discrimination, and violence over the life course—problems that engender major psychosocial challenges for TGNB people as they access and utilize health services (Lampe et al., 2023; Sumerau and Mathers, 2019). Prolonged exposures to these stressors often exacerbate the need for gender-affirming care services, providers, and resources among TGNB patients (Clark et al., 2018; Johnson and Rogers, 2020; Miller, 2023). This is especially the case for TGNB youth and young adults, a medically underserved population with limited financial security and legal protections in the United States (Ashley, 2019; Robinson and Schmitz, 2021). Although these studies have begun integrating TGNB populations into sociological literature, less work in this area has examined TGNB young Americans’ strategies for mitigating inequality in healthcare settings. Therefore, I ask: How do transgender and non-binary young people experience gender inequality within US healthcare systems? What strategies do transgender and non-binary young people use to resist and reduce gender inequality within US healthcare systems?
To address these research questions, I build on sociological research concerning TGNB health and medicine (Johnson, 2015, 2019; shuster, 2021) by using 20 in-depth interviews with TGNB young adults (19–24 years of age) in the Southeastern US that illustrated their care experiences and strategies for minimizing inequality in healthcare settings. My analysis draws on sociological conceptualizations of accountability structures (Hollander, 2013; Johnson, 2015; West and Zimmerman, 1987, 2009) within and beyond TGNB medicine and specifically the conceptualization of cisnormative accountability (Lampe, 2019; Stallings, Lampe, and Mann, 2021). Cisnormative accountability articulates a more accurate and tailored accountability process that TGNB people face by highlighting how cisgender versions with negotiating accounts and accountability are not the only ways of organizing the social world. Thus, cisnormative accountability allows for sociological examination of ways that medical institutions and authorities, regardless of their intentions, enforce cisnormativity and the subordination of TGNB people.
In this article, I demonstrate how interview respondents, as TGNB young people, are held accountable by others and themselves to the institutional and interpersonal maintenance of (a) cisnormativity and (b) the medical model of transgender identity in US healthcare systems. I argue that such exposures to cisnormative accountability structures reproduce inequality in healthcare settings for TGNB populations. Further, I explain how respondents engage in strategies to resist and reduce inequality in healthcare settings through (a) avoidance of health services and (b) selective disclosure of TGNB identities. By examining the experiences and strategies TGNB young patients use to navigate US healthcare systems as a cisnormative accountability structure (Lampe, 2019; Stallings et al., 2021), these findings further illustrate the strategies TGNB young people use to mitigate inequality in healthcare, along with its structural limitations and consequences.
Literature Review
This article draws upon and extends three, emerging areas of sociological literature. First, I describe sociological studies that examine the ways TGNB people experience gender inequality in US society. Then, I discuss prior research on TGNB people’s care experiences and how TGNB patients navigate healthcare institutions and interactions. Finally, I examine sociological conceptualizations of accountability structures within and beyond the context of TGNB healthcare. In this study, I contribute to these areas of research by (a) investigating how TGNB young people experience and mitigate inequality in healthcare and (b) how such findings speak to notable gaps in sociological literature.
Transgender and Non-Binary Studies in Sociology
As Schilt and Lagos (2017) note, sociologists are only beginning to systematically examine the lives, experiences, outcomes, and issues faced by TGNB communities despite references to people who would now be referred to as transgender (hereafter trans) at least as early as the mid-1800s in scientific texts (Stryker, 2017). Although TGNB populations occasionally showed up in the field as far back as the mid-1960s (Sumerau and Mathers, 2019), such studies typically assumed TGNB people were problematic and sought to make sense of such individuals through cisgender or binary-based frameworks (Westbrook and Schilt, 2014). In recent years, this focus has shifted to understanding gender inequalities more broadly, and how TGNB experiences may illustrate notable gaps in inequality sociological scholarship and operations of unequal gender systems (Sumerau, 2020). To this end, sociologists are continuing to map the ways cisgender assumptions have limited science (Nowakowski, Sumerau, and Mathers, 2016), public knowledge (Sumerau and Mathers, 2019), and the pursuit of more equitable gender relations in US society (Pfeffer, 2017).
Emerging sociological research has sought to ascertain how and why TGNB communities experience inequalities, whether concerning TGNB people’s experiences in religion (Sumerau, Cragun, and Mathers, 2016), education (Coley, 2017), the workplace (Ueno et al., 2020), families and partnerships (Pfeffer, 2017), or medicine (shuster, 2021). Prior research notes how TGNB Americans are exposed to high levels of victimization (Sumerau and Mathers, 2019), mistreatment and harassment (Buchanan and Ikuku, 2021; Miller and Denise, 2015), poverty (Badgett, Choi, and Wilson, 2019), and incarceration (Rogers and Rogers, 2021) relative to their cisgender peers, but have fewer legal protections due to increasing anti-trans politics and legislation in the US (Burke et al., 2023). Findings from the 2015 U.S. Transgender Survey, for example, indicate almost half (48%) of trans respondents (N = 27,715) report experiencing unequal treatment, verbal harassment, and/or physical assault (James et al., 2016). TGNB people’s experiences with stigma, discrimination, and violence also vary across sociodemographic subgroups of TGNB communities (Crenshaw, 1989), such as racial and ethnic minority TGNB communities experiencing intersecting forms of oppression (Buchanan and Ikuku, 2021; Crenshaw, 1989). Overall, such studies emphasize the importance of TGNB perspectives in the development of gender inclusivity and diversity within inequality sociological scholarship.
Transgender and Non-Binary People’s Healthcare Experiences
Prior sociological research notes an ongoing crisis in contemporary TGNB medicine (Lampe, 2022; shuster, 2021) with most American healthcare professionals lacking formal education and training on TGNB patients’ health and healthcare needs (Hsieh and shuster, 2021; Obedin-Maliver et al., 2011). These knowledge deficiencies can lead to medical providers and staff, regardless of their intentions, placing TGNB patients in vulnerable and uncomfortable positions, such as misgendering patients, disclosing patients’ TGNB identities to family members without their consent, and referring to their anatomical features in gendered ways (Lampe and Nowakowski, 2021; Santos, Mann, and Pfeffer, 2021). This is especially the case for TGNB people navigating reproductive and sexual healthcare settings that are normatively women-centric or stereotypically feminized (Nowakowski, Sumerau, and Lampe, 2020; Riggs et al., 2020).
Sociological scholarship also illuminates how many TGNB patients experience substantial obstacles in accessing TGNB-inclusive healthcare (Johnson et al., 2020; Santos et al., 2021). TGNB people, especially those from financially disadvantaged and rural backgrounds, often face challenges with finding local healthcare facilities and providers that practice gender-affirming care (Lampe et al., 2023). Limited or lack of health insurance coverage and financial insecurities are also common barriers to care for TGNB communities in the US where there is no universal healthcare system (Hsieh and shuster, 2021). In the case of gender-affirming medical interventions (e.g., hormone therapy services), TGNB people face added barriers to qualifying for and obtaining insurance carrier payment for such interventions (Lampe, 2022).
Although sociologists have increasingly examined TGNB patient experiences, less work adequately pinpoints the unique challenges TGNB young people face when navigating US healthcare systems, from their own perspectives (Sumerau and Mathers, 2019; Robinson and Schmitz, 2021). Many TGNB young Americans struggle to access TGNB-inclusive healthcare due to limited independent resources and protections (Ashley, 2019). TGNB young people, for example, may heavily rely on families of origin (e.g., parents) to make medical decisions on their behalf and maintain health insurance coverage due to financial and legal constraints. Not all family caregivers of TGNB young people are supportive of their medical decisions and services, which can substantially drive barriers to gender-affirming care (Johnson et al., 2020). Overall, prior literature demonstrates the sociolegal vulnerabilities, as well as the differences in healthcare disparities, experienced by TGNB young Americans.
Emerging research also examines the various strategies TGNB communities use to resist and reduce inequality in care settings (Lampe and Nowakowski, 2021; Robinson and Schmitz, 2021). Sociologists, for example, note how TGNB people practice self-advocacy and empowerment in peer-support spaces (Johnson and Rogers, 2020). Sociological literature also highlights the gender dynamics with TGNB patients’ strategies to minimize inequality in healthcare (Goldenberg et al., 2021; Sumerau and Mathers, 2019). TGNB patients with feminine gender expressions may exert emotional labor by educating clinicians about TGNB care (Nowakowski and Sumerau, 2019), whereas TGNB patients with masculine gender expressions may completely avoid preventive care services (Lampe and Nowakowski, 2021). However, assigning the responsibility for implementing these strategies to TGNB patients, rather than to medical authorities and institutions, fails to adequately address the inherent structural inequities present in TGNB healthcare (Lampe, 2019; Robinson and Schmitz, 2021). Additional sociological scholarship on TGNB young patients’ strategies to minimize inequality in healthcare is especially warranted.
Accountability Structures in Healthcare
Sociologists have demonstrated the importance of conceptualizing gender as an interactional and institutional accomplishment (West and Zimmerman, 1987, 2009). To understand gender or “doing gender,” West and Zimmerman (1987) called special attention to “the accountability structure,” or the ways people expect others to act and hold others to social expectations in daily life (Heritage, 1984). Doing gender involves dominant groups and institutions deeming behaviors and interactions of individuals as “gender-appropriate” or “gender-inappropriate” (West and Zimmermann, 1987:136). When certain interactions of individuals are deemed gender-inappropriate, gender accountability occurs. West and Zimmermann (2009) further clarified their conceptual framework while emphasizing how accountability relies upon what we do (i.e., giving accounts) and what others reinforce in social contexts.
Thus, gender accountability is an unavoidable, interactive process of people giving accounts and holding normative expectations of gender onto others based on preexisting assumptions of assigned sex categories (Crawley 2022; Kessler and McKenna, 1978). For example, if someone believes being feminine is what a woman should act or look like, then they treat someone else, who they presume to be female based on embodied social cues and who does not look “feminine enough” in their estimation, as if that person is not a woman (Lucal, 1999). As Crawley (2022:374) clearly notes, “we cannot not know the sex category of a body in order for social interaction to intelligibly proceed.” In other words, people hold themselves and others accountable to “appropriately” present gendered selves in society (Goffman, 1976), wherein “appropriateness” is defined by the alignment of normative social expectations between sex categorization and gender presentation (Hollander, 2013).
In the case of TGNB people, prior sociological research documents differing modes of accountability structures (Mathers, 2017; shuster, 2017; Sumerau and Mathers, 2019). Examining the use of language in interactions with others, for example, shuster (2017) demonstrates how trans people navigate the gendered belief systems of other people in varied social settings. Similarly, Sumerau and Mathers (2019) outline multiple ways transgender people report navigating encounters with cisgender others as a necessary part of surviving and otherwise existing in everyday social settings. Further, Mathers (2017) shows cisgender people create the need for these linguistic (shuster, 2017) and interactional (Sumerau and Mathers, 2019) practices through their own expectations and assumptions about trans communities.
Sociological research has begun to explain similar dynamics in healthcare settings (see Oyarvide Tuthill and Gorman, 2019; Johnson, 2019, for example). Some analyses focus on TGNB people’s experiences with navigating barriers to gender-affirming medical interventions (Johnson, 2019; Rogers, 2020). Others examine the perspectives of medical providers who may (shuster, 2021) or may not (Stallings et al., 2021) specialize in TGNB medicine. Such studies report medical providers assuming a TGNB patient’s gender identity conforming to their assigned sex category within a presumed binary gender system (i.e., a cis woman or man) or face medical uncertainty during the patient encounter (shuster, 2021). Consequently, medical providers’ uncertainties about TGNB care may reinforce medical gatekeeping practices that prevent, impede, or delay access to gender-affirming medical interventions for TGNB people.
Accountability structures can also reinforce trans patients’ bodies and embodiment as medicalized phenomena (Johnson, 2019; Schrock, Reid, and Boyd, 2005). The medical model of transgender identity is a standardized set of norms that “limits what will or will not be recognized as transgender” in clinical spaces and patients who adopt this model receive medical recognition as transgender (Sumerau and Mathers, 2019:118). This model reinforces transnormativity, or the ideology that specifies “how to be trans” (Johnson, 2016), by dictating who can be considered trans in healthcare settings. Receiving this medical recognition as transgender also involves reinforcing TGNB bodies and experiences through a gender binary system (e.g., trans woman/trans man) only with limited acceptance of non-binary experiences (shuster, 2021).
As a complex process, those who do not conform to this rigid model may be denied access to gender-affirming medical interventions (Johnson, 2019; Mason-Schrock, 1996). However, the trans medical model can also benefit those seeking gender-affirming medical interventions when their specific patient narrative fits within the transnormative expectations for that model (e.g., a trans woman who conforms to normative standards of femininity and womanhood). But for TGNB people who do not conform to the trans medical model (e.g., a non-binary person who wants chest reconstructive surgery but does not identify as a trans man or appear normatively masculine), this accountability structure can become a substantial barrier to accessing gender-affirming care.
Johnson (2015) further explains how the medical model of transgender identity acts as a normative accountability structure. Normative accountability is an interactive process of self-enforcing and/or enforcing onto others normative assumptions of gendered behavior (Johnson, 2015; Mann, 2022). Normative accountability is different from West and Zimmerman’s (2009) conceptualization of gender accountability because normative accountability underlines how people hold others accountable to preconceived gender norms instead of others’ assigned sex categories (Johnson, 2015). The trans medical model is driven by a consistent set of normative assumptions of gendered (i.e., specifically transgender) behavior in medicine. In other words, the normalization of gendered behavior is a catalyst for accountability processes to occur (Heritage, 1984; Mann, 2022).
Extending the conceptualization of normative accountability, cisnormative accountability pinpoints the accountability processes of self-enforcing and/or enforcing onto others the normalization of cisgender experiences (Lampe, 2019; Stallings et al., 2021). Cisnormative accountability articulates a more tailored accountability process that TGNB people face by highlighting how cisgender versions with negotiating accounts and accountability are not the only ways of organizing the social world. Cisnormative accountability refers to the ways TGNB people are held to normative standards of gender, not only having to do with expectations of masculine or feminine behavior and presentation, but also specific expectations around what “real” trans people are “supposed” to be in a cisnormative society (Lampe, 2019; Stallings et al., 2021). Thus, TGNB communities are located at the heart of inferences around and consequences for cisnormative accountability processes (Lampe, 2019), which contribute to the reproduction of gender inequality among TGNB communities (Schiffer, 2022). Overall, I extend prior sociological scholarship by examining TGNB young people’s strategies for resisting and reducing inequality in care settings, while pinpointing how cisnormativity operates in medicine as an accountability structure and contributes to TGNB inequality.
Methods
This study was approved by the University of Central Florida Institutional Review Board. Qualitative data consist of 20 semi-structured, in-depth interviews with TGNB young adults who reside in the US Southeast. An interview guide was developed and pre-tested with 3 TGNB young people to ensure questions were insightful, affirming, and culturally appropriate. Interview respondents were recruited through distributing flyers and purposive social network sampling (Pfeffer, 2012) wherein TGNB community leaders and social service organizations serving LGBTQIA+ communities (e.g., gender-affirming care facilities) advertised the study to community members. Eligibility included respondents who: (a) self-identified as transgender and/or non-binary, (b) were 18–24 years of age, (c) lived in the Southeastern US, and (d) consented to be audio-recorded during the interview. In-person interviews (n = 12) and telephone interviews (n = 8) were conducted from June to July 2018. On average, the interviews lasted about 75 min (range: 30–135 min). Each respondent received a monetary incentive of $35. Interviews were audio-recorded, then transcribed verbatim by a professional transcriptionist. Analytic memos were also written during the qualitative data collection and analysis process to note emerging themes and areas of sociological interest.
Interview respondents in this study are an extreme case purposeful sample (Patton, 2015), given that I expected to see more explicit forms of barriers to gender-affirming healthcare in the US Southeast (Johnson et al., 2020; Stone, 2018), particularly when it comes to TGNB young people and the accountability structures they encounter when accessing and receiving care services, support, and resources (Johnson and Rogers, 2020; Santos et al., 2021). Extreme cases can often provide key insights into mechanisms and processes that might otherwise be obscured in less extreme or unusual contexts (Patton, 2015). I purposefully sample an extreme case of TGNB young Southerners to capture how they experience and respond to cisnormative accountability structures within US healthcare systems (Stallings et al., 2021). Sociologists have demonstrated the importance and power of sampling geographically understudied groups to provide insights into gender accountability processes (Johnson, 2015; Stone, 2018). As such, TGNB young people in this study provide important insight into the barriers to accessing and utilizing healthcare in the US Southeast.
Respondent Demographic Characteristics (N = 20).
Analyses focused on how TGNB young Southerners navigated and responded to accountability structures in US healthcare systems. Data were coded using NVivo (Release 1.5) software and analyzed inductively through grounded theory analysis (Charmaz, 2014). From this output, a coding scheme consisting of sets of networked codes was developed. Developing categories and themes were reviewed to discern emergent patterns and connections. I engaged in initial or open coding, meaning I read a subset of transcripts to develop a general sense of the data and generated an initial list of codes. Subsequently, I engaged in focused or thematic coding, which involves the identification of coding overlaps and divergences, resulting in the combining and collapsing of open codes to form broader thematic codes/themes that are then placed in network relationships with one another. I also coded disconfirming evidence during the focused coding process. Finally, I engaged in axial coding, linking demographic attributes in the dataset (e.g., race/ethnicity) to specific codes and themes, which provided information about particular patterns among and between various subgroups of respondents.
Utilizing detailed codes and analytic memos from qualitative data analysis, I examined recurring themes that answer the following research questions: (1) How do transgender and non-binary young people experience gender inequality within US healthcare systems? (2) What strategies do transgender and non-binary young people use to resist and reduce gender inequality within US healthcare systems? By examining the experiences and strategies TGNB young respondents use to navigate US healthcare systems as cisnormative accountability structures (Lampe, 2019; Stallings et al., 2021), these findings further demonstrate how cisnormativity operates in medicine as an accountability structure and reproduces gender inequality in care environments for TGNB young people.
Persistence of Cisnormative Accountability
Prior sociological research notes the ways medical institutions and authorities hold TGNB patients accountable to cisnormative assumptions of gender (Johnson et al., 2020; Sumerau and Mathers, 2019). Cisnormativity is enforced through medicine that often discounts TGNB patients’ care needs and experiences (Sumerau et al., 2016; shuster, 2021). All interview respondents in this study self-reported instances of cisnormative accountability within healthcare settings through the maintenance of (a) cisnormativity and/or (b) the medical model of transgender identity. At the same time, how cisnormative accountability operates within respondents’ care experiences varied by their gender identities and conformity (or lack of conformity).
Maintaining Cisnormativity
Throughout the interview, Petal, a white non-Hispanic/Latina queer trans woman, described her fear of utilizing health services due to prior negative interactions with medical providers (e.g., frequent misgendering and deadnaming)—and in one instance, kicking her out of a patient exam room after she disclosed her gender identity. As an adolescent, Petal was also involuntarily admitted to a behavioral health hospital after reporting high levels of suicidal ideation and immediate suicide risk. Petal explained that the catalyst for her suicidal ideation at the time was due to her mental health counselor “outing” Petal (a minor child) as a trans woman to her father, who Petal describes as “emotionally and verbally abusive.” Petal’s father immediately rejected Petal’s gender identity and threw away all of Petal’s feminine clothing. During her time at the hospital, Petal felt even more distress when medical care staff initially placed her in the men’s residential ward: I went to [behavioral health hospital], and when I was being admitted, I told them that I was trans… Half of the space was male, and half the space was female. And the first night, I got put on the male side… and then at some point during the staff change, they got the message, and they moved me over with the girls, and I was given a room with another trans patient on that side. And some of the staff would make comments and say things, asking me what I was. And if I wasn’t in the right space, they’d yell at me and say, “Well, aren’t you a girl? So, get over here.” …It was really upsetting. It was really demeaning… And so being yelled at by staff and having them be transphobic towards me wasn’t great.
Petal’s initial placement was a consequence of cisnormative accountability through the maintenance of cisnormativity. Such forms of cisnormative accountability exposed her to greater potential for becoming a target of cisgender men’s stigma, discrimination, and violence. Petal was placed in the men’s ward based on her assigned sex, while her care team initially neglected her repeated pleas to be transferred to the women’s ward. After correcting the issue by moving Petal to the women’s residential area, the medical care staff held her accountable to their interpretations within the binary gender structure of the hospital. Placing Petal with another transgender resident in the women’s ward also signified broader processes of gender segregation that differentiate cis and trans women and the “othering” of trans patients in clinical spaces (Stallings et al., 2021).
TGNB young people also navigate cisnormative accountability structures when receiving emergency healthcare. Arbor described his experience in the emergency room as a multiracial (Black, white, Indigenous, and Latino) bisexual non-binary trans man: Arbor: I recently have been in and out of the ER. I feel like if you saw it [my clinical symptoms] on a piece of paper, you'd be very concerned. But once I actually went into an ER, it was written off… And I do feel like it was due to the fact that I am someone of color. And that I am someone that identifies as trans and is not afraid to tell them that I have had surgeries and that I am on testosterone. And once I tell doctors that… doctors seem to have a shift in how they treat me. NML: How so? Arbor: One doctor decided to change my chart. Originally, they had had it as male… and it ended up changing to female because I told them that I did transition from female to male… [Clinician] was very listening to me attentive… And then after I told him, “Hey, I have had chest surgery. I have been on hormones,” then it seemed like, “Oh, this is what’s wrong with you. This is what’s wrong with you.” It wasn’t so much more of a “I’m listening to you”; it’s more of a “I’m telling you what’s wrong with you.” And they're just really seemed to be a dramatic shift. It was very awkward.
Upholding cisnormative accountability, a clinician changed Arbor’s sex from male to female on his patient chart and refused to change his sex marker back. In doing so, they imposed a cisnormative logic that understands sex categorized at birth as primary and essential in accounting for Arbor’s gender, while erasing Arbor’s explicitly articulated self-identification and previous institutional categorization as a man. Arbor reported that the doctor’s decision to change his sex marker without his consent increased his stress and anxiety during the ER visit, ultimately worsening his chronic pain symptoms. Such instances of cisnormative accountability act as catalysts for reproducing inequality in care settings for TGNB patients.
All non-binary respondents reported feelings of invalidation during clinical encounters due to cisnormative accountability structures. Most of them experienced providers repeatedly holding them accountable to assigned sex in medical documentation. Ember, a white Hispanic/Latinx bisexual non-binary person, summarized this process: It’s pretty much the same thing… Assigned female—that’s how they refer to me. I get all the same questions like, “When was your last period? Let’s test your blood for your iron level” and whatever… [I]t’s pretty much just the same kind of, “We're treating you as a girl.” Because that’s all they know.
Over half of interview respondents noted having medical providers with limited or inadequate knowledge of TGNB communities. As Ember illustrates, undergoing accountability of cisnormativity in healthcare was incongruent with their patient experiences as a non-binary person. However, Ember accepts their clinician’s lack of understanding TGNB patient needs as “all they know.” Ember’s narrative further illustrates cisnormative accountability through the maintenance of cisnormativity in healthcare.
Most trans men respondents reported major concerns with addressing their patient needs in reproductive healthcare settings, which are often normatively framed as women-centric spaces. As Marble, a white non-Hispanic/Latino asexual trans man, conveyed: Definitely going to a gynecologist, I think is something where I’m very hesitant to go, because I’m like, “Do I want to have to have that conversation?” Because… it feels like such a vulnerable position to be in… [G]oing to a gynecologist is like—it’s very much a woman’s—a woman’s doctor, and all the things are very woman-themed. It’s hard to reconcile your own identity with that kind of onslaught from all sides of being like, “Oh, you're at a place where women go.”
Marble describes his feelings of vulnerability and hesitancy to disclose his gender identity as a trans man in a normatively feminine care environment. By acknowledging that a gynecologist is “a woman’s doctor,” Marble holds himself accountable to cisnormativity in medicine through this assumption of only (cis)women seeking gynecological services. This quote also reflects how cisnormative accountability disallows TGNB affirmation in reproductive care settings, reinforcing cisnormative assumptions of reproduction.
The narratives above highlight how cisnormative accountability prioritizes cisgender experiences and often precludes TGNB young respondents from receiving TGNB-inclusive care. Such instances of cisnormative accountability or a medical system predicated upon cisgender-only norms, regardless of intention, contribute to the reproduction of inequality in healthcare for TGNB communities. In what follows, I explore how interview respondents navigate cisnormative accountability through the maintenance of the trans medical model.
Maintaining the Transgender Medical Model
All interview respondents who received hormone therapy services and/or gender-affirming surgeries described navigating cisnormative accountability structures centered on the medical model of transgender identity. For example, respondents reported strategic pathways they have used for obtaining hormones. One interviewee even reported resorting to illegal purchase of hormones out of concern that her parents would discover her usage since she was on their health insurance plan. Many respondents shared how their medical providers created additional barriers to accessing gender-affirming care (Johnson, 2015; 2019), such as substantially delaying a medical recommendation letter for gender-affirming surgery. Accountability to the trans medical model was a driving force in how successful respondents were in navigating such medical gatekeeping practices. As Cypress, a white non-Hispanic/Latino bisexual trans man, emphasized, “For anyone, it can be difficult because of how it [receiving healthcare] is here in America, but to find someone who would—if you’re trans, especially if you don’t ‘pass’ or you’re not on hormones or anything that they view makes you ‘really trans’, quote unquote, they will be less likely to respect that.” Cypress illustrates how cisnormative accountability operates by holding TGNB people to cis- and transnormative expectations about the “real” way to be trans in healthcare settings.
TGNB people who do not engage in gender-affirming medical interventions (e.g., hormone therapies and gender-affirming surgeries) disrupt the trans medical model. Sociologists note how clinicians may struggle with deviating from the medical model of trans identity when providing gender-affirming care to TGNB patients (Mason-Schrock, 1996; shuster, 2021). Most non-binary respondents disclosed their need for TGNB inclusive care (e.g., honoring chosen names and pronouns) during clinical encounters without desiring the need for gender-affirming medical interventions. In doing so, they reported instances where medical providers ignored their requests. Iris, a white non-Hispanic/Latinx bisexual non-binary person, explained: There ha[ve] been some other times where I’ve gone to go make an appointment and just me giving them my insurance card or my ID with my name on it and the different gender marker was enough for them to be like, “So what should I put you in as?” And I’m like, “Well, my name.”… They were like, “Well, is your medical history…?” A lot of them, especially in healthcare, will ask like, well, what am I doing with transitioning? And it’s also weird to tell them that I’m not, because a lot of them… they’re confused… But the [TGNB] people that they can immediately see are the ones that are fully transitioned. So, in their mind, if somebody’s gender doesn't match their whatever, it’s weird for them that [TGNB] people aren’t like doing something about it… that weird in-between section where they can’t entirely tell what to do and what to ask.
Iris’s narrative exemplifies accountability to the trans medical model through the provision of gender-affirming care for patients who are “trans enough,” while attempting to subsume TGNB individuals who do not fit neatly in this model. Iris reported that clinicians heavily relied on medicalized assumptions of TGNB experiences during clinical encounters when expressing confusion with Iris’s non-binary identity, name, and pronouns. They explained how complying with the trans medical model as a “fully transitioned” TGNB person via seeking and utilizing gender-affirming medical interventions would be less confusing for their medical providers to understand. Thus, Iris is held accountable to and rendered “unreadable” by the medical model of trans identity, a medical model that structurally dictates medical recognition of trans status.
Even respondents who utilized multiple gender-affirming medical interventions reported medical providers and staff frequently confirming whether they were “fully trans” or “fully transitioned” in concurrence with the trans medical model. River, a white non-Hispanic/Latino queer trans man, shared his frustration on this topic: [E]very time I went [to a medical appointment], the people who did my intake… they would ask me something like, “Are you fully transitioned?” or something like that… And that’s just so frustrating to me. I want to be able to exist… I just think about how it shouldn't be anyone’s obligation—anybody who identifies within the [TGNB] community, it shouldn't be their obligation or prerogative to have to explain their identity to someone who they're literally paying for a service with. So, it’s just very discouraging… I’m fully transitioned when I am done with my transition and what is necessary for myself. I’m not… what you think is a man or I’ve had every surgery in your mind of how that works, now I’m fully transitioned. And that’s just really invalidating.
River’s narrative echoes the substantial challenges TGNB communities have faced with the trans medical model for the past five decades (Mason-Schrock, 1996; shuster, 2021). River discloses how medical providers would frequently confirm whether he is “fully transitioned,” while expressing feelings of invalidation during these instances. Such interactions about whether a TGNB person is or will be “fully transitioned” is a concrete example of medicalization and standardization of TGNB experiences.
Like River, even respondents who undergo gender-affirming medical interventions have reported they are still held accountable to the trans medical model based on cisgender medical authorities’ demarcation of what is or is not transgender (Johnson 2015, 2019). Such instances of cisnormative accountability, regardless of cisgender people’s intentions, contribute to the reproduction of gender inequality among TGNB communities. As such, respondents disclosed instances of medical gatekeeping practices where those who do not conform to others’ definitions are “closed off” from important services and resources (Garfinkel, 1967).
The medical model of trans identity was initially designed to understand, medicalize, and treat TGNB patients (Sumerau and Mathers, 2019). By solely relying upon the trans medical model, medical institutions and providers do not fully account for the array of TGNB patients’ needs and experiences. To receive gender-affirming medical interventions, TGNB people are forced to comply with this cisnormative accountability structure (Johnson, 2015; Stallings et al., 2021). As Winter, a white non-Hispanic/Latina heterosexual trans woman, noted: “I remember seeing medical documents that I had, that I needed for school… little notes saying something along the lines of [me] being ‘gender-confused’, which is something I… I find it very belittling.” Winter conveys how a clinician classified her as “gender confused” because she intended to delay hormone therapy services until she had secured enough money for consistent treatments. Thus, such instances of cisnormative accountability through the trans medical model depend upon the notion that being transgender is a fixed phenomenon that is only “real” if trans people have “fully transitioned” in such a way that fits cisnormative expectations about the alignment between one’s body and gender (Westbrook and Schilt, 2014; West and Zimmerman, 1987).
Strategies to Minimize Inequality in Care
What follows is an analysis of how TGNB young respondents engage in strategies to resist and reduce inequality in healthcare settings through (a) avoidance of health services and (b) selective disclosure of TGNB identities. Such examination of strategies offers critical insight into TGNB resistance and resilience processes in response to cisnormative accountability (Lampe, 2019; Stallings et al., 2021). While these notable strategies allow interview respondents to limit potentially harmful engagements with medical institutions and authorities, they also maintain structural inequalities in healthcare and lead to disruptions in preventive care for TGNB communities.
Avoiding Health Services
Respondents reported engaging in various strategies to minimize instances of TGNB inequality and to protect themselves from emotional or psychological harm in healthcare settings. In a critical review of LGBTQ+ youth research, Robinson and Schmitz (2021) emphasized the importance of examining resistance among LGBTQ+ youth when navigating oppression and how collective forms of resistance may lead to positive effects on health and well-being among LGBTQ+ youth. Echoing Robinson and Schmitz (2021), many interview respondents resisted traditional approaches to accessing and utilizing health services (e.g., consultations with licensed medical providers), especially in the case of gender-affirming medical interventions.
As mentioned earlier, Winter recounted her experiences of buying hormones illegally due to fear of Winter’s parents discovering her gender identity as a trans woman. Winter further explained her justification for ordering hormones illegally through a website that can only be accessed through specialized browsers (i.e., the dark web): I strongly, strongly prefer it because it has just been an uphill struggle. And it has been annoying trying to get the right prescription, making sure my prescription is covered by my insurance, making sure it’s a high enough dose, making sure you don’t run out too quickly. And so just doing it myself and ordering it myself makes it that much easier.
Winter explains the “uphill struggle” she has faced with obtaining hormone therapy services through licensed clinicians and the convenience of ordering non-prescribed hormones has been for her. Avoidance of clinical oversight is a strategy for Winter to resist inequality in her access to gender-affirming care. Like Winter, most respondents emphasized how medical authority and power play a vital role in their decision-making process to avoid care utilization. As Lily, a white Hispanic/Latina bisexual pansexual trans woman, explained her reason for completely halting non-emergency care services: There’s always the feeling of just not wanting to deal with having to explain to another person who has some sort of power over me that I’m trans, and that extends to healthcare. It’s slightly part of the reason why, even though I have a physician that I should be calling and seeing if I can get an appointment, I haven't… Just that fear of I really don’t want to not be accepted by yet another person.
Avoiding the possibility of experiencing TGNB stigma and rejection from clinicians, Lily stopped receiving non-emergency healthcare entirely. Winter and Lily both reported avoiding health services due to prior negative clinical interactions that foregrounded cisnormative accountability and limited their access to TGNB-competent care.
Additionally, the majority of trans men respondents have reported avoiding reproductive healthcare settings primarily due to severe discomfort and vulnerability within such spaces. As Geo, a white non-Hispanic/Latino gay trans man, noted: “I want to go to a gynecologist, but my fear has sort of held me back because that’s sort of a complicated thing to go to as a trans guy.” When I asked Geo to elaborate on his fear, he replied: It has been a long time since I’ve been to the gynecologist, but when I went to a gynecologist, they really tried to convince you… that you were visiting like a woman’s doctor… [I]t makes me scared, because if I’m going to a gynecologist or any doctor that only deals with cis people, it sort of makes me feel uncomfortable because they've never dealt with a body like mine before and they probably don’t even know like necessary to my care. Because most doctors, if they don’t have to learn trans healthcare, they won’t.
Geo feared that his doctors would not know how to provide gender-affirming reproductive care, while emphasizing his belief that gynecologists have no experience or desire with providing care to trans men. Such attitudes reflect broader accountability structures through the institutional and interpersonal maintenance of cisnormativity in healthcare (Stallings et al., 2021; Johnson, 2015). TGNB young patients who habitually avoid receiving care, in minimizing inequality in healthcare, are at risk of not receiving the necessary preventative care screenings and services for protecting their health. Such strategy is structurally limited for TGNB patients in both navigating cisnormativity accountability structures and reducing inequality in healthcare settings.
Selective Disclosure of Transgender and Non-Binary Identities
Echoing many bi+ people navigating monosexism
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in lesbian/gay and heterosexual community spaces (Sumerau, Mathers, and Moon, 2020), most respondents in this research sample described selectively disclosing their TGNB identities to medical providers and staff. This process of selective disclosure involves TGNB young people disclosing their gender identity selectively or strategically with healthcare professionals to further reduce experiences of TGNB stigma and discrimination (Kcomt et al., 2020). Respondents noted how (a) their immediate patient needs, (b) medical providers’ knowledge or experience with TGNB communities, and (c) the care environment were all notable factors for selectively disclosing their TGNB identities in clinical spaces. Arbor explained his reasoning for not disclosing his trans identity in emergency care settings: I don’t even think it’s safe—especially with the ER doc, I didn’t want to. I just had to, for medical reasons. Because again, they would have found out anyway. So, I just feel like it’s better to be off-bat, because even—then I feel like they treat you worse, after that, because then it’s like, “Oh, you were hiding this from me. You're hiding everything else. I’m not going to treat you, because obviously, these symptoms might not be—you're just faking all this.”
Additionally, some respondents believed they would receive “worse treatment” from clinicians if they disclosed their TGNB identities in care settings. As Ember noted: It’s [disclosing non-binary identity] a hassle, because especially now, saying something like that could get you not-as-good healthcare, worse treatment, they make you wait longer so it’s more inconvenient, or just nasty words or something, or just flat out, “I’m not going to take you.” And I don’t want that, because if I have an emergency, I need help.
Similarly, Shell, a white non-Hispanic/Latino gay gender-fluid trans man, recalled his experience in the emergency room after suffering a life-threatening, head injury: Every time I’ve talked about going to the emergency room, it [trans identity] has never really come up, because it has never really been related… I’ve never been injured in a way where it has really needed to be brought up. I was misgendered in those situations because I either wasn’t in the right mind to correct them or didn’t really find it necessary because more serious things were needing to be done.
Putting their immediate health needs before gender-affirmation, some respondents discussed the importance of selectively disclosing their TGNB identities with medical providers to minimize inequality in care settings.
Selective disclosure of TGNB identities in healthcare interactions varied among respondents with many of them fearful of their personal autonomy and safety being potentially compromised in the process. As Tulip, a white Hispanic/Latina bisexual trans woman, explained, “At least from my fears, identifying as a gender other than the one you were assigned at birth [in clinical spaces] just feels scary because it makes me worried about how the doctors will look at me at that point or will be judging or possibly out me.” Similarly, Marble noted, “Any doctors back in my hometown I am not out to… [laughing] back where my parents are because they also go to those doctors.” Most respondents, like Marble, expressed the fear of medical providers outing them as TGNB to their parents—who all of them reported as their main source of income and housing security. Such insecurities among respondents outweighed their need or desire to disclose their TGNB identities to healthcare professionals.
Others have discussed how disclosing their TGNB identities and pronouns in clinical spaces is not worth their emotional labor due to medical providers’ preconceived bias and knowledge of TGNB communities. As Ivy, a white non-Hispanic/Latinx bisexual gender nonconforming person, emphasized, “[T]here’s part of me that’s like—they’re just not going to care [about my pronouns], they’re not going to respect it, and then suddenly it’s going to be an issue.” Ant, a white non-Hispanic/Latino queer non-binary genderqueer person, also noted, “I don’t know how I would go about it [disclosing gender identity in care settings] now. I still get kind of anxious telling people upfront, because I’m just afraid their reaction is going to be dumb.” Ivy and Ant both explained their fears of TGNB identity disclosure in healthcare settings and its potential consequences. Similar to cisgender people rendering invisible trans experiences in public spaces (Sumerau and Mathers, 2019), they believed medical providers would render invisible their TGNB identities in clinical spaces.
Finally, respondents reported struggling with not “coming out” to providers and “being trans enough” for them in accordance with the medical model of trans identity (Johnson, 2015). For example, Petal described the possibility of not having access to hormone therapy treatments due to medical gatekeeping practices, “[I]f I wasn’t able to access my hormones, and if I wasn’t able to get medication and counseling for my mental illnesses, I just—yeah, I probably wouldn’t be alive. I probably would have killed myself.” To have their health insurance carriers cover gender-affirming medical interventions, respondents are also forced to comply with the trans medical model. Consequently, respondents must disclose their TGNB identities to healthcare professionals when seeking and maintaining TGNB-specific care, even when they feel uncomfortable doing so.
As Terran, a white non-Hispanic queer trans man, explained: “If I had to pay out of pocket for top surgery, for testosterone, I wouldn’t be able to. I genuinely think it would result in me ending up killing myself because of my dysphoria.” Such narratives stress the notable limitations of selective disclosure by revealing how TGNB young people are pressured to fully disclose their TGNB identities to access life-saving healthcare. Strategies for resisting and reducing inequality in healthcare settings may temporarily help TGNB young people navigate medical institutions and authorities. However, these strategies are structurally ineffective at addressing the health and healthcare needs of TGNB young patients and minimizing the impact that accountability structures have in TGNB healthcare experience.
Discussion
In this article, I examine TGNB young people’s care experiences and strategies for minimizing inequality in healthcare settings. Drawing on the conceptualization of cisnormative accountability (Lampe, 2019; Stallings et al., 2021), I demonstrate how TGNB patients are held accountable to the maintenance of (a) cisnormativity and (b) the medical model of transgender identity in US healthcare systems. My findings reflect broader observations of how cisnormativity operates in medicine as an accountability structure and contributes to the reproduction of gender inequality in healthcare for TGNB communities (Lampe, 2019; Stallings et al., 2021). Cisnormative accountability allows for sociological examination of ways that medical institutions and authorities, regardless of their intentions, enforce cisnormativity in medicine and the subordination of TGNB people.
Although sociological attention to TGNB communities has rapidly increased in recent years (Johnson and Rogers, 2020; shuster, 2021; Sumerau and Mathers, 2019), there remains limited focus on how TGNB young people engage in strategies to resist and reduce TGNB-specific stigma and discrimination in care settings. Future research should examine how TGNB young people engage in strategies to minimize inequality in healthcare and its relationship with the rapid increase in anti-trans legislation and politics throughout the US. Additionally, pinpointing the strategies that TGNB young patients use that meaningfully contribute to clinical intervention development and implementation for TGNB populations. This study offers researchers and clinicians the opportunity to further examine how cisnormative accountability impacts TGNB young people’s experiences with and resistance to gender inequality in healthcare.
Interview respondents reported broader patterns of inequality in healthcare among TGNB communities. I further extend this work by exploring how TGNB young people navigate accountability for cisnormativity in medicine and the trans medical model, while explaining deliberate strategies (and its limitations) when aiming to prevent TGNB stigma and discrimination in care settings. I join other sociologists (Johnson, 2015; shuster, 2021; Sumerau and Mathers, 2019) in calling for new growth and development in these respective areas of research to investigate the consequences cisnormative accountability structures have on TGNB people and how such accounts contribute to the reproduction of gender inequality. I also call for sociologists to continue examining the strategies TGNB patients use to resist and reduce inequality in healthcare, along with its structural limitations and consequences. Further investigation matters for the betterment of TGNB people’s health and well-being.
Patient narratives, such as the accounts offered herein, may help clinicians and policymakers more fully address the barriers to care that TGNB young people often face when accessing and utilizing health services. Dismantling the harm that TGNB people experience within care settings requires intentional and collaborative action. Mitigation strategies should draw on thoughtful research that explores how TGNB young people cultivate resilience, resourcefulness, and resistance when seeking gender-affirming medical interventions during this rapid increase in anti-trans legislation and policies. Only critical analyses of the ways TGNB patient communities endure cisnormative accountability (Lampe, 2019; Stallings et al., 2021)—and the consequences of such structures—will allow us to distinguish the theoretical potential of “gender accountability” from the real-world, direct impact of cisnormativity in American medicine (shuster, 2021; Sumerau, 2020).
Footnotes
Acknowledgments
The content of this article is solely my responsibility and does not necessarily represent the official views of the National Institute on Aging, the University of Central Florida, or Trans Lifeline. For their valuable mentorship, feedback, resources, and encouragement with this project, I thank Carla A. Pfeffer, Alexandra “Xan” C. H. Nowakowski, J. E. Sumerau, Lain A. B. Mathers, Emily S. Mann, Shannon K. Carter, and Lindsay A. Taliaferro. I also thank Sociologists for Women in Society—South and the Mid-South Sociological Association for awarding earlier versions of this manuscript in their paper competitions. Finally, I thank Ezri A. Tyler for her research support at the Vanderbilt LGBTQ+ Policy Lab and the interview respondents who participated in this study.
Declaration of Conflicting Interests
I declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
I disclose receipt of the following financial support for the research, authorship, and/or publication of this article: Funding from the University of Central Florida College of Medicine was used in support of this research (PI: Lindsay A. Taliaferro). Other funding from the University of Central Florida Department of Sociology and Trans Lifeline was used to assist with monetary incentives for interview respondents. I was also supported by the National Institute on Aging during the journal peer review process of this manuscript (PI: Tara McKay; R01AG063771-01).
