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Abstract

Trans people’s gender identity is frequently cited as a source of health care denial, even when it has no bearing on their symptom presentation. A latent belief among health care workers that trans people are fundamentally different from cis people is deeply implicated in the finding that between one fifth and one third of trans people have been denied care because of their gender identity. In this study, the authors use data from a nationally representative survey (n = 2,458) to examine whether Americans believe a doctor who denies care to a trans patient on the basis of claims of inadequate training. The authors find a majority of Americans trust this explanation. These views are more common among Evangelicals and Republicans, whereas Black respondents are less inclined to deem this justification valid. Qualitative analyses reveal that those who accept the doctor’s rationale are more likely to acquiesce to doctors’ medical knowledge, to assert that doctors have professional discretion in making referrals, and to reference complications stemming from the patient’s presumed receipt of gender-affirming care despite the routine nature of their sick visit. These findings indicate that doctors’ enduring cultural authority powerfully intersects with “trans exceptionalism” to inform Americans’ perspectives on the denial of care to trans people.

Keywords

transgender health health care denial transgender discrimination

Trans people’s gender identity is frequently identified as a source of clinical uncertainty by medical providers (shuster 2021; Snelgrove et al. 2012; Vance, Halpern-Felsher, and Rosenthal 2015), in part because exposure to trans people and training in trans health care are not prominent features of medical education in the United States (Obedin-Maliver et al. 2011). As a result, some providers mistakenly attribute all of trans patients’ medical concerns to their gender identity, even in instances in which it has no relationship to their symptoms, a phenomenon colloquially known as “trans broken arm syndrome” (Paine 2021). Research also documents providers’ susceptibility to “trans exceptionalism,” or a spurious belief that trans people’s bodies are so different from cis people’s they are unable to extrapolate from their training to render basic medical care to these patients (shuster 2021). Alongside outright discrimination, these dynamics help explain why between one fifth and one third of trans people report being denied medical care because of their actual or perceived gender identity (Grant et al. 2010; Medina et al. 2021).

It is unclear whether “trans broken arm syndrome” and “trans exceptionalism” are confined to medical professionals, or instead, more deeply rooted in broader normative beliefs about trans people. To date, we know little about how Americans view this form of treatment discrimination, or the cultural logics that underlie their beliefs. To answer these questions, we use quantitative and qualitative data collected as part of a nationally representative survey experiment (n = 2,458) to interrogate who acquiesces to medical authority in the case of treatment denial to trans people and why. Using the case of a trans patient denied care during a routine sick visit because of a doctor’s claims of inadequate training, we find that a majority of Americans believe the doctor’s rationale. Although Black respondents are more likely than other racial-ethnic groups to doubt inadequate training is the true reason for treatment denial, other groups, which tend to hold less favorable views of trans people—namely, Evangelicals and Republicans—are more inclined to believe the doctor’s explanation.

Analysis of qualitative data provides evidence that pervasive beliefs regarding the cultural authority of doctors collide with beliefs about trans exceptionalism to inform respondents’ willingness to believe the doctor’s explanation of inadequate training. With respect to the former, respondents tended to trust the doctor’s knowledge of their clinical limitations and believed doctors have a professional right to refer patients as they deem fit. In terms of the latter, a nontrivial portion of respondents referenced potential medical complications arising from the patient’s presumed receipt of gender-affirming care despite the fact this was never mentioned in the vignette and that the patient depicted was seeking care for a general illness. By contrast, respondents who pushed back on the doctor’s claims tended to view doctors as morally and professionally bound to provide treatment to all patients, and to believe that doctors should treat patients equally regardless of the different identities they embody. These findings suggest a lack of sophistication about trans people in general, and their health care issues in particular, among the public. We discuss these implications for future research aimed at understanding the treatment disparities faced by trans people.

The Health Care Experiences of Trans People

Trans people in the United States confront prejudicial attitudes, discriminatory treatment, and instances of victimization rooted in the pervasiveness of transphobia (Flores et al. 2021; Medina et al. 2021). Recent years have witnessed accelerated efforts to erase trans people’s lives and experiences from society (Sumerau, Cragun, and Mathers 2016; Sumerau and Mathers 2019), with concerted attempts by state legislatures to inscribe discriminatory and exclusionary practices targeting trans people into law. Amidst a rapidly changing legal landscape, marked by a wave of legislation aimed at curbing their civil rights (Trans Legislation Tracker 2023), trans people continue to face institutional forms of discrimination including the denial of medical care (Hsieh and Shuster 2021). This is especially noteworthy because in many states legal transitions, including gender marker corrections and modifications to identification documents, continue to hinge on medical acknowledgment of anatomical coherence and/or the administration of gender-affirming care (Johnson 2015; Meadow 2010).

In the realm of health care, trans people are less likely than the cisgender population to have a regular health care provider or to report a routine medical visit in the past year (Medina et al. 2021). This scenario is a reflection of both inequitable access stemming from heightened economic precarity among this population, as well as a widespread belief among trans people that they will be disrespected and discriminated against during the clinical encounter (James et al. 2016). Substantiating these fears, research on trans people’s health care experiences indicates that providers enact many of the same forms of harassment and victimization trans people experience elsewhere in society. Nearly half of trans people have experienced medical mistreatment at the hands of their doctors, ranging from being handled roughly and subjected to abusive language, to being misgendered or deadnamed (Medina et al. 2021). Yet even among those who brave the clinic, trans patients may ultimately be denied medical care altogether. Between one fifth and one third of trans people have been refused routine medical care because of their gender identity (Grant et al. 2010; Medina et al. 2021). Research focused on health care providers’ perspectives suggests this treatment refusal is often rooted in the uncertainty and discomfort providers experience because of insufficient training during medical education (shuster 2021; Snelgrove et al. 2012; Vance et al. 2015).

Even when health care providers have experience working with trans patients, their views are sharply circumscribed by transnormativity, an ideology that holds trans people accountable to a binary medical model (Johnson 2015, 2016). Central to this framework is a homogenizing narrative wherein all trans people are believed to experience lifelong discontent with their bodies and a corresponding desire to “cross over” from one side of the gender binary to the other (Johnson 2016; Rogers 2020; shuster 2021). It is expected trans individuals will pursue gender-affirming care that helps them most fully embody the “other” gender, and enact corresponding stereotypical masculine or feminine behaviors (shuster 2021). Those who are nonbinary, or who possess more fluid identities, are viewed as inauthentic by providers and restricted from accessing gender-affirming care (Johnson 2016; shuster 2021). Because many states require formal proof of medical intervention to permit modification to gender markers on state and federal documents, transnormative accountability structures thus limit the social and legal recognition of trans people to those who adhere to the gender binary (Johnson 2015). In this way, health care providers remain the ultimate arbiters of trans identities in the eyes of the state, serving as the guarantor of trans people’s claims to personhood.

“Trans Broken Arm Syndrome” and “Trans Exceptionalism”

Studies routinely show that trans patients report having to instruct their health care providers about trans people in order to receive appropriate care (Bauer et al. 2014; Bradford et al. 2013; Grant et al. 2011; Medina et al. 2021; Poteat, German, and Kerrigan 2013). When surveyed about their experiences with trans patients, health care providers often describe a great deal of clinical uncertainty in treating this population, with both a lack of exposure to trans patients and deficits in formal training pinpointed as the leading culprits behind this insufficient knowledge base (shuster 2021; Snelgrove et al. 2012; Vance et al. 2015). On one hand, because trans people constitute less than 1 percent of the population (Lagos and Compton 2021), it is entirely plausible that health care providers may go the length of their training with only limited interaction with trans patients. On the other hand, the absence of training is trans medicine is a purposeful choice. Medical schools devote only a handful of hours to training in LGBT issues (Obedin-Maliver et al. 2011), with some failing to formally instruct students on these issues at all. Even when such topics are touched upon, they are often not included as part the didactic curriculum (Moll et al. 2014), which may have the unintended consequence of downplaying their importance for medical students (Olsen 2019). The cumulative effect of these decisions is a medical workforce that reports low levels of confidence (Vance et al. 2015) and comfort (Eliason, Dibble, and Robertson 2011; Lurie 2005) in treating trans patients.

Feelings of inadequacy, incompetence, and trepidation experienced by practitioners in their interactions with trans patients may lead them to deny care altogether, even when the issue at hand is unrelated to gender-affirming treatment or a patient’s gender identity (Paine 2021; shuster 2021). Such instances of treatment denial are emblematic of a phenomenon termed “trans broken arm syndrome,” wherein a trans patient seeks care for a medical issue wholly unrelated to their gender but discovers medical providers quick to label it as a result of being trans (Paine 2021). Treatment refusal may also be a function of “trans exceptionalism,” a scenario in which medical providers erroneously believe trans patients are so fundamentally different from cis patients that they are unable to apply their training to even routine health issues faced by trans people (shuster 2021). Whether these beliefs are borne of clinical uncertainty or more deeply rooted in broader cultural beliefs regarding the “exceptional” nature of trans people’s health issues is an open empirical question we address in this study.

Although there is no clinical justification for a doctor, or any other health care provider, to deny non-gender-affirming medical care to a trans patient on the basis of inadequate training, to date, we know little about the public’s willingness to accept these claims as valid. The public’s willingness to take the doctor’s word at face value may also depend on the demographic features of the patient and perceptions of social worth attached to their demographic characteristics. In American society, social categories of people are ranked hierarchically, with some groups afforded more respect and esteem than others; more often than not, because of their possession of greater resources (Ridgeway 2014). With respect to gender identity, the findings of public opinion research suggest that masculinity is a highly esteemed status that is easily forfeited by status incongruent behavior (Mize and Manago 2018). As such, trans women may be viewed by the public as relinquishing a privileged status in society, and thus evaluated more negatively relative to trans men. It follows that members of the public may in turn be more willing to accept a doctor’s justification of ‘inadequate training’ in the case of a patient who is a trans woman. In a similar vein, other research finds that Americans are more likely to devise elaborate justifications to condone the denial of care to trans people of color compared with White trans patients (Doan and Grace 2022). Consequently, respondents may be predisposed to trust a doctor’s assertions of inadequate training when the person being denied care is a person of color.

Why Study Public Attitudes?

Debates about the cultural authority of physicians have endured for decades, with some viewing the profession on an inexorable decline (McKinlay and Marceau 2002), some viewing it as largely unaffected by broader social trends (Freidson 1970), and still others observing historical periods of fluctuation (Light 2010). At the turn of the twenty-first century, confidence in the medical profession remained largely intact, though certain negative beliefs about doctors proliferated, including the view that doctors do not always treat patients with respect, are not always thorough in their examinations, and sometimes take unnecessary risks (Pescosolido, Tuch, and Martin 2001). The commercial tilt of the late twentieth century also led to a companionate rise in the public’s perceptions of wanton avarice among some health care professionals and the institution of medicine more broadly (Mechanic 1996). To date, physician trust has been one of the most extensively studied aspects of doctor-patient relationship (Hankin and Wright 2010). Central to working definitions of physician trust are a constellation of beliefs regarding the doctor’s competence, honesty, confidentiality, and willingness act in the best interests of their patients (Hall et al. 2001). Studying public attitudes with respect to the denial of health care to trans people provides a window into ongoing shifts in the cultural authority of medical professionals, the public’s trust in medicine as an institution, and the consequences of how these views collide with normative, societal beliefs about trans people.

Sociodemographic Variation in Physician Trust and Attitudes about Trans People

To the extent the public is willing to believe inadequate training is the primary rationale behind a doctor’s denial of care to a trans patient, demographic patterns might mirror trends regarding physician trust. At the same time, given the salience of trans issues in public discourse in recent years, respondents’ views of this case may instead be more accurately explained by demographic factors that tend to be predictive of attitudes regarding trans people in general.

A body of empirical research suggests that people’s sociodemographic characteristics play a vital role in explaining their general level of trust in physicians. For instance, women are considerably more likely to trust physicians than men (Schnittker 2004; Stepanikova et al. 2006). By contrast, people of color, and especially those who identify as Black or Latinx, have lower levels of trust compared with White respondents (Doescher et al. 2000; Schnittker 2004; Stepanikova et al. 2006). Diminished trust among Black Americans in particular can be understood not only as the logical outgrowth of both the systematically inferior care they receive and the severity of physician biases they face (Gerber et al. 2013; van Ryn 2002) but also the historical abuses visited upon this group in the name of medical science (Washington 2006). In terms of socioeconomic status, some research suggests higher levels of income and educational attainment are associated with lower levels of trust (Stepanikova et al. 2006), whereas other research suggests the opposite holds true (Schnittker 2004). With respect to religious affiliation, Evangelicals are less trusting than other Protestants (Sewell and Ray 2015). Although clear partisan divides about the institution of medicine have emerged in the wake of the COVID-19 pandemic, Republicans and Democrats tend to hold equally positive views about medical doctors (Funk and Gramlich 2020). In terms of health care use, those with both more frequent and more recent health care visits are also more inclined to trust doctors (Doescher et al. 2000; Stepanikova et al. 2006)

However, these demographic patterns in physician trust may be superseded by how respondents view trans people more specifically. Polarized debates over trans rights are a relatively recent phenomenon (Castle 2019). Indeed, discourse surrounding the rights of trans people went from barely registering at the national level, to becoming highly politicized following a U.S. district court’s ruling in 2016 that a Virginia school’s restroom policy, which compelled a trans student to use restrooms corresponding with the sex they were assigned at birth, violated the Equal Protection Clause of Title IX (Jones and Brewer 2020). A raft of antitrans legislation and “bathroom bills” followed suit. In the intervening years, conservative ideologues and Evangelical leaders have deployed antitrans rhetoric that frames trans people as an imminent threat to both cis women (in public restrooms) and children (by deeming gender-affirming care for minors a form of child abuse) (Libby 2022). With respect to the latter, recent legal opinions issued in Republican-led states render the parents of trans children—and health care professionals who provide them gender-affirming care—vulnerable to criminal prosecution (Paxton 2022). It follows that Evangelical Christians and Republicans tend to hold consistently less favorable attitudes about trans people (Flores 2015; Lewis et al. 2017; Tadlock et al. 2017). Evangelicals commonly express essentialist views of gender (Kanamori et al. 2017). As a consequence, they voice greater discomfort with trans people and hold less positive views about members of this group (Castle 2019; Kanamori et al. 2017; Lewis et al. 2017). Evangelicals who evince higher levels of religiosity are also more inclined to agree that states should pass antitrans bathroom bills (Castle 2019). Republicans are similarly less supportive of measures to ensure public facilities access for trans people, as well as discrimination protections for this group in schools, the workplace, and the military (Jones et al. 2018).

In sharp contrast, cis women consistently hold more positive feelings about trans people than cis men, and analogously, voice a greater willingness to support discrimination protections for this group (Cragun and Sumerau 2015; Flores 2015; Lewis et al. 2017; Tadlock et al. 2017). Findings regarding race-ethnicity are more nuanced, with some studies documenting more positive attitudes about trans people among Black respondents (Cragun and Sumerau 2015) and some revealing more negative views among members of this group (Flores 2015). Higher levels of education (Norton and Herek 2013) and being a member of the LGB community (Cragun and Sumerau 2015; Tadlock et al. 2017) are both indicative of more positive views of trans people.

In view of these at times diametrically opposed patterns of public opinion concerning physician trust and trans people, in this study we first explore how sociodemographic characteristics inform people’s willingness to believe a doctor’s claims of inadequate training as justification for denying care to a trans patient. As a secondary objective, we then examine the logics that help explain why some Americans are more likely than others to accede to a doctor’s claims of insufficient training.

Method

Data

To examine who acquiesces to physicians’ medical authority in the case of trans health care denial and why, we use data collected as part of a nationally representative survey experiment supported by the Time-Sharing Experiments for the Social Sciences (TESS) program. Respondents were recruited via AmeriSpeak, an online panel of U.S. adults maintained by the National Opinion Research Center. Panel members are first identified using the center’s National Sample Frame and subsequently contacted by U.S. mail, by telephone, or in person to gauge their interest in participation. A total of 5,028 respondents participated in the larger survey, fielded from October 10 to 22, 2019. Given this study’s specific focus on how people respond to doctors’ claims to medical authority, we focus on the subset of 2,475 respondents who read a vignette describing a doctor’s treatment refusal because of “inadequate training.” After dropping cases missing on the study’s focal dependent variable (n = 9) and those with missing data on key sociodemographic measures included in regression analyses (n = 8), our final sample consists of 2,458 respondents. Table 1 presents weighted descriptive statistics for the sample.

Table 1.

Weighted Descriptive Statistics for Sociodemographic Measures and Key Study Variables (n = 2,458).

	% or Mean (SD)
Dependent variable
Agree inadequate training primary reason for treatment refusal	.53
Gender Identity
Male	.48
Female	.51
Trans/another gender identity	.01
Race-ethnicity
White	.61
Black	.13
Else	.01
Latinx	.18
Multiracial (non-Hispanic)	.03
Asian	.03
Age	46.83 (17.34)
LGB	.08
Socioeconomic status
Education	10.25 (2.02)
Annual household income	9.37 (4.28)
Employed	.60
Unemployed	.12
Retired	.20
Disability	.08
Married	.60
Evangelical	.25
Republican	.36
Health care worker	.06
Knows an LGB person	.66
Knows a transgender person	.36
Last doctor visit	4.58 (.88)
Health care knowledge	3.34 (.69)
Region
Northeast	.15
Midwest	.20
South	.41
West	.24

Stimulus

Respondents are first randomly given one of eight hypothetical vignettes about a patient seeking treatment at a local urgent care for a nondescript illness. The vignettes are identical except for the race (Black, White, Asian, or Latinx) and gender identity (man or woman) of the patient, which varies across the eight vignettes. Race is signaled using names from Gaddis’s (2017a, 2017b) research on the demographic profile of names from New York birth records to ensure the names clearly signaled race. Gender identity is manipulated by explaining the vignette character was assigned a different sex at birth than their current gender identity. An example vignette is shown below (see Appendix A for all vignettes):

One evening, Tyra Washington began to feel ill. Tyra went to the local urgent care and was seen by Dr. Smith. Tyra, who was born male but now identifies as a woman, began by telling Dr. Smith about the symptoms. After hearing the symptoms, Dr. Smith said that he would not treat Tyra. Dr. Smith explained that he had inadequate training for treating patients who are transgender and would feel more comfortable if Tyra visited another provider since it was a non-emergency.

After reading the vignette, respondents are asked a series of questions about their views regarding the doctor’s justification for treatment denial and the rationale behind their answers.

Quantitative Measures

Agreement with Inadequate Training as the Primary Explanation for Treatment Refusal

Our primary outcome is respondents’ level of agreement that inadequate training is the main reason behind the doctor’s denial of care. This is assessed by an item that asks, “To what extent do you agree that inadequate training is the primary reason why Dr. Smith will not treat [name]?” Response categories include (1) “strongly disagree,” (2) “somewhat disagree,” (3) “somewhat agree,” and (4) “strongly agree.” For regression analyses, we dichotomized this measure to contrast those who (1) somewhat or strongly agree with those who (0) somewhat or strongly disagree to provide a more intuitive sense of the magnitude of effect sizes. However, results are substantively similar when this item is left in its ordinal form (available upon request).

Respondent Sociodemographic Characteristics

Analyses include a host of sociodemographic measures previously associated with physician trust and attitudes about trans people. Respondents’ gender identity is operationalized as female (1), trans (1), and male (0). Race-ethnicity is measured as Black (1), else (1), Latinx (1), multiracial (1), Asian (1), and White (0). Age is a continuous variable (range = 18–93 years). Sexual orientation is measured using a binary variable for LGB respondents (1; 0 = straight respondents). We operationalize respondents’ socioeconomic status using measures of annual household income (ordinal; 1 = less than $5,000, 18 = $200,000 or more) and educational attainment (ordinal; 1 = none, 14 = professional degree or doctorate). Binary measures are also included to account for those who are married (1; 0 = else), Evangelical (1; 0 = non-Evangelical), or Republican (1; 0 = Democrat or independent). A dichotomous variable is used to compare health care workers (1) with the general public (0). Health care providers are a heterogeneous group of occupations including doctors, advanced practice providers (e.g., nurse practitioner), nurses, allied health professionals (e.g., speech pathologist), technicians or technologists, aides, counselors, and pharmacists.¹ We also include measures that gauge whether respondents know someone who is lesbian, gay, or bisexual (1) or trans (1).

Health care use is captured by an item that asks respondents how long it has been since their last checkup with a doctor (ordinal; 1 = never, 5 = past year). We also created a measure of respondents’ confidence in health care knowledge on the basis of seven items that asked respondents about their level of confidence understanding different health care–related terms, including premium, deductible, copayments, coinsurance, maximum annual out-of-pocket spending, provider network, and covered services (α = .91). Response categories for these items range from “not at all confident” (1) to “very confident”. We created a mean scale on the basis of responses across these seven items such that higher scores are indicative of greater confidence in one’s health care knowledge. Finally, a measure of respondents’ geographic region is incorporated into analyses, consisting of those from South (0), the Northeast (1), the Midwest (1), and the West (1).

In addition to respondent characteristics, we also examined whether and how patient characteristics affected deference to the doctor. Regression analyses include a binary variable capturing the vignette character’s gender identity (0 = trans woman, 1 = trans man). The character’s race-ethnicity is measured as Black (1), Latinx (1), Asian (1), and White (0).

Quantitative Analyses

To assess variation in respondents’ beliefs about the veracity of the doctor’s explanation for treatment denial, we estimated a logistic regression model in which this outcome is regressed on sociodemographic variables and patient characteristics. The model includes survey weights to ensure results are reflective of the adult, English-speaking population of the United States.

Qualitative Data

Immediately following a separate survey item gauging level of agreement with the doctor’s decision to deny care, respondents were asked an open-ended follow-up question: “Why do you [strongly disagree, somewhat disagree, somewhat agree, or strongly agree] that Dr. Smith should be [allowed to refuse or required] to treat [name]? In your own words, please write a few sentences explaining why you feel this way.” We use these data to further understand why some respondents believe the doctor’s explanation for treatment refusal while others voice skepticism.

Qualitative Analyses

Qualitative responses were analyzed using an inductive approach (Strauss 1987). The first author conducted a preliminary open coding of all textual data. Ten percent of cases were then randomly selected and independently coded by each author using this expansive set of codes. Although intercoder reliability was high (Gwet’s AC₁ = .95) (Gwet 2008), we collapsed a number of codes with substantive overlap. Data were then fully recoded by the first author to ensure uniformity in our approach. Twenty-one codes emerged in total, though for the present analyses we narrow our focus to themes occurring in at least 10 percent of all cases. Narratives presented in the results section were selected for their representativeness of a given theme and their significance for addressing our research questions.

Quantitative Results

Descriptive Results

Descriptive statistics are presented in Table 1. The findings reveal a majority of Americans (53 percent) either somewhat or strongly agree that inadequate training is the primary reason why Dr. Smith declined to treat the patient, despite the only information about the patient’s symptoms being that they “began to feel ill” and subsequently visited an urgent care center. That is to say, there is no explicit indication the patient is contending with symptoms beyond the scope of what a trained medical doctor would encounter in general practice.

Sociodemographic Trends in Who Believes the Doctor

Figure 1 depicts the average marginal effects derived from a logistic regression where agreement with the veracity of the doctor’s explanation for treatment refusal is regressed on study variables (full results are provided in Appendix B). We begin by examining sociodemographic variation in who believes the doctor. There are three noteworthy findings in this regard. First, Black respondents are 12 percentage points (p < .01) less likely compared with White respondents to somewhat or strongly agree that inadequate training is the primary reason behind the doctor’s refusal to treat the patient. By contrast, Evangelicals are 11 percentage points (p < .001) more likely than non-Evangelicals, and Republicans are 13 percentage points (p < .001) more likely than respondents of other political affiliations, to agree that insufficient training is the primary reason behind the doctor’s decision to deny care. Beyond these associations, no other sociodemographic factors meaningfully bear on respondents’ beliefs regarding the veracity of the doctor’s claims. Strikingly, there is no significant difference between health care workers and the general public, suggesting these groups are equally likely to believe the doctor’s claim that he is ill equipped to treat a trans patient for a routine sick visit. In a similar vein, neither gender identity, sexual orientation, socioeconomic standing, marital status, familiarity with LGB or trans people, health care use, health care knowledge, or geographic region have significant associations with the study’s focal outcome.

Figure 1.

Average marginal effects of belief in doctor’s explanation for treatment refusal (n = 2,458).

The Effects of Patient Characteristics on Believing the Doctor

There is even less variation in the effect of patient characteristics on respondents’ willingness to believe the doctor’s justification for treatment refusal: neither the patient’s gender identity nor their race-ethnicity was significant. Collectively, these findings suggest a uniform deference to the doctor regardless of who the patient happens to be.

Qualitative Results

Quantitative analyses demonstrate that certain segments of the population, namely Evangelicals and Republicans, are more likely than others to acquiesce to the doctor’s assertion of insufficient medical training, whereas others, most notably Black Americans, are dubious of these claims. In what follows, we focus on the five most prominent themes that came up across at least 10 percent of all cases. Organizationally, we begin with the three most common reasons provided by respondents who believed the doctor’s justification for treatment denial. We then shift our focus to the two primary reasons given by respondents who doubted the doctor. To highlight the variation in endorsement identified in the quantitative results, we indicate the respondent’s race-ethnicity, religion, and political affiliation alongside each corresponding quotation.

Trust in Doctor’s Medical Knowledge

Approximately 54 percent of respondents who agreed inadequate training was the primary reason behind treatment denial referenced the doctor’s assessment of his own clinical limitations as a reasonable justification for treatment refusal. Both Republicans and Evangelicals are disproportionately represented among those invoking this logic, constituting 46 percent and 28 percent of those who referenced this idea as part of their justification for believing the doctor (despite constituting 36 percent and 27 percent of the sample, respectively). A striking number of respondents matter-of-factly voiced trust in the doctor’s explanation, reiterating more or less verbatim the doctor simply did not have sufficient training to treat trans patients: “He feels he is not the best doctor because he doesn’t have proper education or training to treat him” (ID #118, White, Evangelical, Republican). Yet other narratives illuminate a deep and abiding belief in doctors’ jurisdictional claims over medical knowledge:

because Dr. Smith explained he was unqualified to treat what ever the illness is which was not mentioned. No one would be more qualified than the doctor himself to make that determination. . . . If you take your automobile to a mechanic and the mechanic says because your problem is in the transmission and he is not qualified to work on transmissions, should he be forced to fit your transmission? (ID #16762, White, Evangelical, Republican)

Honestly . . . I won’t second guess him. . . . He has the education and should know what he’s doing (ID #8205, White, non-Evangelical, Republican)

Still other respondents lauded the doctor, framing his recognition of inadequate training as a testament to his good character. To this point, some respondents deemed the doctor’s admission an ethically responsible act aimed at averting potential harm to the patient. As one respondent noted, “If Dr. Smith really is flummoxed by the problem and is willing to say ‘I don’t know’ and admit that there might be better doctors who can help her, that’s positive” (ID #12309, White, non-Evangelical, Republican). Other respondents similarly viewed the doctor’s justification through a rosier lens because it appeared to go against the greed they associated with the American health care system:

If the doctor is being honest about the transgender aspect and it is not an emergency then this doctor is unusual because too many doctors seem to jump to treating for the purpose of profit and not for the patient’s best interest. (ID #800, multiracial, non-Evangelical, Republican)

Thus, respondents more inclined to agree the doctor was being truthful generally trusted doctors to know best whether they were suited to provide care and viewed the doctor’s reference to inadequate training —framed as an earnest admission to protect the patient’s health and wallet—as signaling something morally noteworthy about their character.

The Doctor’s Right to Issue a Referral

Roughly 26 percent of respondents who agreed that inadequate training was the true reason behind the doctor’s refusal to provide care mentioned the doctor either should, or had the right to, make a referral to another health care provider. Republicans, though not Evangelicals, were overrepresented among those voicing this belief, with the former accounting for 40 percent of those who referenced this logic as part of their explanation for trusting the doctor. A notable portion of these respondents argued that part of a doctor’s professional duty is to defer to more knowledgeable colleagues who can provide superior care. In a response emblematic of this position, one respondent noted, “If he hasn’t worked with transgender people, and isn’t familiar with helping them, he should refer them somewhere better” (ID #64, White, non-Evangelical, Republican). Although such exhortations to issue a referral are ostensibly couched in doing what is in the best interests of the patient, others viewed referrals as a tool doctors could discharge at their professional discretion. Many respondents used the language of doctor’s having a fundamental “right” to issue a referral:

Since it was not an emergency Dr. Smith Had the right to refer the patient to someone else. (ID #7511, White, non-Evangelical, Republican)

It should be his right to refuse to treat a patient if he thinks another doctor would be able to help (ID #16290, White, Evangelical, Republican)

As the second excerpt makes plain, the language of doctors having “the right to refer” is used by some as a more diplomatic way of articulating a belief that doctors have a right to refuse treatment to any patient for whatever the reason. Regardless of whether respondents framed referral as a professional obligation, or instead a blunt instrument to discard unwanted patients, this stance presupposes an ability to access care that is at fundamentally at odds with the reality of health care in the United States; particularly for trans people. Despite efforts to expand access, health care is not universally guaranteed in the United States, and for most, remains tethered to employment. Relative to the cis population, trans people are considerably more likely to live below the poverty line and to be unemployed (Conron et al. 2012). As such, a sizable portion of trans people have postponed or foregone needed care because they could not afford it (Grant et al. 2010; James et al. 2016). Beyond issues of access, other research finds a major obstacle to care for trans people includes physicians with suboptimal referral networks for trans patients (Snelgrove et al. 2012). Thus, although referral may provide moral license for the doctor to refuse treatment in the eyes of some respondents, in reality there is no guarantee a referral would lead to more optimal care—or in fact any care at all—for the patient.

Complications from Gender-Affirming Care

Close to 14 percent of respondents who deemed the doctor’s justification valid presumed the patient was either currently receiving gender-affirming care, or had in the past, despite this scenario not being mentioned in the vignette. Respondents who identified as Republican or Evangelical were overrepresented among those who referenced potential complications stemming from gender-affirming treatment, constituting approximately 41 percent and 30 percent, respectively, of those who mentioned this consideration as part of their justification for trusting the doctor. Among these respondents, a common refrain was as follows: “Dr. Smith may not be trained or comfortable treating someone who has had a gender reassignment surgery or is taking any type of hormone injections. These could impact the patient’s symptoms in ways that the doctor is not specialized” (ID #13199, White, non-Evangelical, Republican). These medical “complications” were often vaguely attributed to either adverse side effects of hormone therapy or gender-affirming surgery. Echoing the phenomenon of “trans broken arm syndrome” found among medical providers (Paine 2021), many respondents even speculated that gender-affirming care itself could be the source of the patient’s illness:

If issue was related to a sex change operation, the doctor may not be qualified to diagnose the condition. (ID #1833, White, Evangelical, Republican)

His symptoms could have caused by hormone therapy and the doctor might have a problem with diagnosis. (ID #16047, White, non-Evangelical, Republican)

On one hand, recurring reference to hormone treatment and surgical intervention suggests a level of medical sophistication and awareness of trans issues among the public. But on the other hand, this persistent emphasis on medical intervention as an essential aspect of trans identity also underscores the public’s incomplete understanding of trans people, including the possibility that one may elect to socially, but not medically, transition.

There was also a clear dichotomy in terms of how respondents referenced potential medical complications. For some, problems arising from gender-affirming care were framed as an important consideration to ensure the patient received appropriate medical care. But for others, the specter of medical complications was not raised with the patient’s well-being in mind, but rather, the possible negative repercussions this circumstance could pose for the doctor; including their vulnerability to malpractice litigation or ability to practice in the future:

If the doctor is not trained in the aspects what kind of complications can happen from being transgender, then the doctor should not have to risk his/her license. (ID #1829, White, Evangelical, Republican)

The medical issue could have been related to something related to hormones that the transgender person was taking and if it wasn’t an emergency, and the doctor didn’t treat it correctly the transgender person could have sued for malpractice (ID #1226, White, Evangelical, Republican)

Such narratives speak to broader, public beliefs about trans people’s location in the social hierarchy, as these respondents privileged the doctor’s professional standing over the patient’s well-being.

Still other respondents mentioned gender-affirming care within the broader logic of “trans exceptionalism.” Mirroring prior research on health care providers, these respondents voiced a perspective that gender-affirming care rendered trans patients’ so physiologically anomalous as to require specialized training regardless of the symptoms:

For Tyra to receive proper care they should have a doctor who is familiar with transgender issues ie medication, hormones (ID #11394, White, Evangelical, Republican)

If anything medically was done to this person, a doctor who is not well versed in that treatment should not be required to treat that person. A podiatrist would not be treating a cardiac patient. (ID #12365, White, Evangelical, Republican)

Assumptions about gender-affirming care, including fuzzy references to hypothetical medical complications that could result from it, became a device used by some respondents to justify the provider’s actions. For some, it was the logical source of the patient’s symptoms, for others a source of uncertainty that justified refusal, and for others still, it rendered the patient wholly unfit for routine medical care.

Doctors’ Professional Obligation to Treat and Treatment Refusal as Discriminatory

A sizable portion of respondents who did not believe the doctor’s justification for treatment denial, 44 percent, described the doctor as having both a professional and moral obligation to treat the patient. These respondents had a greater propensity to view doctors as duty-bound to render aid to any patient in need. Some respondents who employed this line of argumentation made vague references to a “code” or “oath” sworn by doctors to render care to any patient to the best of their ability. Still others directly referenced the Hippocratic oath and its axiom to “do no harm”:

The dr. took an oath to help all those in need. This is no exception. (ID #15351, Hispanic, non-Evangelical, Democrat)

Because the physician has taken an oath to help the sick if at all possible. His reluctance to help him goes against everything he’s sworn to do. (ID #6807, Black, non-Evangelical, Democrat)

The sheer prevalence of this theme suggests the public holds doctors to a higher ethical and moral standard. Indeed, doctors seen as flouting this obligation were framed as debasing the ethos of the profession, as one respondent curtly noted, “Transgender individuals have the same rights as everyone else. Dr. Smith took an oath. He is a disgrace to the medical profession” (ID #2209, White, non-Evangelical, Democrat). Another recommended Dr. Smith change occupations if he is unwilling to uphold this aspect of the profession: “If he or she doesn’t want to they should get a different job” (ID #9410, White, non-Evangelical, Democrat).

Several respondents were perplexed by Dr. Smith’s justification of “inadequate training.” These respondents voiced a steadfast belief that the doctor should at the very least be able to conduct a preliminary examination, while others maintained that health care providers have a professional responsibility to keep abreast of developments in the clinical literature:

Doctors are knowledgeable in many areas so getting lab work, xrays, blood pressure, listening to heart and lungs [is something] he could do for the patient (ID #5919, Black, Evangelical, Democrat)

Dr. Smith has a responsibility to be up to date on new research and education so that he or she is prepared to adequately treat any patient that walks through their clinic doors. (ID #486, White, non-Evangelical, Democrat)

Roughly 28 percent of respondents who disagreed that deficits in training were the primary reason behind treatment refusal described the doctor’s decision making as discriminatory in nature. Linking back to the quantitative findings, it is worth noting that Black respondents constitute 16 percent of those who invoked this belief as part of their explanation relative to making up 13 percent of the sample. The vast majority of these respondents either voiced a belief that “Doctors should treat everyone equally” (ID #6604, multiracial, Evangelical, Democrat) or noted that gender identity, alongside race-ethnicity, sexual orientation, and religious affiliation should be irrelevant to a patient’s treatment. Other respondents were more forthright in labeling the doctor’s decision discriminatory:

Engaging in a pattern or practice of treating someone indifference or subjecting them to a different standard predicated on race, age, sex, disability, and sexual orientation is blatant overt discrimination. (ID #3711, Black, Evangelical, Democrat)

But although many respondents vehemently decried the doctor’s behavior as discriminatory, legal recourse for patients who experience such mistreatment is tenuous. Although the Biden administration rolled back efforts initiated under the Trump administration to narrow the definition of sex in health care discrimination laws to apply only to cisgender women and men (U.S. Department of Health and Human Services 2020), so long as these protections rely on executive orders, they will be subject to shifts in the political landscape.

Discussion

Trans patients’ gender identity is often cited source of clinical uncertainty, and in turn medical care denial, even when it has no relationship to their symptoms (Paine 2021; shuster 2021). To explore how the public views this form of treatment discrimination, we used the case of a trans patient being denied care during a sick visit because of a doctor’s claims of inadequate training. Our findings demonstrate that most Americans are inclined to believe a doctor who cites insufficient training. Qualitative analyses shed light on why this is the case, with the logics issued by respondents reflecting a coalescence between pervasive beliefs regarding the cultural authority of doctors with erroneous, yet commonly held beliefs, about the “exceptionalism” of trans people’s bodies and related health concerns.

Despite the absence of any indication the patient could not be treated by a health care provider with general training, we found that a majority of Americans are willing to accept the doctor’s justification of inadequate training. On its face, these findings suggest a general willingness among the public to acquiesce to doctors’ expertise, perhaps signaling the enduring cultural authority of the profession (Light 2010). To this end, our findings align with recent public opinion research, which documents high confidence in doctors despite eroding trust in other social institutions (Funk and Gramlich 2020). Through another lens, however, these findings may in fact more accurately hinge on who the patient is. The American public is split in terms of whether society has become too accepting of trans people (Parker, Horowitz, and Brown 2022). From this standpoint, the unwillingness of most respondents to second-guess the doctor may instead reflect their implicit approval of treatment denial to a patient they view as undeserving of care (Roth 1972).

There were surprisingly few significant demographic predictors in terms of who was more or less likely to believe in the veracity of the doctor’s explanation. These trends were also neither fully consistent with research on physician trust nor the public opinion literature on trans issues. Black respondents were significantly less likely compared with White respondents to view the doctor’s justification as their primary rationale for treatment denial. Analogously, Black respondents were overrepresented among those who charged the doctor with discriminatory treatment in the qualitative findings. A greater willingness to push back against the doctor’s dubious claims is consistent with a recurring finding that Black people are less trusting of doctors relative to Whites (Doescher et al. 2000; Schnittker 2004; Stepanikova et al. 2006). This skepticism is likely rooted in the negative health care experiences of Black people, whether that is having their symptoms minimized or dismissed (Bonham 2001), being subjected to biases in the clinical encounter (van Ryn and Burke 2000), or the historical injustices visited upon them by the institution of medicine (Gamble 1993).

By contrast, two groups were substantially more likely than their counterparts to accept the validity of the doctor’s claims: Evangelicals and Republicans. Given that Evangelicals are less trusting of doctors than those of other denominations (Sewell and Ray 2015), and that Republicans tend to hold more or less similar views of doctors relative to Democrats and independents (Funk and Gramlich 2020), our findings suggest that these groups’ attitudes about trans people become more salient than their beliefs regarding doctors when the patient being denied care is trans. Indeed, one interpretation of these findings is that the patient’s status characteristics activate negative biases members of these groups tend to hold about trans people (Flores 2015; Lewis et al. 2017; Tadlock et al. 2017). Given that Evangelical Christianity and the Republican Party have become increasingly entwined in recent years (Whitehead, Perry, and Baker 2018), it is plausible that escalating antitrans rhetoric across these groups might explain the ready willingness of Evangelicals and Republicans to trust a doctor who denies care to a trans patient under the pretense of insufficient training.

There were clear-cut discrepancies in the logics employed by those who were more or less likely to believe the doctor. Among those inclined to express skepticism about the doctor’s explanation, respondents maintained that doctors have a professional and moral obligation to provide care to any patient. These respondents often mentioned doctors’ ethical responsibility to uphold the Hippocratic oath, and their professional obligation to stay up to date on the medical literature. Other respondents articulated a belief that doctors should treat all patients equally regardless of the identities they embody, with many explicitly calling out the doctor’s actions as discrimination. By contrast, among those who believed inadequate training was the doctor’s primary reason for treatment denial, there was an overwhelming tendency to trust doctors’ jurisdictional claims over medical knowledge (Freidson 1970), including the limits of their own. Respondents who believed the doctor’s justification were also more likely to express a belief that the doctor either should, or could, make a referral. Although some noted referral was in the best interest of the patient, others asserted doctors have a fundamental right to issue a referral at their discretion; coded language more accurately reflecting an underlying belief that doctors have a right to deny care to any patient regardless of the reason. That these logics were voiced disproportionately by Evangelicals, and especially Republicans, suggests that underlying biases against trans people among these groups might manifest as a seemingly benign tendency to more vigorously defend a doctor’s claims of inadequate training by invoking the profession’s authority over medical knowledge, or questioning the appropriateness of a trans patient visiting a nonspecialist.

Finally, those who tended to believe in the veracity of the doctor’s explanation also tended to assume the patient was currently receiving gender-affirming care or had in the not so distant past. Some respondents voiced concern that there could be unexpected interactions between prescribed medications and hormone treatment, and articulated a belief that the patient would be better served by a provider more familiar with trans health issues. A portion of respondents framed these concerns as rooted in securing adequate care for the patient, while others expressed concern that complications could leave the doctor liable to malpractice litigation. Regardless of motivation, this logic vividly demonstrates how the public, like many clinicians, falls prey to “trans exceptionalism,” believing that even run-of-the-mill illness, when experienced by a trans person, requires a degree of specialization beyond the scope of most doctors’ professional training.

With respect to the study’s practical implications, the widespread willingness of respondents to accept that a trans person’s gender identity would preclude them from receiving routine medical care, coupled with assumptions made by many respondents about the transition status of the patient, suggests an incomplete understanding of trans people at a societal level. Our findings underscore a need for greater public awareness of trans people, including the notion that trans people’s identities can be processual, evolving, and not rigidly tethered to the gender binary (Johnson 2015; Rogers 2020). More heterogeneous depictions of trans people’s lived experiences —in education, media, and public discourse—would also help illuminate the multidimensionality of trans lives, including the joys and triumphs that flow from these identities (Shuster and Westbrook 2022).

There are two limitations related to study design worth noting. Foremost, our survey experiment depicted a patient who adheres to the gender binary. People who are nonbinary or perceived as gender nonconforming are more often the targets of discrimination (Miller and Grollman 2015). Although trans patients’ non-gender-related health concerns are frequently treated with suspicion by providers, Paine’s (2018) study showed that gender nonconformity was especially detrimental to patient’s credibility. These findings suggest respondents’ willingness to accept the doctor’s rationale may be accentuated in cases featuring nonbinary patients. Future research could address this question by including a nonbinary condition. Relatedly, the absence of significant patient effects may be attributable to the vignette’s medium. Given experimental research, which indicates that exposure to images of trans people increases support for trans rights (Flores et al. 2018), future research could examine results across different mediums to detect mode effects.

Our findings demonstrate that most Americans would not second-guess health care providers who cite insufficient training as their primary rationale for denying sick care to a trans patient, with these views especially prominent among Republicans and Evangelicals. Qualitative findings indicate that these individuals tend to trust doctors’ claims to expertise (or lack thereof) and believe that doctors should be wary of potential complications caused by the gender-affirming care, which they presume all trans people pursue. This belief in trans exceptionalism problematizes what should be routine care and, moreover, fails to recognize the myriad gender-affirming procedures cis people commonly receive themselves (Schall and Moses 2023). Our findings suggest belief in trans exceptionalism is a widespread phenomenon beyond medicine, with many Americans under the impression that doctors are unable to provide general care to trans people because of insurmountable physiological differences between trans and cis people. We argue that these erroneous beliefs potently intersect with enduring trust in doctors’ medical authority to explain the public’s willingness to believe that inadequate training is sufficient grounds to deny care to trans people.

Supplemental Material

sj-docx-1-srd-10.1177_23780231241253969 – Supplemental material for Medical Authority, Trans Exceptionalism, and Americans’ Willingness to Believe Claims of Inadequate Training as Justification for the Denial of Care to Trans People

Supplemental material, sj-docx-1-srd-10.1177_23780231241253969 for Medical Authority, Trans Exceptionalism, and Americans’ Willingness to Believe Claims of Inadequate Training as Justification for the Denial of Care to Trans People by Matthew K. Grace and Long Doan in Socius

Supplemental Material

sj-docx-2-srd-10.1177_23780231241253969 – Supplemental material for Medical Authority, Trans Exceptionalism, and Americans’ Willingness to Believe Claims of Inadequate Training as Justification for the Denial of Care to Trans People

Supplemental material, sj-docx-2-srd-10.1177_23780231241253969 for Medical Authority, Trans Exceptionalism, and Americans’ Willingness to Believe Claims of Inadequate Training as Justification for the Denial of Care to Trans People by Matthew K. Grace and Long Doan in Socius

Footnotes

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Support for this study was provided by the TESS program. We thank Maureen Craig, Jamie Druckman, Jeremy Freese, and the TESS reviewers for their feedback on the study design. This study was approved by the institutional review board at Hamilton College (protocol #S19-86).

ORCID iDs

Matthew K. Grace

Long Doan

Supplemental Material

Supplemental material for this article is available online.

1

Results are identical when we limit this group to providers with more extensive face-to-face interactions with patients (i.e., doctors, advanced practice providers, and nurses).

Author Biographies

Matthew K. Grace is an associate professor of sociology at Hamilton College. His research broadly focuses on medical practice and education and the social determinants of mental health. Several of his current projects explore how anticipatory stressors emerge and maintain disparities in psychological distress. His recent publications have appeared in Society and Mental Health, American Sociological Review, and the Journal of Health and Social Behavior.

Long Doan is an associate professor of sociology at the University of Maryland. He is broadly interested in how various social psychological processes motivate behavior and explain patterns of inequality. In particular, he is interested in the intersections of sexuality, gender, and race. His recent publications have appeared in the American Sociological Review, Social Forces, and the Journal of Marriage and Family. His Web site is at longdoan.net.

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Supplementary Material

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Medical Authority,Trans Exceptionalism,and Americans’ Willingness to Believe Claims of Inadequate Training as Justification for the Denial of Care to Trans People

Abstract

Keywords

The Health Care Experiences of Trans People

“Trans Broken Arm Syndrome” and “Trans Exceptionalism”

Why Study Public Attitudes?

Sociodemographic Variation in Physician Trust and Attitudes about Trans People

Method

Data

Stimulus

Quantitative Measures

Agreement with Inadequate Training as the Primary Explanation for Treatment Refusal

Respondent Sociodemographic Characteristics

Quantitative Analyses

Qualitative Data

Qualitative Analyses

Quantitative Results

Descriptive Results

Sociodemographic Trends in Who Believes the Doctor

The Effects of Patient Characteristics on Believing the Doctor

Qualitative Results

Trust in Doctor’s Medical Knowledge

The Doctor’s Right to Issue a Referral

Complications from Gender-Affirming Care

Doctors’ Professional Obligation to Treat and Treatment Refusal as Discriminatory

Discussion

Supplemental Material

sj-docx-1-srd-10.1177_23780231241253969 – Supplemental material for Medical Authority, Trans Exceptionalism, and Americans’ Willingness to Believe Claims of Inadequate Training as Justification for the Denial of Care to Trans People

Supplemental Material

sj-docx-2-srd-10.1177_23780231241253969 – Supplemental material for Medical Authority, Trans Exceptionalism, and Americans’ Willingness to Believe Claims of Inadequate Training as Justification for the Denial of Care to Trans People

Footnotes

Funding

ORCID iDs

Supplemental Material

1

Author Biographies

References

Supplementary Material