In today’s COVID-19 Update, a discussion with Jesse Ehrenfeld, MD, MPH, immediate past chair of the AMA Board of Trustees and senior associate dean, professor of anesthesiology and director of the “Advancing a Healthier Wisconsin Endowment” at the Medical College of Wisconsin, about the challenges transgender individuals have faced during the pandemic and how physicians can help.
Learn more at the AMA COVID-19 resource center.
- Jesse Ehrenfeld, MD, MPH, immediate past chair, AMA Board of Trustees; senior associate dean, professor of anesthesiology and director of the “Advancing a Healthier Wisconsin Endowment,” Medical College of Wisconsin
Unger: Hello, this is the American Medical Association's COVID-19 Update. Today, we're talking with Dr. Jesse Ehrenfeld, immediate past chair of the AMA Board of Trustees and senior associate dean, professor of anesthesiology and director of "Advancing a Healthier Wisconsin Endowment" at the Medical College of Wisconsin, about the challenges transgender individuals have faced during the pandemic and how physicians can help. He's calling in from Milwaukee. I'm Todd Unger, AMA's chief experience officer in Chicago. Well, Dr. Ehrenfeld, a lot of terrible statistics coming out of this past year during the pandemic. Another one to add to that, which is more transgender people were killed in 2020 than in any other year on record. What's driving this increased violence? Is it associated with the pandemic?
Dr. Ehrenfeld: Well, thanks Todd. There are many factors that are leading to this violence. Anti-transgender stigma is a big component, and we've also seen over this past year such a divisive, dehumanizing rhetoric from anti-equality political leaders that has contributed to really what's a toxic mix of racism, sexism and transphobia. That's contributing to the violence. Many transgender people of color, and particularly women, face marginalization, rejection by their families, by their communities, discrimination in education, housing, employment, social services and health care, both in accessing health care and delivering health care.
Those factors are resulting in things like higher homelessness, living in temporary housing, engaging in sex work, and the economic pressure of the COVID-19 pandemic has only made those challenges worse. We know that community belonging is an important component of building resilience among transgender individuals. COVID separated and isolated transgender people just as it has for most of us.
Unger: Well, you mentioned before issues around access to health care. In addition to the increase in deaths that we've seen from violence and other hate crimes, can you talk about how these existing health inequities coupled with the COVID pandemic have contributed to a disproportionate morbidity in this population?
Dr. Ehrenfeld: Well, we know that transgender individuals have faced extraordinary difficulties with mental, physical and social well-being, as well as difficulties accessing health care during the pandemic. Before the pandemic, things were already strained. There were many barriers for transgender individuals when accessing health care, shortage of specialized health care professionals, difficulty in accessing and obtaining health care insurance, difficulty getting coverage for services, making it harder for transgender individuals to get gender affirming medical care, especially in low and middle areas of the country. In some cases also because of the pandemic, gender-affirming care was put on hold because of prohibition on non-urgent or elective procedures. Because these were viewed by some as unnecessary or a lower priority, that just worsened these inequities, becoming more pronounced during the pandemic.
Unger: I guess it may seem a little bit moot, but why is it so critical that physicians understand these issues and be vocal about them?
Dr. Ehrenfeld: Well, these issues are inextricably linked to an individual's ability to live a healthy life. It's just so important that we as physicians speak up about anything that interferes with that. Prior to the pandemic, at the 2019 House of Delegates meeting, the AMA adopted policy to bring the national attention to the epidemic of violence against the transgender community, especially the amplified physical dangers faced by trans people of color. Since then, the AMA has been working to create partnerships with other medical organizations, stakeholders to educate the public, legislatures, law enforcement using verified data about hate crimes against transgender individuals to highlight the disproportionate number of fatal attacks, particularly on Black trans women.
We've been advocating for consistent collection and reporting of data on hate crimes across all levels of law enforcement, that include sexual orientation and gender identity. We've been advocating for a central law enforcement database to collect data on hate crimes that correctly identifies a victim's birth, sex and gender identity. We've also been advocating for stronger law enforcement policies regarding the interactions that transgender individuals have so that we can prevent bias and mistreatment and ultimately increase trust out in the community.
Unger: Well, you mentioned the House of Delegates. I'd like to talk you a little bit more about on the policy side. We have seen legislation out there in different states that can really perpetuate discrimination, or at the federal level. Can you talk about the state policy in particular, that landscape?
Dr. Ehrenfeld: Sure. In 2021, state legislatures all across the country considered more bills targeting LGBTQ+ patients than in any year before. Many of those measures were directed at transgender youths who faced a heightened risk of suicide and mental health disorders. You may know that Arkansas recently became the first state in the country to ban gender transition related care for people under 18. Twenty other states have considered similar bills that would prohibit medical providers from prescribing medications or hormone therapy or performing surgery on transgender minors. Providers in those states may find themselves in a really difficult bind, right? Bound to act in the best interest of their patient and follow the evidence-based guidelines, but potentially subject to criminal penalties or professional disciplinary actions if they do so.
Now, there is some good news in this otherwise kind of bleak picture at the state level. That is that the AMA and our partners across the Federation of Medicine have been working hard to stop those bills. Our efforts have been largely successful with the exception of Arkansas. The AMA is currently considering next steps, and we hope to challenge that Arkansas law.
Unger: Thank you. At the federal level, we've recently seen a win on an issue that the AMA had been advocating for, the reversal of a rule that went into effect last year. Can you talk about the details of that?
Dr. Ehrenfeld: Yeah. The rule you're talking about concerns a very important part of the Affordable Care Act. It's the provision in Section 1557 that prevents health care providers and insurance companies from discriminating on the basis of race, color, national origin, sex, age or disability in certain health programs. Now, under the last administration, HHS enacted a rule that said that, that anti-discrimination provision from the Affordable Care Act of 2010 did not apply to transgender people, essentially erasing all protections for transgender patients against discrimination by hospitals, doctors and health insurance companies.
Now, fortunately, the Biden administration announced just a couple of weeks ago a complete reversal of that policy, and under their new guidance, Health and Human Services will interpret and enforce Section 1557's prohibition on discrimination based on sex to include discrimination based on sexual orientation and gender identity by any health care organization that receives federal funding.
Unger: Well, that is an important change. Why is that so important for physicians and for our transgender patients?
Dr. Ehrenfeld: Well, we know that fear of getting discriminated against will lead individuals to forego care and that can have serious negative health consequences. Everybody, including LGBTQ+ people, should be able to access health care free from discrimination or interference, period. The AMA believes in the critical importance of ensuring health equity, optimal health for all, recognizing the importance and urgency of ensuring that all people in communities reach their full health potential.
Unger: Well, thank you so much, Dr. Ehrenfeld for your continued and tireless advocacy in this arena. That's it for today's COVID-19 Update. We'll be back with another segment tomorrow. In the meantime, for additional resources on COVID-19, visit ama-assn.org/covid-19. Thanks for joining us, please take care.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.