Let’s Talk: Health Care, Reproductive Health Care, and Assigned Female Bodied Trans People

We need to have an honest talk about health care and what happens when you are born with a vagina. This issue can no longer be ignored. Trans people who had female on their original birth — this included non-binary — certificates can no longer be erased because it is literally killing them.

What I’m about to spell out will make a lot of people uncomfortable. It will also make a lot of people defensive. Before attacking in your responses, think about the underlying reasons for your discomfort. Also, there will be triggering information below. Proceed with caution.

Yesterday, an amazing thing happened. Millions of people from around the world marched for women’s rights. It was a sight to behold. Something else also happened that literally made me sick to my stomach: Once again I saw a lot of feminists who label themselves as inter-sectional deny trans men and non-binary people who were assigned female bodied at birth being denied the right to speak about how specific laws impact them, their bodies, and their ability to access care. I saw people who say they are my ally tweet things about how laws meant to strip people the ability to make choices regarding reproductive care as only specifically misogynistic and not an attack on trans men; they are designed to attack women.

While there is a degree of truth to that, those laws are also designed to specifically erase trans men and force them to live as women. We need to come up for a term for that; a term that talks about systems designed to attack and disenfranchise someone because they were born with a vagina. It’s bigger than attacking someone because of gender, it’s about biological essentialism and the treatment one receives as soon as it is learned they have a vagina.

Before I go further with some statistics of which most people are unaware despite being easily available, let me tell you a bit about myself. I have a degree in psychology. I’m a gay trans man in a marriage that is legally recognized as a same-sex marriage but society views it as a “traditional marriage,” because I’ll never have the privilege of being read as cis. While I have socially and legally transitioned, I cannot medically transition because of pre-existing health conditions. A medical transition would kill me. I have multiple disabilities: PTSD, Autism, and Lupus with a host of secondary disorders. I’ve had a stroke and multiple TIAs that, along with the lupus, affect my cognitive abilities. In 2015, I was in the hospital over 13 times because of lupus and, despite M being on all of my ID, every single trip was accompanied by being misgendered. I get sexually harassed by cis men while in the emergency room. I’ve had an abortion, many miscarriages, and two live births. I can’t talk about things like pregnancy, chest feeding, or lupus because people assign those things to women and immediately they turn me into a woman and erase me, even my so-called allies. I had to have a hysterectomy 12 years ago because my lupus caused me to hemorrhage instead of having periods and I nearly died as a result. I don’t have a cervix but I still have to have internal examinations because I could get ovarian cancer. In a few more years, I have to start getting mammograms. If my some miracle, doctors can figure out a way for me to safely have top surgery, I’d still have to get them post-surgery because the glands that can become cancerous do not get removed during top surgery. One side of my family was exterminated by Nazis with my great-grandfather being the only person in his family to escape.

I’m also white-passing, and therefore have white privilege. And while I face daily barriers because the world perceives me as a butch woman and have disabilities, I will never know what it is like to born into the generational trauma assigned female bodied Indigenous women face that includes forced sterilization, as just one small example. I can acknowledge my privileged and understand that it doesn’t take away from my clear barriers and oppression.

Things like internal exams are uncomfortable for cis-women. You’ll never understand how much worse it is for trans men and non-binary people with female on their original birth certificates. And now some stats that illustrate how much worse it is beyond simple discomfort and how, before 2015 and ACA, trans men were legally and routinely denied not only regular health care, but also reproductive health care and transition-related health care, unless they were willing to erase their authentic selves and show up as a woman. If gender marker was changed on their ID, then they were completely ineligible for reproductive health care.

These stats are not hard to find. People quote this paper all the time when talking about trans women and non-binary people with male on their original birth certificates. This is also part of the bigger problem of “things that happen when you have a vagina.” There is another institutional issue that feeds into this which I will get to after I present the following from the 2015 U.S. Transgender Survey regarding health care (all emphasis my own):

Portrait of Female on Original Birth Certificate

It is important to know that 82% of the trans men who responded to this survey have transitioned (page 47). For the purposes of this survey, transitioned means living full-time as your authentic self also known as a social transition. The survey does not falsely limit transition to legal transition or worse, medical transition, though it does sometimes break down different types of transition when it’s relevant. It is also important to note that they fail to breakdown types of transition on certain issues when it probably would have been a good idea to so in order for the reader to truly understand barriers.

The survey does not break down non-binary transitions according to assigned sex — which is problematic as it erases non-binary people — and simply states 43% of non-binary people have transitioned. The survey does note the following on page 48, “A majority reported that people usually assumed they were non-transgender women (58%), including 72% of non-binary respondents with female on their original birth certificate.” Plainly put, 72% of non-binary assigned female bodied people’s identities are erased by society.

Page 95: Denial of Medical Treatment

1. Thirteen percent (13%) reported that they were denied coverage for services often considered to be gender-specific, including routine sexual or reproductive health screenings (such as Pap smears, prostate exams, and mammograms).

It’s too bad these weren’t broken down according to assigned sex on original birth certificate because it’s important. But, it is still important to know that at least one in five assigned female bodied trans people are denied the very basics of reproductive health care because those things are legislated for women, which completely erases the existence of assigned female bodied trans people and forces them to make tough decisions about legal transition if they want to continue to get access to basic health care.

2. Denials for hormone coverage differed by gender, with transgender men (32%) and non-binary people who had female on their original birth certificate (36%) more likely to report being denied hormone coverage than transgender women (18%) and nonbinary people who had male on their original birth certificate (16%).

3. Transgender men (57%) were more likely to be denied surgery coverage than transgender women (54%) and non-binary people, including non-binary people with female on their original birth certificate (49%) and non-binary people with male on their original birth certificate (35%).

You need to pay attention to these numbers. Without access to hormones, the chances of assigned female bodied trans people to ever have “passing privilege” is impossible. And this health care issue leads to other issues I will include further down.

A good portion of AFAB trans people live in this zone, twice as many as trans women. An AFAB trans person just can’t put on men’s clothing and be read as trans because things like pants or short hair or men’s shirts are not seen with the same binary of as dresses or skirts. And while this has ramifications for AMAB trans people, there is a visible model for AMAB trans where there isn’t one for AFAB which leads to erasure and invisibility and we need to talk about these nuances. Acknowledging your privilege does not take away from your oppression. We need to learn this and learn how to construct dialogue around it.

Page 97: Experience with Health Care Providers

4. Transgender men (42%) were more likely to report negative experiences than transgender women (36%) and non-binary respondents (24%). People with disabilities (42%) were also more likely to have at least one negative experience in the past year, compared with respondents who did not identify as having a disability (30%).

These numbers increase for people of colour, not surprisingly. Also, most trans people have to education health care providers on trans health care.

Page 98: Fear of Health Care Professionals

5. Fear of being disrespected or mistreated by a health care provider also differed by gender identity, with transgender men (31%) being more likely to avoid care out of fear of discrimination than transgender women (22%) and non-binary respondents (20%).

These are not small numbers and I can tell you, the fear is legitimate.

Beginning on page 99, there is talk about hormonal therapy. When reading it, keep in mind the large numbers of AFAB people who are denied this treatment option. The study doesn’t break down this medical treatment according to assigned gender. So, when reading, “49% of” remember, that does not mean half of the assigned female bodies trans population since many are simply denied and many others simply do not want it. That 49% is half of a fraction of the community. Keep the same in mind when you read stats about other forms of medical transition, like 21% of trans men have had top surgery. When you do all the math, it becomes clear only a small number of trans men will ever reach the ability to be read as a cis man. It also denies many people in the United States the ability to change their ID, since in many states, that requires surgeries and over one half of trans men are denied surgery. That 21% is of the less than one half who were not denied this basic medical treatment.

It is really important that you get the picture here and understand that because of it, trans men face regular discrimination that comes with vaginaness rather than womanhood. We really do need to think of a word for this that separates it from misogyny without erasing this type of violence on bodies with vaginas.

Okay. Let’s continue.

Page 104: Health Status

6. Respondents’ self-reported health varied by gender identity, with non-binary respondents with female on their original birth certificate (35%) being less likely to report excellent or very good health compared to transgender men (47%), non-binary people with male on their original birth certificate (48%), transgender women (50%), and crossdressers (57%).

Translation: Overall health status is worse among non-binary people with female on original birth certificate, followed by trans men.

Page 114: Suicide Rates

7. Lifetime suicide attempt rates were higher for transgender men (45%) than for transgender women (40%) and non-binary respondents (39%), and crossdressers had a substantially lower rate of attempted suicide in their lifetime (15%).  Lifetime suicide attempts were also higher among people of color, with American Indian (57%) respondents reporting the highest rates, followed by multiracial (50%), Black (47%), Latino/a (45%), and Middle Eastern (44%) respondents, in contrast to white (37%) respondents.

This is obviously a health care issue. Roots for this vary. From violence against assigned female bodies, to denying of basic health care in order to erase assigned female trans people and violently try to force them into subservient positions because of vaginas.

That consistent denial of not only basic health care but also transition-related health care, plus vaginas, leads to the following:

Page 186: Police Treatment

8. Non-binary respondents (71%) and transgender men (62%) were more likely to report having never or only sometimes been treated with respect than transgender women (51%) (Figure 14.3). People of color were also more likely to report never or only sometimes being treated with respect, particularly American Indian (72%) and Black (70%) respondents (Figure 14.4).

I almost want to ask cis women to do a thought experiment here about asking to me referred to by male pronouns when law enforcement perceives you as a woman, but I’m not sure it will produce any fruit. Remember: trans men and non-binary assigned female on their original birth certificate face systematic oppression that is designed to make sure they never get to be read as their correct gender.

I’m going to jump here to airport security because it’s part of the same systems that begin with the denial of health care before going back in page order to sexual assault and bathrooms.

Page 222: Airport Security

9. Forty-three percent (43%) of those who went through airport security in the past year experienced at least one issue related to their gender identity or expression, such as TSA officers using the wrong pronoun or title to refer to them, searching their bodies or belongings because of a gender-related item, or detaining them (Table 16.14).

More than half (56%) of Middle Eastern and 50% of multiracial respondents who went through airport security in the past year reported one or more of these experiences (Figure 16.8). Respondents who said that others can always or usually (61%) or sometimes (53%) tell that they are transgender were more likely to report one or more of these experiences, in comparison to those who said that others can rarely or never tell that they are transgender without being told (35%). Experiences also differed by gender, with transgender men (52%) being more likely to report one or more of these experiences than transgender women (31%). Respondents who said that none of their IDs reflect the name and/or gender they prefer (51%) were also more likely to report negative experiences in airport security related to their gender identity.

(As a side note: I am one of those trans men who were detained because my ID did not match my presentation. My ID said F and I packed like a man, and US Customs profiles people not only based on race and ethnic group, but also by how you pack according to gender. For over two hours, my passport was seized and I was interrogated.)

We are almost done. We are now going to back up and talk about sexual assault.

Page 205: Sexual Assault

10.  Experiences also varied across gender, with transgender men (51%) and non-binary people with female on their original birth certificate (58%) being more likely to have been sexually assaulted, in contrast to transgender women (37%) and nonbinary people with male on their original birth certificate (41%) (Figure 15.16). Among transgender men and non-binary people with female on their original birth certificates, rates of sexual assault were higher among people of color, particularly American Indian, Middle Eastern, and multiracial people (Figure 15.17 & Figure 15.18).

If you don’t want to look up the figures, this is the breakdown for female on their original birth certificates according to race and ethnicity for transgender men:

  • Asian 42%
  • Latino 48%
  • Black 51%
  • White 52%
  • Multiracial 58%
  • Middle Eastern 67%
  • American Indian 71%

And this is the breakdown for female on their original birth certificates according to race and ethnicity for non-binary:

  • Asian 47%
  • Latino/a 55%
  • White 59%
  • Middle Eastern 62%
  • Black 65%
  • Multiracial 67%
  • American Indian 74%

Hopefully, I don’t have to spell out how this also ties into access to health care, including reproductive health care, and systematic erasure of trans people with F on their original birth certificates.

Page 228: Bathrooms

11. Transgender men (75%) were far more likely to report sometimes or always avoiding using a public restroom, in contrast to transgender women (53%) and non-binary respondents (53%) (Figure 17.5).

This statistic is important for a whole lot of reasons. Not only are issues regarding how “bathroom bills” affect assigned female bodied trans people and what the simple act of ignoring this group of people means in terms of erasure, but it also impacts health. Let’s just focus on health and what this results in:

  • 52% avoid eating and drinking
  • 12% get urinary tract infections
  • 2% get kidney infections

There is also the worry of sexual assault because 80% report being visibly trans, which for a good number of trans men and non-binary assigned female bodies, which means society seeing a woman walking into the men’s washroom. If you are a cis-woman, would you worry about being sexually assaulted if you had to use a men’s room without a bodyguard? How would you feel if you had to change your menstruation pad or tampon in a men’s washroom? Those are just a couple of things to think about.

There is one final thing I want to talk about that relates to both my formal education in psychology and my lived experiences: Until very recently, trans men were denied recognition of being trans. The disparity rates of “transness” between trans women and trans men were huge because of the DSM used to demand dysphoria regarding genitals in someone’s pants.

While a good number of trans men experience dysphoria surrounding their chests, they do not when it comes to their genitals because they are hidden and chest is a more visible sign of “gender.” And without that diagnosis, they were denied transition-related health care. The DSM-V has removed that criteria. Since then, numbers between AMAB and AFAB trans people are starting to even out.

This has not only led to huge discrepancies and erasure of AFAB transness, but it also led to trans men not being included in studies. To this day, most studies about trans people focus mostly on trans women or AMAB non-binary people. This 2015 study is the first study I have read where the numbers of assigned male bodied trans people and assigned female bodies trans people was nearly equal. Before this study, trans men and non-binary people with female on their original birth certificates have been hugely unrepresented.

I don’t know what label we can assign to violence that continues throughout one’s lifetime because they have a vagina, but we need to have one. The above numbers cannot be ignored. We need to learn how to have these conversations while both acknowledging the misogyny that is behind health care laws and the specific type of transphobia designed to eliminate trans men and boil us down to our vaginas to continue to enact vagina-based violence against us.

We need to learn how to start having these conversations and making sure that trans men who live in the United States aren’t once again denied reproductive health care because they have M on their ID, or are otherwise forced to present as a woman, never being able to go through any type of transition in order to get even the most basic of health care. The narrative surrounding this issue is the opposite of the statistics and that needs to change.

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