Protect trans people:

gender equality and equity in action

#ProtectTransPeople has surfaced on social media as transgender (trans) civil rights have come into US national discussion. [1] Trans people continue to experience hostility and overt discrimination, as exemplified by US President Donald Trump's proposed ban on trans people serving in the US military [2] and his administration's support of reversal of workplace protections and “bathroom” bills that oppose gender-neutral bathrooms. [3] Gender equality and equity for trans populations is at stake as 16 US states to date have introduced “bathroom bills” restricting access to sex-segregated facilities on the basis of sex-assigned at birth, with 14 states targeting public schools. [4] Efforts to overturn these discriminatory bills rely on protections under the Equal Protection Clause of the Fourteenth Amendment of the US Constitution and Title IX of the Education Amendments of 1972. [4] While these legal efforts are vital, they must be accompanied by multisector public health initiatives.

What can public health professionals—ie, practitioners, researchers, administrators, and advocates—do to protect trans people? Many trans people face difficulties accessing health care, employment, housing, and legal services because of stigma and discrimination against this community. [5] Such prejudice and discrimination can induce stress [6] and are associated with co-occurring negative health outcomes, including HIV and sexually transmitted infections (STIs), [7] depression, suicidal behaviour, [8] and even death. [9] The past 3 years in the USA have been the deadliest years on record for trans communities experiencing hate crimes that largely result in homicide or suicide, especially for trans immigrants and people of colour.9 Global monitoring of violence-related incidences shows homicide cases continue to rise in trans people. [10]

The epidemic of anti-trans discriminatory bills, deaths, and denial of rights [11] demands the attention of the public health community. Public health has the capacity to address the health of trans people through partnerships with multiple sectors, including education, employment, housing, and law enforcement.
There has been a painful history of erasing, pathologising, and stigmatising trans people in medicine and related fields. [12] However, many public health professionals have begun to listen, affirm, and heal relationships with trans communities. Increasingly, health and medical organisations are establishing person-centred care and trans-related health services, including hormone therapy, HIV and STI prevention and treatment, and mental health counselling. [12] Emerging medical and continuing education programmes are improving competency and trans patient-provider relationships. [13] Some have implemented best-practice recommendations, [14] including routinely asking respondents about gender identity and sex assigned at birth. Moreover, some continuing education programmes have created community advisory boards with trans people to inform research and practice. [12]

Public health practitioners and policy makers must continue these efforts and go further. Public health training programmes must start to develop diversity and inclusion action plans that invite trans students and faculty members, and incorporate trans conscious curricula. A 2015 US Transgender Survey national report [5] of more than 20 000 trans adults found prevalent social and institutional-level discrimination in education for trans people. Trans students experience mistreatment both from students and staff, including harassments, physical and sexual attacks, being told to use the bathroom based on their sex-assigned at birth, and being expelled from school. [5] The public health community must reflect on its institutions and practices and encourage trans people in admissions, faculty positions, and curricula. Furthermore, implementation of anti-discrimination policies based on gender identity should be highlighted in staff and student handbooks.
Trans communities experience pressing health-related issues that public health cannot address alone. Partners outside the health sector need to contribute to gender inclusivity efforts. In terms of employment, trans people in the USA have unemployment rates that are three times higher than cisgender people (15% vs 5%). [5] And the poverty rate in the USA is higher in the trans population than in the general population (29% vs 14%). [5] Since employment is a powerful health determinant, public health must collaborate with the labour sector to increase workforce trans representation, including in leadership positions, and create safe and welcoming workplaces with anti-discrimination policies and professional training that allow trans employees to grow in their careers and financially. Furthermore, ensuring trans-related health insurance coverage as part of compensation packages is a crucial step in encouraging trans employees.

In the USA about a quarter of trans people experience housing discrimination, and a third experience homelessness in their lifetime. [5] Public health must engage with the housing sector for solutions that give trans communities safe housing, including implementing anti-discrimination policies, updating housing forms, and familiarising employees with trans people's housing needs. Trans people must be welcomed as tenants and residents.

Criminal justice systems mistreat trans communities. Trans people, particularly trans people of colour or with a history of sex work, can experience mistreatment from police officers, including being harassed and repeatedly addressed with wrong pronouns. [5] Misassignment to prison facilities based on sex assigned at birth is also common, [5] placing trans people at high risk of violence and sexual assault inside prisons. [15] Prison systems can exacerbate risk for HIV-related and STI-related health outcomes. [16] Yet interventions that address police and prison staff's attitudes and practices towards trans people in and out of prison settings are scarce. [16] Public health has the capacity to motivate behavioural, social, and structural interventions that holistically incorporate the criminal justice sector.

We recommend some tangible solutions on how to protect trans people at the institutional-level across sectors (table). These recommendations encourage public health professionals to think and act pragmatically to improve trans health, engage in trans justice work, and promote gender equality and equity. Protecting trans people starts by valuing trans lives. Health professionals can influence the culture of public health. Public health can and should continue to lead in gender-inclusive work and motivate other sectors to do the same. Most importantly, trans people must be included in institutional change efforts. Meaningful engagement of trans communities is vital to achieve optimal health for all people.

Table. Recommendations for trans-inclusive protections at the institutional level across sectors

References