Transmasculine Health Justice: Los Angeles (TMHJ:LA) calls attention to serious health inequities impacting Transmasculine people* on Tongva Land (Los Angeles). This report was assembled as part of a research and organizing initiative led by Gender Justice Los Angeles and based on the principles of research justice, healing justice, and collective care. We analyzed findings from the community-generated Transmasculine Sexual Health & Reproductive Justice Survey that engaged 310 participants in Los Angeles County in 2017. This survey remains the single largest effort to understand and respond to inequities facing Transmasculine people in Los Angeles to date.
The health inequities facing Transmasculine people are preventable. Existing inequities are the result of deliberate power structures that impose a gender binary, restrict bodily autonomy, and create dangerous conditions in health care. TMHJ:LA calls for action towards health justice through: community building, cultural organizing, education, policy change, and community-led research. Our report centers Transmasculine Black, Indigenous, People of Color (BIPOC) who experience health inequities at the intersections of transphobia, anti-black racism, colonization, and xenophobia. We imagine and work for a future where all Transgender, Gender non-conforming, and Intersex (TGI) people can age, heal, evolve, thrive and create families and kinship with dignity.
Universal access to health care and medical autonomy is a human right. All people should be able to access health care systems and medical treatments equitably and with respect for human dignity. This requires policies and protections that increase safety, choice, and autonomy in accessing health care. Achieving health justice for Transmasculine people requires undoing legacies and layers of transphobia, racism, xenophobia, sexism, and ableism in medicine and healthcare practices. Ensuring medical autonomy requires rejecting policies that allow mental health and medical care providers to act as gatekeepers over who, when, and how transmasculine people can access treatment.
Transmasculine participants in Los Angeles faced significant economic inequities and many relied on public health insurance due to workforce exclusions and displacement from families and places of origin. Even when Transmasculine people have health care insurance, many do not have access to safe and meaningful care because of the history of medical racism and entrenched binary gender norms in health care services.
In our survey analysis, we found:
- Most participants had low to extremely low incomes with nearly 70% earning less than $36,000 per year. This was despite the fact that 64% of participants (ages 25+) had a four-year college degree, a figure that doubles the estimated 32% of the general population (ages 25+) with a four-year degree in Los Angeles County.
- About 1 in 10 participants lacked health care insurance altogether, and these participants were disproportionately immigrants to the United States. Only 41% of participants had a health care insurance plan provided by their employer or school. One-third relied on a public health insurance plan (32%) and nearly 20% relied on a parent’s or partner/spouse’s plan. 47% of participants paid out of pocket for one or more forms of gender-affirming care that were not covered by insurance.
- 90% of participants delayed care in the past year with economic factors playing a significant role. Half had delayed care due to a lack of money (50%) and nearly one-third due to a lack of time off work (31%). Other reasons included anxiety related to past traumatic health care experiences (48%), distrust in providers (38%) and fears of mistreatment due to transphobia (45%), mental health stigma (23%), or racism or xenophobia (17% of BIPOC participants).
- Racism is influencing who has access to gender-affirming medical treatment. The majority of participants sought chest reconstructive surgery (88%). Only 37% of BIPOC participants had already accessed chest surgery compared to 61% of white participants.
- 66% had asked a mental health provider for an authorization letter for gender-affirming care. Among those who had asked, only 1 in 4 received a letter in their first appointment; 49% did not feel like the process was helpful in making medical decisions.
The two-gender health care system has traumatized many TGI people and institutionalized inequities in research, policy, practice, and life expectancy.
Health justice is not just a matter of changing terminology in health care, but about addressing the role of health care systems in contributing to health and reproductive inequities for Transmasculine people, and especially Transmasculine Black Indigenous, People of Color. Providing gender-affirming health care requires radically transforming our health care systems by reorganizing the ways that services are designed and delivered.
Transmasculine participants reported being ignored, turned away, and mistreated in services that health care services, especially those organized as “men’s health” or “women’s health.” This results in more limited access to preventive sexual and reproductive health services, such as contraceptives, family planning, and HIV prevention.
In our survey analysis, we found:
- Nearly 1 in 3 Transmasculine survey participants in Los Angeles said that their last pelvic exam was “very uncomfortable” and 1 in 5 said they were unlikely to get one in the future.
- Misgendering in health care settings is common. 80% of Transmasculine participants were referred to by the wrong pronouns by a provider in the past 3 years.
- Two-gender health care services create barriers to accessing contraceptives. About 20% participants had used emergency birth control in their lifetimes (compared to about 11% in the general population nationally). About 6% of all participants had used emergency contraception in the past year.
- The majority of participants identified as queer (70%) and most had sexual partners of various genders in their lifetime. Recent efforts to focus HIV prevention resources on “trans men who have sex with men” is insufficient and unnecessarily reinforces binary assumptions about gender and health risks. The majority of survey participants said they have had at least one sexual partner that was transgender, nonbinary, gender nonconforming or two-spirit (63%).
- More BIPOC participants indicated an interest in future fertility treatments (15%) compared to white participants (7%). Social, economic, and health care inequities create barriers to gestational parenting. Only 3% of participants had ever given birth.
Transmasculine people are rarely seen as survivors of intimate partner, domestic, or sexual violence, or as people in need of support or resources. We must invest in violence prevention efforts led by TGI people. We need transformative justice and healing strategies that interrupt cycles of trauma, violence and health inequities.
Transmasculine participants, especially BIPOC under the age of 18, experienced extraordinarily high rates of violence. The root causes of these inequities are layered and complex and include: histories of colonization and displacement from families and places of origin; enforced racialized gender roles; shaming, punishment and criminalization of gender non-conforming children and youth; lack of family acceptance; social isolation; and guarded access to services and public resources. Exposure to violence and abuse are associated with higher rates of homelessness and contact with state systems (e.g., child welfare, jails, prisons). Experiences of trauma are often diagnosed and treated as individual psychiatric or behavioral health problems, rather than collective social problems.
In our survey analysis, we found:
- Transmasculine participants reported high rates of early childhood victimization. 1 in 2 survey participants experienced abuse or violence by a primary caretaker before age 18 (53%). About 5% of survey participants had been in foster care, a figure much greater than the estimated 1% of children in LA County in foster care today.
- Nearly 3 in 4 of all participants experienced sexual violence in their lifetimes. 60% of BIPOC participants and 47% of white participants experienced sexual violence as children or adolescents, which dramatically exceeds national estimates on childhood sexual violence experienced by girls (25%) and boys (8%).
- Nearly 1 in 10 participants indicated experiencing patterns of abuse or control from a recent or current intimate partner; and 12% experienced sexual violence in the past year.
- Many participants had experienced housing instability. Nearly one-quarter of participants experienced homelessness in their lifetime (21%) and only 7% owned their own home. About 1 in 4 BIPOC participants had experienced homelessness compared to about 1 in 8 white participants.
- Nearly 1 in 4 participants had been hospitalized for psychiatric reasons in their lifetime, including 12% who had been hospitalized more than one time.
Histories of trauma, social isolation, stigma, and discrimination have led Transmasculine people to experience some of the highest rates of depression, anxiety, and suicide attempts of any known social group. Access to mental health care services is crucial but does not address root causes. Health justice is creating proactive and collective strategies for holistic well-being.
Transmasculine participants experienced very high rates of anxiety and depression. Many participants delayed seeking health care because of anxiety or depression, as well as concerns about mistreatment based on mental health stigma. Mistreatment in health care settings can make symptoms worse. Transmasculine people have developed personal and collective care tools and practices within and outside of mainstream medical systems–out of necessity. We can invest in and build on what Transmasculine want and have already created to advance health equity.
In our survey analysis, we found:
- Nearly 65% of participants had been prescribed medications for depression or anxiety in their lifetimes; and 39% were currently experiencing moderate to severe depression.
- Nearly 3 in 4 said they had at least one negative experience with a mental health care provider. Those who said that they had received “excellent” care by a mental health provider in their lifetime were less likely to be experiencing moderate to severe depression now (when compared to those who had not received excellent care).
- About half of participants recently delayed seeking health care due to depression (52%) or anxiety related to past health care (48%). Nearly 1 in 4 said they delayed care in the past year for fear of mistreatment based on their mental health symptoms or diagnoses.
- 92% of participants preferred health care providers that specialize in transgender health and 59% of BIPOC participants said they preferred to see providers of color. Only one-third currently had a primary care provider that specialized in transgender health (34%) and these participants reported fewer barriers to care and lower rates of moderate to severe depression.
Health justice means trusting and investing in strategies of collective care by and for TGI people. Our research and foundations for action build on a legacy of health justice organizing by TGI people working to create and circulate health knowledge as a radical practice of love and collective care. We take action through showing up for each other, cultural organizing, changing policy, and transforming institutions by demanding change. We envision a world where TGI people are seen and valued, and where all people can access the kinds of care they want and need.
FOUNDATIONS FOR ACTION
Transmasculine Health Justice: Los Angeles highlights some of the serious health and health care inequities facing Transmasculine people. As we work to envision and create the futures we want, we lift up some of the many ways Transmasculine people and our allies can and do take action now to reduce harms and build communities of care.
Our foundations for action include:
- Community building: We need each other and fight for each other. We strengthen our bonds by investing in cultural work, sharing our health knowledge, nurturing intergenerational relationships, and building power and voice.
- Health care practice: We invite health care providers to trust us, include us, protect us, join us, and let us lead in a fight for health justice. Health care workers are essential to improving the medical experiences of TGI people. We mobilize change in health care settings by advocating for ourselves and others.
- Policy advocacy: We are fighting for inclusion in social and health policies to prevent and reduce systemic harms and acquire resources to address our specific needs. Health inequities are a structural problem. Trans people and our allies have the power to work collectively to pass protective policies and to repeal dangerous ones, and to redistribute resources to those most in need.
- Community-led research: We are resisting research that exploits and pathologizes TGI people and taking control of our narrative through our own research and knowledge making practices. We are building the knowledge we need to address health challenges together.
This report was developed by the TMHJ:LA core team and volunteers including trans health researchers and educators, cultural workers, policy advocates, activists, and artists. TMHJ:LA is part of a broader strategy within Gender Justice Los Angeles to build power among gender non-conforming, two spirit, Black, Indigenous, trans people of color in LA. This strategy includes research and community organizing efforts led by and for TGI people to advance health justice in California.