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Towards Healthier Transgender Youth
Richard Haynes
[Abstract] Full Text [PDF]
No one wants to go to the doctor,
right? Studies indicate that young people especially do not seek health care
unless they are sick or in crisis. Of course, these studies usually describe
only a certain segment of young people - namely those with homes, with
families, in school, and not gay, lesbian, bisexual or transgender (GLBT)
identified. These youth, in stable environments are the youth most likely to
be healthy and not engage in risky behaviours in the first place.
Recent studies of New York City's homeless
youth, unsurprisingly, showed many pressing health care needs. Because of
the exposure they endure on the street, these youth are particularly
susceptible to many negative health conditions. Violence, rape, sexually
transmitted diseases (STDs), tuberculosis (TB), HIV/AIDS, poor nutrition,
poor hygiene, chemical dependency and a host of health related issues that
are the result of surviving on the street are not uncommon.
However, one study also showed that when
youth on the street have a respectful, trusting and meaningful relationship
with an outreach worker they are more likely to seek health care services
- both acute services (like STD treatment) and preventative services (like
immunizations). Also, when connected to a respectful outreach worker or team
offering referrals, they are apt to seek social and psychosocial and
psychosocial services from youth-serving agencies. They are even more likely
to access care when those health and social services are appropriate to
their needs, respectful, and accessible on all levels (no cost, easily
reachable location, culturally competent staff).
Many youth expressing non-gender conforming
behaviours or identifying as transgender find themselves rejected by family,
school, church, peers and other communities of origin. They often become
homeless and unemployable and are forced into the street economy - very
often into sex work. Compared to their gay, lesbian and bisexual (GLB)
peers, transgender youth are often far more marginalized and
disenfranchised, often finding themselves unwelcome even at GLB
youth-serving agencies.
'Traditional' housing alternatives, drug
treatment programs, health centres and other services are ill-prepared to
work with transgender youth in any kind of affirming, supportive manner. The
educational system, while slowly moving towards a more GLB friendly
environment is still transgender ignorant and -phobic. these places for
youth refuse to deal with young people who do not fit their 'norms.' Youth
who present these challenges are often just left out.
Transgender Youth Health Risks
The list of negative influences could go on ,
and unfortunately the result is the same: transgender youth become further
at-risk. Those on the street are often faced with double and triple stigmas
that can directly and negatively impact their health. for instance, transgender
youth taking hormones are often doing so without the supervision of a
licensed medical provider. They may be using bootleg substances, may be
over self medicating, and may be incorrectly injecting or sharing needles to
administer their hormones.
Few medical providers are adequately
trained in the proper hormonal treatment of transgender people, and those
that are, rarely provide care to minors without parental consent. Since
parental consent is not the norm, especially for those who are homeless or
otherwise detached from their families, many young people legitimately
requiring hormonal therapy go without until they reach the age of majority.
They also encounter disreputable providers with a 'street reputation' who
are willing to sell hormones to anyone with the resources to afford them,
but who dangerously and unethically do not provide the comprehensive
follow-up that is critical to successful therapy.
Hormone therapy, with either female or male
hormones is not without risks and needs to be regularly monitored for
negative side effects that can be life threatening. The risk-taking
behaviours in which homeless transgender youth engage to get the money to
pay for their illicit hormones also places their health in jeopardy. The
economics of sex work puts youth at risk for HIV/AIDS and STD's,
exploitation and violence, and chemical dependency. ''Johns' and 'dates'
usually pay more money or provide more drugs if condoms are not used. Youth
also use crack or other illegal substances to 'numb the pain' of their lives
and make the sex work tolerable, impairing their judgement and lowering
their resistance.
Supportive Health Services
Managing the health care of a transgender
youth is a complicated matter. A patient-provider relationship requires
several critical components for maximum positive effect:
- an ongoing and trusting relationship
between the youth and the provider;
- a commitment by the provider to
addressing the stigmas, disenfranchisement, and added challenges faced
by transgender youth;
- and a personal commitment by the young
person to their overall health and well being.
Since many of us are not the best health
care consumers, empowering youth to accept this personal commitment may
be the most critical component.
Transgender youth and their providers must
realize the holistic health needs other than just those surrounding gender
identity. Gender transitioning is never a simple matter of merely taking
hormones. Optimally, it includes primary health care, psychosocial support,
mental health services, peer support and education. For those on the street,
case management (including entitlements and benefits advocacy), supportive
housing services, harm reduction and drug treatment services, HIV/AIDS care,
and employment and educational opportunities are required as well. We also
must not overlook the necessity of educating transgender youth and all youth
to make healthy choices. this is done through comprehensive health and
sexuality education on issues including proper diet and nutrition, pregnancy
prevention, HIV prevention, self breast or testicular examinations, and
vaccinations.
For Community Health Project's Transgender
Health and education (THE) Clinic, the combination of mental health and
peer support services appears to be the single best predictor of successful
transition. Social isolation can be a devastating factor in the lives of
all GLB and transgender youth. when transgender youth find peer support,
role modelling and mentorship from peer counsellors, the results are
positive and life affirming.
Economic Barriers to Services
Of course, the health care described above is
not inexpensive. Few transgender youth are medically insured, privately or
publicly. Coverage for hormone treatment, even for those with insurance, is
not always immediate.
In the age of managed care, few health
centres or private physicians are prepared or able to provide the intensive
medical and case management services needed to appropriately care for
transgender youth. The economic realities of this situation strongly
contribute to transgender youth engaging in sex work and being exposed to
the potentially negative health outcomes resulting from it. There is no
simple answer.
The economic, ethical, racial, class and
access issues involved are complicated. Even health care systems designed
for the underserved are not often designed to be able to meet the specific
needs of transgender individuals. Those that are, are also faced with the
medical ethics issues surrounding hormonal therapy for minors. Those that
have surmounted the ethical issues and are willing to treat transgender
youth are often themselves small and under funded.
A systematic shift must begin at the
community based level, with youth workers and the transgender youth they
serve.
- Youth-serving agencies working with
transgender youth must give their clients tools to become empowered as
educated health care consumers.
- Agencies must provide materials designed
by and for transgender youth to reach them and attractive, supportive
environments in which to learn.
- Youth-serving agencies must adopt
non-judgemental harm reduction models of care to support transgender
youth in their struggle to balance making their transitions while
staying healthy.
- Agencies must meet youth where they are
at, even while they are surviving in an economic and social system
designed to keep them on the streets, engaging in sex work, and
receiving services from disreputable providers. Education must include
not only safer sex, but safer sex work, safer needle use and access to
needle exchange programs, development of peer and other support systems,
and instruction on how to talk to a medical provider.
An effective health education component for
transgender youth must include specific information about the health risks
associated with cross-gender hormone therapy, so that young people can make
informed choices about their lives.
It is ironic that while the medical
profession has advanced to the point of being able to effectively and
appropriately treat transgender individuals, there is an internalised
system-wide phobia that prohibits it from embracing the challenge. On the
brighter side, there are a few pioneering health programs that have begun
addressing the needs of transgender individuals, and are leading the way for
these services to become more mainstream in both GLBT and traditional health
care settings.
Unfortunately, in the meantime, the health
and well being of transgender youth hangs in jeopardy.
Citation:
Crossroads 2001; an
article published on the Internet by Youth Resource
<http://www.youthresource.com/community/transgender/>
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