Letters to the Editor
We thank Danish Zaidi for the thoughtful comments on transgender health in an age of bathroom bills, and we strongly agree that criminalizing bathroom use based on gender identity is a form of structural stigma contributing to health inequities among gender-diverse individuals. Denial of access to gendered spaces has been associated with lifetime suicide attempts,1 higher cortisol levels,2 and avoidance of health care3 among members of transgender communities. Recognizing that limiting access to spaces such as restrooms by sex assigned at birth is discrimination—and that this discrimination has clinical repercussions—is the first step in applying a structural competency framework. We further agree that developing structural interventions, including lobbying against laws criminalizing access to bathrooms based on gender identity, is paramount to structural competency, and we commend the immediate response of the American Academy of Pediatrics (AAP) opposing North Carolina’s House Bill 2 (HB2).4
Ensuring access to bathrooms will certainly lessen the threat of criminalization; however, additional significant effort is required to promote and achieve health equity. Medical communities must continue to develop political and educational interventions to support the health of transgender individuals.5 All health care providers must be equipped to provide responsible health care for gender-diverse communities,6 and gender-affirming medical and surgical care should be accessible and cost-effective.5 Educational guidelines providing this training are becoming more prevalent,7 and medical organizations such as the AAP are increasingly supporting health care for gender-diverse individuals. In addition to simply opposing discriminatory legislation, we encourage the development of proactive structural interventions that deliver effective and comprehensive health care to transgender communities.
Cameron A. Donald, MS
Second-year medical student, School of Medicine, University of California, San Francisco, San Francisco, California; Cameron.Donald@ucsf.edu; ORCID: http://orcid.org/0000-0001-8942-6443.
Kristen L. Eckstrand, MD, PhD
Founding chair, Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development, Association of American Medical Colleges, Washington, DC, and third-year psychiatry resident, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; ORCID: http://orcid.org/0000-0002-6506-3649.
1. Seelman KL. Transgender adults’ access to college bathrooms and housing and the relationship to suicidality. J Homosex. 2016;63:1378–1399.
2. Wernick LJ, Kulick A, Chin M. Gender identity disparities in bathroom safety and wellbeing among high school students. J Youth Adolesc. 2017;46:917–930.
3. Chisolm-Straker M, Jardine L, Bennouna C, et al. Transgender and gender nonconforming in emergency departments: A qualitative report of patient experiences. Transgend Health. 2017;2:8–16.
5. Schuster MA, Reisner SL, Onorato SE. Beyond bathrooms—Meeting the health needs of transgender people. N Engl J Med. 2016;375:101–103.
6. Eckstrand KL, Ng H, Potter J. Affirmative and responsible health care for people with nonconforming gender identities and expressions. AMA J Ethics. 2016;18:1107–1118.
7. Eckstrand KL, Potter J, Bayer CR, Englander R. Giving context to the physician competency reference set: Adapting to the needs of diverse populations. Acad Med. 2016;91:930–935.