by Em Rabelais, PhD, MBE, MS, MA, RN

In the very best of times, and just like cisgender people, non-binary and transgender folx find medicine a difficult landscape to navigate (for definitions, see here). Healthcare while trans: It’s not fun. Trans existence isn’t normal according to medicine and the other health professions. Our bodies are medicalized. Our knowledge of our own bodies is deemed irrelevant, whether or not we’re seeking gender care. Genders that are not cisgender are considered morbidities. Is my body, my gender, morbid to you? I don’t understand what it is to be cisgender, yet I don’t think your body, your gender, is morbid. I have to write this post in a language that is foreign to me, but easier for you to understand. To catch and hold your attention, I must pander my words and syntax to a cisgender understanding of existence. This isn’t easy, and I have to work hard to do it. Is the same expected of you to get a handle upon my existence?

Clinical biomedicine has so many intentional barriers for transgender folx to even be able to access gender care. Gender care is often guarded, requiring us proving our existence to multiple clinicians. Any health care-seeking outside of gender care is often treated with “trans broken arm syndrome,” whereby gender identity becomes the clinician’s focus. This is not unlike how fat people are treated when seeking health care. For example, I came out a few years ago, just after my thirty-ninth birthday: trans, non-binary, and queer. Now no longer hidden, clinicians are generally confused by my realities: trans yet not within the binary; queer and thus subverting the traditional binaries of lesbian, gay, and bisexual sexualities. Because of a family history of breast cancer, I started breast cancer screening at age 40 with every test so far identifying abnormalities. Breast cancer screening views cellular activity in normal breast growth as abnormal in a 40-year-old person, and I’m compared to either/both a cis woman or a cis man. Cisgender is not normal, but it is positioned as if it were normal. Suggestions I’ve been given: don’t be trans, be trans but don’t take hormones, stop taking hormones, switch back to your original hormones, and—spoken in complete seriousness—let us remove your (less than 2 years old) breasts. While swept up in the best of intentions to save me for a possible future with breast cancer, these comments tell me my life is not worth living now. Considering any of these options manifests suicidal ideation. Even physicians who are considered trans-friendly or even trans-competent struggle to understand the realities of being transgender.

How does the sudden turn that medicine has had to take under COVID-19 affect trans people? In the time of SARS-COV-2, the virus responsible for COVID-19, everything becomes worse. First, many hospitals have canceled what they perceive as “elective procedures.” Gender care is not elective nor cosmetic, and gender surgeries are also not elective nor cosmetic. Trans folx, “out” or not, are facing access problems—even to just talk to a clinician. Gender care and surgeries are essential care to being who we are, and when we are denied our lives, mental illness and suicide skyrocket. I’m watching my around me experience despair when initial consults for gender surgeries are canceled, and it’s soul-crushing when surgeries are canceled.

Second, we fear that we are or will be viewed as not worth being placed/kept on a ventilator. Across the country, hospitals and health ethicists are creating plans to allocate scarce resources. Notably, disability justice advocates and experts are critiquing these protocols—while, at the same time, businesses are finally offering disability-friendly work environments (example: work from home). Allocation protocols using quality of life criteria and existence of co-morbidities are ableist. They are also easily interpretable to enact a strong bias toward trans people. Are we to be added to the ‘bodies not worth saving’ pile? These concerns are not overblown. Consider that New York Governor Cuomo waived all state-imposed healthcare record keeping requirements, including those for a medical record “that accurately reflect(s) the evaluation and treatment of patients.” Is this to protect clinician decision-making from lawsuits (although Cuomo’s executive order also grants immunity for injury or death)? Will those of us relying on hormone replacement therapies be set aside because we require those medications and monitoring?

Nearly a tenth of those testing positive for COVID-19 in Italy and 13.6% in Spain are health personnel. Will the “friendly” and “competent” clinicians giving us access to gender care make it through these next several months/years? Will personal protective equipment (PPE) production ramp up enough and will United Statesians, who even have the agency, ever follow instructions to shelter at home and maintain physical distance while out? The risks to us, trans folk, is incredible. No, collectively we do not have cardiovascular or respiratory or gastrointestinal conditions. But we do have what cis-centric biomedicine finds too strange or complicated to try to understand.