Advancing LGBTQI+ health through better coverage

I had the chance this month to join a webinar panel organized by the Association for Community Affiliated Plans (ACAP), on how health coverage can advance LGBTQI+ health and equity. ACAP represents non-profit Safety Net Health Plans around the country, and they invited me to contribute to their recent report, Safety Net Health Plan Initiatives to Improve LGBTQI+ Health Equity, and to join ACAP and ACAP member staff to discuss it.

The report highlights some existing steps ACAP members are taking to improve the inequities in health access, quality of care, and outcomes that LGBTQI+ communities face. I was also fortunate to get to craft a section outlining additional “Additional and Emerging Areas for LGBTQI+ Equity and Inclusion,” including including equitable practices for coverage of HIV medications, fertility care, gender affirming care for youth and adults, ensuring informed-consent protections for intersex children, revisiting gender-coding of services, as well as gender marker and name change practices. While all health plans have a long way to go on health equity—and our indeed health system needs fundamental, structural reforms to truly achieve it—it was great to hear from ACAP members about the steps they are taking to improve care for the communities they serve, and to discuss where we can make further progress.

Mourn the dead and fight like hell for the living.

November 20 is the 22nd annual Transgender Day of Remembrance (TDoR). TDoR began in 1999 to mark the anniversary of the murder of Rita Hester in Allston, Massachusetts, and has since been observed around the world to honor transgender people, known and unknown, who have died by violence, and to call for action. This call has expanded in more recent years to Trans Awareness Week leading up to TDoR. Unfortunately, the killings of these trans sibling, and those still uncounted, are just a fraction of the widespread and grossly disproportionate physical and sexual violence against trans people—not to the mention structural violence that is the ultimate driver of it all. This year on the day before TDoR , headlines about the full acquittal of a young man who killed two men at a Black Lives Matter demonstration last year has sent shockwaves around the country, threatening to embolden threats and violence against marginalized communities and activists.

In 2021 to date, in the US alone, 47 trans and gender nonconforming people that we know about have died by violence. This is not official mortality data—that is simply not available to date—and does not represent a “homicide rate.” These are only the cases community groups have identified from press reports, so it surely an under-count. Nevertheless, it is the largest number of publicly-reported trans homicides in the two decades anyone has trying to count. (See also the related post below about one recent study on this question.) This underscores the importance of better data collection—and more importantly, substantive action.

Trans people are beautiful, resilient, sacred. Trans people are diverse, we are everywhere, and we always have been. Trans people have struggled for generations to carve out spaces for ourselves in our communities and the public square. That work has always been led by trans people who are multiply marginalized, and inextricable from the work of racial, gender, disability, immigrant, economic, climate justice, and democratic self-government.

Today trans people live our lives in the midst of a historic and double-edged “visibility,” of hard-won but unevenly enjoyed progress and mounting backlash, of real and rich possibility and a peril that is bound up in dire threats to democracy and pluralism. Ending anti-trans violence requires making generational investments in economic and racial justice for all, investing in marginalized trans communities in particular, and preserving and bolstering our flawed and endangered democracy—which is the prerequisite for all else. If you want to honor and support our trans communities in the face of this violence, consider your contribution to that mission. If you want to mark the day, by all means respectfully attend a local event—and consider donating to the Trans Justice Funding Project, which supports countless grassroots trans-led organizations each year. (I’m a monthly donor.) If you are trans, remember also that your life and well-being are sacred, and take care of yourself in the way that’s right for you.

So today I light candles, I offer prayers, and I offer the injunction of Mother Jones: “Pray for the dead and fight like hell for the living!”

What we do know about violence and violent deaths among trans people?

Every year as we approach the Transgender Day or Remembrance, we have a lot of conversations about numbers. As I note in another post, we do not have reliable mortality data on transgender people in the US. That means we can’t really calculate a “homicide rate,” because we just don’t have the data. The names and the numbers we have—47 this year so far—are simply the ones journalists and advocates have been able to identify from community members and press reports. We do know from government surveys and many other sources that trans people face non-fatal violence at very disproportionate rates. We need local, state, and federal governments to collect meaningful data, and we need more rigorous research to really understand the full picture—though we certainly know enough to take meaningful action and make investments in marginalized trans communities that can help prevent this violence.

There is one study I know of that has tried to actually measure mortality in a US trans population and compare it to cisgender people. This study was published this year and the data comes from veterans receiving VA care. Here’s the citation:

• Taylor L. Boyer, Ada O. Youk, Ann P. Haas, George R. Brown, Jillian C. Shipherd, Michael R. Kauth, Guneet K. Jasuja, and John R. Blosnich, Suicide, Homicide, and All-Cause Mortality Among Transgender and Cisgender Patients in the Veterans Health Administration, 8 LGBT Health 173 (2021). http://doi.org/10.1089/lgbt.2020.0235.
  

I am not a research scientist, but here is my take on this study:

Key takeaways from this data:

• This is the first US study to directly compare official mortality data of transgender and cisgender patients. Until the CDC begins routinely collecting trans demographics in its mortality data, pulling data from large sets of patient records is the best we can do.

• It’s important to note that while the sample is relatively large (n = 32,441, of whom 8,112 were transgender 24,329 cisgender), it is not a general-population study. The data comes directly from Veterans Health Administration patient records, so it only represents military veterans who are eligible for VA care—on average, an older and sicker population. Still, VHA is a huge system and its population easier to study than patients in private care, and this first-of-its-kind data is invaluable.

• In this sample of veterans in VHA care, transgender people across age groups were more than twice as likely to die by suicide during the 17-year study period, when accounting for other demographic factors. For those under 40 it was more than three times greater than cisgender peers, while for those over 65 it was more than nine times greater. Transgender veterans who did died at significantly younger ages than their cisgender peers.

• In this veteran sample, transgender people were more likely to die by homicide than their cisgender peers. The average age at which they were killed did not differ significantly. This finding should be interpreted with caution because the total number of homicide deaths in the sample was very small. This is important as the first data of its kind, but much more research is needed.

• The ten most common causes of death were the same for transgender and cisgender patients in the sample, with the ranking broadly similar except that suicide was the fourth leading cause of death for transgender people, whereas it was tenth for the cisgender sample and in the US overall.

• Over the 17-year period studied and adjusting for other demographics, all-cause mortality among transgender people under 65 was lower than their cisgender peers—but for trans people over 65 it was higher than for cisgender people over 65. (This just means that they died for any reason during this 17-year period.) This mixed and generationally-divided result was unexpected, given that numerous studies have found disparities in both physical and mental health across age groups, including for some chronic conditions that are leading causes of death.

Key policy implications from this data:

• The White House-led Interagency Working Group on Safety, Inclusion, and Opportunity for Transgender Individuals should produce a bold and specific action plan that is focused on root causes of prevention and is folded into broader gender, equity, and anti-violence efforts. State and local governments should do likewise. Just doing better counting or better investigations is not enough, and we can’t prosecute and incarcerate our way to ending violence. Despite the limitations of this data and the urgent need for more research, this is the first actual US comparative mortality we have, and it shows higher death by homicide among transgender people. Moreover, it is consistent with many other studies that have found transgender people are more likely to experience non-fatal violence across all areas of social life, including domestic, intimate partner, sexual, and hate violence (which often overlap).

• Transgender youth need proactive equity and prevention efforts as well as strong civil rights enforcement, including outreach and technical assistance to schools and health providers and leveraging federal education and prevention funding and guidance to promote equity and safe-schools efforts. The Justice Department needs to make clear that it will take action against state laws that target trans youth. The Departments of HHS and Education need to place transgender youth front and center in suicide prevention and school safety initiatives. And the Administration can build on its current effort to fund and promote community-based violence prevention and intervention efforts by funding and incentivizing projects that focus on trans populations and violence against trans people.

• Economic recovery programs and health system transformation efforts must include a focus on reaching transgender people, who were already facing 2020 unemployment rates in 2015 (per the US Trans Survey) and face barriers throughout the health care system. This means making real investments in both making existing programs and systems trans-inclusive and funding targeted, transgender-specific initiatives to promote economic opportunities and public health. The Biden Administration, Congress, states, and localities all need to take up this charge. President Biden has already promised to do this and should work with DOL, SBA, Commerce, and HHS to do it, including through implementation efforts for the COVID-19 recovery, infrastructure, and (hopefully) Build Back Better acts.

• The Biden Administration should prioritize transgender data collection, including mortality and victimization data. Measures are missing from most key federal surveys. In some systems, such as the National Violent Death Reporting System, have the data fields but states and localities need help and encouragement to ensure it’s actually reported. A few key surveys collect this data but it hasn’t yet been publicly reported. Others need to further test Spanish-language and proxy questions. Agencies need clear standards and guidance from the White House. Congress should provide more funding for federal statistical agencies to support important efforts like these.

• The Administration for Community Living/AoA should develop guidance, incentives, and resources to ensure that supports reach trans older adults and are nondiscriminatory and culturally competent, and should develop effective data collection measures to learn more about trans older adults’ experiences. State and local governments should do likewise. The finding here that trans older adults had higher all-cause mortality and extremely high death by suicide is consistent numerous other findings of mental and physical health disparities in trans older adults.

If you know of other important data or projects on these issues, let me know. Kudos, as always, to all the researchers and advocates moving this work forward.

Are we showing Haitian refugees “who we are”?

As a feminist and LGBTQI+ lobbyist, when I’m writing to the Biden-Harris White House it’s usually on a positive note. We’ve accomplished a lot working with them in recent months, and set the stage for much more progress to come. Alas, not today:

President Biden has done much to save lives, prevent suffering, and work toward restoring and strengthening norms and values we can be proud of.

So I am shocked by the President’s “Title 42” policy, and by what now-former Amb. Daniel Foote aptly called the “inhumane, counterproductive decision" to deport thousands of Haitian refugees and other migrants to a “collapsed state.” The images of US officials charging Haitian refugees on horseback will and must be indelible additions to the sad picture book of our nation’s moral failings.

I take some solace in knowing President Biden is a man who has shown he knows how to admit when he is wrong. On this issue, I implore the President to remember all his words over the last two years about “who we are.”

Sincerely,

On Living in “Tobin’s America”

Kate Sosin has written an extremely flattering profile of me for The 19th. It’s got me thinking.

Which America?

While I can’t take issue with Kate’s reporting or the glowing praise from admired colleagues, it’s a strange thing to read in the same week as reports of families planning to move out of state and spikes in suicidality in the wake of anti-trans and -intersex laws in state after state.

I’ve said a dozen times over the last few years that it’s been “the best of times and the worst of times” for trans people. I’ve never felt it more deeply, though, than I do right now: how proud I am of the progress we’ve made, and how scared I am of the backlash. The President of the United States speaks to a trans fundraiser, and asks Congress to fund a new program for trans survivors. And parents warn they’re convinced “Children will die” from what state lawmakers are doing.

Please, follow my colleague and hero Chase Strangio for the latest on these attacks on our young people and what you can do.

Listen, the progress is real. As I’ve been reminded many times in the last few days, it’s really, really important to stop and let us feel the joy, gratitude, relief, and pride in that, and in whatever role we’ve played in it. The backlash is very real, too, and there’s no denying this latest may be the deadliest yet. Some of us, frankly, won’t make it. We’ll save each other, as many as we can. Our communities will survive. We will continue to struggle for progress—halting, uneven, fraught though it may be.

Our backbone is all of us

I am so moved by the everyday heroism of so many folks who have gotten us here and are getting us through it. So, yes, I’m going to spend ten minutes listing the sorts of folks I’d really like to see (more) profiles of.

I want to see more profiles of trans Executive Directors of color like Gabriel Foster, Andy Marra, Dominique Morgan, Bamby Salcedo, Toni-Michelle Williams, Janetta Johnson, Kris Hayashi, Kiara St. James, Emmett Schelling, Carter Brown, Tre’Andre Valentine, Ceyenne Doroshow.

I want to see more profiles of trans lawyers outside the world of DC policy, like Alex Chen, Omar Gonzalez-Pagan, Taylor Brown, Alejandra Caraballo, Avatara Smith-Carrington, Chrysanthemum Desir, Charlie Arrowood, Malita Picasso, Remy Green, Sei Young Pyo, Bre Kidman, Alex Binsfield, Whit Washington, Alesdair Ittelson.

More profiles of trans scholars like Sandy James, Arjee Restar, Asa Radix, Sari Reisner, Bali White, Trystan Cotten.

I want to see more profiles of organizers and advocates like Tamika Spellman, Zahara Green, Micky Bradford, LaLa Zannell, Ash Stephens, Tori Cooper, Barbara Satin, Zephyr Williams, Holliday Simmons, Jennicet Gutiérre.

Or of trans folks in philantropy like Gabriel Foster (again!), Rye Young, and Hua Boonyapisomparn.

I want to read more profiles of trans folks working in government—yes, the high-level appointees like Rachel Levine and Raffi Freedman-Gurspan, and the state and local electeds like Andrea, Phillipe, Mauree, Danica, Lisa, Tyler, Gerri, Brionna, Victoria, Rosemary, Taylor, Evelyn, but also the career civil servants like Kyle Rapiñan, Ashe McGovern, Ez Cukor, Diana Flynn.

And on and on: the therapists, artists, street medics, journalists, faith leaders, provocateurs, GSA and campus leaders, who are just as indispensable to trans futures as any policy wonk in DC.

What fingerprints do I want to leave?

Every single one of us, including our advocacy groups, needs to supporting, listening, collaborating, mentoring, funding, and making space for the leadership of trans people who are most marginalized—of Black trans women, of all BIPOC trans people, of all trans youth, of trans immigrants, sex workers, currently and formerly incarcerated folks. And how much we're doing that will determine our ultimate success. Fortunately, as I’ve just mentioned, we have so many incredible trans activists, leaders, scholars, even more and more lawyers and elected officials, so many other folks moving and shaking in different ways who are some or all of those things.

Like many trans people in prominent positions today, I'm a white, US-born, highly formally educated woman who has always been middle-class. That doesn't mean we haven't been trailblazers in some ways, or experts, or leaders. But we need to put that privilege to work with a huge helping of humility, listening, and partnership. A DC-focused policy shop is constrained in some ways from working in completely the same ways that a grassroots coalition can. I struggle with that every day. But even institutions and advocates steeped in lobbying—working every day with the most hidebound political institutions—can grow far beyond the habits that perpetuate racism and other inequities and be more effective than ever.

Good leaders are also good followers when they need to be, ready to share the podium, to pass the torch, and to get the pushback when they should be doing better.

Closing thought

Seriously, though: My friends and loved ones are probably never going to stop ribbing me about “living in Tobin’s America.” I hear it’s the new “future liberals want.”

If you liked this piece, you might also appreciate my post from last fall, “Advocacy Lessons for November and Beyond.”