Marginalization of Transgender Women

As a family nurse practitioner (FNP) student, it is
important to provide unbiased and culturally-competent healthcare services
regardless of age, race, religion, socio-economic status, or gender


is an umbrella term for individuals who identify with a
gender different than what was assigned at birth (World Health
Organization, 2018)


As with any other subpopulation, transgender
women come from all walks of life and are mothers, fathers, sisters, and brothers
in their families.  Despite their
prevalence and presence all throughout history, they are classified as a
marginalized population that struggle to receive inequitable healthcare due to
their gender orientation (Bradford, Reisner, Honnold, &
Xavier, 2013).  The focus of this paper is to evaluate the
marginalization of transgender women.  It
will include the current prevalence, socioeconomic aspects, social justice and
its relationship to health disparities, ethical issues, plans for action to
address the health issue, and conclude with a summary of key points.


An individual’s gender identity is based on their personal judgement of whether they identify as male, female, or neither sex.  Some transgender people identify themselves with their transitioned gender: female to male, male to female, or members of a third sex (World Health Organization, 2018).  Legal identification documents that contradict a person’s birth gender may subject transgender individuals to punitive laws and discriminatory policies.  According to the World Health Organization (2018), marginalized populations such as transgender women are often stigmatized and criminalized for their contradictory gender identity from their birth gender; affecting their ability to access health care services, social protection, and equal opportunity for employment.  Transgender women are considered one of the five subpopulations that are disproportionately affected by HIV because their increased risk exposure (Divan, Cortez, Smelyanskaya, & Keatley, 2016).  The other subpopulations that World Health Organization identifies are: intravenous drug abusers, men who have sex with men, sex workers, and prisoners.  In some countries, transgender women are 49-80 times more likely to have HIV compared to non-transgender adults of reproductive age, an estimated 19% prevalence worldwide (World Health Organization, 2018).  In addition to the HIV epidemic amongst transgender population, mental health issues including depression, anxiety, mood disorders, and suicidal ideations were the most commonly identified health issues in researched publications.

Another essential component for gaining wider
recognition for transgender health issues is required revision of the

International statistical classification of
diseases and related health problems

(ICD), the standard diagnostic
reference for epidemiology, health management, and clinical practice.  The current version, ICD-10, “gender identity
disorders” were categorized under “mental and behavioral disorders”.  The next edition, ICD-11, which is due to be
published in 2018 will classify transgender health issues in a new category of
“gender incongruence” (Robles, et al., 2016).

On June 29, 2015, Nevada became the 10


state that banned transgender discrimination in healthcare and insurance.  Nevada State’s insurance commissioner
determined that the state and administrative code would “prohibit the denial,
exclusion or limitation of benefits relating to coverage of medically necessary
health care services on the basis of sex as it relates to gender identity or
expression” (National Center for Transgender
Equality, 2015).  This inclusion for transition-related
healthcare has since made it more accessible for transgender individuals to
move forward with gender assignment surgeries which were formerly not covered
by health insurance carriers.


The ways in which marginalization impacts a transgender person’s life are interconnected to socioeconomics derivatives.  Stigma and transphobia in the community hearten a society of isolation, poverty, violence, lack of socioeconomic support systems, and compromised health outcomes since each circumstance cohabits and exacerbates the other (Divan, Cortez, Smelyanskaya, & Keatley, 2016).  This is pertains especially to those individuals who express their gender identity from youth, they are often rejected or outcast by their own nuclear families.  This behavioral trend typically results in the lack of opportunities for education and further disregard to their need for mental and physical health needs.  The hostile environment that envelopes the young transgender community fail to understand their needs and threaten their safety by being discordant to provide sensitivity to health and social requirements.  Such discrimination and exclusion criteria fuel a sense of vulnerability, resulting in fewer opportunities to advance education, increased odds of unemployment, higher risk for homelessness and poverty (Lenning & Buist, 2013).

Transgender workers are the most marginalized in the
workplace, often excluded from gainful employment and undergo severe
discrimination during all phases of the employment process (including
recruitment, training, benefits, and advancement opportunities) (Divan,
Cortez, Smelyanskaya, & Keatley, 2016).  These workplace adversaries incubate
pessimism and internalized transphobia in transgender people and ultimately
discourage attempts to applying to many professional careers.  Extreme limitations in employment often lead
transgender people to uphold positions that have limited opportunities for
career growth and development such as beauticians, entertainers or sex
workers.  The high prevalence of
unemployment and low-income, high-risk unstable jobs promote the cycle of
homelessness and poverty.  In 2016, a
socioeconomic study reported the estimated annual incomes of two groups: A –
socioeconomic and racial privileged (


transgender, with associate’s degrees and were non-Latino, White), B –
educational privileged (


transgender, with bachelor’s degrees and people of color).  Group A reported annual household incomes of
$60,000 or more and Group B reported total household incomes of $10,000 or less
per year (Budge, Thai, Tebbe, & Howard,

Social Justice

The transgender society continue to endure adversarial
challenges despite the increased social awareness of gender orientation and
gender identity portrayed in media, news, politics, and even early education in
recent years.  The ever growing
prevalence of the lesbian, gay, bisexual, transgender, queer (LGBTQ) community’s
presence in society continue to surpass the rate of open-mindedness and
acceptance amongst coexisting citizens and is demonstrated by unequal societal
structures (Budge, Thai, Tebbe, & Howard,
2016).  The antagonistic perceptions they endure from
the public are linked to ambiguity in


– the binary classification of identification and differentiation in western
society (Neufeld, 2014).  The severity of marginalization deepens when
transgender individuals reside in smaller remote communities where resources
are limited and the prominent impact of colonization isolate transgender
individuals.  The collective consequence
of family, social, and institutional transphobia contributes to the increased
risk of mental health issues, frequency of substance abuse, and prevalence of
sexually transmitted infections within the transgender population (Lenning &
Buist, 2013).  Social justice for transgender patients in
healthcare should translate to the equally entitled fair distribution of
healthcare resources with unbiased regard to their gender identity, preferred
name in the electronic medical record (EMR).
Furthermore, billing for medical procedures should be exceedingly
scrutinized to ensure that the billing name and pronoun match the patient’s
insurance identity (Hann, Ivester, & Denton,

Ethical Issues

The principal ethical issue that concerns the transgender community is the inequality of healthcare access.  Transgender individuals that contribute to the society should be provided equal access to healthcare as a non-transgender individual who mirrors the same type of existence in society.  Transgender care should have equal focus in medical education, research and funding.  Extending to healthcare access for transgender inmates in prison, Amendment VIII of the United States Constitution should be enforced.  “Excessive bail should not be required, nor excessive fines imposed, no cruel and unusual punishments inflicted” (United States Constitution, Amendment VIII).

Plan for Practice

Considering that Nevada is one of ten states that
passed a law which bans discrimination of transgender persons in healthcare and
insurance, it is imperative to have a plan for practice that echoes the same
intent.  Forecasting the future as an FNP
in the clinic setting, the three actions for practice that I plan to implement
are: 1) Encouraging of cultural competency training amongst staff in regards to
LGBTQ population.  This includes
incorporating written nondiscrimination statements specifically to protect
transgender rights (Hayhurst, 2016).  This can be measured implementing an annual
competency written test, to assess retained knowledge and also provide
opportunity to refresh their practice.
Another method of outcome measurement can be the report card from a
transgender (secret-shopper) patient’s care experience.  2) Establishing transgender-friendly
environment from arrival.  Offering small
clues such as a rainbow sticker or flag at the check-in counter or adding LGBTQ
community literature in the waiting room (Hayhurst, 2016).  The outcome of this intervention can be
measured by asking a transgender patient if they were able to identify LGBTQ
clues in the clinic and if it made them feel more welcomed to the
practice.  3) Gender neutral restrooms
can be simply implemented by eliminating any gender specific signs (women or
men) (London, 2014).  Measuring the outcome of this change can be
determined by implementing random audits – monitoring if patients and visitors
do not hesitate to use the restroom because of a gender exclusive sign.

Stigma and lack of legal recognition remain the backbone to structural barriers (laws, policies, and regulations), impeding adequate healthcare provisions to transgender women in 40 different United States (Bradford, Reisner, Honnold, & Xavier, 2013).  Transgender individuals who exercise human fundamental rights – to life, liberty, equality, health, privacy, speech, and expression are often dismissed by their own families.  These experiences of severe stigma and marginalization continue to negatively impact their lives by discriminating against career opportunities, increasing the risk for homelessness, and further projecting them to high risk behavior such as engaging in sex work – which heighten their risk for HIV infection (Divan, Cortez, Smelyanskaya, & Keatley, 2016).  Health disparities continue due to adversarial issues that encompass their lives and they are less likely to seek healthcare treatment in a timely or preventative manner.

I hope that research focused on the transgender
population continues in the future, as there seems to be a lack of new
knowledge and slow implementation to changing the approach to healthcare
practice to better address transgender concerns.  As mentioned in my plan for practice, I am
quite confident that I will succeed in implementing those actions for
change.  They are all fairly simple
interventions that are of minimal cost and can benefit both the practice
generate income (with new patients) and transgender individuals to seek
healthcare in a transgender-friendly environment.


Bradford, J., Reisner, S. L., Honnold, J.
A., & Xavier, J. (2013). Experiences of transgender-related discrimination
and implications for health: Results from the Virginia transgender health
initiative study.

American Journal of Public Health, 103

(10), 1820-1829.

Budge, S. L., Thai,
J. L., Tebbe, E. A., & Howard, K. A. (2016). The intersection of race,
sexual orientation, socioeconomic status, trans identity, and mental health

The Counseling Psychologist, 44

(7), 1025-1049.

Divan, V., Cortez,
C., Smelyanskaya, M., & Keatley, J. (2016). Transgender social inclusion
and equality: A pivotal path to development.

Journal of the International
Aids Society, 19

(3). doi:10.7448/IAS.19.3.20803

Hann, M., Ivester,
R., & Denton, G. D. (2017). Bioethics in practice: Ethical issues in the
care of transgender patients.

The Ochsner Journal, 17

(2), 144-145.
Retrieved from

Lenning, E., &
Buist, C. L. (2013). Social, psychological and economic challenges faced by
transgender individuals and their significant others: Gaining insight through
personal narratives.

Cultures, Health & Sexuality, 15

(1), 44-57.

London, J. (2014).
Let’s talk about bathrooms.

Diversity Best Practices

. Retrieved from

National Center for
Transgender Equality. (2015).

Nevada becomes tenth state to ban transgender
health exclusions

. Retrieved from National Center for Transgender Equality:

Neufeld, A. C.
(2014). Transgender therapy, social justice, and the northern context:
Challenges and opportunities.

Canadian Journal of Counseling and
Psychotherapy, 48

(3), 218-230. Retrieved from

Robles, R., Fresan,
A., Vega-Ramirez, H., Cruz-Islas, J., Rodriguez-Perez, V., Dominguez-Martinez,
T., & Reed, G. M. (2016). Removing transgender identity from the
classification of mental disorders: a Mexican field study for ICD-11.

The Lancet
Psychiatry, 3

(9), 850-859. doi:10.1016/S2215-0366(16)30165-1

United States
Constitution, Amendment VIII. (n.d.). Retrieved from

World Health
Organization. (2018).

Transgender people

. Retrieved from World Health