Study: Oregon's gender-affirming health care policies are not fully realized in practice

While Oregon ranks highly nationwide for its gender-affirming policies and health care for transgender women, many of those polices are not fully realized in practice, a recent study from Oregon State University found.

Monday's Supreme Court decision barring employment discrimination against LGBTQ people brings national law more in line with laws that have been in place in Oregon for several years -- laws that have led some trans people to move to Oregon from more conservative states.

The Oregon Equality Act of 2008 protects trans people against employment and housing discrimination, while the expansion of Medicaid in 2015 expanded health coverage to include gender-affirming care like hormone-replacement therapy and transition surgery.

However, those legal protections are not enough to address social determinants of health such as financial status and access to housing, or the everyday discrimination still felt by many trans women in Oregon, said Jonathan Garcia, a researcher ins the OSU College of Public Health and Human Sciences said. The cumulative effect of those subtler forms of discrimination takes a significant toll on trans women.

In spite of ranking so highly in terms of Oregon's support for gender-affirming care, the impact of social discrimination is so great that it challenges policy implementation and the lived experience of people. This is how discrimination sort of gets in between the cracks -- it plays out in more complicated and indirect ways so that you can't really weed it out."

Jonathan Garcia, researcher ins the OSU College of Public Health and Human Sciences

Garcia's study, published earlier this month in the Transgender Health journal, gathered detailed interviews with 25 trans women in Oregon, ages 18 to 39. Of those 25, six had been homeless at some point in the 12 months prior and only 20% had full-time employment, though all had some form of health insurance.

According to the study's findings, one of the biggest challenges facing Oregon trans women is navigating the health care system. Though the law requires insurance to cover hormone-replacement therapy, many trans women, especially those in rural areas, couldn't find a doctor trained to provide those hormones, and the doctors they could access did not know where to refer them for more specialized care.

In other cases, trans women had to undergo a psychological evaluation to obtain a diagnosis of gender dysphoria -- the distress people feel when the sex they're assigned at birth doesn't match the gender with which they identify -- before they could begin to access hormone replacement therapy. This route is much more time-consuming and cost-prohibitive than the "informed consent model," wherein trans patients can attest that they understand the risks and benefits of pursuing gender-affirming medical treatment, without first having to prove psychological distress. For some study participants, the idea of gender dysphoria made them feel like they had a medical problem and invalidated their lived experience.

"All of that is really, really confusing," Garcia said. "It requires them to become experts in their rights, in the law, in the availability of these services and where they are offered."

Most trans women who were able to navigate that system credit their success to their social support network of other trans people. In addition to this informal network, Garcia said, the system needs to have trained and properly compensated health workers in place who can act as navigators, and they need to understand not just health care but the intersections with housing and the legal system that affect people's access to care.

"We need help with navigating these systems and establishing trust, so that people are actually able to claim and enjoy the rights that they have, so that the rights don't remain on paper," he said.

The study was limited in that 21 of 25 participants were white women. Despite numerous efforts to recruit Black and Latinx trans women, Garcia said, they were unable to reach them through participant referrals and community center contacts. He attributed this to their extreme marginalization in queer spaces in Oregon.

"But we can tell that whatever this set of women is experiencing, I expect the experience of trans women of color to be far more challenging," Garcia said. "Specifically because of structural racism and disenfranchisement from queer networks, which were a critical resource for the women who were able to navigate these systems."

Garcia anticipates that Monday's Supreme Court ruling will result in some trans women in neighboring states not feeling as compelled to move to Oregon for its more affirming policies because they can remain in their home states and receive more protection under the law than before the court's decision.

Garcia's co-author was Richard Crosby at the University of Kentucky.