Kelly Marshall remembers a time when health providers in Texas treated transgender people like mental health patients, misdiagnosed them with other conditions, misgendered them, or refused to treat them because they lacked the specialization.
“I had times where doctors would tell me I can’t treat you because you are transgender, or I don’t know how to treat you. I would say I am not there for gender-affirming care, I am here for general care,” Marshall said.
But amid a push to improve care across all specialties for LGBTQ+ patients over the last two decades, Texas medical schools have turned to Marshall to help teach mental and physical health care students to better treat their transgender patients.
Marshall, who is a transgender social worker and DEI educator, doesn’t train students on how to deliver hormone replacement therapy and gender transition surgeries. Marshall discusses topics that can be implemented across all types of health care for transgender and nonbinary people, such as asking patients for pronouns on intake forms, incorporating trauma-informed care and gauging patients’ comfort about talking about specific body parts.
Despite winning accolades for their work, universities have stopped asking Marshall to speak in medical classrooms about this specialized form of care.
Amid Texas Republicans’ push to limit government recognition of trans people and increase the control university regents have over higher education in the state, public medical schools are reviewing how trans people are discussed in the classroom. Already, the Texas Tech University and Texas A&M University systems — both of which operate three of the state’s 17 medical schools — have limited how trans people can be discussed in classrooms or required approval before their identities are taught.
Nearly a dozen health professors, LGBTQ+ trainers, and health providers for trans patients told The Texas Tribune that universities’ anti-transgender policies will cause future generations of health care providers educated in Texas to lose essential training on how to care for transgender patients. That includes how to screen trans people for depression and suicidality and treat them for conditions such as stomach pains and blood clots, which trans people are at higher risk for than their cisgender peers.
For several years now, medical and mental health providers have been encouraged — and, in some cases, required for licensing renewal — to complete gender-affirming care training and other diversity measures before entering the health care field. Gender-affirming care is defined as a broad range of treatments and procedures that help individuals align their gender identities with their physical bodies.
In 2014, the Association of American Medical Colleges published 30 competency objectives intended to improve medical education in the LGBTQ+ population. Medical schools across the country incorporated these guidelines into their existing curricula in various ways, such as through separate courses or programs, guest speakers, or online presentations.
The Center for American Progress released a report in 2021 found that 81% of transgender respondents reported having contemplated suicide during their lifetime, 25% reported using drugs at least twice a month, and 48% percent of transgender adults reported that they had been physically attacked or sexually assaulted at least once since the age of 18.
“If we’re not training individuals on how to be receptive to the needs of this population, the numbers are only going to get worse,” said Kendrick Clack, a nurse practitioner at CrofootMD in Houston, which specializes in medical care for LGBTQ+ patients, adding that many trans people delay care for chronic conditions because they fear discrimination.
The Texas Tribune contacted all 17 private and public medical schools in Texas to ask how these new restrictions and any other anti-transgender directives might affect training. The Tribune’s questions included what medical school professors should do if, in a clinical setting, they are presented with transgender patients or if a medical student asks a professor a question related to the health care of transgender people. Would their question or the patient be ignored? How will they teach students how to treat transgender or nonconforming patients if they can’t be mentioned in the classrooms?
Most medical schools didn’t respond. The University of Texas Health Science Center at Houston officials declined to answer the questions. The University of Texas Medical Branch responded, saying they don’t offer a specific course or formal training in gender-affirming care, but that, within their curriculum, students are trained to provide compassionate, evidence-based care to all patients they serve.
Faculty members and trainers who spoke to the Tribune said most medical schools do not have standalone courses on transgender care. Most of the training comes from invited guest speakers like Marshall, in lessons about health care topics that also happen to apply to transgender patients, and in clinical settings with a trans patient.
Texas Tech University System, which did not respond to a request for comment, released a memo earlier this month that imposed restrictions on how faculty’s gender identity and sexual orientation, among other topics, are discussed in classrooms. It, however, made exceptions to topics taught in a clinical setting.
But, that exception does little to mollify fears that training might be affected. Some faculty members told the Tribune that clinical settings are supposed to allow students to implement everything they have learned in the classroom and leaving instruction to clinical settings puts too much pressure on clinical professors to teach on the fly and also turns trans patients into lab rats.
“Not only does this mean people who exist are being turned invisible, but it also denies the people who might provide care the necessary content in their training. By allowing politically motivated interference in the classroom, it will successfully shape reality in ways that are completely contradictory to what many of us experience day in and day out,” said Andrew Martin, a Texas Tech art professor and the president of that campus’ chapter of the American Association of University Professors. “That is extremely disturbing.”
Despite almost every central medical organization‘s board and groups, including the American Medical Association and the American Medical Student Association, recognizing the medical necessity of treatments for gender dysphoria and endorsing such therapies, Texas is threatening to reverse the progress the health care community has made over the last 20 years, experts say.
There are approximately 120,000 transgender people in Texas, making up less than 0.4% of the total state population.
“It’s very concerning,” said Clack of the Texas Tech announcement. “This population is already vulnerable. They already have poor outcomes.”
What is happening in Texas?
Earlier this year, a Texas A&M University professor was fired over transgender topics in her course, leading to a cascade of events that included the resignation of the university’s president. Seeking to preempt any similar controversy, the Texas Tech University System issued guidance in September instructing faculty to ensure that their courses comply with a federal executive order, a letter from Gov. Greg Abbott, and a new state law that recognizes only two sexes.
Texas Tech officials say they must implement these policies because of President Donald Trump’s January executive order instructing federal agencies to recognize only two sexes and prohibiting federal funds from being used to promote “gender ideology.” They also cited Gov. Greg Abbott’s letter requiring the same of state agencies and a new state law related to collecting vital statistics. None of these measures had to do with teaching.
In the December memo, new Texas Tech chancellor Brandon Creighton provided more guidance. He said any course content that touched on prohibited topics — including transgender topics, according to faculty members — had to be sent to department chairs, university administrators, and ultimately the board of regents for review and approval in accordance with House Bill 229 and Senate Bill 37. He said this did not apply to student-directed work, clinical and research areas “at this time.”
Creighton, a former Republican senator who wrote many of the laws now transforming higher education, said higher education has “too often drifted from its core purpose, allowing activism and ideology to overshadow academics and innovation.”
“As a leading Carnegie R1 research institution, our mission is to educate the next generation of doctors, lawyers, engineers, entrepreneurs, teachers, and innovators — not to engage in ideological or political battles,” Creighton said in a statement to The Texas Tribune earlier this year.
A nursing professor, who spoke on condition of anonymity for fear of losing her job at a Texas public university, said clinical professors should focus on overseeing students as they implement what they learn in the classroom, not taking on the majority of the burden of teaching transgender care, including gender-affirming care, as the memo’s policies encourage. Without classroom instruction beforehand, students will have to learn how to treat a trans patient with trial and error in a clinical setting.
“The worst case scenario is that some people will die if they show up to an emergency department and nobody is willing or trained to provide proper care. The next best scenario is that people learn what facilities will not treat them and find ones that will, which are likely to be located outside of Texas,” the professor said.
Professors fear muzzling transgender discussion will affect research and medical practices conducted at university-run facilities, such as teaching hospitals and research labs. They fear suppression of evidence-based medical practices, delayed access to clinical trials and new therapies, eroded trust in clinical providers, reduced provider competency through restricted curricula for medical trainees, increased burnout and faculty exodus from Texas, and the undermining of academic freedom and opportunity for open and objective debate within the medical and scientific community.
Martin said that exempting the clinical and research arms of universities doesn’t address concerns because it doesn’t clearly define what might be considered research or what might be regarded as advocacy, leaving faculty to guess or, more than likely, avoid discussing trans issues altogether.
“It seems like it’s putting faculty who teach a lot of topics that would relate to this in a very difficult position. It tries to put it on the faculty to sort of self-determine, whether or not they’re in contradiction to any of this,” he said.
On the heels of Texas Tech’s changes, at least three public university systems — the University of North Texas, the University of Texas, and Texas Woman’s University — have ordered course reviews. They have framed the effort as ensuring compliance with state and federal law.
Gender-affirming care encompasses various interventions such as hormone therapy, gender-affirming surgeries, mental health support, and social transition assistance. These treatments are widely recognized as essential in alleviating gender dysphoria, improving mental health, and enhancing the overall well-being of transgender individuals.
Health care for transgender people goes beyond just providing them with hormones and gender surgeries. Training on how to provide care for trans people integrates sensitivities around their gender identity with typical health practices, such as how to monitor cholesterol and lipid levels, conduct routine health screenings, take medical records, and much more.
“For example, the particulars of conducting breast cancer or cervical screenings. They’ll talk about, in general medical care, how to do breast cancer screenings for women, but we have transgender women who’ve taken hormones and who have breasts who need screenings,” said Dr. Asa Radix, president of the World Professional Association for Transgender Health.
The organization provides training to medical students across the country, and has also seen requests from Texas schools decline recently.
“If future practitioners are prohibited from being educated about these issues and faculty and staff are being actively discouraged from discussing gender-affirming care within the auspices of their departments, the lack of normalization and education about these issues creates a wider gap between the community’s needs and access to care via competently educated practitioners,” Marshall said.
Consequences: The past becomes the present
Dr. Bradley Eisemann, a Houston plastic surgeon, said that when he went to medical school in the 2010s, he, like most medical professionals at the time, didn’t learn much about gender-affirming care. He said most medical providers’ experience with the transgender and nonconforming population was from direct patient care, a trial-and-error method that is unfair to the patient.
“Just trying to forget about it and not have any discussions about it doesn’t really make anything go away. You’re just avoiding the situation,” he said. “You are just putting both the patients and the medical practitioners at a disservice.”
Radix said she witnessed firsthand the consequences of inequitable care during the 1980s and 1990s, when she noticed the disproportionate impact the HIV epidemic had on transgender women, specifically of color.
For many years, the transgender population relied on unproven and unregulated methods of care, leading to dangerous self-hormone treatments, botched surgeries being conducted overseas, and the spread of disease and substance use.
Radix fears that what has happened in the past will be the new normal.
Eisemann said transgender and nonbinary people are not monolithic nor do all of them want gender-affirming surgeries. Helping a patient decide on whether to move forward with a procedure is a rigorous process that includes psychological screenings and evaluations by multiple medical providers who must come together and agree this will benefit the patient. He said this entire process might take years to complete before a patient even gets near a surgery room.
“Not every patient is a candidate for this, necessarily. Or has the desire to do it. There is a vetting process to make sure that what we’re doing is going to help this patient the most,” he said. “We have to make sure because it’s irreversible. You can’t go back in time so everyone has to be on the same page and committed to this.”
Without training for providers on how to properly assess patients for gender-affirming care, more people might end up regretting undergoing irreversible procedures, Radix said. In other words, political attempts to rid transgender topics from classrooms could create what some politicians fear the most — people who transition to another gender who shouldn’t have.
“The reality is, you can take this education out of the medical curriculum. You can take it out of the nation’s curriculum, but it doesn’t make trans people disappear. They are still going to be in front of you needing medical care,” she said. “The only thing this does is make those providers less able to take care of them adequately.”
The narrowing and eventual erasure of specialized care for transgender people will increase risks of homelessness, unemployment, violence, depression and suicide, according to mental health experts.
“That is what is at stake: Trans and nonbinary people’s lives and the fallout that their families will face,” said James Vining, a clinical social work therapist in New York who has specialized training in working with gender and sexuality, and fears anti-trans policies at Texas universities will reach the rest of the nation.
Clack says his transgender patients tell him of experiences where medical providers have resisted treating their medical problems and even delayed refilling prescriptions. “So if there is stigma associated with them … they may forego getting those screenings done,” he said.
Because his medical school didn’t provide training on gender-affirming care, Eisemann learned primarily through practicing alongside his father, one of the first plastic surgeons in Houston to also provide gender-affirming care. He also attends medical conferences on caring for people with different gender identities and tries to learn as much as he can about his patients — his first question is often, “tell me about yourself.” Building that trust and getting to know as much information as possible will keep patients safe.
“You don’t necessarily have to support or advocate for this, but knowing that these people exist and having the resources to take care of them in an optimal way is hard to argue against,” he said.
Great Job Texas Tribune, Stephen Simpson, Terri Langford And Lindsey Byman & the Team @ KSAT San Antonio for sharing this story.
