Homeless transgender individuals
Primary author: Barry Zevin, MD
One fifth of transgender people surveyed in the National Transgender Discrimination Survey reported experiencing homelessness. Homelessness frequently resulted from fleeing intolerant family, being forced out by family, by losing a job due to discrimination, or not being able to be employed due to discrimination and disability. In the same survey, of those who experienced homelessness, the majority of those trying to access a homeless shelter were harassed by shelter staff or residents (55%), 29% were turned away altogether, and 22% were sexually assaulted by residents or staff. Many transgender individuals have found health care and social service providers to be ignorant about transgender issues and needs. It is essential that homeless service providers are well educated in this area as they are likely to encounter trans individuals. The National Healthcare for the Homeless Clinicians Network has offered high quality trainings in this area.[2-4]
Assault and discrimination in public settings, especially homeless shelters, are frequently reported by homeless trans people. While federal and other policies forbid discrimination, many individuals are still unable to express their felt gender due to this discrimination, and best practices start with the collection of gender identity data in a confidential non-discriminatory manner, followed by an inquiry of housing preference if the shelter is sex segregated. Most individuals will prefer to be housed according to the gender in which they live or identify, however in some instances individuals may prefer to be housed based on their birth sex due to safety or other concerns. Best practice guidelines for shelters are now available.[7,8]
Functional disability is very common in homeless transgender individuals. Many homeless transgender individuals are unable to work due to disabilities. Gender dysphoria itself may lead to severe depression, anxiety, and suicidality. Adverse childhood experiences, losses, and traumas may result in PTSD and other persistent problems. Physical assaults, alcohol and drug use may result in chronic physical conditions. Loss of educational opportunities and lack of job opportunities may result in poor capacity to learn and acquire new skills. These problems often cause long-term loss of capacity to work. Individuals may be eligible for social security disability, which may be their only way out of homelessness. Careful documentation of disability will be helpful for these individuals.
Homelessness and gender affirming care
Hormone therapy and transgender surgeries are considered medically necessary (when desired) for the treatment of gender dysphoria. Homelessness has in some cases been used as a blanket exclusion for these medical services. In most cases individuals who need hormone therapy are highly motivated, and despite the stresses of homelessness are able to adhere to treatment and monitoring. Healthcare for the Homeless providers have successfully treated many patients with hormone therapy. Homelessness is also not a contraindication for planning surgery for those patients who seek chest, breast, genital or other gender confirming procedures. The degree of housing stability required for successful outcomes for each of these surgeries will vary with the procedure and individual. Medical respite programs may have the capacity to allow some patients to recuperate from some surgeries. Since there is often a year or more waiting period from referral to surgery, this period is a time to intensively work on stabilization of housing status. The hope and promise of surgery is often a very strong motivator for individuals who were previously hopeless. Some patients may have unrealistic ideas about the rigor of surgery, recovery and aftercare or the possibility of their being stably housed. These individuals require intensive work with primary care providers, mental health providers, care navigators, and others to develop the stability needed for successful surgery outcomes. Care should be taken during the education and preparation process prior to surgery to avoid creating the perception of caregivers' concerns about housing instability as discriminatory or as arbitrary "hoops to jump through."
Prevention of homelessness is dependent upon decreasing discrimination in family, work, and other social settings, and providing transgender individuals with equal opportunities. Assisting people who are unable to work to obtain disability entitlements is an important way out of homelessness. Prevention of the harms of homelessness can be accomplished by implementing best practices and educating homeless service providers. While substantial research has been initiated in this area [12,13] more research is needed to inform the development of best practices for implementing these changes.
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