When Joseph Schneier, a transgender man in his early 40s, started experiencing unusual spotting and elevated progesterone levels in 2021, his partner urged him to get checked out. They could not have known it would take a year for Schneier to find a willing gynecologist who did not turn him away.
Through Zocdoc, Schneier made an appointment with an OBGYN in New York City for late October. But the practice called Schneier to tell him the doctor would not treat him.
“They don’t see patients like you,” Schneier recalled being told. “I was like, ‘What are you talking about? This is just biology.’”
The person on the phone requested that he cancel the appointment but say it was an insurance issue.
Appalled, Schneier reported the incident to Zocdoc and confided in a nurse he knew. In an email exchange with his nurse acquaintance, which was reviewed by Fierce Healthcare, Schneier recalled that someone at the OBGYN practice whispered to him on the phone, "The doctor won’t see you because you are trans."
The practice and the gynecologist did not respond to multiple requests for comment.
In the meantime, Schneier mustered up the courage to continue his search. “It can be very unnerving to go to an OBGYN, it can bring up dysphoria to even talk about going there,” Schneier said.
But he was rejected by two more practices in New York. “It was clear to me,” Schneier recalled, “that the reason was not for any other reason than that I was trans.”
After that, Schneier suspended his search for a doctor for several months. “I was so turned off by the whole thing,” Schneier said. “It’s just very dehumanizing.”
It wasn’t until August 2022 that Schneier finally got an appointment with a gynecologist specializing in gender-affirming surgery at NYU Langone with the help of his nurse acquaintance. The doctor recommended a procedure to remove Schneier’s uterus, cervix, ovaries and fallopian tubes, which was scheduled for October 2022.
A subsequent pathology test, the results of which were viewed by Fierce Healthcare, revealed that Schneier had ovarian cancer—the deadliest of all gynecologic malignancies. His doctor told him he was lucky to have had the surgery when he did. Nonetheless, Schneier would have to undergo chemo for treatment.
I often ask myself, ‘If this could happen to me, what about other people?' I find it incredibly alarming that I have all the tools that one could have to navigate healthcare, and I still almost died because of discrimination.—Joseph Schneier
As a trans man, Schneier has had top surgery and has been on testosterone replacement therapy for years. He suspects that’s what makes it confusing for OBGYNs, “even though biologically, it shouldn’t be.”
Ovarian cancer is usually diagnosed late, in part because symptoms can mimic other conditions. But even when one recognizes that something is wrong, like Schneier had, there is no guarantee of swift care as a trans patient. Blatant discrimination in healthcare is rampant and, Schneier says, the only setting where he experiences it.
“That kind of thing is pervasive and underlies so much of my experience in the healthcare system,” Schneier said. “The alienation really prevents people from getting the care that they need.”
Schneier is the founder and CEO of Trusty.care, which helps older adults navigate Medicare and Medicaid benefits. He sits on the board of numerous LGBTQ+ advocacy organizations and as an experienced businessman, knows how to stand up for himself. Yet still, he had to lean on his connections to find care.
“I often ask myself, ‘If this could happen to me, what about other people?’” Schneier said. “I find it incredibly alarming that I have all the tools that one could have to navigate healthcare, and I still almost died because of discrimination.”
Nearly a quarter of trans people didn’t see a doctor when they needed to in the last year for fear of mistreatment, according to a survey by the National Center for Transgender Equality. Of those who saw a provider, nearly half had at least one negative experience, like being refused healthcare, because they are trans. Barriers to care, often driven by stigma, also block trans people from primary care and can lead to their heavier reliance on emergency care.
After the denial of care that he reported to Zocdoc, the platform responded to Schneier, apologizing for the experience, a Zocdoc spokesperson told Fierce Healthcare in a statement.
“We recognize the barriers that members of LGBTQ+ community face within the healthcare industry, and we deeply regret that this individual had this experience,” the spokesperson said. "However, the fact is that Zocdoc should have done more back in 2021 to directly engage with the provider.”
Zocdoc has since invested in a system to address each patient complaint and take corrective action if needed, per the spokesperson. Consequences for violating Zocdoc’s community standards can range from warnings to suspension or termination from the platform.
“We take seriously our responsibility to help patients access the right providers for their individual needs, and we remain committed to building a trusted service that helps every patient find and book every type of care,” the spokesperson said.
'Pervasive' systemic prejudice
Such denials of care are far from uncommon, according to Dustin Nowaskie, M.D., a psychiatrist and founder and president of OutCare Health, a nonprofit focused on LGBTQ+ health equity. Nowaskie often hears of these struggles from patients, who are anxious, timid and traumatized by past encounters with providers. Many were turned away by doctors after they came out.
“Stigma and marginalization is quite pervasive and experienced by LGBTQ+ people every day across this country,” Nowaskie told Fierce Healthcare. “It puts a high level of distrust into a system and therefore you are going to avoid care because you no longer trust that system.”
It’s not an excuse to say, ‘I don’t know about trans people, so I can’t care for a trans person.' It’s not fair to pretend that our knowledge gaps or deficits are an excuse for discrimination or refusal to care for a patient.—Halley Crissman, M.D.
LGBTQ+ adults trust primary care doctors and specialists 30% less than cisgender-heterosexual people and trust the general healthcare system 94% less. Nowaskie has cared for some people who have not seen providers in two decades, and the reason they end up back in the system is usually because of an emergency.
Providers who discriminate against patients harm not only the patient, but also other providers, Omar Gonzalez-Pagan, counsel and healthcare strategist at Lambda Legal, added. A condition that is not treated timely can become chronic or difficult to treat.
“There are downstream effects to all of this, just from an initial discriminatory denial of healthcare," Gonzalez-Pagan said. "And it creates a public health problem where people have health needs that go unaddressed."
“People of all genders need and deserve to have access to care that is safe and gender-affirming, regardless of what care is needed,” Halley Crissman, M.D., an OGBYN and adjunct clinical assistant professor at Michigan Medicine, told Fierce Healthcare. She is also director of gender-affirming care and associate medical director at Planned Parenthood of Michigan.
Every provider will eventually face a patient with a unique condition or rare disease they do not know how to help, Crissman said, yet they still have a duty to see them and direct them to care. They can consult with peers or mentors on best practices, as providers do all the time. In any case, being gender-diverse is not rare, Crissman stressed; millions of American adults are trans or nonbinary.
“It’s not an excuse to say, ‘I don’t know about trans people, so I can’t care for a trans person,’” Crissman said. “It’s not fair to pretend that our knowledge gaps or deficits are an excuse for discrimination or refusal to care for a patient.”
“My initial reaction isn’t ‘refer because it’s a little uncomfortable,’” Nowaskie echoed. “I’m a provider, I'll figure it out for you.”
Untangling the web of healthcare regulation
The Affordable Care Act (ACA) prohibits discrimination based on sex at facilities that receive federal funding. But does that protection extend to sexual orientation and gender identity?
Legal experts say yes, though there is still no federal law explicitly protecting LGBTQ+ people from discrimination in public places. (Pending federal legislation, the Equality Act, aims to do so.)
In 2016, an Obama-era rule explained that the protections laid out in the ACA apply to gender identity. Then, under President Donald Trump in 2020, the Department of Health & Human Services (HHS) finalized an extensive planned rollback of nondiscrimination protections for LBGTQ+ people.
However, just days after the HHS announcement, the Supreme Court held in Bostock v. Clayton County that the prohibition of sex discrimination in employment includes sexual orientation and gender identity.
Based on that ruling, the Biden administration directed agencies to interpret Bostock to apply not just to employment, but to other areas of law where sex discrimination is prohibited, including healthcare.
“This case provides strong precedent for interpreting the protections in the ACA to also prohibit discrimination against transgender people,” Christy Mallory, legal director at the Williams Institute, a think tank conducting independent research on gender identity law and public policy, told Fierce Healthcare. “And many lower courts have interpreted this language consistent with the Court’s decision in Bostock.”
Still, LGBTQ+ civil rights organization the Human Rights Campaign warns that future administrations may refuse to interpret the law this way.
State law explicitly prohibited discrimination based on sexual orientation and gender identity in at least 22 states and Washington, D.C., as of early 2023. At least 10 additional states interpret existing protections against sex discrimination to include sexual orientation and gender identity.
Since 2019, under the New York State Human Rights Law, discrimination based on gender identity or expression has been explicitly prohibited in places of public accommodation, including clinics and hospitals. New York City, where Schneier sought his care, also has its own version of the law.
Physicians are generally free to not take on new patients across the board, Gonzalez-Pagan said. But if they provide a service a patient is seeking and turn them down because of a protected characteristic, including trans status, that’s unlawful under the ACA for covered entities, he said.
“LGBTQ people seek medical care. The care that they seek is no different just because they're LGBTQ,” Gonzalez-Pagan said. “The idea that only LGBTQ-specialized healthcare providers can see LGBTQ people is not real.”
A gynecologic exam, which Schneier needed, is a “fairly routine aspect of the practice for any OBGYN, so the fact that the person has a male identity versus a female identity makes no difference as to whether they can conduct that exam,” Gonzalez-Pagan said.
Public health facilities in New York are regulated by the state Department of Health (DOH), which requires that they establish policies and procedures regarding patients’ right to receive services without regard to sex or gender identity. In addition to the state and city Human Rights Laws, physicians in private practice answer to the state education department and the DOH’s Office of Professional Medical Conduct, a DOH spokesperson said.
“While healthcare providers are not required to provide professional services to new patients, such refusal cannot, at a minimum, be based on a person’s race, creed, color or national origin,” Cadence Acquaviva, public information officer at DOH, told Fierce Healthcare in a statement. “In general, a healthcare provider should not provide services that they are not competent to provide.”
Individuals who have been discriminated against can file claims directly in court. But Gonzalez-Pagan recommends first filing an administrative complaint with a regulatory body that will investigate the complaint and can assign its own attorneys to the case.
Individuals cannot currently file complaints with HHS, which enforces the ACA’s nondiscrimination protections, because of a court order, according to Mallory.
Disjointed training, guidelines for providers
Medical students receive little training on LGTBQ+ health. Having this knowledge can increase provider comfort and confidence when treating these individuals. Med students, on average, report getting less than 5.5 curricular hours and less than 13 extracurricular hours of LGBTQ+ education during school, according to one study.
The study, co-authored by Nowaskie, also found a disconnect between students’ moderately high trans-specific knowledge yet very low clinical preparedness, especially when compared to their preparedness in treating lesbian, gay and bisexual patients. This finding is consistent with those of previous studies.
Nowaskie and colleagues' study recommends at least 35 hours of training for competence in LGBTQ+ health, though Nowaskie acknowledged it is likely students need “much more” than that to account for margins of error.
Meanwhile, a survey of 600 frontline Michigan Medicine employees found 75% had no formal training in caring for trans patients. A third experienced a situation where they felt unprepared for a trans patient or visitor. That figure is likely higher, Crissman noted, as "you can’t tell who’s trans and nonbinary by looking at them."
OBGYNs routinely care for trans patients, even though most don’t have any trans-specific training. One recent survey found more than 67% of OBGYN residency program directors do not have an established trans care training curriculum, though most reported plans to implement one within a year.
The American College of Obstetricians and Gynecologists (ACOG) has guidelines on caring for trans and gender-diverse patients, as well as guidelines on refusals of care.
“Professional ethics requires that health be delivered in a way that is respectful of patient autonomy, timely and effective, evidence-based and nondiscriminatory,” its guidance on conscientious refusals reads. Discriminatory attitudes are not genuine claims of conscience and refusals that oppress already marginalized groups, like LGBTQ+ individuals, should raise “significant caution.”
ACOG’s guidance on caring for trans patients says OBGYNs “should make their offices inclusive and inviting to all individuals who need … care.” Any anatomical structure that warrants screening should be screened, regardless of gender identity. “Evaluation of transmasculine individuals with abnormal uterine bleeding are the same as those for cisgender women,” the guidance says. Routine screening for breast and cervical cancer should also be performed.
Yet Schneier’s case exemplifies how gynecologists—even in a relatively progressive, medically-advanced city like New York—routinely disregard these professional recommendations. Considering their limited training on LGBTQ+ health, that should come as no surprise.
“As medical students we are indoctrinated into the language of women's health from the beginning of our education,” Natalie Sadlak, a queer student at Harvard Medical School wrote in ACOG’s academic journal last year. Ignorance and assumptions are “rooted in implicit bias that defines obstetric and gynecologic patients as cisgender women,” she wrote.
Referring to gynecological care as women’s care is “very binary, it’s very problematic,” Nowaskie agreed. Seeing this language used in healthcare settings can feel invalidating to trans and nonbinary patients, deterring them from seeking care, Nowaskie said.
Incorporating gender inclusivity enables clinicians to better listen to their patients, understand their unique experiences and deliver more personalized care, Sadlak wrote. Thus, leaning into such principles does not come at the expense of women’s health, but rather enhances the quality of care for all.
Training on LGBTQ+ health should be a standard part of medical education, Sadlak continued. Once integrated into the curriculum, it can then be folded into licensing exams and accreditation requirements.
The way the current system is set up suggests there is still a long way to go. Apart from the obvious benefits to patients, there appears to be little incentive for institutions to consider more robust LGBTQ+ training. Accrediting bodies do not mandate specific curricula.
The Accreditation Council for Graduate Medical Education, which accredits residencies and fellowship programs, has criteria that require residents to demonstrate “respect and responsiveness to diverse patient populations, including but not limited to diversity in gender … and sexual orientation.” Its institutional criteria prohibit discrimination in the working and learning environment. But it does not set curricula for programs, a spokesperson confirmed. (Complaints of requirement violations can be filed through the organization’s Office of Complaints.)
The Liaison Committee on Medical Education, which accredits medical schools, also does not set specific curricular requirements. Its guidelines recommend that a curriculum touch on diversity, disparities and the basic principles of culturally competent care. But it is up to each school to develop a program that meets these and other expectations, a spokesperson said.
Disparate frameworks for competency extend beyond the educational setting. In some cases, they exist quietly online. For instance, recommendations for providers published in 2022 by a national panel of experts appear to have slipped under the radar of the press, nor were they brought up by a single expert spoken to for this story (though Nowaskie later clarified about having served as a peer reviewer for the standards).
In other cases, efforts are home-grown at provider organizations. Einstein Healthcare Network, part of Jefferson Health, established its Pride Program in 2015 to serve LGBTQ+ patients. Though there are many providers in Philadelphia where Einstein is based, “sadly, there's not equality,” David Jaspan, D.O., chair of the Department of Obstetrics and Gynecology at Einstein, told Fierce Healthcare. “The opportunities are not the same for trans patients.”
The Pride program has trained hundreds of Einstein employees on LGBTQ+ competency and sensitivity. To be designated as an “LGBTQIA+ affirming” clinician, Einstein providers must complete several steps, including an application, a coaching session with an executive committee, annual training and more. Jefferson is working to make this training enterprise-wide.
‘Sad state of affairs’
Since the start of 2024 alone, more than 440 anti-trans bills have been introduced around the country. A quarter target access to gender-affirming care. As with attacks on reproductive autonomy today, LGBTQ+ people are similarly at the whims of the political climate to access their care, Einstein's Jaspan said.
“Individual rights are being restricted every day,” he said. “This is a group that will be subject to the same.”
Seven states exclude coverage for gender-affirming care from their Medicaid programs, and some expect that to grow. A federal appeals court is considering a closely watched case, likely headed for the Supreme Court, in West Virginia. The state argues its Medicaid program will pay for a gender-affirming surgery to treat cancer in trans people, but not to treat their gender dysphoria. Paradoxically, without getting such a procedure, trans people like Schneier may not know they have cancer.
“The sad state of affairs is that I would be dead today if I was on Medicaid and lived in one of these states,” Schneier said. “Without a trans-affirmative hysterectomy, I would not be here. But to me, that just means that all people, regardless of being trans or not, should have the right to obtain a hysterectomy as part of their health choice over their own body.”