As we end Pride Month, Josie Madden, a student in the Accelerated Bachelor of Science in Nursing program, offers her perspective on how her gender identity is influencing her decision to become a nurse.

As a transgender woman pursuing a degree in nursing, my identity—and the experiences I have had within the healthcare system because of my gender identity—have propelled me to be a part of what I believe is the next phase of equity within health care for transgender individuals. It’s time for representation.

The history of trans healthcare has, until very recently, been a history of gatekeeping. Transgender individuals historically have had significant difficulty in accessing gender-affirming treatment. Many trans individuals were denied treatment because they didn’t conform closely enough to the cisnormative gender binary, or because they expressed a non-heterosexual orientation. Furthermore, many doctors required more than a year of intensive psychological assessment and “real life experience” (socially transitioning and living publicly as one’s internally understood gender) as a prerequisite for hormone replacement therapy, or HRT. 

HRT, many trans individuals will tell you, can be crucial both for one’s mental wellbeing and for being perceived by others as one’s identified gender. And yet, accessing HRT often meant jumping through a series of difficult to understand policies and procedures. Often, trans patients would learn to play along and even coach each other in how to give these gatekeepers exactly what they wanted to see and hear; realizing this, these same gatekeepers often labeled trans people as “impatient” and “deceptive” in the medical literature.
To many transgender individuals, one thing felt abundantly clear: this was a system built not to uplift a group of people, but to control and manage a marginalized "other". As Julia Serano puts it in her seminal Whipping Girl, these practices “were primarily designed to protect the cissexual public from their own gender anxiety” and “reduced the issue of relieving trans people’s gender dissonance to a secondary, if not marginal, concern.” These sorts of practices, standard until very recently, ring cruel and ill-informed to our contemporary ears, but we still have a long ways to go.

There’s a snappy slogan popular in disability activist circles that grafts perfectly onto the issue of trans healthcare: “nothing about us without us.” This is a call not simply to consult people from marginalized groups, but to make them an integral part of systems that affect them. It is one of the reasons I am becoming a nurse and thankfully, I am part of a growing wave of transgender healthcare providers. 

Those of us transitioning in the U.S. today have unprecedented access to gender-affirming treatment under the informed consent model. And yet, it cannot be stressed enough how recent and incomplete these developments are; only 15 years ago, Stephen Wittle became the first trans president of the World Professional Association of Transgender Health (or WPATH) since its inception in 1979. In the last decade, changes in trans healthcare—largely in the form of insurance anti-discrimination laws—belie the fact that for many trans people, the health care promised to them by legislation remains beyond their grasp. This was the case for me, and the Boston area’s glut of trans health programs was one of the reasons I was drawn here—despite my home state of Colorado being, on paper, a leader in transgender rights.

Our health care doesn’t begin and end with gender-affirming treatments; trans people, believe it or not, get sick and grow old too. We go for annual physicals and flu shots, we wind up in the ER, we need dialysis and chemo and rehab and bed baths. Oftentimes in these scenarios, we still get treated as curiosities, our trans status suddenly and inexplicably taking center-stage as a pre-existing condition that must be related to our present complaint, no matter how commonplace that complaint is. This phenomenon is common enough that writer Naith Payton has given it a name: Trans Broken Arm Syndrome. This is the sort of subtle cultural problem that, in my eyes, can’t be legislated away or revised out of practice standards or even educated away by a consultant. It’s a problem that can only be undone by having people of marginalized groups as parts of a care team, as colleagues, as people you see and talk to and work with every day, and maybe even befriend.

This gap in representation and access has been one of my primary motivations for beginning a career in health care. I likely will not end up working specifically in transgender health, or even with a primarily LGBTQIA+ population (there are paltry few options to do so). Nor do I necessarily believe I’ll have any hand in writing the next WPATH standards of care, or directly influencing trans health legislation. No matter where my career takes me, however, I will be one more nurse who understands what it is to be trans, and what it is to be queer.