Most primary care physicians in the U.S. are willing to provide routine care to transgender individuals, but that doesn’t mean they are well prepared to do so, a small study suggests.

Overall, 86 percent of doctors who responded were willing to provide routine care to transgender patients and 79 percent were willing to give Pap tests to transgender men to screen for cervical cancer, according to the results reported in Annals of Family Medicine.

Many physicians, however, reported a lack of familiarity with transgender transition care guidelines, lack of training in transgender-specific care, lack of exposure to transgender patients, and lack of knowledge about transgender patients among office staff, medical assistants or nursing staff.

These barriers suggest that willingness is not necessarily equivalent to competence, study leader Deirdre Shires of Michigan State University in East Lansing told Reuters Health by email.

“A number of studies have shown that transgender people often have negative experiences when they try to access healthcare services, including experiencing bias, harassment and even being denied care altogether,” Shires said. “What we realized is that no one had really gotten the perspective of providers to find out why this was happening.”

Shires’ team sent surveys to 308 internal medicine and family practice doctors in a large Midwest health system and had evaluable responses from 140 of them.

Doctors who had met transgender people were more willing to provide Pap tests to transgender men, the researchers found. And older doctors in the survey were less willing than their younger peers to provide routine care to transgender patients.

“Medical knowledge and clinical experience may be less important than personally feeling comfortable with transgender people,” Shires said. “Therefore, it is important for medical education to address not only clinical knowledge but also personal biases and attitudes as well.”

John Ayers, a public health researcher at the University of California, San Diego, agrees.

“A lack of training was not associated with a willingness to provide care, instead the more important factor is having experience with transgender people,” said Ayers, who was not involved in the study.

“During the 80’s and early 90’s some doctors were unwilling to care for AIDS patients, but as familiarity with HIV grew this problem abated.”

The study was restricted to only one medical system, so the findings might not be widely applicable, the researchers point out.

Another limitation, notes Dr. Janelle Downing of the University of South Carolina in Columbia, who was not involved in the study, is that so many of the doctors invited to participate declined to do so.

For that reason, the responses are “likely an overreport of willingness to provide care,” because clinicians who felt uncomfortable with transgender populations may have declined to respond to the survey, Downing said.

“As more individuals are identifying as a gender other than that assigned to them at birth, younger providers are more likely to know transgender individuals and therefore more comfortable providing care for them,” Dr. Carl Streed, Jr. of the Center for Transgender Medicine and Surgery at the Boston Medical Center, suggested in an email.

Streed, who was not involved in the study, said, “Given the significant lack of training in sexual and gender minority health in medical schools, it is no surprise that providers are unfamiliar with transgender health issues and primary care needs.”

“This is also rooted historically in the shuttering of transgender clinics across the United States in the late 1970’s and 1980’s,” Streed added.A 2016 study by The Williams Institute at the UCLA School of Law estimated that 0.6 percent of American adults, or 1.4 million individuals, identify as transgender.

It’s no surprise that after the death of former president George H.W. Bush we’re seeing media pundits, advocates and popular historians promote a rosy view of his tenure as president. In the era of Donald Trump, there’s a tendency to portray every Republican leader of the past in a nostalgic, sugar-coated way.

The first thing that caught my eye was a report on CNN’s website that included a tweet from the president of Covenant House, a charity that runs shelters across the U.S. for homeless youth and which has a historical connection to the Catholic Church. The tweet included photos of the former president and the late first lady Barbara Bush hugging children, implying that Bush was an important advocate for people with AIDS.

Then I saw a tweet from Yahoo News with a quote from the well-known historian Jon Meacham, describing Bush as a man who “believed that he was not a Republican president — he was a president,” noting that “there’s something very old-fashioned about that.”

Perhaps that was what Bush “believed,” but it was far from the truth. Bush was as captive to the evangelical right on social issues — and thus a decidedly Republican president — as was his predecessor, Ronald Reagan, who cultivated religious conservatives as a potent political force and bowed to their anti-LGBTQ agenda as the AIDS epidemic mushroomed in the 1980s. Reagan’s history of callously ignoring the epidemic while thousands died is well-documented. Bush, at the outset of his term, promised a “kinder, gentler” presidency than the man he’d served under as vice president. He even gave a speech on the AIDS epidemic in 1990, which was long on compassion but short on strategy and commitment to funding. During the speech, in fact, Urvashi Vaid, an invited guest and then the executive director of the prominent National Gay and Lesbian Task Force, now the National LGBTQ Task Force, took the unprecedented and heroic act of standing up and holding a sign, “Talk Is Cheap. AIDS Funding Is Not.”

Bush, in the end, bowed to the same extremists Reagan did when it came to AIDS and LGBTQ rights. As The Washington Post noted, Bush allowed evangelicals to mature as a movement within the GOP after Reagan brought them in, rather than pushing back.

Bush did sign the Americans With Disabilities Act, which protected people with disabilities against discrimination, including people with HIV.  And he signed 1990′s Ryan White Care Act — after it passed overwhelmingly in Congress — which federally funded treatment for AIDS for people with little resources. But it took years of work by the indefatigable Democrats Sen. Edward Kennedy and Rep. Henry Waxman, and was too little, too late. By that point, nearly 10 years into the epidemic, 150,000 cases of people with HIV had been reported in the U.S., and 100,000 people had died due to AIDS.

Bush’s administration still dragged its feet on drug treatment and refused to address prevention to the most affected community, gay and bisexual men, which it could have done by simply promoting and funding critical safer sex programs and condom distribution. When ACT UP, the AIDS activist group, targeted Bush in actions at the White House and at his Kennebunkport, Maine, summer retreat, Bush said “behavioral change” was the best way to fight the disease.

Infamously, Bush had said in a television interview that if he had a grandchild who was gay he would “love” the child but would tell the child he wasn’t normal. And like Reagan, he stocked his Cabinet with anti-gay zealots. Health Secretary Louis Sullivan, also protested by ACT UP for his terrible response to HIV, joined forces with evangelical leaders to cover up a government-funded study on teen suicide that found LGBTQ teens were at much higher risk. 

While Bush signed the Hate Crimes Statistics Act in 1990, which allowed for collecting data on anti-gay hate crimes in addition to other hate-motivated crimes, and signed a measure that struck “sexual deviation” from an immigration law used to ban LGBTQ immigrants, he took a hard turn to the far right when conservative commentator and former Reagan aide Pat Buchanan scared him with a strong challenge in the 1992 Republican primaries.

Bush eventually joined anti-gay attacks on the National Endowment for the Arts that had originated with right-wing members of Congress over the agency’s funding of queer artists, and put in place an acting chairwoman who defunded gay and lesbian film festivals. That same year, Bush signed a bill to stop the Washington, D.C., Council, a body that Congress can ultimately overrule, from offering health care benefits to domestic partners of gay and lesbian city workers.

And after Buchanan, who Bush offered a prime slot at the Republican National Convention in Houston, gave his infamous “culture war” speech, declaring there is a “religious war” in this country, and attacking, among others, the “militant homosexual rights movement,” Bush refused to denounce the speech and instead publicly denounced same-sex marriage, which was nowhere near a reality at the time. This prompted even the Log Cabin Republicans, the largest gay GOP group, to refuse to endorse him.

Meanwhile, the GOP platform that year condemned anti-discrimination statutes protecting gays and lesbians, and, responding to Democratic nominee Bill Clinton’s campaign promise to end the ban on gays serving in the military, adopted a plank banning gay service.

The military issue is instructive in defining the legacy Bush left and the direction he took the GOP on LGBTQ rights. In 1991, I wrote a controversial article for The Advocate, revealing that the assistant secretary of defense for public affairs, Pete Williams — the face of the Gulf War, on television every day during the conflict— was gay while not public about it, even though the Pentagon was ejecting gay men and lesbians from the military, claiming at the time that they were susceptible to blackmail (even, illogically, if they were openly gay).

A policy that dated back decades, the gay military ban was coming under scrutiny in the Bush years because more and more people were coming out of the closet — and being thrown out of the military. Defense Secretary Dick Cheney, who had hand-picked Williams as his loyal aide, was put on the spot about my Williams revelation in an interview with Sam Donaldson on ABC News. Cheney responded by distancing himself from the anti-gay policy, saying he “inherited” it, confirming his aide would not be made to resign and stating that government employees have a right to keep government from intruding on their “private lives.”

This was seen by many as a positive indication that the Bush administration was chipping away at the gay military ban, especially as Cheney in that same week had called the policy an “old chestnut” when asked about it by openly gay Rep. Barney Frank. These actions are what inspired candidate Clinton to promise to overturn the ban, courting gay voters during the campaign.

But the Bush administration took no concrete action to change the policy, and a year later, as Buchanan threatened Bush, the president went in the complete opposite direction, doubling down on the demonization of LGBTQ people.

If Bush had come into office with perhaps a vague ambition that he might move away from the harsh Reagan years, with its religious morality crusade, he left the presidency having paved the way for his own son’s even more anti-LGBTQ administration, firmly ensconcing religious conservative power within the Republican party.

A federal district court judge on Friday denied the Trump administration’s request to block or limit the scope of a ruling that temporarily prohibits the government from enforcing its ban on transgender people serving in the military.

Judge Colleen Kollar-Kotelly, a Clinton appointee on the U.S. District Court for the District of Columbia, said the court is not convinced the government will suffer irreparable harm without a stay of the court's October 2017 preliminary injunction.


The government had asked for a stay pending any potential, future proceedings in the Supreme Court. Bypassing normal judicial order, the Department of Justice asked the Supreme Court last week to review the case before the D.C. Circuit Court of Appeals has ruled.

Arguments before the appeals court are scheduled for Dec. 10.

At the very least, the government asked the district court to limit the nationwide scope of the injunction while the court weighs in, but Kollar-Kotelly refused. She said the government had not convinced the court that a more limited injunction is appropriate.

“Without supporting evidence, defendants’ bare assertion that the Court’s injunction poses a threat to military readiness is insufficient to overcome the public interest in ensuring that the government does not engage in unconstitutional and discriminatory conduct,” she said.

“After all, ‘it must be remembered that all Plaintiffs seek during this litigation is to serve their nation with honor and dignity, volunteering to face extreme hardships, to endure lengthy deployments and separation from family and friends, and to willingly make the ultimate sacrifice of their lives if necessary to protect the Nation, the people of the United States, and the Constitution against all who would attack them,’ ” she said

As a nonbinary Latinx person, a little thing such as getting the gender marker "X" on my Texas driver's license looked like a possibility, as it seemed as though the U.S. were headed toward progress.

As I look at my license now, though, the "F" gender marker continues to become more foreign to me. Throughout my life, I've always felt that something was different about me, whether it was my sexuality or my gender identity — and, as it turns out, I was right about both. My gender identity is something I have to work with every day – in fact, my therapist told me recently that I have to learn to be OK with the fact that I might never figure out whether I'm a "boy" or a "girl."

Part of learning to be OK with that was the possibility of "X" as my gender marker on my license, but this fall things began to look dimmer. As I read the news one Sunday, I thought to myself, Here is a memo that would nullify you and so many other people,

On Sunday, October 21, the New York Times reported that the Department of Health and Human Services was preparing to redefine the term "sex" under Title IX for the purposes of several key government agencies, allegedly writing in an internal memo the Times obtained that these agencies "needed to adopt an explicit and uniform definition of gender" that "would define sex as either male or female, unchangeable and determined by the genitals that a person is born with." But such a redefinition flies in the face of science, medicine and the law. It seems an attempt not just to eliminate protections for transgender individuals, but to stop recognizing them altogether.

Reducing someone's gender identity to their genitals is violence. It tells me and my community that my existence doesn't matter because I don't identify with my sex assigned at birth — it's why to date this year, at least 22 transgender individuals have been killed, a majority of them trans women of color.

This administration has repeatedly attempted to erase transgender people and deny them protections, and their messages that target the transgender community have only fueled similar legislation at the state levels. This year, according to the National Center for Trans Equality, there have been 21 anti-trans bills introduced in 10 states, and anti-trans ballot initiatives could show up in two other states.

I saw it happen in my own city when the Houston Equal Rights Ordinance (HERO) did not pass, a devastating blow to Houston and its LGBTQ+ community. Despite clear messages from the mainstream medical, psychological and scientific communities, this administration continues to try to effectively erase protections for transgender individuals — protections such as access to health care, housing and employment.

Though the rhetoric and violence continues to put our lives at risk, I know it's not over. This memo serves as a reminder that the fight for equality is at the beginning, not the end — our fight for equal rights did not end with marriage equality. This proposed plan to redefine "sex" does not take away the fact that my community and I have worked to ensure that our voices are heard and present.

But we can't continue to do the work alone.

If you identify as an ally to the trans and nonbinary community at any capacity, now is the time to speak up and do the work to help us. Just in 2017, there was nearly one homicide a week of an LGBTQ person in the U.S.

Though the memo can't hide our existence and the precedents set by dozens of federal court decisions in the past two decades affirming the trans community, our safety might be compromised. This means that your contributions to the trans community can't stop at the voting booth or hashtagging #WontBeErased on your posts.

It means things such as volunteering your time to a transgender-supporting organization, starting transgender support groups in your neighborhood or school, donating to organizations that support trans women of color or undocumented communities, confronting hate speak and implicit bias or even sharing the messaging of other trans activists in your community.

But, most importantly, it means never stopping asking how you can best support this community in this volatile climate — let "ally" become a verb for you.

PHOENIX, Arizona – An independent autopsy conducted on the body of a transgender woman who died in ICE custody in May in New Mexico concluded that she likely died as the result of severe dehydration complicated by HIV infection but also found evidence she had been beaten.

The body of 33-year-old Roxsana Hernandez Rodriguez, who was HIV positive when taken into ICE custody, showed deep bruising on the left and right sides of her chest that was not evident externally, according to the independent autopsy conducted on behalf of her family.

The autopsy also found deep contusions on the left and right sides of her upper back.

The "blunt force trauma of lateral thoracic walls and posterior thorax (are) indicative of blows, and/or kicks, and possible strikes with blunt object," according to the autopsy report.

The independent autopsy also found "extensive deep hemorrhages" on the right and left wrists and hands "typical of handcuff injuries."

The independent autopsy was conducted on behalf of members of Hernandez's family. It was released this week as part of a wrongful death notice claim filed Monday with the New Mexico Attorney General's Office by the Transgender Law Center and Andrew Free, a civil rights attorney in Nashville who is representing Hernandez's family.

Free, the attorney representing Hernandez's family, told The Arizona Republic he believes the injuries found on Hernandez's body by the independent autopsy happened while Hernandez was in ICE custody because the injuries were relatively recent.

Hernandez presented herself to U.S. border officers at the San Ysidro port of entry near San Diego on May 9 and died on May 25, Free said.

What's more, while traveling with the migrant caravan, Hernandez was surrounded by other migrants, many of whom were interviewed as part of a wrongful death claim investigation.

"None of those people reported any physical abuse that would have been indicated by the pathology having occurred in Mexico or prior to crossing," Free said.

He said there are no allegations of physical abuse while Hernandez was hospitalized. In addition, the autopsy also found no signs of "defensive" wounds or bruises typically caused by "putting your hands up" indicating Hernandez was beaten while handcuffed, he said.

"Piecing together the timeline and dating the injuries based on the pathology, it seems that the injuries (happened) when she was handcuffed and in custody," Free said, though he acknowledged "there is not 100 percent certainty."

ICE spokeswoman Leticia Zamarripa said in a written statement any allegations that Hernandez was abused while in ICE custody are false.

Hernandez was part of the caravan of migrants from Honduras and Central America that arrived in Tijuana in April after leaving Tapachula in southern Mexico in March. That caravan preceded the much larger migrant caravan that has arrived in Tijuana over the last two weeks.

The independent autopsy was conducted after an official autopsy conducted as part of a death investigation by the New Mexico Office of the Medical Investigator.

The death investigation has not yet been completed and the autopsy results have not yet been released, said Alex Sanchez, a spokeswoman for the University of New Mexico Health Science Center, which oversees the medical investigator's office. 

The independent autopsy was conducted on June 8 by Dr. Kris Sperry, an independent pathologist in Peachtree City, Georgia.

Sperry was Georgia's chief medical examiner from 1997 until he abruptly retired in 2015 after the Atlanta Journal-Constitution published an investigation. The investigation reported Sperry moonlighted as a paid forensic expert in over 500 cases while employed as the state's chief medical examiner.

Sperry did not respond to an email request for comment. 

Hernandez entered ICE custody on May 13 and was transferred to the Cibola County Correctional Center, ICE officials said.

She was admitted on May 17 to the Cibola General Hospital with symptoms of pneumonia, dehydration and complications associated with untreated HIV. Later in the day, she was transferred via air ambulance to Lovelace Medical Center, where she remained in the intensive care unit until she died, ICE officials said. Staff at Lovelace Medical Center identified the preliminary cause of death as cardiac arrest, ICE officials said. 

"A review of Hernandez's death conducted by ICE Health Service Corps medical professionals confirmed that she suffered from a history of untreated HIV," Zamarripa said. "At no time did the medical personnel treating Ms. Hernandez at Cibola General Hospital or Lovelace Medical Center raise any issues of suspected physical abuse."

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