An excerpt from Pandemics, Poverty, and Politics: Decoding the Social and Political Drivers of Pandemics from Plague to COVID-19.

Many transgender (TG) people live with the constant threat of violence. International research documented a total of over 2,000 murders of TG humans between January 2008 and April 2016.43 (These findings are likely greatly underreported.) Even more widespread is nonlethal violence against TG communities. A national U.S. study indicated that 35 percent of TG/nonbinary (NB) youths between the ages of 5 and 18 (roughly) fell victim to physical violence and 12 percent to sexual violence. In the same study, 6–7 percent had been either physically or sexually assaulted at work.

The sum total of this violence and discrimination naturally affects behavioral health. Of the participants in the U.S. study noted above, 41 percent reported attempting suicide (compared with 1.6 percent of the general population). In addition, a national Australian study found that over 50 percent and 38 percent of TG humans had been diagnosed with depression and anxiety, respectively, at some point in their lives, which is four times the rate for the general population. Even worse, TG/NB youths are disproportionately burdened by poor mental health outcomes. These disparities are likely due to high levels of social rejection during the formative development years, such as a lack of support from parents and bullying.

Outside of poor mental health and SUD outcomes, multiple factors stemming from stigma and discrimination likely also contribute to high rates of infectious disease—namely HIV. In a large multinational study, the overall standardized HIV prevalence was nearly 20.0 percent and 2.56 percent for TG women and men, respectively. Just to add more clarity, TG women’s odds of being infected with HIV were a staggering 66 times higher compared with rates in the general population (the rate was 6.8 times higher for TG men). Breaking this down regionally is also helpful to allow us to better contextualize how risk translates for TG communities. In sub-Saharan Africa, the infection rate odds were 30 percent for a sample of 1,192 individuals, which was 21.5 times higher than for the general population. In Latin America the prevalence was 25.9 percent, which was 95.6 times higher than for the general population. In Asia the prevalence was 13.5 percent, which was 68 times higher than for the general population. Last, Australia, Europe, and North America demonstrated a prevalence of 17.1 percent with an odds ratio of 48.4 (compared to the general population). Hopefully, these stark comparisons can begin to tell a story. I have a few.

While finishing up my residency training, I was moonlighting as an HIV doctor in Buffalo, New York. I was so excited to complete my seemingly endless training (17 years in total) and be “unleashed” on the medical world to make my own autonomous clinical decisions. A few months in, my boss, the medical director, dropped a manual on my desk and sternly asked me to learn it by the next day. The manual was on gender-affirming care for TG communities. I was shocked. Was he serious? I wasn’t trained for this. No one really was at the time. So I did what I was told, as any upstanding medical resident would, and spent several hours assimilating this information. I was about to have the health of a human being transferred into my care with a “disease” I was completely unfamiliar with yet stood the chance to learn so much and help this person. Learn, I did.

This physician-patient relationship became one of my most memorable. The TG female (or male/female) patient ended up becoming one of my favorites, and I devoured anything I could on the subject. She was trying hormone therapy for the first time (surgeries were far from being approved by major insurance payers at the time), and I was helping her navigate the complexities of transition within the social milieu that she lived in. While my understanding was still nascent in this space, I did know a fair bit about generally counseling patients about socially driven grief and anxiety. As it turns out, there were few differences between the two, and even the notion that she suffered from a “dis-ease” (often classified as gender identity disorder so that insurance companies would pay for the encounter) was wrong. This ultimately became a highly contentious discussion throughout the nation.

Another remarkable patient who came under my care years later in East Hollywood was a TG person with some of the most complex health issues I had ever seen in an outpatient clinic. In addition to having HIV (well controlled), she was schizophrenic, diabetic, and deaf, with recurrent STIs, hepatitis C, meth use, and end-stage renal disease, on dialysis, and to top it all off, she was homeless. She also had one of the most challenging “no show” rates (for many of the reasons noted above) and likely could have made more effective choices, but we knew that if we could help her with housing, stability would follow. We were right.

We were able to get her a single-room occupancy unit (with a common bathroom), and after a few months, she was adherent with her insulin, on hepatitis C medication, and quickly en route to a cure, as treatment nowadays can take place as early as two months. One day when I went to visit her at her apartment, one of the case managers told me that she was generally doing well but that he was frustrated because she consistently defecated in the corner of her room. I couldn’t help but chuckle and simply assured the case manager that this was yet another scenario where we must not impose our standards on certain communities who live differently and simply “meet them where they’re at.” The problem is that most of the health care world does not see it that clearly.

Tyler B. Evans is an infectious disease physician and author of Pandemics, Poverty, and Politics: Decoding the Social and Political Drivers of Pandemics from Plague to COVID-19.