AMA Journal of Ethics^®

It is recognized that members of the transgender community suffer from disparities in health care [1]. Although lack of access to appropriate care (due to lack of clinicians knowledgeable about transgender patients’ specific needs and vulnerabilities) is the biggest barrier, other barriers include financial and socioeconomic obstacles, physicians’ lack of awareness or education about physicians’ roles in transgender health care, and discrimination [1]. The AMA Code of Medical Ethics is far from silent on matters of discrimination and disparities in health care.

Ensuring Basic Rights

Opinion 11.1.1, “Defining Basic Health Care” [2], does just that. The opinion recognizes health care as a fundamental human good, and acknowledges that “physicians regularly confront the effects of lack of access to adequate care and have a corresponding responsibility to contribute their expertise to societal decisions about what health care services should be included in a minimum package of care for all.” Opinion 8.5, “Disparities in Health Care,” recognizes that physicians’ attitudes can exacerbate variations in patients’ access to health care services or the quality of health care patients receive.

Stereotypes, prejudice, or bias based on gender expectations and other arbitrary evaluations of any individual can manifest in a variety of subtle ways. Differences in treatment that are not directly related to differences in individual patients’ clinical needs or preferences constitute inappropriate variations in health care. Such variations may contribute to health outcomes that are considerably worse in members of some populations than those of members of majority populations [3].

The opinion calls on physicians to examine their own practices to ensure that stereotypes and biases against patients’ traits (including gender identity) do not affect their clinical judgment or affective demeanor toward patients.

Physicians’ Choices and their Limits

Opinion 1.1.2, “Prospective Patients” [4], explains that while physicians may choose their patients in nonemergency settings, they may not discriminate against a patient on the basis of gender identity, sexual orientation, or other nonclinical characteristics. Opinion 1.1.7, “Physician Exercise of Conscience” [5], explains that while there is some leniency regarding practices that contradict physicians’ “well-considered, deeply held beliefs that are central to their self-identities,” this latitude is not unlimited. Physicians still must “respect basic civil liberties and not discriminate against individuals in deciding whether to enter into a professional relationship with a new patient” and “take care that their actions do not discriminate against or unduly burden individual patients or populations of patients and do not adversely affect patient or public trust.” This sentiment is echoed in discussions of reproductive medicine. Opinion 4.2.1, “Assisted Reproductive Technology” [6], is particularly relevant; it notes that physicians who offer these services should “not discriminate against patients … on the basis of race, socioeconomic status, or sexual orientation or gender identity.”

Protecting Patients

Physicians’ obligations are not limited to an injunction against discrimination on the basis of gender identity or other nonclinical criteria. They also have responsibilities to protect their transgender patients as they would any other patient. Examples of opinions in the Code that address common patient protections include Opinion 3.2.2, “Confidentiality Post Mortem” [7], which states that “patients are entitled to the same respect for the confidentiality of their personal information after death as they were in life,” and Opinion 4.1.3, “Third-Party Access to Genetic Information” [8], which explains that “patients who undergo genetic testing have a right to have their information kept in confidence.” Importantly, Opinion 8.10, “Preventing, Identifying and Treating Violence and Abuse” [9], is pertinent for physicians who care for lesbian, gay, bisexual, and transgender (LGBT) patients, who are among the most likely targets of hate crimes [10]. Violence is widely regarded as a public health issue [11], and violent hate crimes certainly fall under that rubric. A critical part of the American Medical Association mission is dedication to the betterment of public health [12]. This opinion comprehensively outlines what physicians should do to recognize signs of abuse and protect a patient’s well-being.

All opinions referenced in this article can be found here.