Structural Violence in Transgender Health: Perspectives From Medical Students in the South

In health care, structural violence has remained hidden, yet it profoundly influences the experiences of both patients and practitioners. Structural violence refers to the systemic ways that social structures, whether economic, political, legal, religious, or cultural, cause preventable harm to individuals or groups.1,2 In medicine, structural violence is evident in discriminatory policies, biased educational practices, and health care inequities.1,3 While structural racism refers to systemic policies that create and maintain racial inequalities and is a form of structural violence, structural violence refers to the broader social structures that perpetuate harm and prevent individuals from accessing basic resources and opportunities. Vulnerable populations, including transgender individuals, are particularly at risk for structural violence, and this violence plays out in communities, schools, and hospital care.Structural violence is increasingly evident in transgender health where restrictive state-level policies force medical practitioners to navigate political constraints, hindering their ability to provide essential services and adequately train the next generation.4–7 Structural violence pervades many areas nationwide; however, as medical students in the South, we are providing insights from a southern perspective. Our journey to becoming healers begins with the Hippocratic Oath, which professes an unwavering commitment to health and compassion and reminds us to “do no harm” above all else. In reality, we grapple with an insidious force that transcends the boundaries of individual attitudes: the structural violence embedded in the fabric of medicine.This perspective highlights the compounding effects of structural violence within transgender health in the South, acknowledging the difficult decisions and dilemmas medical students and practitioners face when practicing and learning in a region that enforces regressive policies. Furthermore, this perspective provides suggestions on how to address structural violence and the potential medical exodus currently happening in the South. While structural violence and a medical exodus in transgender health affects many regions across the country and is certainly not confined to the South, this article specifically examines structural violence in transgender health through the lens of medical students in the South.Structural violence in medicine takes on many forms and evolves over time. Its deep history is rooted in myriad injustices including unequal access to care, exclusion, and erasure that place some individuals or groups at a higher risk of harm while sparing others.3,8,9 Structural violence is invisible because it is embedded in broader social and legal marginalizations, creating conditions in which violence is minimized or even normalized. Although structural violence is invisible, the consequences are visible health disparities.1,3,10,11 The sometimes subtle nature of structural violence can lead practitioners to unintentionally engage in actions that may not completely align with the oath they are committed to uphold to align with the law.For transgender youth, structural violence is palpable in the form of the following: (1) bills that restrict practitioners’ autonomy in delivering evidence-based gender-affirming treatment that result in denial of care; (2) biased attitudes and behaviors; and (3) organizational policies that foster exclusion (eg, misinformation, demolition of diversity, equity, inclusion, belonging initiatives, lack of antidiscriminatory protections, etc).12–15 The gender minority stress model suggests social environments are sources of stress (distal stressors) that disproportionately affect gender minorities.16 Distal stressors significantly impact transgender youth.16–18 The compounding effects of place-based factors and distal stressors contribute to increased risks of mental health struggles, suicide, and physical harm that further contribute to a public health crisis precipitated by structural violence.17–20It is important to understand the correlation between health and place, specifically how social, economic, and political systems shape environments and influence health outcomes.21 The deep South (Mississippi, Alabama, Tennessee, Arkansas, Georgia, Louisiana, and Florida) is one of the areas with a deep history of oppression that continues to be intensified by social conservatism, religion, cultural practices, and political ideologies.22–26 Structural violence affects transgender health through the implementation of regressive policies and discriminatory practices.27–30 The compounding effects of factors rooted in the political landscape and inequitable policies create hostile environments that leave transgender youth especially vulnerable to harm from policies meant to safeguard their health and well-being.As a part of our training, we talked with a mother of transgender son about the legislative wave happening specifically in Tennessee. The mother stated, “If my son was under 18 while these laws were being discussed, we would’ve for sure moved.” She discussed the struggles of finding a pediatrician who provides gender-affirming care and a practitioner to oversee her son’s transition process. The mother described navigating the health and legal system as a “trial and error” process that required traveling several hours to receive care. Throughout the process, both mother and son often experienced disappointment and discrimination. She believed hypervigilance, a supportive community, and particular providers’ understanding of gender-affirming care safeguarded their health and well-being. While anecdotal, this is just one of the many stories about the harmful effects of structural violence.31,32Structural violence continues to be enforced through state and institutional actions that maintain existing power structures and inequities, leaving students, trainees, and practitioners stranded amid political agendas.33 Many practitioners struggle with the ethical dilemma between adhering to sometimes oppressive legislation to protect their licenses and advocating for the well-being of their patients, specifically transgender youth.34 With the emerging threat of legal repercussions, practitioners are confined to practices that erode autonomy, compromising the doctor-patient relationship and infringing on the fundamental right of individuals to access life-saving health care. Structural violence is not limited to policies that result in immediate denial of medical care for transgender individuals, but it also exists throughout medical curricula and education,35–38 influencing the minds of future health practitioners who must contend with their allegiance to their ethical compass in an oppressive legislative framework. This contention stifles the pursuit of knowledge and innovation in transgender health care, leading to a medical exodus of aspiring practitioners.The looming medical exodus in the South and other areas with restrictive policies underscores the devastating consequences of structural violence on vulnerable populations, including transgender youth. The byproducts of restrictive legislative policies and discriminatory practices in clinical and educational settings limit the provision of care and essential medical services. The overturn of Roe v Wade mirrors how structural violence perpetuates harm through the reinforcement of existing inequities. Regardless of political perspective, laws that criminalize abortion blur the lines between politics and medicine, transcending into the physician-patient relationship. In a nationwide poll of obstetricians and gynecologists, most participants believe that the Dobb’s decision has had detrimental impacts on maternal health and patient safety.39,40 Since the Roe v Wade overturn, preliminary data point to many practitioners and trainees leaving and/or avoiding practice in areas with restrictive policies. In a 2022 poll, 82% of medical professionals and trainees reported preferring to work and train in states with preserved abortion access.41 As future practitioners, we are concerned that the new legislation will mirror this exodus. Restrictive policies concerning transgender care leave medical students, trainees, and practitioners with a similar decision: whether to navigate these oppressive environments or seek opportunities elsewhere. The looming medical exodus not only exacerbates the scarcity of competent and compassionate practitioners but also maintains a cycle of inequity for historically disadvantaged communities, notably transgender youth.Structural violence and restrictive policies also significantly impact hospital medicine, specifically for vulnerable populations like transgender individuals. Hospital-based practitioners, who are frontline during acute and chronic health crises, face challenges in delivering comprehensive, gender-affirming, evidence-based care to transgender patients. These policies can lead to delays in care, legal concerns, and a lack of institutional support, all of which compromise patient outcomes. Additionally, the medical exodus may worsen staffing shortages in hospitals, particularly in already underserved areas, leading to longer wait times and reduced access to specialized hospital care. These challenges highlight the broader consequences of structural violence on the entire health care system.The pervasive nature of structural violence in medicine, particularly in the South, has far-reaching consequences. As we grapple with systemic barriers that create fear and legal jeopardy, transgender youth face heightened challenges in accessing affirming care. State legislatures, often under the guise of moral or religious principles, are passing laws that directly impact transgender youth. The intersection of these concerns, compounded by the cultural climate, leaves practitioners, students, and trainees with few options. This legislation is also driving the migration of skilled practitioners, resulting in the draining of intellectual and medical resources from transgender communities. Ultimately, we are asking ourselves, “Should we stay or should we go?”Collectively, we can address structural violence and potentially remedy the medical exodus through various concerted efforts. These efforts include coalition building among practitioners, community members, and advocacy groups to develop and implement top-down, proactive strategies that directly reduce structural violence.5 Education and training should be restructured to include topics on political and structural drivers of health, anti-oppressive practices, and cultural humility that should be taught consistently in medical school and beyond. We suggest allocating sustainable and meaningful resources toward the inclusion, training, and retention of trainees who identify as underrepresented in medicine, gender and sexual minorities, or trainees who have disabilities given the inequities that exist in these populations. Investing in adequate support and resources, including robust training programs for practitioners, may mitigate factors that contribute to the medical exodus thus retaining skilled providers who choose to stay in the South. By providing continuing education, mental health support, and infrastructure improvements, we can cultivate a more sustainable health care system that retains skilled practitioners who choose to remain in communities with more restrictive health care policies. Through collective efforts, we can address structural violence and mitigate the medical exodus, ultimately building a more resilient and equitable health care system.