Dear World Health Organization,

Let me state at the outset that, as an American who values public health, human rights and international cooperation, I appreciate what you do.

I’m thankful that the United States remains a member of your organisation despite our previous president’s puerile decision to initiate withdrawal, which President Biden, sensibly, reversed. I also endorse the vision you’ve laid out in your 2013–30 Comprehensive Mental Health Action Plan.

But, as a transgender woman in a country where access to mental health specialists is often a luxury, and prejudice against people like me is on the rise, I find it hard to be optimistic about the US’s prospects for progress – because of influential right-wing opposition to LGBTQ equality and a systemic crisis in the affordability and accessibility of healthcare.

While the frenzied imaginations of anti-trans bigots conjure visions of mad doctors chasing down young people to hand out puberty blockers and hormones, like candy on Halloween, in reality, access to gender-confirming medical care is difficult to obtain. And not only for minors.

Naming and raising awareness about critical problems is the first step towards finding a solution. So, on this World Mental Health Day (10 October), I want to talk to you about not only the current mental health crisis, but also some of the trans community’s particular needs and concerns in this area.

Let me tell you a story. A cisgender friend of mine has a much younger transgender relative who was recently hospitalised because of a mental health emergency. She flew to visit him in another state and found him in surprisingly good spirits. “I got a diagnosis of gender dysphoria!” he exclaimed. “Do you know how hard that is to get?”

While being transgender is, thankfully, no longer considered a mental illness by the medical establishment, gender dysphoria is a condition listed in the DSM-5 – the main diagnostic manual used by American psychologists. It is defined as “psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity”.

This is important because even in relatively trans-friendly states in the US, a diagnosis of gender dysphoria can be life-saving for trans people – because it is needed to access gender-confirming surgeries. Mental health professionals play a key gatekeeping role for those undergoing transition. (Whether insurance will cover the surgeries is another question entirely.)

Things are generally worse in states run by Republican governments, which are increasingly enshrining open hostility to trans people in the law. By contrast, in solidly Democratic states, access to hormone replacement therapy is often significantly easier to get than it is, for example, in the UK, and it is also usually far easier to change one’s name and gender on legal documents.

Because trans people experience marginalisation and stigma, we also have higher rates of mental illness and suicide than the general population. The COVID-19 pandemic and its stresses have exacerbated these issues, as has an ongoing affordability crisis in mental healthcare.

Finding a therapist can be a difficult and demoralising process, particularly for those who are already suffering from depression. I know this from personal experience. I have repeatedly been shut down or ghosted by care providers, both in my search for a regular, long-term therapist, and even when trying to book a single appointment for the evaluation necessary to get that coveted diagnosis of gender dysphoria – without which I cannot even schedule a consultation with a surgeon.

Medical doctors Susan Hata and Thalia Krakower recently made an impassioned call for the American Medical Association to declare a national mental health emergency, citing systemic issues that push “many mental health providers to choose private practices, where high fees put services out of reach for many”. They describe how US patients must often “hunt, one phone call at a time, for an available, affordable provider who calls back – a process known to be rife with racial and class bias”.

These problems affect many people. Hata and Krakower cite a nationwide US study showing that “55% of participants contacted a psychiatrist only to learn the doctor was not accepting new patients, and 33% could not find a single mental health provider who accepted their insurance.”

I appreciate that the WHO’s action plan for mental health highlights the LGBTQ community, among other marginalised groups, whose needs should be addressed by community-based services. And even as many of us continue to fall through the cracks, I’m aware that there are numerous community organisations whose heroic staff and volunteers are doing life-saving work locally throughout the US.

Going forward, I hope the WHO will focus more on healthcare access for both the transgender and broader LGBTQ communities – access that in the US is threatened by systemic issues in how care is provided, as well as by the right-wing pursuit of religious exemptions that amount to discrimination by conservative Christians against trans and queer people.

Sincerely,

Chrissy Stroop