Social Determinants of (un)Health for Transgender People: Ohio

Summary of Social Determinants – People who are Transgender, Courtesy @BrynnTannehill – click to enlarge

The suicide of Leelah Alcorn  raised a lot of questions for me about the community conditions that could contribute to an environment that’s hostile to a young person who is transgender. I reached out to expert Brynn Tannehill  (@BrynnTannehill) who lives in Ohio, for a breakdown of the policies in that state.

I really am just learning about the impact of these, and I hope to learn more as #KPLantern starts (posting about that next…)

Here is a list she shared with me, I am quoting the items verbatim for completeness, with the exception of a few in the interest of focus on health and being non-partisan:

  • Governor is hostile to trans community. One of his first acts in office was to repeal gender identity protections for state workers.
  • Lieutenant governor is also responsible for deciding what is covered under state ACA policies.
  • Ohio is one of a small number of states (Tennessee, Idaho, and Texas being the others) where changing your birth certificate is more or less impossible. The reason is a marriage case in 1987 involving a transgender man trying to marry a woman. Case is called In re Ladrach. I will forward you the decision. It would be laughable, except for the fact that legally its unassailable.
  • Ohio has no hate crimes law covering gender identity
  • Ohio leads the nation in murdered transwomen for 2013
  • Ohio is the location of the recent Leelah Alcorn suicide. What her parents did is not considered abuse.
  • Reparative therapy on minors is legal.
  • No employment, housing, lending, or public accommodations for LGBT people in Ohio.
  • Ohio is likely to be among the last states to have marriage equality. Indeed, the 6th Circuit ruling could roll it back across the country with an unfavorable Supreme Court decision in June. (thanks, Ohio!)
  • The lone bright spot for trans people in Ohio is driver’s licenses. Ohio has a very favorable policy there, which does not require surgery for a gender marker change.

Brynn provided me the text of the Ladrach case, where it states “in the contemplation of Ohio jursiprudence, one’s gender at birth is one’s gender throughout life.” Further, there is reliance on case law originating deep in the 20th Century (1966), in other words, as modern as the era before CT scanners (and as correct as diagnosing a brain hemorrhage with an ankle x-ray).

This environment could not be any more opposite than Washington, DC. So much so that I cannot even imagine it, and yet so patiently explained to me by Brynn.

This of course saddens me. I shared elements of this list with a new mentor to me, Garrett G, who said that there are things, damage, that don’t appear as quickly as a suicide, created by policies that actively work against human beings who happen to be trans. He’s right.

I can imagine a 21st century therapist/nurse/physician, equipped with the knowledge and compassion to provide medically necessary care that (a) we know works (b) prevents suicide (c) costs less to society than not providing care, but unable to save a life because they are thwarted by an environment like this.

Brynn furnished me the diagram above which shows how this comes together.

The additional sadness for the people of Ohio is that these non-science-based policies cost a lot more money/time/lives than providing the evidence-based medical care. The data has clearly shown it. And what’s the future value of a 17 year old’s productivity and membership in a community, almost unmeasurable.

The good news is that we do have the science and knowledge that medically supervised care reverses all of this, creates more exemplars in society, which ultimately creates a healthy environment because more people get to know people who are trans*. See this blog post for a summary.

Based on policies that are changing or have already changed in places like Washington, DC (see: Photo Friday: The end of discrimination in health care for people who are transgender, Washington, DC USA | Ted Eytan, MD), it’s inevitable.

This is a great platform for what I have said many times, which is that none of us went into medicine to support discrimination, and fortunately we don’t have to. Our generation has the power to change everything. Come join us 🙂

(Title updated in response to feedback – thank you!)


Ted, thanks for this. As usual, you’ve distilled an issue down. One thing missing though – where is the discussion of the religious element here? Without the intense religiosity of the parents and the community, Leelah, might still be alive. Yes, all the other determinants would likely still be in place, but the profound impact of the negative response from the parents, their church community and the wider religious community in place cannot be understated. Of course, not calling the parents’ actions abuse is legally and morally reprehensible, but the fact remains that is true in most states where ‘religious freedom’ trumps medical necessity. My concern is that children brought up in these intensely conservative religions are (anecdotally, at least) much more likely to be kicked out, run away, or find some other form of escape from persecution – including suicidal ideation and completion. Along with all the information included in the lovely visual, we must find a way to address the religiously based abusive behaviors – (to separate them from some broken sense of separations of church and state) – and keep them from happening to our most vulnerable populations. Until we do, we might stem the tide of tragedy, but we will not conquer it.


Clearly there are more social determinants than I have listed. I changed the title of the post to support dialogue and learning. Thanks for your investment in time and thought,


As always, Ted, I am grateful for your willingness to look beyond … what you know, to all that we need to know. Thank you. For everything.

Ted Eytan, MD