Author’s Note: The author is a cisgender person with very limited personal experience on the topic of transgender health. She wished to write on the topic because she believed it was one of importance, and intended to approach it in a sensitive manner. If any of the concepts, arguments, terminologies, etc. are perceived as insensitive or upsetting, she is very open to hearing how she could make amendments atmadeline_noh@brown.edu.

Chest binding is a practice performed by an array of individuals — from primarily trans men to butch women and androgynous or gender non-conforming individuals — to suppress breasts and create the appearance of a more “masculine” chest. For transgender men and those who cannot afford gender reconstructive top surgery, or who simply do not wish to undergo this procedure, chest binders are often used to reduce gender dysphoria, defined as “a condition where a person experiences discomfort or distress because there’s a mismatch between their biological sex and gender identity.” Binders range from commercial binders to alternatives such as duct tape, Ace bandages, or sports bras. While chest binders have a large number of mental and emotional health benefits such as reduced gender dysphoria, many who bind suffer from physical pains. There lacks robust medical research and knowledge of safe chest binding, as well as safe and affordable binders. Inattention devoted to the niche public health issue reflects a broader lack of political agency of transgender individuals in society, in addition to poor healthcare infrastructures for this community. More efforts should be made towards the research and production of safe and accessible binders, and transgender health in general.

Chest binding has been touted by many as a means of achieving harmony between mind, identity, and the physical body. A study, “Health impact of chest binding among transgender adults: a community-engaged, cross-sectional study”, conducted by The Binding Health Project of Boston University in An International Journal for Research, Intervention and Care, found that “self-reported mental health effects were almost universally positive, with qualitative data indicating decreases in suicidality, anxiety and dysphoria and increased self-esteem, confidence and ability to go out safely in public”. In fact, the participants described “positive” and “very positive” mood increases from 7.5% to 69.9% before and after binding.

Despite producing such positive psychological outcomes, binding can have severe physical effects. The same study found that 97.2% noted at least one negative health effect. These included back pain (53.8%), overheating (53.5%), chest pain (48.8%), shortness of breath (46.6%), and a slew of other pains including rib fractures and swelling. Commercial binders, compared to other methods of binding such as bandages, were found to produce the worst physical health outcomes because they have the ability to compress the most strongly. Yet, commercial binders are actually the most commonly used method of binding, with 87.2% of participants reporting that they used a commercial binder. High rates of commercial binder usage, despite their negative health effects, are indicative of an oncoming public health concern. Health issues related to queer individuals have often been overlooked and the concerns surrounding the lack of safe binding methods will only serve to exacerbate the issue.

"Inattention devoted to the niche public health issue reflects a broader lack of political agency of transgender individuals in society, in addition to poor healthcare infrastructures for this community."

Medical providers and legislators have long been criticized for inattention towards health issues specifically affecting the transgender community. For example, 80% of gynecologists and 81% of endocrinologists — doctors which would be the closest things to specialists on the topic of sex hormones prescription and monitoring — are untrained on transgender health. In January 2018, Trump’s administration pushed to allow medical professionals and organizations to deny healthcare services to transgender or gender non conforming individuals on the basis of religion. In October 2018, much controversy was incited when Trump’s administration urged federal agencies to adopt a definition of gender as defined “on a biological basis that is clear, grounded in science, objective and administrable,” asserting that gender should only be defined by the “immutable biological traits identifiable by or before birth” — in other words, genitalia at birth. Adopting such a definition would render the identity of 1.4 million transgender Americans invisible.

Furthermore, 31% of transgender Americans do not have regular access to healthcare, compared to an estimated 8.8% of uninsured Americans nationwide. According to an NPR poll, “22 percent of transgender people said they’d avoided doctors or healthcare for fear of being discriminated against”. Research asserts that 19% of transgender individuals have been denied care due to their gender identity.

In recent years, notably under Obama’s administration, some progress was made in passing legislation to improve transgender healthcare. The Affordable Care Act and the Patient’s Bill of Rights instituted policies which supported healthcare insurance for transgender people, eliminated coverage denials based on pre-existing conditions, and made plan cancellations illegal. Obama’s Section 1557 of the ACA prohibited discrimination by healthcare entities against patients on the basis of sex, which included gender identity. While such measures attempted to make discrimination on the basis of gender identity illegal, they did not proceed without opposition. Some private insurers have consistently refused to cover transgender health-related procedures based on arguments that such procedures are not included under the Essential Health Benefits, a list of services that the ACA mandates that insurers must cover. Additionally, 10 states’ Medicaid policies exclude healthcare related to gender transition.

Yet, there remains hope. “The tides are turning: more and more insurance companies in the United States are accepting the medical necessity of Gender Reassignment Surgeries (GRS) and are covering FTM chest surgery. The medical necessity of GRS has been affirmed by the American Medical Association, American Psychiatric Association, and World Professional Organization for Transgender Health, as well as insurance companies such as Aetna.” The ACA was considered a significant step towards fairness and justice for transgender health.

However, despite some legislative success, it is important to zoom in on specific aspects of the issue. The issue of chest binding is one case study which illustrates how niche overlooked issues exist despite certain political advancements. The potential negative health outcomes and lack of research associated with chest binding parallel lack of political acceptance and recognition — as is the case in countless other examples such as health disparities in women, POCs, and lower socioeconomic classes. Inattention towards chest binding is poignant, an issue which is niche, but almost like a microcosm of larger injustices reflected in society.

Thus, a call to action is important, on the issue of chest binders specifically and broader transgender health. Production and design of commercial binders should be more regulated since their negative health effects have been researched and documented. There should be more safe and affordable binders produced. Additional research should be done in this field. The Binding Health Project was the first study of its kind and called a “long overdue study” by Vice. It claimed to be the first study on chest binding ever published in a medical journal. Medical providers should become more aware of the issue to be better equipped to advise patients. “Off days” may be quite suitable and beneficial for some, as binding every day has been associated with negative effects. “Providers should counsel patients on how to prevent specific symptoms that this study found were common, such as practising good skin hygiene to avoid skin issues and treat symptoms as they arise.” Additionally, for those interested in top surgery, medical providers should be better equipped to connect their patients with resources and referrals.

“Many trans and gender non-conforming individuals say that they would continue binding regardless of the physical health risks. The psychological relief provided by binding — as well as the increased ability to pass in public as one’s correct gender — often overweighs any potential downside”. Desires to bind for those suffering from gender dysphoria can be immensely strong, as its positive psychological effects are remarkable. If this is the case, then medical infrastructures in society as they relate to research, care, insurance, and quality of binders, must improve in order to best accommodate the needs and desires of those who find benefit in binding. Increasing awareness and empathy towards issues like these will help improve the broader situation of transgender health concerns.

Photo: “2018.06.09 Capital Pride Parade, Washington, DC USA 03173”