Have we reached the LGBTQ healthcare trust thermocline?

What is the trust thermocline?

In the ocean, the temperature drops slowly as you go deeper—until the thermocline. Suddenly, the water is very, very cold.

The trust thermocline was coined by Gareth Edwards in 2022, to describe the manner in which businesses, particularly digital services businesses, suddenly lose consumer trust and collapse.

According to Edwards, we could consider, for example, the implosion of Twitter after the Musk acquisition. Or—remember Evernote? Once a leader in the note-taking and productivity space, they made a series of poor decisions that undermined user confidence. Even after the decisions were reversed, Evernote never recovered.

These collapses happen because trust can be a communal asset, not just an individual one. Edwards writes, “A multitude of micro-infractions for consumers don’t just harm an individual’s experience; they damage that trust commons until the trust thermocline is breached for large groups of users at the same time.“

Businesses often see customer experience as a linear system. In a linear system, causes quickly lead to effects, which means that businesses assume that if they were on the verge of a trust implosion, they’d see it in their metrics and reverse course in time.

Not so, says Edwards. The trust thermocline is nonlinear. Many of the reasons a consumer may cross the trust thermocline may have happened well into the past. A consumer may also continue in the product relationship for a while after a breach of trust, either due to an element of the previous emotional commitment, or due to perceived challenges with switching. But once they cross the thermocline, there are few routes for a business to regain that trust.

We are at a trust thermocline moment for LGBTQ healthcare

Over the past few months, we have seen numerous healthcare programs serving trans youth close their doors. Many of these programs had worked closely with trans youth and their families for years, and families were left scrambling for care.

This is no longer about individual young people and their families. This is about trust in healthcare institutions being breached simultaneously for an entire generation of LGBTQ young people, and for many adults as well.

The full effects of this breach of trust may not be seen for years.

People may not immediately leave these institutions en masse — but they’ll remember this moment when it comes time to find a new doctor. They may look to smaller practices, LGBTQ-specific telehealth services, or seek more care from a community-based healer or alternative medicine provider.

Medical trainees won’t leave their current training programs, but tomorrow’s med students will keep this in mind when applying to training programs. We’ve already seen the changes in residency application trends after the Dobbs decision, with substantial reductions in applications to residencies in states where abortion is illegal. These changes weren’t limited to ob/gyn residents either — shifts were seen in emergency medicine, internal medicine, family medicine, and even pediatrics.

Meanwhile, there are more options than ever.

LGBTQ-affirming telehealth platforms like Folx, Plume, and Carrot have raised a combined total of over $210 million in venture capital. Folx now accepts several major insurance plans.

Community acupuncture clinics — where people can access acupuncture and sometimes other wellness services on a sliding scale or at low cost — have exploded over the past two decades. These are often places where queer and trans people can come to care for their health needs outside of an institutional medical environment.

And finally, historian Jules Gill-Peterson has been working to surface the invisible histories of DIY gender transition, which have existed far longer than you might think.

Those who know trans history know that this isn’t the first time the institutional gender clinics closed. Many gender clinics opened at major academic medical centers in the 1960s, only to close by the 1980s, due to political pressure and, yes, a challenging regulatory environment.

But trans people have always found ways to share information and to take care of each other.

Where do we go from here?

We still need to fight to reopen or replace these services, and to expand access to LGBTQ-affirming healthcare wherever possible.

But the center of gravity has shifted now.

Community trust is more important than ever — and for providers working in institutions that have recently turned their backs on trans youth, or institutions with a similar profile — it will be harder and harder to build.

Harder, not impossible.

If LGBTQ people are increasingly turning to telehealth apps and alternative medicine — and the numbers show us they are — then those of us who care about LGBTQ health need to be building warm-handoff referral networks with these providers, so that those who need a different level of care can be referred safely and with trust.

If LGBTQ people are turning to underground sources for their hormone therapy, we need to stop telling them not to do that. They may be making the overall safest decision for themselves. We — mainstream institutional providers — had our chance to build dependable, welcoming systems for providing hormone therapy, and, collectively, overall, we failed. Forty-eight percent of people in the 2022 US Trans Survey who saw a doctor in the past year reported a negative experience in a healthcare setting. This is actually an increase from the last time data was collected in 2015.

Those of us who work with major medical centers in any capacity need to assume that we are no longer trusted by our patients and communities. Regardless of our intentions, our identities, or our extensive personal and professional efforts — our institutions have shown our patients that they need to be wary. We need to accept what this means — our patients may not come to us anymore, they might not be fully truthful with us, they might take out on us their grief and rage at being a trans person in this country right now. Given the massive breach of trust by major medical institutions, these attitudes seem appropriate.

Community takes care of community.

As Joan Westenberg wrote earlier this month, in the context of online communities, “communities are not fungible.”

At this moment, the relationship between any institutional healthcare provider and its local LGBTQ communities has shifted. We can meet that shift—we can even work together to create new futures of LGBTQ health and community collaborations — but first we need to acknowledge it.