Closing the Gap in Transgender Care

The health care system is beginning to respond to the challenges transgender men and women face in getting the care they need.

Word spread quickly among transgender members of a support group in Tulsa, Oklahoma, when a popular clinic closed and was replaced by one they didn’t view as trans-friendly. It was another blow to a population of people who already struggled to find providers trained to address their unique medical needs.

“There were times during my transition that I didn’t want to go out or want people to know — a time where I never would have wanted to go to the doctor,” says Jonathan Stenquist, a member of the group. “We are just not treated the same.”

This experience is not uncommon, according to a recent poll conducted for the Harvard T.H. Chan School of Public Health, the Robert Wood Johnson Foundation and National Public Radio.

One in 10 of the transgender respondents said they’d experienced discrimination because of their gender identity when going to a doctor or clinic, according to the poll. One in five said they had avoided seeking medical care because they feared being discriminated against. Nearly a third said they don’t have a regular medical provider.

About 1.4 million people in the U.S. identify as transgender, according to the Williams Institute at UCLA School of Law. But the health care system in many ways is just beginning to grapple with the specific needs of the trans community.

Transgender men and women face a variety of challenges in getting access to the care they need. In addition to discrimination, they encounter a system in many ways tethered to the gender they were assigned at birth, leading to awkward and demeaning encounters that make them less likely to seek care at all.

They also have significant needs for medical and behavioral health care beyond the hormone therapy and procedures related to transition. They’re frequently victims of violence and are disproportionately likely to suffer from depression and HIV.

Barriers to care

Medical care for transgender patients may be compromised simply because medical records and coding systems are not designed to accommodate transgender patients. If a transgender male gets a hysterectomy or a cervical exam, for example, it may look like fraud on insurance claims.

This type of confusion is common, says Leslie McMurray, a Lesbian, Gay, Bisexual, Transgender or Queer/Questioning (LGBTQ) activist and an insurance assistance coordinator at the Resource Center in Dallas. A transgender man, for example, had trouble getting treated for a form of breast cancer that doesn’t affect men. He considered switching the gender on his ID back to female, McMurray says, just to get the care he needed.

A transgender woman, McMurray says, told her she was taken for emergency care to a hospital where she’d been a patient before as a man. The hospital staff pulled up her records and gave her an ID bracelet with her previous name and gender instead of what was on her driver’s license, causing confusion and distracting from her care throughout the visit.

McMurray, who has been a guest lecturer at UT Southwestern Medical School, says one of the biggest problems for transgender patients is that clinicians generally haven’t been trained to understand them and their medical needs.

That may be starting to change. In 2014, the Association of American Medical Colleges published a report to help implement curriculum and institutional changes to improve health care for individuals who are LGBTQ, gender nonconforming, or born with a difference of sexual development. The World Professional Association for Transgender Health provides clinical guidance to help health professionals deliver appropriate care for transgender and gender nonconforming people.

GLMA: Health Professionals Advancing LGBT Equality, maintains a directory of primary care physicians, specialists, therapists, dentists and other providers. This year Blue Cross and Blue Shield Plans in Illinois, Montana, New Mexico, Oklahoma and Texas added a link to the directory on their websites.

In 2016 the U.S. Department of Health and Human Services determined that the Affordable Care Act prohibits health insurers from limiting coverage of sex-specific preventive services, such as mammograms, based on sex assigned at birth, gender identity or recorded gender. (This year the agency signaled it may modify that position, citing a court ruling in Texas.)

Many employer’s health plans still exclude some transition-related services, but the advocacy group Human Rights Campaign has compiled a growing list of companies that offer at least one transgender-inclusive plan.

Data-driven solutions

Still, as health care providers and insurers attempt to improve access to quality care for the transgender population, the dearth of data on their access to care and health outcomes is a significant hurdle.

In California, the UCLA Center for Health Policy Research recently added questions about gender identity to its annual California Health Interview Survey, noting that knowledge about the health and experiences of the transgender population is limited by a lack of systematically collected data.

The first results, published in October 2017, suggest California’s transgender adults have similar rates of health insurance as the rest of the state’s population but are three times as likely to delay or not get prescribed medication. One in five have attempted suicide, according to the survey, which is nearly six times the rate of other Californians.

Dr. Derek Robinson, vice president of quality and accreditation for the Blue Cross and Blue Shield Plans in Illinois, Montana, New Mexico, Oklahoma and Texas, said the company is making it possible to collect data that will help LGBTQ members receive quality care.

[Related: Why Equal Care May Yield Lower Costs]

Robinson leads the insurer’s Health Equity Steering Committee, which recently partnered with the company’s Pride Alliance business resource group to identify opportunities to improve health equity for the LGBTQ community.

“In the past, we haven’t had the ability to identify variations in care and health outcomes across diverse sub-populations,” says Robinson, “We are working together to be more effective in addressing the needs of our members and employees, empowered with data.”

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