June 25, 2019

Read Advisory Board's take: 2 imperatives for providers to support transgender patients

Transgender patients "still struggle to find competent basic care, much less trans-specific care," and the Trump administration's recent proposed rule threatens to return the trans community to a health care environment that can deny them care, Katelyn Burns, a freelance journalist who is transgender, writes for Vox.

A prescription pickup that resulted in 'humiliation, anger, and embarrassment'

Burns recalls a time early in her transition when she went to pick up her prescribed hormone replacement therapy at the pharmacy with her two children. At the time, Burns writes her children didn't yet know "the person they thought was their dad was actually a woman."

When she reached the speaker at the drive-thru, the pharmacist said, "Sir, do you understand what these medications are for?" When Burns explained that she understood and said the medication was prescribed to her, the pharmacist stated, "Sir, these are female hormones. For women," Burns writes.

After explaining that she had gender dysphoria, Burns was met with "a long pause on the other end."

The pharmacist then told Burns, "Sir, we canceled your prescription because we couldn't figure out why a man would need female hormones. You'll have to have your doctor call us to confirm this is correct because it doesn't make any sense."

Burns writes that in that moment she felt "[h]umiliation, anger, and embarrassment …  and tears quickly began running down my face."

Overall, the interaction was "a reminder that being trans is still not a comfortable concept in our society," Burns writes.

All too common

Unfortunately, situations like what Burns experienced at the pharmacy are "all too common in the U.S. health care system," she writes.

Weeks ago, the Trump administration announced plans to roll back gender identify nondiscrimination protections in the Affordable Care Act, which protected transgender patients against discrimination, Burns writes. However, even with the protections in place, Burns writes, "discrimination against trans people ran rampant in the health care system."

According to Burns, one-fifth of all transgender patients said they received unequal treatment from clinicians. The inequalities, Burn writes, can stem from a "lack of knowledge on how to address trans people."

For instance, some health systems do not allow patients to use their preferred pronouns or non-legal name at medical facilities. In other cases, doctors' assumptions about transgender patients' bodies can leave transgender patients responsible for explaining to clinicians how they should go about providing them basic care.

Burns recalls one interaction with an urgent care nurse when she sought treatment for a urinary tract infection (UTI), "which I had had before and was familiar with."

The nurse asked her how she could "be sure it's a UTI" and "not vaginal discharge."

"Because I don't have a vagina," Burns responded. Burns recalls that the nurse "grew visibly uncomfortable" upon her response and continued to doubt that Burns had a UTI. The nurse eventually brought in the doctor who Burns writes "began asking me detailed questions about my sex life in front of my children," assuming she had a sexually transmitted infection. "I had to beg the doctor to order tests on my urine sample and prescribe me an antibiotic, which she eventually agreed to," Burns writes.

Transgender patients lack access to care

These experiences caused Burns, who is insured, to question what navigating the health system must "be like for those with even less access to insurance and the health care system at large" she writes.

A 2015 survey from the National Center for Transgender Equality revealed that 13% of transgender people in the United States are uninsured, compared with 10% of the general population. And this number might be grow, Burns writes, as the Trump administration's proposed rule would again allow insurance companies to exclude transition-related coverage on a wide scale.

In addition to barriers to transition care, transgender patients still "face a daunting lack of compassion and knowledge from the wider medical community," according to Burns. For instance, Burns says "trans broken arm syndrome —a phenomenon where every little ailment, from an infection to a broken arm, is blamed on the hormones …  is a common occurrence within the medical community."

And while more medical providers are undergoing training to better treat transgender patients, Burns writes that transgender patients still struggle to find decent basic health care, let alone care that is specific to transgender patients.

"We all have basic health care needs beyond just hormones and surgery. Yet doctors and other health care providers simply don't expect trans bodies in their practices," she writes (Burns, Vox, 6/21).

Advisory Board's take

Sarah Musco, Senior Consultant, Service Line Strategy Advisor and Kaci Brooks , Analyst, Service Line Strategy Advisor

Katelyn's story shows that transgender people often face challenges when interacting with many parts of the U.S. healthcare system—from filling prescriptions to getting routine care. But when hospitals and health systems think about providing gender-affirming services, surgery is often the first (and maybe only) thing that comes to mind.

However, the 2015 U.S. Transgender Survey found that only 25% of respondents had undergone some form of transition-related surgery, either because of health or financial barriers (55% of respondents who sought coverage for transition-related surgery in the past year were denied), or because they don't want to undergo these procedures. Conversely, almost 50% of respondents had received hormone therapy—indicating the prevalence of medical services.

Taken together, these factors clearly point to a need for transgender services beyond just surgery. Here are two ways programs can meet this imperative:

    1. Provide wraparound medical and social services

    The pathway to gender affirmation has been described by many transgender people as a journey, as every experience and choice is different. Not everyone who is transgender desires a full medical transition.

    Comprehensive programs should offer the wraparound services sought out by the transgender community, such as medical services (specifically, hormone and voice therapy), hair removal, and behavioral health consults. These services are often required as pre-requisites for surgery by payers, but also to a degree by surgeons, who must make judgment calls with their multi-disciplinary care teams—and with patients themselves—about the surgical readiness of each patient.

    If you do not offer the medical services necessary in advance of surgery, you must be prepared to refer your patients to an external partner to meet those requirements, such as a clinic for hormone therapy, a behavioral health facility for psychotherapy, or a rehabilitation facility for physical therapy as needed.

    In addition to medical services, all programs should offer social services such as social workers for case management and insurance navigators to help patients move through their chosen care pathway. Comprehensive programs may also help patients join support groups to ensure they have the support they need during their transition, especially post-surgery.

    2. Offer universal cultural competency training on the unique needs of the transgender community

    The same 2015 U.S. Transgender Survey found that 33% of respondents who had seen a health care provider in the past year had at least one negative experience related to being transgender. Because of these damages to patient trust, the onus is on the provider organization to prove that your program is capable of providing care in an affirming and friendly environment.

    To adequately serve this patient population and provide affirming care, leaders must invest in facility-wide education. Not only do the physicians involved need to be educated, but so do all staff who may interact with patients (e.g., nurses, administrative staff). Some programs hire consultants to lead cultural competency trainings, while other organizations use resources from programs like the National LGBT Health Education Center to own training in-house.

    In addition to educating staff, many organizations create connections and partner with local and state LGBTQ+ centers or other community-based organizations to drive volumes and engender trust. These partnerships and connections help reaffirm your organization's commitment to providing affirming and friendly care through your participation in them.

We're currently conducting research on how leading organizations are supporting transgender patients, so stay tuned to learn more. In the meantime, however, view our blog post on how to decide which services to offer in your gender affirmation program. Then, to understand the latest trends in surgical services—and how your organization should respond—download our ready-to-present slides on general surgery market trends.

Download the Slides