When Caitlyn Jenner, formerly known as Bruce Jenner, unveiled her new name and appearance last year, the event shined a light on the transgender community. “Transgender” is a broad term used for people whose gender identity or gender expression differs from their assigned sex at birth. Much about this community, such as its size, remains unclear, yet knowing more about transgender people is important for policy-making in many areas including education, criminal justice, social services, sports, and the military — but particularly in regard to healthcare.
The transgender population, which has long been stigmatized, has also been thought to make up less than 1 percent of the total population. Recently, though, that number has been updated, and some insurance companies now place it as high as 4 percent of their total patient population. This is, indeed, a very large number of patients. However, there has been very little evidence-based research concerning transgender healthcare needs.
According to the Fenway Institute in Boston, the majority of transgender people experience various forms of derision, rejection, and animosity in their lives. As a result of this discrimination, transgender people are much more likely to be the victims of violent crimes, unemployed, maintain a low-income status, and have poor overall health. Furthermore, transgender individuals, particularly transgender youth, are disproportionately represented in the homeless population. Once homeless, they may be denied access to shelters because of their gender identity. Subsequently, many homeless transgender individuals turn to survival sex — the exchange of sex for food, clothing, shelter, or other basic needs — which increases the risk of exposure to sexually transmitted infections. It is, without question, a vicious cycle.
Transgender individuals face many barriers to receiving quality medical care. Too often they will avoid seeing a healthcare provider simply because they fear they will be humiliated, ostracized, or just plain misunderstood. The consequences of inadequate medical treatment are staggering. Fifty-four percent of transgender youth have attempted suicide, and 21 percent resort to self-mutilation. More than 50 percent of persons identifying as transgender have used injected hormones obtained illegally or taken outside of conventional medical settings. Additionally, such individuals frequently resort to the illegal and dangerous use of self-administered silicone injections to spur masculine or feminine physiologic changes. According to Anne Koch, DMD — senior fellow in the Division of LGBT Health at the University of Pennsylvania Health System and a professor of endodontics at the University of Pennsylvania School of Dental Medicine — when you see figures like this, it is immediately apparent that this is a public health issue.
Another barrier to quality healthcare for transgender individuals is the lack of adequate health insurance. Transgender people are still fighting for access to crucial health services despite the Affordable Care Act’s requirement that insurance companies not deny coverage based on gender or health history. While there have been great strides made in insurance coverage, most health insurance plans fail to cover the cost of mental health services, cross-sex hormone therapy, or gender affirmation surgery. The American College of Obstetricians and Gynecologists, therefore, urges public and private health insurance companies to cover the treatment of gender identity disorder. The issue stems from the fact that enrollees must check a single gender box when they sign up for a plan sold on the individual or small group markets. “What happens is that health insurance companies have specific codes, and they put you in as female or male; you only get services that go with that code,” Koch says.
However, someone transitioning from a woman to a man, or vice versa, may still have organs associated with the other gender, such as a uterus and breast tissue for someone born as a woman or a prostate for someone born as a man. As a result, they may still need annual mammograms or pap smears or require treatment for problems typically regarded as gender specific. “The idea that you have insurance and you’re still being denied basic care is ridiculous,” says Koch.
The insurance industry argues that the responsibility for clarifying health service needs should fall on healthcare providers, stating that doctors can explain that a patient is transgender in the notes section of a submitted claim.
The exceedingly high unemployment rate in the transgender community also has a direct impact on barriers to healthcare. The unemployment rate among this group is 14 percent — double the national average. For African American transgender individuals, this number is 28 percent. Consequently, the lack of health insurance is such a significant factor that many transgender people go to the Internet with their primary care questions and to the black market for their medications. Most transgender people have neither the resources nor the support from their family members that Caitlyn Jenner enjoys. In addition, it may take years to fully transition, which will likely involve surgery, hormonal therapy, and behavioral changes.
One of the biggest problems in transgender medicine is that with the exception of some large gender centers and institutions, there is no continuity of care. This issue could be alleviated by conducting more professional Continuing Medical Education (CME) courses for primary care providers (PCPs) and psychotherapists.
Recently, Philadelphia College of Osteopathic Medicine (PCOM) sponsored a CME Transgender Medicine Symposium that featured physicians and psychologists who have been recognized internationally for their expertise in establishing realistic treatment plans for transgender patients. These experts all agree that better transgender medicine starts with the PCP; the PCP is many times the first contact a transgender individual has with a healthcare provider. While the medical aspect is often simple — baseline laboratory testing and hormone administration — the management of the patient is not. PCPs should own the treatment plans. In other words, they should help patients navigate the minefield that is transgender medicine and ensure that they safely work their way through the system.
Many transgender people take lifelong hormone therapy, and for trans-women (people transitioning from male to female), this treatment includes estrogens and anti-androgens that block their body’s testosterone. The majority of transgender patients don’t go the surgery route, and the percentage of those who actually undergo full genital reconstruction is low. Approximately 100 to 500 genital surgeries occur every year in the United States as part of gender transition, according to the Encyclopedia of Surgery. The reality is that there are a very limited number of surgeons in North America who perform gender affirmation or gender confirmation surgery, and those who are experienced are booked years in advance.
In addition to medical doctors, transgender medicine needs properly trained psychologists to work with the transgender population in areas of mental health. These specialists need to understand not only the psychosocial and psychiatric aspects of transitioning, but also the various steps, processes, and issues (i.e., physical, medical, and economic) that arise for transgender patients. It actually may not be in the patient’s best interest to go through the complete gender reassignment surgery.
As hospitals create centers focused on transgender medicine, they are all facing the same issue of figuring out how to train their surgeons. Standardized training programs don’t exist, and surgeons need extensive experience before conducting gender reassignment surgeries. Most surgeons learn to do gender reassignment procedures primarily by watching other surgeons do it. The lack of able surgeons reveals the need to create one-year surgical fellowship training programs to improve the quality of care for transgender patients — as they deserve better.●
Lisa McBride, PhD, is the chief diversity officer for the Philadelphia College of Osteopathic Medicine (PCOM). She is also a member of the INSIGHT Into Diversity Editorial Board. PCOM is a 2015 INSIGHT Into Diversity HEED Award recipient and a 2016 INSIGHT Into Diversity Diversity Champion.