(WOMENSENEWS)— For a trans person, finding a health care provider without the help of a website or recommendations from trans peers can be tough.
“I called every endocrinologist in my area and in my health care network and asked if they’d be willing to facilitate hormone replacement therapy and most said no,” says Austin Johnson, a trans man. “I’d say 99 percent said no.”
Some physicians decline based on moral grounds. “Some will recite scripture to you,” says Johnson, a doctoral candidate studying transgender health in the department of sociology at Kent State University.
Other physicians turn transgender men and women away because they’re unfamiliar with typical transgender treatments, like hormone therapy, and aren’t comfortable agreeing to provide it, which was the case with Johnson.
Says Johnson, “They treat trans health as though it’s this obscure, very specialized kind of system of medicine, but hormone therapy for me requires the exact same kind of monitoring that a cis male would get if they had a hormone deficiency.”
That speaks to a severe lack of training. Nearly 7 percent of medical schools surveyed reported dedicating zero hours of their curriculum to LGBTQ-related content during the preclinical years of medical training, finds a 2011 study published in the Journal of the American Medical Association.
During the clinical years, when physicians’ training involves working with real patients, that same percentage of responding schools reporting zero hours of LGBT content jumped up to a third. Overall, the median number of hours committed to LGBT content throughout all four years of medical school was only five.
“A lot of trans health care providers are not specialists,” says Johnson. “So a lot of what we find are benevolent health care providers who want to help trans people or who see it as their oath. And what that looks like for a lot of trans people is finding providers by word of mouth.”
When Johnson did find a doctor, he wound up helping him decide his own treatment.
“At my first appointment, my general practitioner asked me how much testosterone I was taking, how long I’d been on it and if that was typical of transgender people,” says Johnson, “There’s a huge online community and luckily I knew from YouTube and Facebook what was typical.”
Dr. Madeline Deutsch is a professor in the department of family and community medicine at the University of California San Francisco and is the director of clinical services at the UCSF Center of Excellence for Transgender Health. She recently gave a talk about transgender health care at the 2016 Women’s Health Congress put on by the Academy of Women’s Health.
Deutsch calls for more research funding in trans health care.
“Medicine has three components to it,” says Deutsch, “it has medical care, teaching and research. So in addition to making sure people have access to medical care today, there also needs to be research.”
A 2014 American Journal of Public Health study determined that when HIV-related projects were excluded, only 0.1 percent of studies funded by the National Institutes of Health addressed LGBT health.
“The trans population makes up about 0.3-0.5 percent of the population, so there should be at least that amount of funding, but actually they should get more than that because when there’s a disparity, you throw more money at it,” says Deutsch.
When asked what percentage of medical providers are trans-knowledgeable or trans-friendly, Deutsch responded, “Unfortunately we don’t have that information. We know how many orthopedic surgeons we have, we probably know how many orthopedic surgeons we have that specialize in the shoulder, but we don’t have a good population-based nationwide survey on this.”
Jaymeson Emery, a trans man living in Greenville, South Carolina, thinks more medical training would be helpful.
“I think all medical professionals should be educated on trans health issues, vocabulary, how to work around insurance and pronouns,” says Emery.
In a recent email he described how he finds a physician. “All of the doctors I see now, such as my endocrinologist, my general practitioner and my therapist, I’ve found on the Southeastern Trans Resource Guide,” Emery says, referring to a list of trans-friendly medical providers, service providers and attorneys in the southeast put together by members of the trans community.
Concentrated in Cities
“The problem with that is a lot of the information is concentrated in metropolitan areas,” says Johnson, the doctoral student.
“I’ve tried to use MyTransHealth,” says Emery, “but, unfortunately, they don’t have any of the providers in my area listed.”
Medical insurance is another problem.
“I have health insurance, but it doesn’t cover any trans-related health care,” says Emery, “It doesn’t cover my testosterone, but thankfully my endocrinologist is willing to work with me on that.”
Helpful and compassionate physicians can play a key role in bending the rules for a population that is currently outside the system. For instance, some are willing to code gender affirming hormone therapies, such as testosterone treatments, as general, non trans-related diagnoses in order to guarantee insurance coverage. So, for example, coding hormone treatments as “endocrine disorder – non specified” rather than “gender dysphoria.”
In May, the Department of Health and Human Services added a rule to the Affordable Care Act prohibiting discrimination on the basis of race, color, national origin, sex, age or disability. But though the spirit of the amendment, also known as Section 1557, may aim to protect transgender individuals seeking medical care, its lack of specificity still allows for trans people to be denied services in many circumstances.
“It gets complicated there because I think the official statement is you can’t deny someone something if you’d cover it for someone else,” says Johnson, “So if they would cover hormone replacement for a cis person, they can’t deny it for a trans person. But what that means is if they wouldn’t cover gender affirming surgery for a cis person, they don’t have to cover it for a trans person.” But as Johnson points out, there are some advantages to this new amendment, “It will benefit a lot of people such as trans men who need gynecological care or trans women who need prostate care. That is definitely helpful.”
A study published in the Journal of General Internal Medicine in 2015 found that when the positive effects of health insurance are taken into account, providing full health coverage to trans individuals is cost effective.
Health insurance can reduce the risk of HIV, depression, drug abuse and suicide, all of which are very expensive to treat or handle. Authors also estimated that providing trans coverage would cost other plan members less than 2 additional cents per month.
“We provide access to so many other health care services that are costly and we don’t blink an eye about it,” says Deutsch. “We’re doing bypass surgeries that cost hundreds of thousands of dollars and we don’t have a cohesive nutrition education preventative plan in this country, but we’re splitting hairs about $30,000 for gender affirming care.”
Johnson says a priority is extending more mental health coverage to trans people.
Johnson believes that a focus on mental health care for trans people would go a long way. “So whether that be traditional mental health care services or a rerouting of resources to community groups where peer to peer support has been found by psychologists and sociologists to be what matters most when improving mental health.”
A national survey of trans-knowledgeable or trans-friendly providers would also benefit the trans population.
“WPATH and GLMA do these sorts of things, but these are really self-selected organizations,” says Johnson. “It would be important for trans people in non-metropolitan areas if physicians in those areas had to say or explicitly write out whether they are welcoming, friendly, supportive and useful to trans people, and the American Medical Association could help with that. They’re a large organization with power and authority among physicians, if they took the lead on this, I think it would be very beneficial to the trans population.”