Tackling transgender health disparities

MASSACHUSETTS VOTERS SOUNDLY rejected efforts to allow discrimination against transgender individuals – upholding the current law that protects them from unfair treatment. Despite this positive news, there are continuing efforts at the federal level to bar transgender status from discussions of gender, limiting all individuals to a designation of male or female at birth.

That change could have profound health care implications for many transgender Americans, who are already struggling to get the care they need. For transgender individuals who have begun the journey of publicly affirming their gender identity, interacting with the health care system is often a source of discouragement, insensitivity, or worse.

Many transgender patients feel marginalized when seeking care – largely because there are a host of overwhelming challenges and indignities that must be overcome.

First, transgender patients must deal with medical providers who often lack knowledge of transgender care needs, and in some cases, they must educate health professionals while they seek care. About 29 percent of transgender patients reported having to teach their provider about transgender issues, according to Fenway Health.

There is also a significant shortage of trans-competent providers in primary care and behavioral health, an area critical to transgender people who experience higher rates of depression than non-trans individuals. While mental health evaluations are often required before patients can begin gender affirmation treatment, those appointments can take six months to schedule because of the limited number of clinicians practicing trans-health. There is also the difficulty in figuring out what – if any – hormone therapy is covered by insurance. Expenses can quickly mount for necessary items and treatments that are not covered.

In addition, across New England, there are a limited amount of surgeons who provide gender-affirming surgery, and those services are only available for specific procedures, forcing many individuals to go out of state and out of network, and in many cases, pay out of pocket for surgery.

The lack of access to culturally-affirming and informed health care professionals and trans-health services is having real consequences, leading to major health disparities for transgender individuals.

A report released by Fenway Health found that one in five transgender people postponed or did not try to get health care in the past year, and that gender-minority adults experience lower rates of preventive screenings, such as mammography and pap smears. According to the Health and Human Services Healthy People 2020 initiative, gender-minority adults have higher rates of depression, anxiety, substance use disorder and unhealthy weight control.

If our commitment to serving all individuals is to carry any credibility, those of us in the health care community must do more for our transgender patients and members. Medical schools should seriously consider adding trans-health to the curriculum so future patients feel respected and understood.

There are policies health plans can adopt to try to ease the process for transgender individuals. For example, Tufts Health Plan member intake forms collect gender identity information and trans members are assigned a case manager to answer questions or concerns. Case managers coordinate with the behavioral health team for a more integrated care experience. And we have implemented a cross-department system to prevent immediate rejection of claims based on gender discrepancies.

In addition, it is important to work collaboratively with provider organizations well-versed in LGBTQ health to make sure staff receive transgender competency training. This means using pronouns appropriate to the member’s gender identity and having the knowledge to address questions specific to transgender health. That way, when we seek answers about care, transgender members are not further marginalized. We can also tap into the insight of our employees, who reflect the diversity of our customer base.

Tufts Health Plan’s LGBTQ Business Resource Group (BRG) serves as a focus group to enhance service and to educate our staff and senior leaders on issues impacting the broader LGBTQ community. Recently the LGBTQ BRG led the charge around transforming many of the bathrooms across our Watertown headquarters with signage indicating they are open to all genders. They are also active participants in local advocacy events, including Boston Pride and the First Event transgender conference. Groups like this can provide valuable advice on the use of terms, and influence training guidelines for front line staff.

Transgender health is an issue we can and should address, not seek to outlaw. As health plans, we must continue to improve our systems and processes. Working with the transgender community is critical in order to create meaningful change and provide more comprehensive and compassionate care.

Tom Croswell is the president and CEO of Tufts Health Plan