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Transgender Healthcare:  What does “Access” Really Mean?

Post submitted by: Renee McLaughlin, MD FACS

We all know the statistics: 60% of trans people lack employer-based health insurance, 50% have to educate their providers, 19% have been denied healthcare – or worse. This adds up to a crisis in access to healthcare for the 1.6 million Americans who identify as transgender. But what do we really mean when we say “access”? Is it being able to afford care? Is it having a healthcare provider in one’s own community who has the knowledge and compassion to serve and treat us? What about active research into the unique needs and health risks that affect gender non-conforming people?https://lh3.googleusercontent.com/2cCyetMjtN80dZU2bRHIPxDFCqffKoWsoiEYy-Qiy7ApcqdtqBCJgm8OuEULjGYADlLU3aSeplHPq2WBUxv2WY5k0VvRitAcgKIXMgAq8GXFv4tn44J5W3qjtZKEGT82P7aPYCUm5Q-M9I2XOA

I offer to you that access to effective and appropriate healthcare includes all of these elements. The correct medical treatment and advice cannot be delivered if we don’t know the definition of “correct.” Knowledge cannot be applied if there are not adequate numbers of appropriately trained healthcare providers. And competent providers in every community cannot improve the health of trans people if we can’t afford the services provided by these caregivers.

So, how are we doing on access when defined this way? Well, there is certainly some good news and reason for optimism, yet still much to be done.

Great strides are being made in securing insurance coverage for some transgender-specific care, including hormone therapy and gender-confirming surgery. The private sector has played an important role in these advances: There has been a 600% increase in the last 5 years in the number of companies surveyed in HRC’s Corporate Equality Index that provide transgender-inclusive coverage. Additionally, an increasing number of businesses are offering plans that include coverage for procedures such as electrolysis, facial feminization surgery, and breast augmentation — services that we know are often critical to the acceptance of a trans person in our gender-binary world.

To top it all off, starting in 2017, the Affordable Care Act will greatly expand coverage for transgender-related services for those purchasing insurance on most health insurance exchanges and other individual and small-group plans. So, for most trans people, the financial part of “access” is looking much brighter. While the Affordable Care Act’s future may be uncertain, HRC and other advocates are fighting to preserve the protections it has offered transgender patients and many others.

It is often the case that when one mountain is crossed we see another looming, and this is so for the current state of access to appropriate healthcare providers. It is uncommon for a person with diabetes or high blood pressure to be unable to find a doctor in their own town, or at least nearby, to treat their conditions. But this is the rule, not the exception, for transgender people seeking care for mental health needs, hormone replacement therapy management, or surgery. Worse, there are many providers who refuse to treat trans people for any reason.

Not long ago I watched with great dismay – and more than a little shock – as a large group of third- and fourth-year medical students were asked if, with appropriate training, they would treat a transgender patient and almost half said no! Today, while the Association of American Medical Colleges strongly supports meaningful education in LGBTQ health issues, very few medical schools are providing it. The average medical student receives just five hours of training in this area during all four years medical school, and that’s where formal training stops. There are no fellowships, certificates of added training, or even generally accepted credentialing standards for physicians who treat transgender patients.

While most medical care for trans people is straightforward, the necessary surgical procedures are highly complex and demand significant experience and skill. Without formal training programs and standards, there will continue to be few qualified and competent surgeons to meet our needs. I recently met with a group of six surgeons who a majority of gender reassignment surgery in the U.S., and most report waiting lists of a year or more. As the Canadian Supreme Court correctly stated a year ago, “Access to a waiting list is not access to healthcare”.

Finally, access to healthcare means access to the right healthcare, which is founded on sound, research-based knowledge. The body of general medical knowledge is expanding at an incredible rate, and in the U.S. alone, the government spent more than $32 billion on healthcare research in 2016. Little research, however, is focused on the unique needs of transgender people: Last year alone more than 50,000 medical research grants were supported by the National Institutes of Health, yet between 1989 and 2011 fewer than 50 were trans-specific. Thankfully there is a bright spot here as well — the National Institutes of Health recently classified LGBT people as a health disparities population, which may lead to enhanced funding for LGBT research. We can only hope that the “T” will not be silent here, and that talented researchers will receive appropriate funding to better understand and define optimal care for transgender people, a long-neglected population.

Speaking as a physician, and a transgender one at that, we fundamentally seek to enhance the wellness of the patients we serve. We are only able to do this if we are equipped with the correct knowledge, receive ample and appropriate training in the unique needs of our transgender patients, and ensure that our patients have the financial means to see us. This is what “access to healthcare” means.

So how are we doing on access? Better, to be sure, but we have a long journey ahead of us. Advocates and employers – as the largest purchasers of health insurance plans – must continue to work together to remove these barriers to appropriate care.

For more information on transgender inclusion in the workplace including information on transgender inclusive employer-provided healthcare, see HRC’s Transgender Inclusion in the Workplace: A Toolkit for Employers.

This week, HRC marks Transgender Week of Awareness, dedicated to the progress, continued challenges, and unfinished work in the fight for transgender equality. Throughout the week, HRC will dedicate each day to urgent and important issues facing the transgender community, including support for youth and families, workplace equality, access to life-saving and inclusive health care, and combatting violence against the transgender community. The week concludes with with Transgender Day of Remembrance on November 20 when the community comes together for vigils around the country to honor those lost in the past year. Learn more at hrc.im/TransAwarenessWeek.