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DR. MADELINE DEUTSCH: JoAnne and Dr. Bockting did a great job of setting up the final piece
of this puzzle, which is a brief overview of medical needs of transgender people. And
there will be some references that I’ll cite at the end for more in-depth and we will
just kind of -- do a very basic level survey review of some of the concerns.
So we can go to the next slide. And I like to put this slide up first because I think
it’s important to first point out why it is important that we focus on the health of
transgender people by looking at some of the disparities. This is a study that was conducted
by the Transgender Law Center in California, looking at 646 transgender respondents from
within California. If you look on the left there, 33 percent were denied surgery and
27 percent were denied hormones; 21 percent were denied counseling and mental health services.
So we have a fairly high prevalence of folks being denied transgender specific care, as
well as one in five being denied access to counseling and mental health services. Now,
if you move over to the box here, this is even more alarming. You could be a provider
saying, well, I really can’t give you hormones because I’m not familiar with that material.
But 15 percent were denied gender-specific care such as a pap smear or a prostate exam,
and 10 percent were denied primary health care. So these are folks that are being denied
care that is well within the scope of any primary care provider.
And if you look at the box at the bottom, some 30 percent of the community report that
they postpone care for illness or preventive care due directly to the disrespect or discrimination
from doctors or other health care providers. So we have almost a third of transgender people
in California are putting off going to the doctor because of a prior experience or bad
experiences they’re having in their health care.
We can go to the next slide. I’m just going to show you a couple of excerpts from this
fantastic study for colleges in the province of Ontario, Canada. You can go to the next
slide. I’m just going to read this narrative because I couldn’t say it any better: “Viewed
through a social determinants of health lens, the existing body of literature clearly indicates
that trans people frequently face a multiplicity of challenges to their health and well-being,
and these include challenges to accessing relevant health care services.” And “the
lack of research on trans lives and trans issues has resulted in a dearth of information
on health-related topics...”
So this is showing what the results are: the lack of both providers able to provide care
or willing to provide care, and then there’s a secondary level, which is research, which
drives the care that is provided.
We can go to the next slide, please. Now, prevalence of gender nonconformity or transgenderism
– or any of the terms– and I don’t want to get too hung up on terminology in this
brief discussion -- but the prevalence has been studies in limited areas. It’s been
studied primary in Europe with methodologies that are not necessarily applicable to U.S.
populations. And there are some other issues with the way these populations were studied.
What this narrative is showing here is that according to the prevalence estimates from
the Netherlands, there would be 615 transgender people in the province of Ontario. However,
this republically funded community health center in Toronto provides and sees more trans
patients that there should be in the entire province. So this is really empiric proof
that we are underestimating in our prevalence studies, and really should be a call for expansion
of prevalence studies and analyzing the methodology in these prevalence studies so that we are
properly capturing the community.
We can go to the next slide. This is a narrative from that same study from a qualitative component.
“I got told by one of those three doctors that I should probably seek health care elsewhere,
because for some reason he did not know [that I was trans] in advance, because that wasn’t
what I was seeing him for, and when he found out, he pretty much said word for word, ‘Please
go somewhere else.’” So this is something that JoAnne had spoken about where, you know,
the patient might have been there for an ingrown toenail and they’re being denied access
to health care in somewhat of a noxious environment.
We can go to the next slide. So now that we’ve kind of set the stage of why do we need to
focus on transgender health, what are these folks going to be showing up at the office?
What are they looking for? First and foremost, transgender people are going to be coming
to the office looking for hormones. Now, when they come for hormones, as you’ll see as
we go through this, you have the opportunity to establish a relationship with a patient
that you can then begin to encourage them to address primary care issues, preventive
issues, STI screening, etc. So this could be a real linkage and retention.
At the same time, we would never want to hold hormones as a carrot on a stick saying I will
only give you hormones if you have a pap smear; I will only give you hormones if you have
an *** test; I will only give you hormones if you take your cholesterol medicine. So
we want to use this as a very fine line that a provider might need to walk where you’re
having this opportunity if a patient is coming to see you to get hormones, and, oh, while
you’re here, I’d like to talk to you about your blood pressure.
And patients also, on a case by case basis as JoAnne mentioned, may seek surgery. And
each patient will seek a different range of hormone and surgical procedures that are of
interest and importance to them based on their goals, their desires, any medical contraindications,
their financial capacity and the availability of providers. Each patient has a different
narrative. There is no one pathway or narrative.
We can go to the next slide. Well, what do transgender people need? They need care to
be covered and paid for currently, and most insurance plans have exclusions, although
we have improvement of that. But it is still a big issue. As JoAnne mentioned, having your
front office being culturally sensitive and able to welcome the patient into the clinic;
maybe having reading materials or some wall materials in the clinics that are transgender-themed
will improve the patient’s experience in the clinic.
And we know some research across the board -- and you can extend it to any demographic
-- if you have a clinic that is serving a primary Chinese neighborhood and there is
Chinese wall art when they walk into the waiting room, they’re going to feel immediately
more comfortable and that this is a clinic that understands their particular needs and
demographic; and the same thing with LGBT and transgender specific people.
We can go to the next slide. So what we just talked about some of this. Now, I want to
skip down to electronic medical records. JoAnne spoke about a lot of the other bullets, and
I just mention some of them: having a system of electronic medical records in your office
can sometimes complicate issues because the patient may have a chosen name, prefer a chosen
gender, or an assigned gender or an assigned name, and you may even have even more complicated
situations where the patient has had a legal change of name, but they have not had a legal
change of gender.
So the patient may have a legal name of Jennifer, the patient may look like a Jennifer, but
they may not have been able to get their gender marker changed on their Medicaid documentation
or whatever it might be. And so you may have any one of a number of combinations of name
and gender issues in an EMR.
There is currently a developing program looking at coming up with recommendations and how
to address this. But it is something to think about. I won’t be able to solve the problem
here, but just to think about ways to allow your medical records system to identify a
preferred name and gender in addition to legal.
We can go to the next slide. So what can you do? JoAnne, again, spoke about a lot of this.
I just want to reiterate it and point out a couple of issues that first of all, not
all transgender people are obviously transgender. And they may not be there for a transgender-related
issue. So if somebody comes in for a sprained ankle, and then you see that they’re taking
testosterone. Oh, okay, well, that’s interesting. Think about will that affect your treatment
in any way. No, it probably won’t, so there’s no need to start asking them, you know, have
you had the surgery yet or anything like that, which you never want to ask anyone anyway.
Transgender people may have very complicated feelings about something as basic as putting
on a gown. So, you know, I think we are kind of -- as health care providers -- accustomed
to opening the door and saying, “Here’s a gown and just put this on, opening in the
back, and I’ll be back.” That may really traumatize transgender people, and they feel
very vulnerable. So every step of the way has to be with just extra kid gloves.
We can go to the next slide. So what can hormones do? Well, they’ll change your secondary
sex characteristics, for the most part, in one direction or the other. I don’t want
to get too into the details of this in the interest of time, but I will say that a couple
of considerations here is that the voice in people going from male to female is not profoundly
affected by hormones. In fact, it’s not affected at all. It may arrest some further
virilization of the voice that would go on, but it does not feminize the voice. It’s
transgender women tend to seek therapy if that’s important for them.
We can go to the next slide. This is a list of basic regimens and a kind of overview of
what is used. So estrogens are used in male to female persons, along with most of the
time a testosterone blockade using one of a number of medications. And progestagen may
be used, and there is some scientific debate about the role of progestagens in cross sex
hormone therapy.
Female to male persons, almost always they’re using testosterone. Progestagens may be used
in cases of persistent *** or are unable to address other pelvic health issues.