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Trans Issues for Healthcare Providers- April 2013
Transcript of Trans Issues for Healthcare Providers- April 2013
The Evolution of
Best Practices for
What is Gender?
Some medical interventions some Trans* people pursue
What is Trans*
Informed Consent for Access to Trans* Healthcare (ICATH)
Harry Benjamin Standards of Care
Today's WPATH Guidelines
Many Trans* People Are Afraid of Their Healthcare Providers
Died of Medical Transphobia- August 7th, 1995
Historically, most public and private insurance companies have discriminated against trans* patients by denying them coverage for medically necessary treatment and procedures.
Named for a US endocrinologist and colleague of Alfred Kinsey, who was widely know for his clinical work in transsexualism. Harry Benjamin treated his first patient with hormone therapy in 1948.
Most recent version released in 2011, and aspires to provide Ethical Guidelines for health professional concerning patients with "Gender Identity Disorders".
ICATH is an alternative Standard of Care that promotes the ultimate well-being and autonomy for transgender, transsexual, intersex and other gender non-conforming people.
Sex is a social assignment we are given, based upon which body parts and hormones we were born with, or currently have.
Umbrella term for people who do not fit neatly into the sex-gender paradigm that much of our culture operates from.
This may include people who identify as:
November 8, 2014
Tyra Hunter was a 25 year old African-American transexual woman. Tyra died after being injured as a passenger in a car accident and being refused emergency medical care.
The Emergency Medical Technicians who responded to the scene used derogatory epithets and withdrew medical care when they discovered that Tyra had a penis.
Doctors at D.C. General failed to diagnose and treat Tyra who died of internal bleeding in the hospital emergency room.
Evidence at the trial demonstrated that had Tyra been provided with a blood transfusion and referred to a surgeon, she would have had a 90% chance of surviving.
7, 000 Transgender and Gender Non-Conforming Respondents
Findings of a Study by the National Center for Transgender Equality and the National Gay and Lesbian Task Force- October 2010
By Jaime M. Grant, Ph.D., Lisa A. Mottet, J.D., and Justin Tanis, D.Min.With Jody L. Herman, Ph.D., Jack Harrison, and Mara Keisling
19% of respondents reported being refused treatment by a doctor or other provider because of their transgender or gender non-conforming status.
28% reported being verbally harassed in a medical setting
2% of respondents reported being physically assaulted in a medical setting
33% delayed or did not try to access preventative healthcare
28% postponed or avoided treatment when they were sick or injured out of fear of discrimination
50% of respondents reported having to teach their medical providers about some aspect of their health needs
How Is This Affecting Trans* People's Health?
Trans* Competent Healthcare Is A Social Justice Issue
2.64% reported HIV infections-
4 times the sero-prevalence of the general population (.6%)
41% have attempted suicide
26% use, or have used, alcohol or drugs to cope with the impact of discrimination
30% reported smoking daily
The first version of the Standards of Care were released in 1979 by the Harry Benjamin International Gender Dysphoria Association. They laid out the best practices for the clinical treatment of transsexuals.
The 1979 Standards of Care required a letter from a therapist in order to access hormone therapy. In order to access gender confirming surgery, the patient must provide two letters from therapists and live as their preferred gender for a year minimum.
The Standards of Care have been revised six times, and have grown from a two-page document to the 120-page document released in 2011.
The Harry Benjamin International Gender Dysphoria Association became The World Professional Association for Transgender Health in 2006.
Since 1980, the DSM (The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders) has included the diagnoses of "Gender Identity Disorder" (GID) F.64.
The DSM-5, released in May 2013, recatagorized gender variance as "Gender Dysphoria".
"The overall goal of the SOC is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being,
"The SOC are intended to be
in order to meet the diverse health care needs of transsexual, transgender, and gender nonconforming people."
-This was a major clarification in the recently released version.
The WPATH SOC Outline:
The differences between Gender Non-Conformity and Gender Dysphoria
Assessment and Treatment of Children and Adolescents
Surgeries and Post-Operative Care
Global application of the SOC, as well as it's application in institutional environments and with intersex patients
Significant Changes in the 7th Edition SOC
Strong affirmation that attempts to change gender identity through "reparative therapy" are ineffective and unethical
Allows for a spectrum of non-binary gender identities
Stronger guidance on children/adolescents- including puberty delay
Psychotherapy is no longer a requirement to receive hormones- still suggested
Removal of the 1 year "real life experience" requirements for some surgeries, such as hysterectomy and testicle removal
Continues to recommend 1 year "RLE" for genital reconstructive surgeries
Call for providers to advocate for their clients through public policy reforms
WPATH's Medical Necessity Statement
WPATH Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage for Transgender and Transsexual People Worldwide
"The WPATH Board of Directors urges state healthcare providers and insurers throughout the world to eliminate transgender or trans-sex exclusions and to provide coverage for transgender patients including the medically prescribed sex reassignment services necessary for their treatment and well-being, and to ensure that their ongoing healthcare (both routine and specialized) is readily accessible."
Trans* people are not required to attend therapy to receive desired gender confirming health care. No one should have to go to therapy to prove their true gender, or to get permission to change their bodies.
Trans* people are able to decide what is best for themselves and their bodies, and when.
Therapy is an option, not a requirement, for accessing gender confirming health care.
Informed Consent for Access to Trans* Healthcare (ICATH)
Insurance and Trans* Healthcare
This has typically happened three different ways:
#1 Denial of Health Insurance based on Trangender status.
The majority of transgender people who have applied for health insurance alone (not as part of a group plan) have been denied if the company knew that they are transgender.
This has resulted in a disproportionately high number of trans* people who have not had access to, or delayed accessing healthcare.
The Affordable Care Act has changed this. Because insurance companies can no longer deny coverage based on a pre-exisiting condition, they cannot deny covering someone simply on the basis of their transgender status.
#2 Transgender Health Exclusions in Insurance Policies
Almost every public and private insurance policy has an "exclusion" written into the terms of it's contract absconding themselves from covering transition related procedures.
This means that even trans* people who do have health insurance often pay out of pocket for transition related medical care.
Hormones can average up to $100 per month
Average therapy is around $100 per session
Surgeries range from $5,000 to $50,000 with some phalloplasties up to $100,000
Insurance companies often interpret their policies very broadly to avoid covering care for trans* patients by claiming that more general medical conditions are the result of trans* treatments or procedures.
#3 Insurance Policies Function on a Gender Binary that Denies Coverage for Services Many Trans* Patients Need
Insurance companies often do not cover care based assumptions about the patient based on gender.
For example, they may refuse to pay for a PAP smear needed by a trans* man, or a prostate exam for a trans* woman, even though that person requires such preventative exams to stay healthy.
In January of 2013, the Insurance Division of the Dept. of Consumer and Business Services made Trans* exclusions illegal in the State of Oregon.
A bulletin was issued, effective immediately, specifically stating:
Health insurers cannot categorically exclude trans* patients from coverage
Health insurers must provide coverage of treatments for all trans* patients if they provide coverage of those services for other policy holders
Health insurers may not deny treatment based on the policy holders actual or perceived gender.
The statewide mandate for the coverage of mental health services must also be applied to trans* patients.
Gender is an internal and external identity, often rooted in groupings of social behaviors, presentations and patterns. Often gender identities reside along the spectrum of masculine-androgynous-feminine, though many are not fixed.
Sex and gender often interact, but they are not the same thing.
Everyone has a gender identity.
Gender is incredibly complex. It doesn't actually exist on a binary and isn't always a function of sex, but we often catagorize it as though it is.
Drivers license/ID documents
And, apparently, ball point pens...
It is respectful to address a person by the name and pronouns they prefer, and it is okay to ask politely.
It is also respectful to use the language that person uses to identify their body parts.
Some terms to become familiar with:
Sexual reassignment (or alignment) surgery
Hormone therapy or Hormone Replacement Therapy (HRT)
It is disrespectful to:
Use the wrong name, pronouns or other gendered language
Ask questions that do not directly pertain to that persons health out of curiosity.
Suggest that a non-related health condition is the consequence of a person's gender identity
Assume you know more about a patient's gender related therapies than they do
Use gender related slurs, refer to a person as "it", or do anything that might make that person feel anything less that fully human
Hormone Therapy- Estrogen, Testosterone, Hormone Blockers, Puberty Delay
Chest Surgeries- Breast Augmentation, Masectomy
Genital Surgeries- vaginoplasty, phalloplasty and others
Facial Feminization Surgery
Voice feminization surgery or voice lessons
National Student Nursing Association Conference
Some Useful Resources
National Center for Transgender Equality- transequality.org
Transgender Law Center- transgenderlawcenter.org
World Professional Association for Transgender Health- wpath.org
Basic Rights Oregon Trans Justice Program- basicrights.org/programs/transgender-justice
Hudson's FTM Resource Guide- ftmguide.org
Laura's Playground (MTF Resources)- lauras-playground.com