Trans*gender I nclusive H ealth Care

Trans*gender Inclusive Health Care Challenges and Opportunities

Hello and Welcome • My name is Nicole Nisly • My pronouns are she, her and hers • I am a physician and my title is as below • Professor of Internal Medicine • Co-Director of the LGBTQ Clinic at the University of Iowa Health Care • Director of Complementary and Alternative Medicine Clinic • Internal Medicine Diversity Officer • I am a Primary Care Physician

Is Trans*gender care medically necessary? • AMA: “An established body of medical research demonstrates the effectiveness and medical necessity of mental health care, hormone therapy, and sex reassignment surgery as forms of therapeutic treatment for many people diagnosed with GID (gender identity disorder)” • RESOLVED, That our American Medical Association support public and private health insurance coverage for treatment of gender identity disorder as recommended by the patient’s physician. (AMA HOD Resolution 122, 2008)

National Association of Social Workers 2008 Position Statement • “NASW supports the rights of all individuals to receive health insurance and other health care coverage without discrimination on the basis of gender identity, and specifically without the exclusion of services related to transgender or transsexual transition, in order to receive medical and mental health services through their PCP and the appropriate referrals to medical specialists, which may include hormone replacement therapy, surgical interventions, prosthetic devices and other medical procedures”

HHS Secretary K Sebelius LGBT Pride Month Statement, 2013 • Affordable Care Act (Obamacare) as of 2014; • No longer imposing life time dollar limit on healthcare insurance coverage • Cannot deny coverage or impose higher rates because someone is lesbian, gay, bisexual or transgender • Requires coverage for preventive health services including HIV screening, contraception, intimate partner violence screening at no out of pocket charge • New inclusive National Standards for Culturally and Linguistically Appropriate Services • www.ThinkCulturalHealth.hhs.gov

On Health Disparities Experienced by Gender Non Conforming Patients • Institute of Medicine Report, 2011 • The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a foundation for Better Understanding • Challenges posed by lack of adequate data, as few surveys include gender identity questions • Barriers to accessing healthcare: personal and system • Increased risk of depression and suicide, STI, lack of routine health care, suffer violence and bullying, lack of social support

WPATH: Standards of Care • World Professional Association for Transgender Health • International, multidisciplinary professional organization whose mission is to promote evidence-based care, research, public policy…developing standards for best practices • Standards of Care for the Health of Transsexual, Transgender, and Gender Non Conforming People, 7th edition, 2011 • Recognized as authoritative guidelines and standards of care by American Medical Association, American Psychological Association, National Association of Social Workers • www.wpath.org

In October of 2012 the new LGBTQ clinic was launched • A bit of history and reasons why we created the clinic, with the help from many here in this audience: faculty, staff, students and community members. • Dr Imborek and I met at the Transweek, organized by the UI Trans* students and allies. The idea came up as we heard their stories… • Let’s create an LGBTQ home, a safe and welcoming space

The stories that inspired • Luna* is a 62 year old Trans* woman whose sex assigned at birth was male. She was married for several years and has 2 daughters. Later in life she transitioned to her tru gender identity as a Trans* woman. I am ready to complete a physical and she says: “Doc, you are about to enter uncharted territory”. What do you mean? I reply. “I have never had a full physical including breast and pelvic exam since my transition 10 years ago”. I pause shocked and think: but you have received care every 3 months here…But I say, well, today is the day, get undressed and put on the gown dear and I will come right back.

And then I tried to make an appointment… • Jack* is a 22 year old Gender Non Conforming person who identifies as Queer and who uses He/Him/His as pronouns, he was a female as his sex assigned at birth. • He has been receiving testosterone for several months but has been experiencing heavy vaginal bleeding. He tries to make an appointment in two different areas at a Health Center and is met with barriers, because of his gender identity and finally needs to be seen at the ETC, where he feels disregarded, is told that “we don’t know how to treat people like you” and has his pronoun and preferred name incorrectly used and disrespected.

Is this common? Sadly, yes… LGBTQ individuals across their life spectrum are target of discrimination, stigma, harassment and violence. They have a higher risk of depression and suicide, homelessness, STI including HIV and substance abuse than their heterosexual peers. They have less access to health care and even when access is available, they use the health system less frequently. The health of LGBTQ patients is not well known and research is particularly lacking on Transgender specific health needs. The Health of Lesbian, Gay, Bisexual and Transgender People: Building a Foundation for Better Understanding. Institute of medicine, 2011

Providers for Trans*gender inclusive care at the UIHC • LGBTQ clinic: provides primary care home for gender non conforming patients, initiates hormone management, generates appropriate surgical referrals and provides post surgical follow up. • It was launched in October of 2012 to address a critical need for safe and effective evidence-based care and care coordination for gender non conforming patients. • Health provider education and training and research initiatives are part of the mission for this program. • Team approach with Gynecology, Urology, Plastic Surgery, Psychology and Family Counseling, Pharm D, Social Work. Dermatology, others to come.

Early experience for UI LGBTQ clinic • New patients to UIHC seeking gender affirming care • Most are interested in hormone therapy care • Those interested in surgery are most interested in surgical procedures widely utilized by many and available at the UIHC: • Orchiectomy, TAH/BSO, Mastectomy (male chest wall re-construction), Breast Augmentation • As need and volume grow, will expand to complete sex change operations as needed, the UIHC has the expertise.

Gender Non conformity • Gender non conformity: expression of gender characteristics, including identities, that are not stereotypically associated with one’s assigned sex at birth is a common and culturally diverse human phenomenon that should not be judged as inherently pathological or negative. (WPATH 2011) • Gender non conforming people may experience minority stress from chronic experience of suffering stigma, discrimination, prejudice, abuse, neglect, violence, which may make people vulnerable to anxiety, depression. (IOM 2001) • Gender non conforming people are not inherently disordered.

Gender Dysphoria DSM-V • Discomfort and distress that is caused by a discrepancy between a person’s gender identity and their sex assigned at birth. • Treatment to assist people with such distress to explore their gender identity is individualized. What helps one person may not help another. • Gender dysphoria can in large be alleviated through treatment. • A diagnosis of dysphoria should lead to evaluation and treatment consideration • Unrecognized gender dysphoria may be diagnosed when patients are seen for GAD, MDD, substance abuse, etc

Issues of Cost Vs Benefits Analysis • Medical benefit: widely recognized. These are medically necessary, life-saving treatments • Hidden cost of no treatment: suffering, mental health costs, suicide risk, campus violence, work place intolerance • Insurance coverage for City and County of SF: • 30,000 employees • 80,000 plan members • Estimated cost: 35 people per year accessing $50,000 in services, per individual claim. • 5 year utilization: 97 claims, total of $383,000

Opportunities • Education: physicians, residents and students, nurses, social workers, counselors, lawyers, corrections officers • Research: bridge the gap. Ideas: LGBTQ health registry, Trans* folks in the corrections systems • Information dissemination: web site, publications, lectures • Changing the system works towards eliminating health disparities for sexual and gender minority folks

How to support our LGBTQ patients: EMR • Document on EMR: may use feature Epic FYI • Preferred name and Preferred pronoun should always be documented and used in documentation, letters. May use AKA: JOHN Doe, AKA Jane Doe. Our staff refers to patient by preferred name. • Sex assigned at birth (legal sex for most people) vs gender identity: there are many ramifications that require discussion and evaluation for legally changing one’s legal sex. • Identify patient support system and refer to support groups, counseling and family counseling as needed (see resource list provided separately) • Identify patients at risk for bullying, violence, sex workers and barriers to care

UIHC LGBTQ patients • Gender affirming care, including hormones, surgery, voice therapy referrals through LGBTQ clinic at IRL: 319/467-2000. Iowa Care included. • Personnel training, creating a welcoming environment: Our staff received Safe Zone Training. • Our web site provides information and useful links for patients who identify as LGBTQ and their families, in particular gender non conforming people should be emphasized. • www.uihealthcare.org/lgbt/

Gender Non Conforming 101 • Sex: Female, Male, Intersex • Genetically determined, based on physical characteristics • “sex assigned at birth”: health care providers and parents name the sex • Gender: one’s self identified sex identity. It may be incongruent with genetically determined sex. • Identified as Woman, Man, Trans* (gender non conforming) • Gender expression: one’s expression of maleness, femaleness. • It is connected but independent of SEX and GENDER identity.

Trans* • Man (transgender man, trans man) • Sex assigned at birth female • Woman (transgender woman, trans woman) • Sex assigned at birth male • Non Binary or Gender Queer • Does not identify in the male or female gender binary • Gender non conforming, gender fluid

Pronouns • They identify your gender, who you are. • Because our society is binary when it comes to gender, most people do not need to identify their pronoun when meeting a new person, it is implied • Sometimes because of one’s gender expression, a pronoun may need to be identified • Babies, telephone, androgynous person • People that identify as Trans* commonly specify their pronouns and name when greeting a new person

Gender inclusive greeting • “Hello, my name is Dr Nisly, my pronouns are she, her and hers. How may I call you and what is your pronoun?” • Call patient by preferred name and pronoun of reference • Sometimes patient’s pronouns are non commonly recognized in the binary spectrum: • They, them, theirs • Zir, zir, zir • “I just met Syd and they were going to the library to pick up their books”

Sexual orientation • Who I am attracted sexually to • Who I have sex with • A person may identify as gay and have never had sex with someone of the same gender. • A person may identify as heterosexual or straight and may occasionally have sex with someone of the same gender. • For health risk evaluation, we ask: do you have sex with man, women, Trans*, all the above or none. • A Trans* person identifying as gay or lesbian, will have sex with someone of the same sex assigned at birth.

LGBTQ in the Corrections System • It is medically very important to address and treat the person based on their gender identity for the sake of their mental health and well being • It creates a safety challenge and safety always comes first. • Examples of inclusive use of gender identity include in personal meetings, medical or health care appointments. • Housing should be based on safety for the gender non conforming inmate and their peers.

Questions and Discussion Deirdre (Donald)Nansen McCloskey Distinguished Professor of Economics, History, English, and CommunicationUniversity of Illinois at Chicago (formerly UI Professor)Professor of Economic History,Gothenburg University, Sweden

Trans*gender I nclusive H ealth Care