The Jenner Tipping Point in the Transgender Health Disparities Conversation

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June 11, 2015; USA Today

When the June issue of Vanity Fair magazine introduced the world to Caitlin Jenner, posing in pinup style on its cover page, Google reported over 10 million searches within a few days. Despite the sensationalism surrounding the news, Jenner’s bold move to talk about the private struggles she has faced as a transgender person has elevated the national dialogue about transgender equality in a way that may represent a tipping point in transgender consciousness in this country, particularly as it relates to disparities in healthcare delivery.

NPQ has been following developments in addressing that inequality. Many transgender individuals describe their reluctance to seek medical care because of their negative encounters with physicians who may be biased, lack sensitivity or knowledge, or who lack confidence in talking about their specific needs. The subsequent dangers of increased medical morbidity and mortality are real. Vanderbilt’s School of Medicine cites some examples. Trans men who still have a uterus, ovaries, or breasts are at risk for cancer in these organs. Trans women are at risk for prostate cancer, though this risk is low. Transgender persons have higher rates of depression and anxiety compared to others and are often at higher risk for heart disease because of hormone use, smoking, and obesity.

Medical colleges around the country are developing programs that train physicians to provide best practices in treating the transgender population. The Vanity Fair publication coincides with an event last Thursday at the University of Louisville School of Medicine bringing together physicians and other healthcare providers to talk about transgender issues, discuss best practices in healthcare, and network with transgender community leaders to identify gaps and steps to improve care.

Beginning in August, the School of Medicine will be the site for a national pilot program and will implement the curriculum developed by the Association of American Medical Colleges to train future doctors on the unique concerns of people who are transgender, gay, lesbian, bisexual, gender non-conforming, or born with differences of sex development.

“We’re being looked at to see what works and what doesn’t and to be a model for the nation,” says Faye Jones, an assistant vice president in the university’s Office of Inclusion. “This is a topic that has been taboo for a long time. Physicians want to provide the best care for these patients, but they may not be aware of issues and how to address someone in a culturally responsive manner.”

Training physicians is part of a larger strategy. “Ultimately, it is our goal to have an identified medical ‘home’ that provides all aspects of care for transgender patients in Louisville, as has been developed in other major clinical centers in the United States,” said Amy Holthouser, MD, associate dean for medical education at the U of L School of Medicine. “This will reinforce the core stance that a competent physician is skilled in the care of all patients within their community and can approach each patient with sensitivity, compassion and the knowledge necessary to promote health and wellness.”

While the AAMC drives systemic change in the way physicians approach their transgender patients, other groups are addressing healthcare delivery disparities in a broader context. In May, New York State attorney general Eric Schneiderman announced a new public-private partnership to improve healthcare services for transgender patients in hospitals throughout the state. A coalition including the New York Attorney General’s Office, Greater New York Hospital Association, Mt. Sinai Health Systems, and Lambda Legal will provide information and training to hospitals about both legal requirements and best practices for addressing the health needs of transgender people.

What may be the most complex issue in the discussion is how the insurance industry responds to these shifts. The University of California’s Center for Excellence for Transgender Health, whose mission is to increase access to comprehensive healthcare services for trans and gender-variant communities, describes discriminatory practices by insurance companies.

The center reports that,Health insurance policies often overtly exclude treatments for transgender or transsexual people’s health care needs, even when these needs are not related to a gender transition.” It goes on to say that, “Physicians or their support staff members may need to interact with insurance claims processors on behalf of their transgender or transsexual patients to insist that medically necessary treatments are covered. In such interactions it will be necessary to support the patient’s preferred gender in relationship to the insurance company in the best interests of the patient’s health.”

It seems that this may be a competency well worth including in any physician-training program.—G. Meredith Betz

  • Johns Hopkins was once a leader in transgender surgeries in the 1960s, but made the decision as an institution to no longer perform them in the 1970s – for behavioral health and effectiveness reasons. In his Wall Street Journal op-ed piece, Paul McHugh describes the reasoning and statistics behind Johns Hopkins’ decision:

    • Jill Davidson

      First, a lot has changed in 40 years, in terms of what research we have on the risks transgender people face, as well as on outcomes of care. Second, Paul McHugh had the express purpose of shutting down the gender clinic when he arrived at Johns Hopkins. He has moral proscriptions against the existence of transgender people – he cannot be considered credible to report objectively about the needs of transgender people and the best ways to address those needs. Although he probably did the trans community a favor. The U.S. has gone to a system a private surgeons performing most of the transition related surgeries here, and if you have the money in pocket, access is not difficult. In countries that still operate a gender clinic system, like the UK, Canada, Australia, New Zealand, wait lists are endless. It’s estimated the wait time for trans men in New Zealand is now 40 years.

  • Lisa Haderlein

    Michael – I would love to read that article, but I am not a WSJ subscriber.

    Can we put the whole transgender movement into perspective for a moment?

    I think what concerns me about all the attention being given to transgender individuals and their issues is that they constitute a tiny proportion of the population while at the same time fully 50% of the world population is still struggling for equal health care, equal pay, equal opportunities to work and have an education and social equality (namely, women). Frankly, transgender issues seem so “first world” in nature. While I feel for the individuals who identify a transgender, as a woman, I see greater urgency and need to fight for equality for women.

    Or, while I’m thinking about it, black Americans. Or Native Americans. Sheesh.

    Does it stink that a transgender person may have an insensitive doctor? Sure. But it stinks that anyone could have an insensitive doctor. Like the doctor who suggested I must be having an extramarital affair because of a particular infection I had. Or the one who suggested that the daily injection of medication I had to take would be good to incorporate into foreplay.

    The fact is that there are always going to be people who are utter, clueless jerks. When any of us encounter them, we choose to put up with it, educate them, or just move on.

    • Jill Davidson

      First, trans women are women; black trans women are black women. Second, to the extent “first world” and “third world” make sense anymore, the U.S. includes first world and third world communities within its borders, in terms of poverty and access to health care. “First world” trans people, those who are white, highly educated, have good employment, socialized as men (such as myself), have little difficulty accessing quality health care. Those who are trans people of color, who were forced to leave school and home, who are unemployed, have much less access to health care and live much more dangerous lives. We have had 8 trans women murdered in the U.S. during the first two months of 2015, all women of color.

      And we’re not talking just insensitivity among doctors here. Twenty percent of trans people have reported verbal harassment in health care offices; 5% have reported being physically assaulted in health care offices. Or my own experience, when I was sent for a diagnostic mammogram after a “suspicious” lesion was seen on the screening mammogram. The radiologist told me there no screening programs for “people like you” and wouldn’t tell me the results.

      This is not a zero sum game. Showing kindness to trans patients doesn’t deprive cisgender patients of kindness. Providing health care to trans people doesn’t deprive cisgender people of care.

  • Jill Davidson

    First, a lot has changed in 40 years, in terms of what research we have on the risks transgender people face, as well as on outcomes of care. Second, Paul McHugh had the express purpose of shutting down the gender clinic when he arrived at Johns Hopkins. He has moral proscriptions against the existence of transgender people – he cannot be considered credible to report objectively about the needs of transgender people and the best ways to address those needs.

  • Meredith Betz

    Lisa, thank you for your response. Our daily newswire articles pick up on the latest and trending news that has significance in the nonprofit sector. However, you have given me pause to thing about ways I would have mentioned other constituencies as well.

    Your bring up a host of issues that NPQ has been following. I agree that there is a critical need to address social inequities, in this case in healthcare. In this particular story my intention was to highlight ways in which new physicians are being taught to be aware of and responsive to cultural differences and to communicate to a patient in a way that builds trust in the patient-doctor relationship. Hospitals are requiring clinicians to be trained in cultural diversity but there needs to be the same opportunity in the primary care setting. Hopefully with this new generation the insensitivity that you experienced won’t exist.