“I feel like I have to educate my doctors about my gender identity and transgender health-related needs, including insurance coverage,” my transgender male patient, V, told me on interview. A series of interviews with V for a community outreach project during medical school elucidated a plethora of health care barriers for transgender individuals. V’s list of unmet needs includes transgender-friendly mental health care and LGBTQ+ educated physicians, including complex gender-diverse language and medical knowledge about gender-affirming care. Fortunately, medical schools and residency programs are beginning to adopt more LGBTQ+ education into their curriculum. However, patient access to the already existing LGBTQ+ competent providers is limited, with insurance being a large root of the problem. “My insurance limits who I can receive mental health and gender-affirming medical care from,” V reinforced during our last interview.
Transgender health care is an increasingly important topic that is gaining recognition as more individuals self-identify as transgender and seek help in medically transitioning. While medical transitioning is legal and accepted in some areas of the country, many barriers to health care remain unrecognized by the non-transgender community.
Barriers to health care that transgender individuals experience include but are not limited to cost, inadequate or no health care coverage, and fear of discrimination. In a Colorado transgender health study in 2014, 40 percent of transgender Coloradans reported that cost was a barrier to accessing care. Another 31 percent cited the fear of discrimination as being another barrier. There were 23 percent of people that said that insurance does not provide adequate coverage, and 7 percent could not find a doctor who accepts their insurance. These barriers are greater than those experienced by cisgender individuals, or those who identify with the gender that they were assigned at birth.
Several ways to eliminate these barriers include adding greater insurance coverage for transgender-related medical care, and financial coverage for training to teach physicians how to be transgender-inclusive. This can improve both mental and physical health outcomes for transgender individuals. Although this may seem costly, the improved health outcomes are likely to be correlated with overall less money spent on mental and physical health care.
Fenway, a Boston community health center, is a program that exists as an example of a decentralized clinic with a series of referrals for transgender health care. They provide accessible care, including hormone administration, reproductive rights counseling, post-op care, behavioral health services, etc. A study by Reisner et al. (2015) concluded that creating such extensive and accessible health care for transgender people attracted more transgender individuals to show up to receive care. This study demonstrated that there are many people that were previously in need of more accessible care. The Boston community health center example shows that “if you build it, they will come.”
Improving monetary coverage for insurance and transgender-friendly physician training will enable health care to become more accessible for transgender individuals. Greater access to health care will allow more people in need to show up for care to improve their mental and physical health. Ultimately, this will reduce costs.
The Journal of General Internal Medicine published a study in 2016 which did a cost-effectiveness analysis to demonstrate the utility in providing health insurance coverage for medically necessary services for transgender people. These researchers discovered that in comparison to no health care benefits for transgender patients, insurance coverage for these medically necessary services came at a greater cost and effectiveness. Despite costs for medical transitions being between $10,000 to $22,000 with provider coverage at $2,175 per year, the negative outcomes are greatly reduced. These include a reduction in risk for HIV, depression, suicidality, and drug abuse. Therefore, this study successfully concluded that health insurance coverage for the U.S. transgender population is affordable and cost-effective with a low-budget impact on our society.
Although not all transgender individuals choose to medically transition, where they use medical interventions such as hormones or surgeries, medical care was ultimately crucial for V and living authentically within his identity. While V had health insurance through Kaiser, he ultimately had to go out of network and pay the full amount of $11,000 for his top surgery, a subcutaneous mastectomy to remove his breast tissue: “My insurance was going to cover it, but I was not comfortable with the one surgeon that they would cover.”
V further shared his disappointment about this surgeon’s lack of portfolio photo results and their admittance to having done only a handful of this particular surgery. Unfortunately, this is a common phenomenon that can be heard buzzing throughout the transgender community, leading individuals to go out of network and pay large amounts of money. In addition to enhanced medical trainee and provider education, it is essential that gender-affirming medical insurance coverage is increased and broadened.
Dylan Herman is a medical student.
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