Transition-related Care Research Articles

Transgender health in medical education.

Transforming our world the 2030 agenda for sustainable development is working towards a world that reflects equity, with universal respect for human dignity, pledging to leave no one behind. However, transgender and gender-diverse individuals experience significant health inequities, including negative health outcomes and multiple barriers to accessing care. In this article, we first highlight the health inequities that transgender and gender-diverse people face globally. We describe important aspects of transgender and gender-diverse health care, including the design and provision of health services, epidemiological considerations, transition-related care, changes in transition-related goals, cultural considerations, and political and legal issues. We then review the existing global literature on incorporating transgender health into medical curricula. We make a case for prioritizing improved education in medical schools on the specific health needs of transgender and gender-diverse people as part of addressing global health inequities in care. Our recommendations for comprehensive education on transgender health include cultural humility and anti-oppression training; involvement of transgender and gender-diverse community members; integration of transgender and gender-diverse health into curricula; practice-focused and in situ training; staff development in medical schools; and improving access to careers in medicine for transgender and gender-diverse people.

Gender-Affirming Health Insurance Reform in the United States.

In May 2014, the US Department of Health and Human Services prohibited insurance discrimination of transgender individuals. Despite this, insurance plans often lack explicit guidelines on gender transition-related care and coverage of surgical procedures is extremely varied. We evaluated the evolution of insurance coverage of gender-affirming care following the 2014 legislative change. Insurance providers were selected based on company market share. We conducted a Web-based search and telephone interviews to identify the corresponding policies related to gender-affirming health care. We compared policy changes made before and after the 2014 US Department of Health and Human Services decision. Of the 92 insurers surveyed, 7% did not have a policy, and 315 policy revisions were documented. After the legislation, a significantly higher proportion of policy revisions were related to coverage of services (36% vs 11%, P < 0.0001), removal of existing criteria significantly decreased (23% vs 49%, P = 0.0044), and addition of criteria unrelated to international standards sharply increased (32% vs 2%, P = 0.0002). This resulted in reduced coverage of facial feminization, hair transplantation, laryngochondroplasty, and voice modification surgery. However, nipple reconstruction experienced increased coverage. The percentage of revisions to add preauthorization criteria to meet international standards (49% vs 45%, P = 0.6714) or to change terminology (37% vs 27%, P = 0.1055) were similar before and after the legislation. After the transformative legislation in 2014, an increasing number of insurance companies established gender transition-related policies. As more patients seek gender-affirming care, insurers deviate from international guidelines and create additional benchmarks that may act as barriers to care.

Early Intervention for LGBTQ Health: A 10-Hour Curriculum for Preclinical Health Professions Students.

IntroductionIndividuals who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ) face significant health disparities and barriers to accessing care. Patients have reported provider lack of knowledge as one of the key barriers to culturally responsive, clinically competent care. Many US and Canadian medical schools still offer few curricular hours dedicated to LGBTQ-related topics, and medical students continue to feel unprepared to care for LGBTQ patients.MethodsWe developed a 10-hour LGBTQ health curriculum for preclinical medical and physician assistant students. The curriculum included lectures and case-based small-group discussions covering LGBTQ terminology, inclusive sexual history taking, primary care and health maintenance, and transition-related care. It also included a panel discussion with LGBTQ community members and a small-group practice session with standardized patients. Students were surveyed before and after completing the curriculum to assess for increases in confidence and knowledge related to LGBTQ-specific care.ResultsForty first- and second-year medical students completed the sessions and provided valid responses on pre- and postcourse surveys. Nearly all students initially felt unprepared to sensitively elicit information, summarize special health needs and primary care recommendations, and identify community resources for LGBTQ individuals. There was significant improvement in students' confidence in meeting these objectives after completion of the five sessions. Knowledge of LGBTQ health issues increased minimally, but there was a significant increase in knowledge of LGBTQ-related terminology.DiscussionOur 10-hour LGBTQ health curriculum was effective at improving medical students' self-confidence in working with LGBTQ patients but was less effective at increasing LGBTQ-related medical knowledge.

Gender-Affirming Health Insurance Reform in the United States

INTRODUCTION In May 2014, the US Department of Health and Human Services prohibited insurance discrimination of transgender individuals. Despite this, insurance plans often lack explicit guidelines on gender transition-related care and coverage of surgical procedures is extremely varied. We evaluated the evolution of insurance coverage of gender-affirming care following the 2014 legislative change. METHODS Insurance providers were selected based on company market share. We conducted a Web-based search and telephone interviews to identify the corresponding policies related to gender-affirming health care. We compared policy changes made before and after the 2014 US Department of Health and Human Services decision. RESULTS Of the 92 insurers surveyed, 7% did not have a policy, and 315 policy revisions were documented. After the legislation, a significantly higher proportion of policy revisions were related to coverage of services (36% vs 11%, P < 0.0001), removal of existing criteria significantly decreased (23% vs 49%, P = 0.0044), and addition of criteria unrelated to international standards sharply increased (32% vs 2%, P = 0.0002). This resulted in reduced coverage of facial feminization, hair transplantation, laryngochondroplasty, and voice modification surgery. However, nipple reconstruction experienced increased coverage. The percentage of revisions to add preauthorization criteria to meet international standards (49% vs 45%, P = 0.6714) or to change terminology (37% vs 27%, P = 0.1055) were similar before and after the legislation. CONCLUSIONS After the transformative legislation in 2014, an increasing number of insurance companies established gender transition-related policies. As more patients seek gender-affirming care, insurers deviate from international guidelines and create additional benchmarks that may act as barriers to care.

Effect of Medicaid Expansion on the Crowdfunding Behavior of Transgender Adolescents

While some states in the USA have increased access to medical transition through mandating the services’ inclusion in their Medicaid expansion and tying in policy mandating transition-related care in private insurance plans, other states have chosen not to. Along with other factors, this uneven expansion has encouraged transgender adolescents to turn to crowdfunding to raise money for transition-related care. This ecological descriptive study compared trends in states with a Medicaid expansion that included access to medical transition for transgender adolescents to those that did not, through the lens of crowdfunding practices used to pay for a variety of transition-related healthcare costs. There was a proportionally higher number of transgender people conducting crowdfunding campaigns in states where Medicaid does not mandate access to a standard set of procedures for transgender people under 18 (unmandated state) than states where Medicaid does mandate access to a standard set of procedures for transgender people under 18 (mandated state). In the total sample of 98 cases, 60% (n = 59) were from unmandated states, while 40% (n = 39) were from mandated states. A surprising finding of this study was the prevalence of campaigns from mandated states. While access barriers previously discussed in the literature can account a great deal of the campaigns, an individual’s ability to work healthcare systems to their advantage, termed savvy in this paper, may account for the other cases. Transgender adolescents may need special outreach to educate them about their ability to use Medicaid to pay for transition, and guidance through overcoming access barriers to do so. Healthcare navigators skilled in the needs of transitioning adolescents are a worthy avenue for future policy development and funding.

Dysmenorrhea and Endometriosis in Transgender Adolescents.

To study the presentation of dysmenorrhea and endometriosis in transmasculine adolescents and review their treatment outcomes. A retrospective review. Boston Children's Hospital. Transmasculine persons younger than 26years old who were diagnosed with dysmenorrhea and treated between January 1, 2000 and March 1,2020. Not applicable. An electronic medical record review of the clinical characteristics, transition-related care, and treatment outcomes. Dysmenorrhea was diagnosed in 35 transmasculine persons. Mean age was 14.9years±1.9years. Twenty-nine (82.9%) were diagnosed after social transition. Twenty-three of 35 (65.7%) were first treated with combined oral contraceptives, but 14/23 (61%) discontinued or transitioned to alternative therapy. Twelve patients with dysmenorrhea alone initiated testosterone treatment, and 4/12 (33.3%) experienced persistent symptoms. Seven of 35 patients with dysmenorrhea (20.0%) were laparoscopically evaluated for endometriosis, and it was confirmed in all seven. Six had stage I disease, and one had stage II. Three of the 7 (42.9%) were diagnosed after social transition, with one diagnosed 20months after initiating testosterone treatment. Their endometriosis was treated with combined oral contraceptives, danazol, or progestins; four experienced suboptimal response during treatment with these therapies alone. Two of those with suboptimal response subsequently resolved their dysmenorrhea when using testosterone. Five patients with endometriosis initiated testosterone treatment, and of the 5 (40%) experienced persistent symptomatology with combined testosterone and progestin therapies. To our knowledge, this is the first study to characterize endometriosis in transmasculine persons. Evaluation for endometriosis was underutilized in transmasculine persons with dysmenorrhea, despite those who underwent laparoscopic evaluation and had disease confirmation. Although testosterone treatment can resolve symptoms in some, others might require additional suppression. Endometriosis should be considered in transmasculine persons with symptoms even when they are using testosterone.

A Matter of Conscience: Examining the Law and Policy of Conscientious Objection in Health Care

Conscientious objection refers to refusal by a health care provider (HCP) to provide certain treatments, including the standard of care, to a patient based upon the provider's personal, ethical, or religious beliefs. Federal and state rules regarding conscientious objection have expanded the scope of legal protections that HCPs and institutions can invoke in support of refusal. Opponents of these rules argue that allowing refusal of care deprives patients of care that conforms to professionally established guidelines, contradicts long-standing principles related to informed consent, interferes with the ability of health care facilities to provide safe and efficient care, and leaves the patient without means of redress for injury. Proponents respond that such rules are necessary to preserve the moral integrity of providers, including institutions. Although refusal rules are most often associated with abortion, some HCPs have cited moral concerns regarding contraception, sterilization, prevention/treatment of sexually transmitted infections, transition-related care for transgender individuals, medication-assisted treatment of substance use disorders, the use of artificial reproductive technologies, and patient preferences for end-of-life care. Evidence suggests that the burden of conscientious refusal falls disproportionately on vulnerable populations, and legitimate concern exists that moral disagreement is merely pretext for discrimination. A careful balance must be struck between the defending the conscience rights of HCPs and the civil rights of patients.

\u201cObjectively terrifying\u201d: a qualitative study of youth\u2019s experiences of transitions out of child and adolescent mental health services at age 18

BackgroundMental health issues presenting in childhood often persist into adulthood, usually requiring youth to transition from child and adolescent mental health services to adult mental health services at 18 years. Discontinuity of care during this transition period is well-documented and can leave youth vulnerable to adverse mental health outcomes. There is growing recognition of the need to improve transition-related care for youth leaving the child and adolescent mental health system. However, the perspectives and experiences of youth have not always been forefront in these discussions, and in particular, the perspectives of youth in the pre-transition period. This study qualitatively explores transition-related knowledge and experiences of youth both prior-to and after transition.MethodsA purposive sample of youth aged 16–19 years was recruited from two child and adolescent mental health programs. Youth were enrolled as part of a longitudinal follow-up study and had the opportunity to opt into this study. Interviews were transcribed and coded using NVivo11 software. Main themes were distilled through descriptive analysis following the principles of directed content analysis. The study followed the principles of participatory action research, engaging youth with lived experience navigating transitions in each stage of the study.ResultsIn-depth, semi-structured interviews were conducted with 14 pre-transition and 8 post-transition youth. All youth reported having either a mood and/or anxiety disorder for which the majority were receiving treatment at the time of the interview. The participants’ experiences were distilled into six major themes. Youth advocated for being considered partners in transition planning and to have increased control over transition-related decisions. Youth also made specific recommendations on how to improve continuity of care during the transition process.ConclusionsTransition planning should be individualized for each youth based on their developmental needs, transition readiness and ongoing mental health needs. Transition pathways, co-designed with youth and caregivers, should be developed to guide providers in transition best practices. Obtaining both the pre- and post-transition experiences of youth is crucial for developing a more complete of understanding of youth perspectives and implementing guidelines that improve transition quality and experiences.

Learning by chance: Investigating gaps in transgender care education amongst family medicine, endocrinology, psychiatry and urology residents.

BackgroundThe transgender (trans) population is one of the most underserved in health care. Not only do they face discrimination and stigma from society as a whole, they also have difficulty accessing transition-related care, leading to adverse outcomes such as suicide. We aimed to increase understanding on how our current postgraduate education system contributes to a lack of care for trans patients.MethodsOur study consisted of 11 semi-structured interviews conducted in 2016 with residents in the following specialties: family medicine (3), endocrinology (3), psychiatry (3), and urology (2). We used Framework Analysis to qualitatively analyze our data.ResultsResidents described a lack of trans care education in the core curriculum, in part due to a lack of exposure to experts in this area. They also expressed discomfort when dealing with trans patients, due to inexperience and lack of knowledge. Furthermore, residents in each specialty had false assumptions that other specialties had sufficient knowledge and expertise in trans care.DiscussionThis study highlights how the lack of teaching and clinical experiences with trans patients during residency contributes to the poor access to healthcare. By systematically embedding trans care in the curriculum, medical education can play a prominent role in addressing the healthcare disparities of this underserved population.

A Review of Insurance Coverage of Gender-Affirming Genital Surgery

Despite the multiple benefits of gender-affirming surgery for treatment of gender dysphoria, research shows that barriers to care still exist. Third-party payers play a pivotal role in enabling access to transition-related care. The authors assessed insurance coverage of genital reconstructive ("bottom") surgery and evaluated the differences between policy criteria and international standards of care. A cross-sectional analysis of insurance policies for coverage of bottom surgery was conducted. Insurance companies were selected based on their state enrollment data and market share. A Web-based search and telephone interviews were performed to identify the policies and coverage status. Medical necessity criteria were abstracted from publicly available policies. Fifty-seven insurers met inclusion criteria. Almost one in 10 providers did not hold a favorable policy for bottom surgery. Of the 52 insurers who provided coverage, 17 percent held criteria that matched international recommendations. No single criterion was universally required by insurers. Minimum age and definition of gender dysphoria were the requirements with most variation across policies. Almost one in five insurers used proof of legal name change as a coverage requirement. Ten percent would provide coverage for fertility preservation, while 17 percent would cover reversal of the procedure. Despite the medical necessity, legislative mandates, and economic benefits, global provision of gender-affirming genital surgery is not in place. Furthermore, there is variable adherence to international standards of care. Use of surplus criteria, such as legal name change, may act as an additional barrier to care even when insurance coverage is provided.

The Misuse of Gender Dysphoria: Toward Greater Conceptual Clarity in Transgender Health

The notion of gender dysphoria is central to transgender health care but is inconsistently used in the clinical literature. Clinicians who work in transgender health must understand the difference between the diagnosis of Gender Dysphoria as defined and described in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and the notion of this term as used to assess eligibility for transition-related interventions such as hormone-replacement therapy and surgery. Unnecessary diagnoses due to the belief that a diagnosis is clinically required to access transition-related care can contribute to stigma and discrimination toward trans individuals.

Trends in Referrals to a Pediatric Transgender Clinic.

We characterized referral trends over time at a transgender clinic within an integrated health system in Northern California. We identified the transition-related requests of pediatric transgender and gender-nonconforming patients and evaluated differences in referrals by age group. Medical records were analyzed for all patients <18 years of age in the Kaiser Permanente Northern California health system who were referred to a specialty transgender clinic between February 2015 and June 2018. Trends in treatment demand, demographic data, service requests, and surgical history were abstracted from medical charts and analyzed by using descriptive statistics. We identified 417 unique transgender and gender-nonconforming pediatric patients. The median age at time of referral was 15 years (range 3-17). Most (62%) identified on the masculine spectrum. Of the 203 patients with available ethnicity data, 68% were non-Hispanic. During the study period, the clinic received a total of 506 referrals with a significant increase over time (P < .001). Most referrals were for requests to start cross-sex hormones and/or blockers (34%), gender-affirming surgery (32%), and mental health (27%). Transition-related requests varied by age group: younger patients sought more mental health services, and older patients sought hormonal and surgical services. Eighty-nine patients underwent gender-affirming surgeries, mostly before age 18 and most frequently mastectomies (77%). The increase in referrals supports the need for expanded and accessible health care services for this population. The transition-related care of patients in this large sample varied by age group, underscoring the need for an individualized approach to gender-affirming care.

Thinking an ethics of gender exploration: Against delaying transition for transgender and gender creative youth.

Youth explore their genders - both theirs and those of others. Exploration is not only a vessel of discovery and understanding but also of creation. Centring the notion of gender exploration, this article inquires into the ethical issues surrounding care for transgender youth. Arguing that exploration is best seen not as a precondition to transition-related care but as a process that can operate through transitioning, the article concludes that the gender-affirmative approach to trans youth care best fosters youth's capacity for healthy exploration. Unbounded social transition and ready access to puberty blockers ought to be treated as the default option, and support should be offered to parents who may have difficulty accepting their youth.

Go fund inequality: the politics of crowdfunding transgender medical care

ABSTRACTDespite improvements in access to transition-related medical care, many transgender people still face numerous barriers to paying for gender-affirming procedures. Crowdfunding websites have gained immense popularity as a strategy for trans people to raise money for transition-related healthcare expenses. Using descriptive statistics and thematic content analysis, this paper illustrates how fundraising campaigns for medical gender transition both reveal and reinforce health and social inequalities. Although trans people crowdfund for a variety of transition-related needs, the majority of online campaigns are used to fund chest surgeries among young, white, binary-identified trans men in the United States. Most campaigns fall dramatically short of their fundraising goals. In addition, campaigns use medicalized, normatively gendered transition narratives that privatize inequality in marginalized communities. The article concludes with a consideration of how to incorporate a ‘revolutionary etiquette’ in crowdfunding for transition healthcare.

Coverage and Coding for Transgender Voice Treatment

Coverage and Coding for Transgender Voice Treatment

Transphobia rather than education predicts provider knowledge of transgender health care

Transgender and gender diverse (TGD) patients face significant hurdles in accessing affirming, knowledgeable care. Lack of provider knowledge presents a substantial barrier to both primary and transition-related care and may deter patients from seeking health care. Little is known about factors that affect provider knowledge or whether exposure to TGD health content during training is associated with improved knowledge among providers. Using the TGD Healthcare Knowledge Scale, this study aimed to determine whether prior education on TGD health predicts clinicians' current knowledge regarding health care for TGD patients. An online survey examining exposure to TGD content and knowledge of TGD health care was distributed to all primary care providers in an integrated health care system in the Midwestern United States. Multivariable linear regression was used to predict provider knowledge, controlling for demographics, transphobia and other potential confounders. The response rate was 57.3% (n=223). The mean knowledge score was 7.41 (SD=1.31) on a 10-point scale. Almost half (48.4%, n=108) had no formal education on TGD health care, yet half (49.7%, n=111) of providers reported previously caring for at least one transgender patient. In regression analysis, provider knowledge of TGD health care was associated with transphobia (β=-0.377, 95% CI=-0.559 to -0.194, p<0.001), but not with hours of formal education (β=-0.027, 95% CI=-0.077 to 0.023, p=0.292) or informal education (β=-0.012, 95% CI=-0.033 to 0.009, p=0.259). Increasing hours of education related to TGD health care may not be sufficient to improve providers' competence in care for TGD individuals. Transphobia may be a barrier to learning that needs to be addressed. Broader efforts to address transphobia in society in general, and in medical education in particular, may be required to improve the quality of medical care for TGD patients.

Findings from Formative Research to Develop a Strength-Based HIV Prevention and Sexual Health Promotion mHealth Intervention for Transgender Women.

Purpose: Transgender women experience significant health disparities, including increased risk of HIV infection. In this study, we examined the sexual health needs of transgender women in the context of their overall health and well-being and to identify overarching content framing strategies and content for a mobile health intervention.Methods: We conducted four focus groups and 20 individual in-depth interviews in the United States with racially and geographically diverse transgender women.Results: Four key themes were identified: structural factors as a central part of health; prioritization of transition-related care and mental health; the need for sexual health beyond preventing sexually transmitted infections and HIV; and the importance of connection and community.Conclusions: These themes can help inform the development of HIV prevention and sexual health promotion interventions for transgender women. The results suggest that the HIV and sexual health needs of transgender women should be addressed within the context of structural factors with a focus on resilience, community connection, and social support.

Perceptions of transition-related health and mental health services among transgender adults

ABSTRACTThe opportunity to live authentically is critical for the well-being of transgender individuals. For many this requires accessing transition-related services. Current knowledge of transition-related care is limited. This study aims to elucidate experiences and needs of transgender individuals (N = 65) related to (a) therapeutic support, (b) medical care, and (c) aspects of living authentically in order to inform the development and delivery of trans-affirmative services. Findings reveal challenges accessing health care providers with trans-specific competency; gaps between critical aspects of transition-related care and receipt of services; and heterogeneity of experiences and needs. Recommendations for improving transgender-affirmative services are provided.

Barriers to Gender Transition-Related Healthcare: Identifying Underserved Transgender Adults in Massachusetts.

Purpose: The present study sought to examine whether individual (e.g., age, gender), interpersonal (e.g., healthcare provider discrimination), and structural (e.g., lack of insurance coverage) factors are associated with access to transition-related care in a statewide sample of transgender adults.Method: In 2013, 364 transgender residents of Massachusetts completed an electronic web-based survey online (87.1%) or in person (12.9%). A multivariable logistic regression model tested whether individual, interpersonal, and structural factors were associated with access to transition-related care.Results: Overall, 23.6% reported being unable to access transition-related care in the past 12 months. In a multivariable model, younger age, low income, low educational attainment, private insurance coverage, and healthcare discrimination were significantly associated with being unable to access transition-related care (all p<0.05).Discussion: Despite state nondiscrimination policies and universal access to healthcare, many of the Massachusetts transgender residents sampled were unable to access transition-related care. Multilevel interventions are needed, including supportive policies and policy enforcement, to ensure that underserved transgender adults can access medically necessary transition-related care.

(Dis)integrated Care: Barriers to Health Care Utilization for Trans Women Living With HIV

Transgender (trans) women have been particularly impacted by HIV. To seek insights into the dynamics of health service utilization, interviews were conducted with trans women living with HIV (n=14) as part of the Trans PULSE community-based research project in Ontario, Canada. Service providers (n=10) were also interviewed to provide additional details about communication between trans women, social service providers, and clinicians. Results highlight how both problematic interactions with individuals and health systems navigation challenges affect access to services and impede the development of trans-specific HIV supports. Participants described discrimination, identified strategies for navigating a dysfunctional system, and outlined specific ways in which health and social services may be failing trans women living with HIV. Findings support the importance of coordinating HIV services and transition-related care, and providing training for service providers.