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Experts push for transgender health priorities in congressional briefing
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WASHINGTON — There is a “durable, biological underpinning” to gender identity that should be considered in any policy determinations that impact transgender people, including antidiscrimination legislation and the coverage of medically necessary treatments for gender incongruence, according to several speakers at an Endocrine Society congressional briefing on transgender health.
Transgender individuals often encounter obstacles in accessing medical care, including a lack of insurance coverage, discrimination and providers lacking proper formal training in transgender medicine, Robert Lash, MD, chief professional and clinical affairs officer for the Endocrine Society, said during a briefing organized to raise awareness on barriers to care for transgender people. The briefing featured speakers who outlined standards of care for transgender persons, public policy hurdles that impact transgender health outcomes, and the latest research on the federal level regarding sexual and gender minorities.
“Our goal for today’s session was to help inform our policy makers about issues of transgender health,” Lash told Endocrine Today. “The government plays such an important role in how health care gets provided that we thought the more that we can do to inform policy makers, legislators and representatives on the transgender medicine issue, the better health care will be for transgender people.”
Evidence-based approach
Despite years of growing awareness of transgender people, and even transgender celebrities, only recently has a noticeable shift begun among the public regarding how to best approach treating people with gender incongruence, Joshua Safer, MD, FACP, executive director of the Mount Sinai Center for Transgender Medicine and Surgery at the Icahn School of Medicine at Mount Sinai, said during the briefing. That shift, he said, is due in part to an increasing evidence base that points to the biological underpinnings of gender identity.
“The establishment medical community recognizes better than it ever did before the biology of gender identity,” Safer said.
While the mechanisms behind transgender identity remain unknown, Safer said, conventional medicine offers options for transgender people to align their physical appearance with their gender identity. Those options include pubertal blockers for transgender or gender-questioning adolescents, hormone therapy and surgical options for adults, which can include facial feminization for transgender women and chest reconstruction for both transgender men and women. Guidelines issued by the Endocrine Society and other professional organizations recognize such options as the standard of care in transgender health, he said.
“We tend to be very genital-focused, thinking, ‘Oh this is all about the sex change operation,’ but, observe that it’s not,” Safer said. “It’s aligning appearance and bodies with gender identity, heavily with hormones.”
“When we go to our meetings, we’re not debating whether we should be treating ambigender people,” Safer said. “Whether Republican or Democrat, we are bipartisan in our [advocacy] organizations. Our debates are on strategy, research gaps, and how we can learn more about transgender people. Those are our scientific conversations.”
Public health 3.0
When considering public policies that impact transgender people, it is important to remember that social determinants of health — defined as where people are born, live, work and age — play a large role in the health outcomes of marginalized populations, Rachel L. Levine, MD, MPH, secretary of health for the commonwealth of Pennsylvania and professor of pediatrics and psychiatry at Penn State College of Medicine, said during a presentation. Social determinants of health, she said, should be looked at as a pillar of public health like clean water access, immunizations and chronic disease management.
According to the 2015 U.S. Transgender Survey conducted by the National Center for Transgender Equality, one-third of transgender adults report experiencing a negative reaction from a health care provider in the past year regarding their status, whereas 40% reported attempting suicide in their lifetime. Additionally, HIV in the transgender community remains five times the rate of the U.S. population at large (1.4% vs. 0.3%) and 55% of transgender adults who sought gender-confirmation surgeries were denied coverage by their health insurance provider, further raising the risk for negative mental health outcomes, Levine said.
“Public health 3.0 emphasizes the social determinants of health — their environment, their housing, their school, their access to medical care,” Levine, who transitioned in 2008, told Endocrine Today. “That applies very specifically to transgender individuals and LGBTQ individuals broadly. There are significant rates of bullying, harassment, discrimination and even sometimes outright violence against transgender individuals in the United States. These lead to negative health outcomes such as depression and anxiety and suicidal ideation and substance abuse. There is nothing inherent with being transgender which would predispose you to those negative health outcomes. It’s the social determinants of health and discrimination that can lead to those negative health outcomes.”
Clinician , public awareness
Most endocrinologists are aware of the available therapies to address transgender needs; however, for some, a gap remains in understanding regarding the nuances of conversation surrounding a person’s decision to transition, Safer said.
“I have people who come in very clear on their gender identity ... and then I’ll have people who show up and they’re uncomfortable with their gender identity and they’re more gender questioning,” Safer told Endocrine Today. “Part of the story is knowing when to be relaxed, and take a step back and be supportive and say ‘I’ll help you however you want to get from A to B.’ We talk about endocrinologists being the experts with regard to the main interventions available to align the visible body with gender identity. Therefore, knowing what a typical course might be could be helpful.
“If someone with an apparently female body comes in gender questioning, giving that person testosterone right off the bat might be the wrong thing,” Safer said. “It’s important to say, ‘You’re going to get facial hair. Is that going to work for you?’”
On the legislative side, Lash said representatives from the Endocrine Society will continue to meet with legislators and government personnel on an ongoing basis with the goal of shaping future policy regarding transgender medicine.
“We’re meeting with legislative offices on a regular basis, bringing down our experts, both for clinical concerns and for research concerns,” Lash said in an interview after the briefing. “We’re always interested in working with our members and our representatives on the hill and at the FDA and CMS and HHS about these issues.” – by Regina Schaffer
Disclosures: Lash is chief professional and clinical affairs officer for the Endocrine Society. Levine is secretary of health for the commonwealth of Pennsylvania. Safer reports no relevant financial disclosures.