Lack of providers, insurance denials among most common barriers to gender-affirming HT
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Key takeaways:
- Transgender people reported insurance denials and difficulty finding a provider as barriers to gender-affirming HT.
- Clinicians reported stigma and lack of training as barriers for providing transgender care.
Lack of available health care providers, health insurance exclusions and a lengthy assessment process are among barriers transgender people face when seeking gender-affirming hormone therapy, according to study findings.
In a scoping review published in Transgender Health, researchers examined studies assessing barriers to transgender care. In addition to barriers faced by patients, some studies surveyed providers and found they had issues in regard to training and insurance reimbursements for gender-affirming HT.
“To reduce the barriers, policymakers and employers should ensure that both public and private insurance plans cover gender-affirming care,” Lauren Porsch-Ortega, PhD, MPH, associate director of health outcomes research at Planned Parenthood Federation of America, told Healio. “Further, it is critical that institutions that train health professionals establish formal teaching, training and mentoring opportunities for future clinicians in gender-affirming HT. Expanding access to gender-affirming HT via telehealth may also improve access to care.”
Porsch-Ortega and colleagues searched the MEDLINE, Embase, CINAHL and PsycINFO databases for studies reporting on barriers and facilitators faced by transgender, nonbinary or gender-expansive youths or adults when accessing gender-affirming HT, or barriers and facilitators clinicians faced to providing gender-affirming HT. Studies published from 2000 to March 10, 2023, were included in the review.
The review included 61 studies, of which 28 assessed barriers for adult patients, 15 assessed barriers for youth patients, 10 examined barriers for providers and eight looked at barriers for both providers and patients.
Provider barriers
For providers, barriers to prescribing gender-affirming HT for adults included gaps in medical knowledge, difficulty navigating gender dysphoria diagnoses, perceived stigma attached to treating transgender people, lack of referral sources and health system deterrents such as health insurance barriers and length of time needed for patient visits. Studies examining facilitators found multidisciplinary health care teams, internal rewards of providing gender-affirming HT, professional guidelines supporting protocols to guide care and telehealth all helped with facilitating care.
For providers caring for transgender youths, barriers included lack of training, lack of exposure to transgender patients, shortage of mental health providers to refer to and lack of insurance coverage.
“Not all health care providers have knowledge and understanding of transgender and gender-expansive identities,” Porsch-Ortega said. “Health care environments can be unwelcoming to transgender and nonbinary patients — from filling out exclusionary demographic surveys, to being misgendered, to concerns over cost and insurance coverage.”
Patient barriers
The most common barriers to gender-affirming HT for transgender adults were discrimination in health care settings, difficulty finding a provider and the cost of care and insurance denials. Some transgender adults reported pressure to prove they were transgender or, in the case of nonbinary adults, pressure to identify as a binary gender. Some transgender adults reported obtaining hormones without a prescription. Lack of a regular health care provider, not having a diagnosis from a psychiatrist and low income were among the factors associated with obtaining hormones from a nontraditional source.
“We were concerned by the reported frequency of transgender and gender-expansive individuals ‘self-prescribing’ hormones, or obtaining them outside of traditional medical sources, likely due to difficulties accessing them through licensed medical providers,” Porsch-Ortega said. “This phenomenon may pose potential health risks to transgender and gender-expansive individuals.”
Facilitators to gender-affirming HT for adults included ability to receive HT through telemedicine visits and use of an informed consent model of care that decreased assessment wait times.
Among youths, common barriers to gender-affirming HT and puberty blockers included challenges navigating the health care system, lack of clear pathways to care, insurance denials and difficulty affording care. Youths also reported long wait times and an extended assessment process prior to starting HT. Two studies examining facilitators to gender-affirming HT for youths focused on telemedicine increasing access to appointments.
Porsch-Ortega said future research needs to examine the impact of additional barriers to gender-affirming HT, especially in areas of the U.S. where recently adopted legislation limits access to care. More studies are also needed to find facilitators to care other than telemedicine, Porsch-Ortega added.
For more information:
Lauren Porsch-Ortega, PhD, MPH, can be reached at lauren.porsch@ppfa.org.
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