Morissa Ladinsky, MD

Section 1557 did several things.

It extended the nondiscrimination protections around a person's inner sense of their gender — even if it did not match the sex the person was assigned at birth — saying transgender people must never receive differential services in health care delivery and cannot be denied equal access to health care. Any provider or institution that received even a penny of federal funding through HHS was obligated to uphold these extended non-discrimination protections.

Section 1557 also gave medical providers and educators a golden opportunity to elevate understanding around gender identity, trans identities and how to deliver quality affirming health care for that population. While we still have much work to do in helping physicians understand transgender identities and medical avenues to address gender dysphoria, we have come a long way since Section 1557’s initial adoption.

Section 1557 also accelerated large strides in in addressing the provision of culturally responsive care in medicine.  Recent demands for racial equity and inclusion can build on these gains. It remains my prayer that this final rule will not derail much needed progress in provision of care for all marginalized and stigmatized patients. The culture in our country has come too far.

The final rule does not mandate health care systems and providers operationally change the care they deliver to LGBTQ-identified people. My hope is that even with this final rule, health care providers and health systems will continue to look inward and become better versions of their best selves. The HHS final rule does not mandate physicians to be ignoramuses and bigots. Our duty remains to our patients and families — all of them.

W. David Hardy, MD, AAHIVS

There are important medical implications of the HHS final rule. Health care providers need to know a person’s sex assigned at birth and current gender identity to deliver adequate, competent, compassionate and culturally appropriate health care. Multiple studies have demonstrated that transgender people often get much less competent health care than their cisgender counterparts, because many medical professionals do not know their patients are transgender and do not do the right kind of tests, examinations, etc. that a patient should have.

For example, a transgender man who has had his breasts surgically removed is still at risk for developing breast cancer, since oftentimes some breast tissue remains after gender-affirmingsurgeries. A transgender woman may not have had her gender-affirming surgeries yet and therefore needs to have her testicles examined for testicular cancer.

Many medical professionals are not sufficiently trained or aware of the specific personal, medical and societal concerns of transgender persons. Consequently, health care providers are often embarrassed when they address  their transgender patients using  the wrong name or gender identity or worse yet, not aware of their frequently traumatic experiences with heath care providers. . For these reasons, even before this final rule, many transgender people often avoided seeking medical care because they feel like they are putting their personal sense of worth on the line every time they walk into a medical facility ostensibly functioning to help them. This final rule will likely more deeply isolate  people who are transgender and drive them even farther away from health care than they are now.

Section 1557 of the Affordable Care Act was originally written in 2010 very broadly in terms of race, color, religious affiliation, sex and gender. With this final rule, Section 1557 effectively denies the existence of the 1.4 million people in the United States who identify themselves as transgender. Section 1557 also now says that transgender people should not and do not exist, even though transgender people feel most comfortable, are well-adjusted and live healthy lives with their current and chosen gender identity.

As a health care provider, I find it highly discomforting that a law that was written to prevent health care discrimination has now been completely re-directed to become highly discriminatory against a group of persons at great personal physical, social and economic risk and who often need health care the most. And this is being quietly perpetuated by simply re-defining the word “sex” in a very narrow fashion. This is very ifficult to swallow as a health care professional.

When physicians graduate from medical school., we swear o the Hippocratic oath, which asks us to commit to taking care of our fellow human beings without personal prejudice, without regard to our own personal feelings and to provide the highest quality of compassionate health care that we can achieve. This final rule ignores the most basic principles upon which doctors, other health care providers and the rest of the health care establishment is built on and mocks the personal and professional commitment to a physician’s life work. Therefore, in my opinion, the great majority of doctors will continue doing what they are trained to do, eveneven if it goes against the rule.

Reference: Flores AR, et al. How many adults identify as transgender in the United States? https://williamsinstitute.law.ucla.edu/wp-content/uploads/How-Many-Adults-Identify-as-Transgender-in-the-United-States.pdf. Accessed June 18, 2020.