Monday, June 24, 2019

Guest Post: Transcend helplessness, advocate for transgender patients

- Hayley E. Cummingham, MD and Tonia Poteat, PA-C, PhD

Do you remember that feeling as a medical student, back against a wall as you watched life and death unfold? You may have felt disappointed when that sense of helplessness did not disappear with a medical degree. It is easy to feel helpless when your patients fear being “defined out of existence.” In October 2018, the New York Times uncovered a memo from the U.S. Department of Health and Human Services (HHS) that proposed redefining “sex” as written in numerous anti-discrimination laws to be “based on immutable biological traits identifiable by or before birth.” This represented a dramatic policy reversal from 2016, when HHS passed a regulation clarifying that discrimination on the basis of sex encompasses gender identity.

Emboldened by the current administration’s perceived animosity toward the transgender community, conservative state representatives and organizations sued the HHS in 2016, rendering it unable to enforce protections against gender identity discrimination as the executive branch reviewed the regulation. The outcome was a proposed rule issued last month, which includes a narrowed definition of “sex” that will allow health care providers and insurers to refuse to provide or cover medically necessary and potentially life-saving care.

According to a 2015 survey, 40% of transgender adults have attempted suicide and 82% have seriously considered it. Rates of suicidal ideation and attempts among transgender adolescents reach 51% and 30%, respectively. A growing body of evidence indicates that access to gender affirming therapies, including but not limited to exogenous hormones and surgery, can reduce the risk for suicide among transgender people.

It is easy to feel helpless in the face of injustice, but physicians have the power to influence social and political determinants of health. For example, having entered a 60-day period for public comment on the proposed HHS regulation, physicians and others can voice their opposition at Physicians can attend advocacy events wearing white coats, meet with elected representatives, or publish opinion pieces. Consider keeping a de-identified record of patient stories and reach out to an advocacy organization for guidance on using them to advocate for those patients. Physician educators, testing boards, and residency programs can train future physicians on the health care needs of gender-diverse individuals.

Within your own practice, ensure that you are not part of the problem, and empower yourself to provide gender-affirming care. One third of transgender persons have had at least one negative experience with a clinician in the past year related to being transgender, including verbal harassment (6%), treatment denial (8-11%), invasive or unnecessary questioning (15%), or clinician ignorance requiring education by the patient (24%). Reading the December 2018 AFP article, Caring for Transgender and Gender-Diverse People: What Clinicians Should Know, is an excellent place to start. In addition to the steps outlined in the article, you can offer to write “carry letters,” which explain that a patient is undergoing gender transition and that appropriate pronouns and facilities are medically necessary. These documents advocate for patients in situations involving bathrooms, airport security, police interactions, employers, residential placement, etc. You can dive deeper by familiarizing yourself with national and global guidelines and utilize online resources offered by the Fenway Institute. Before making referrals, contact providers to assess their level of comfort caring for transgender patients or use a gender-affirming provider directory.

Every day that we care for patients, we put ourselves at risk for feeling helpless. When our patients face increasing social and political injustice, we cannot be wallflowers. For the well-being of our patients and ourselves, we must advocate.