By: Michael Givens/TRT Assistant Editor—
Like many transgender people, Terry often found themself at a loss when accessing high-quality healthcare services that recognized and affirmed their identity.
Terry, who asked not to be identified by their legal name, uses plural pronouns (they, them, and their) and said that culturally competent care for trans people is often lacking.
“My experience receiving healthcare services in Massachusetts has been … mixed,” they said. “I would say that most of my providers have not been outwardly transphobic, but they have not been trans-informed or educated about trans issues.
“By that I mean they seem to not have any info about transition-related issues, did not ask for my pronouns, and did not think through how my being trans has affected my mental or physical health. I would not call them prejudiced, but consciously uninformed about trans issues and concerns. And this is with relatively good, private health insurance and regular access to specialists of all kinds.”
Regardless of the quality of health insurance, many trans people’s experiences when entering the doctor’s office can often be jarring, to say the least. According to the National Center for Transgender Equality 2015 Transgender Survey, roughly one-third of respondents reported having a negative experience with a healthcare provider. Sometimes compounded by inadequate insurance access—or no insurance at all—trans people often have to navigate a system that provides little comfort or specialized care for those who don’t identify as cisgender, a term used to denote someone whose gender identity corresponds to their sex assigned at birth.
“I think the main challenge [I’ve encountered in entering a doctor’s office] is doctors not thinking through how being trans might affect whatever kind of care I’m hoping to access—how being trans might affect my mental health, or how my needs for gynecology might be different as a result of my gender identity,” Terry said. “I don’t expect doctors to be experts in trans health issues, but I don’t think it’s unreasonable to expect them to have a basic understanding of how gender affects healthcare in a broad way.”
Sabrina Santiago, co-director of The Network/La Red, a nonprofit serving the LGBTQ community that advocates for an end to domestic partner abuse, provided a troubling example of the type of challenge a trans person can face when seeking care.
“What we hear from transgender survivors is the experience of being misgendered with doctors, nurses, [and] social workers not using the name or pronouns that the patient has asked to be used,” she said. We have worked with survivors whose doctor’s ask about the patient’s safety at home or how they received a particular injury right in front of their abusive partner. We hear of this experience from not only transgender survivors but also lesbian, gay, and bisexual survivors as well. I believe that because of homophobia and transphobia, doctors, nurses, and social workers are often still not even registering that LGBQ/T relationships exist and that their patient might not be straight and cisgender.”
This erasure or denial of identities can often signal a severe safety issue for those seeking care.
“Too often the safety concerns that transgender survivors may be facing from partner abuse go unaddressed,” she continued. “Medical staff know not to ask someone they perceive as a cisgender, straight woman whether she is safe at home in front of her husband or boyfriend. There needs to be an understanding that you cannot always know who a patient’s partner might be. Questions like this in front of abusive partners at the very least won’t get accurate information and at the worst put the patient at risk of further harm.”
Dr. Robert Goldstein MD, Ph.D.; Medical Director, MGH Transgender Health Program of the Massachusetts; Photo: Massachusetts General Hospital Department of Medicine
Not a Trivial Matter
In Boston, Fenway Community Health has long been considered a resource for members of the trans community to seek care. In recent years, Boston Medical Center has also gained notoriety for its increasing provision of healthcare coverage for transgender people.
But how does the rest of New England shape up?
According to the Human Rights Campaign’s Healthcare Equality Index (HEI), New England is progressing steadily with efforts to equip facilities to not only serve the trans population but serve the trans population equitably.
“As the director of LGBTQ Services, I provide training to various areas of the hospital, as well as the outpatient facilities,” said Aleah Nesteby of Cooley Dickinson Hospital in Northampton, Massachusetts, which received recognition from HRC for its LGBTQ-inclusive healthcare program. “We are currently developing a more explicitly trans-inclusive training for all new hires, as well as discussing the ongoing training and education needs of long-term staff and clinical providers.”
Nesteby says that the hospital is aspiring to standardize the program so that all 1,500 staff members will receive cultural competency training.
“Clinicians and care providers can also participate in a voluntary continuing education program through the Healthcare Equality Index,” she said. “Providers who complete the continuing education hours are designated with a special rainbow icon in our online directory.”
Cooley Dickinson is one of 13 healthcare facilities in Massachusetts acknowledged as providing LGBTQ-inclusive care.
“One of our patients said the following to her provider recently, ‘I am very appreciative of the care I receive … and particularly the women’s health center’,” said Dr. Lauren Schlanger, a primary care physician at the VA Providence Medical Center in Providence, Rhode Island. She reported feeling very comfortable with the staff and getting her care here; she feels she is always treated kindly. She expressed she is grateful to have somewhere to feel comfortable enough to receive her health care, with regards to being transgender. ‘It’s not a trivial matter. [F]or some of us it’s life or death’.”
The center stands out for its healthcare leadership in Rhode Island.
“Our medical center not only received leader designation but was also the only medical center in the state of Rhode Island to receive a perfect score on the [HEI] survey,” Schlanger continued. “The aforementioned speaks to our endless efforts, advocacy, and commitment to diversity and inclusion, breaking barriers, and rising to the standard of promoting equitable and inclusive care for lesbian, gay, bisexual, transgender, and queer patients and their families.”
Training is Key to Competent Care
Salissa Wahlers is a licensed clinical social worker and LGBTQ veteran care coordinator at the VA White River Junction Memorial Center in White River Junction, Vermont. Given the state’s rural nature, she’s said she often sees veterans who forgo care due to embarrassment around their identities.
“Stigma in small, rural environments often plays a role in veterans not seeking all the available services,” she said. “My specific role is to help ensure knowledge about and access to all the services [the] VA offers. This includes education to our staff and providers, as well as the veterans we serve.”
The center runs a support group and has seen the group’s numbers evolve.
“Traditionally, referrals to the group were made by a clinician or provider to provide additional assistance and support as a transgender individual and as a veteran,” she said. “Today, most of our referrals come from peers already in the group and they encourage others to join. The group helps provide peer-support through experiences.”
Similar to other facilities, training has proven key to providing top-notch services at the center, which was also recognized by the HEI as providing quality, inclusive care.
“Our VA staff are provided several options for increasing their knowledge of transgender-specific care,” she said. “The VA has a national education system with several trainings that range from ‘Providing Cross-Sex Hormones’ to ‘Transgender Mental Health Care.’ Even though we are a small, rural healthcare site, we have access to consultation from an interdisciplinary team of experts on transgender care for veterans.
“Our facility also has had numerous clinicians from various disciplines from all over the state take a more intensive, 12-month training program called Trans ECHO (Extension for Community Healthcare Outcomes), which provides more in-depth training.”
Renee LaForce, director of programs at Health Quarters in Beverly, Massachusetts, another HEI survey leader, said that the entire healthcare team has taken courses to increase cultural competency and have partnered with Fenway Health, Providence’s Center for Sexual Health and Pleasure, and the Human Rights Campaign Foundation on a series of trainings.
Moreso, the center is seeking to make sure its staff and board are reflective of the LGBTQ community.
“We have hired a family practice physician from the LGBTQ community who has experience and expertise in providing trans health care services,” she said. “Our health care teams will participate in Brown University’s trans health care training in March 2019, and we are recruiting a transgender person for our Board of Directors.”
Dr. Dawna Blake of the Providence VA Medical Center has been a pioneer and advocate for trans patient care for 20 years and played a leading role in the center’s training efforts.
“She participated in a pilot program to review and assess the training that the VA gives to all providers who work with transgender patients,” said Schlanger, her colleague at the center.
Healthcare as a Social Justice Mission
Though health centers may tout their accolades and programs, those programs are only as effective in as much as people like Terry are aware of them and use them, but they also need to be in every health center, not just in New England, but across the nation.
“I think the key to addressing issues in trans healthcare [is] really in education for medical professionals—from the paperwork and intake aspects, to the care, to the language used, medical professionals should have a basic understanding of gender identity, dysphoria, etc.,” they said.
While several centers are evolving to meet the needs of trans patients, not all of them are, and there still needs to be a comprehensive effort to incorporate competent care into healthcare practices.
Internationally renowned Massachusetts General Hospital has recently started its on Trans Health program, and according to Dr. Robert Goldstein, the medical director for the program, the services it provides are wide-ranging.
“The MGH Transgender Health Program offers comprehensive primary care, hormone management, case management, and links to behavioral health and surgical services for adult patients,” he said in an interview with The Rainbow Times. “The clinic provides a safe, affirming, and inclusive environment for transgender patients and their families, utilizing ‘wrap-around’ services linked to and invested in the community.
“In collaboration with the Departments of Surgery and Obstetrics & Gynecology, the Transgender Health Program helps patients navigate gender affirming procedures, including top surgeries, bottoms surgeries, and facial feminization procedures.”
MGH’s program provides social work services also and opportunities for clients to navigate legal resources, the larger hospital system, and explore mental healthcare services, Goldstein added.
With five sites across Peabody, Salem, and Gloucester, North Shore Community Health (NSCH) is ramping up its efforts to become a comprehensive healthcare facility, and that includes building its trans health program.
“As part of our mission to provide comprehensive primary health care to all of our patients, we decided to begin the important work of enhancing our transgender health services by giving dedicated training through the Fenway Institute to a team of primary care providers across all of our sites in Salem, Peabody and Gloucester as well as at the two high schools, Peabody Veteran Memorial High School and Salem High School, to competently address the specific needs of our current and future transgender patients,” said Damian Archer, chief medical officer at NSCH.
According to Archer, NSCH has completed two years of clinical training through Trans ECHO to prepare clinicians to serve trans patients and a curricula is being developed to train clinical and administrative staff to provide stigma-free and inclusive care to patients. NSCH even reached out to the LGBTQ community for mentorship and advice on how to best roll out the program and incorporate the training into its work.
Most notably, Archer said, “North Shore Community Health stands-out in the medical community of the North Shore as a federally qualified community health center because we are part of a movement to deliver social justice through the provision of equitable, high-quality health care.”
Perhaps NSCH’s work will signal healthcare best practices for the future, both locally and nationally.
