While healthcare access is a crisis in America, broadly speaking, it is especially acute for transgender people. We face significantly disproportionate job loss and job fragility and, therefore, a much-higher-than-average lack of insurance. Additionally, most public and private health insurance plans, when they are available to transgender people at all, have discriminatory exclusions for transgender-related care that often is used to exclude virtually all care. Finally, due to the lack of research data about transgender people there is a lack of funding for transgender health care that often precludes effective public health services. Implementing the recommendations listed below will give transgender people equal access to health care, ultimately saving numerous lives.
March 28-April 3 is LGBT Health Awareness Week. You can learn more about the week and get resources from the National Coalition for LGBT Health. To mark the occasion, here are 7 suggestions for transgender health, one for each day of the week. We’ll also be sending reminders out through Twitter and Facebook as the week goes on.
Because transgender people often face significant barriers to equal access to health care, we need to pay particular attention to our own health. Here are some things to consider:
Get health care. If it has been a while since you’ve had a check up or seen a doctor, dentist or optometrist, it’s time to go. Pick up the phone and make an appointment today. Preventive care is vital to your long term health and can save you money by keeping small problems from becoming large ones. The cost of putting it off can be a burden on your wallet and a significant problem for your health. Here are some resources to overcome the barriers we face in accessing health care:
- If you haven’t been to the doctor because of financial reasons, the US Department of Health and Human Services offers help in finding free and low-cost health programs. You can find them at http://findahealthcenter.hrsa.gov/.
- If you are concerned about experiencing discrimination in a health care setting—a very real issue for transgender people—bring along a friend to act as a peer advocate for you. It’s easier to deal with situations together. Or consider being an advocate for a friend and encourage them to get the care they need. This is especially important for those early in transition or in a health care crisis situation.
- If you would like to find a health care provider who is LGBT-friendly, visit the Gay & Lesbian Medical Association’s (GLMA) website at http://glma.org/. You’ll find a link to “Find a provider” right there on the home page.
- GLMA also has a resource that lists the Top Ten Things Transgender Persons Should Discuss with Their Health Care Provider: http://www.glma.org/_data/n_0001/resources/live/Top%20Ten%20Trans.pdf. It’s a great list to take with you to your doctor’s office.
Relax. As transgender people, we can face a great deal of stress from discrimination. Let’s face it—the unemployment levels, dealing with family, prejudice on the streets—all of these things contribute to our stress levels. Stress over time has been shown to have serious long term health consequences. So today, think of some ways to lower your stress and put that plan into action. Consider things like making plans to hang out with your friends, talk to supportive family members, go for a walk, take a yoga class or enjoy a hobby. Pick anything that relaxes you. Here are some additional resources:
- For more information about the impact of stress and how to reduce it, check out WebMD’s stress management info: http://www.webmd.com/balance/stress-management/default.htm.
- Taking concrete action to end discrimination can help too. Check out NCTE’s 52 things you can do for transgender equality.
How are those hormones doing? If you are on hormones, there are tests that you should have to monitor the impacts of the hormones on your body. Check with a doctor to make sure that your hormone levels are right and that they are affecting your body in the positive ways you want, without creating negative side effects. Taking care of this now can help make sure that you can continue on hormone therapy. If your provider needs more information, here are some resources:
- Medical Therapy and Health Maintenance for Transgender Men: A Guide For Health Care Providers, by R. Nick Gorton MD, Jamie Buth MD, and Dean Spade Esq at http://www.nickgorton.org
- Endocrine Therapy for Transgender Adults in British Columbia: Suggested Guidelines, from the Trans Care Project, Vancouver Coastal Health, http://transhealth.vch.ca/resources/library/tcpdocs/guidelines-endocrine.pdf
Be informed. Pull out that book that the insurance company sent you, check with Human Resources at work, or with Medicaid/Medicare and know what your plan does and does not cover. Be sure to pay attention to things like your deductibles (how much you have to pay out of pocket ) and any exclusions the plan may have. If you work for a corporation that covers transition-related care, make sure you know how that works if you want to access it.
- If you don’t have insurance and want some information about obtaining it, WebMD has a resource for that. http://www.webmd.com/healthy-aging/guide/choosing-using-health-plan.
- If you would like to find out if you are eligible for government benefits to help with health care, visit Gov Benefits at http://www.govbenefits.gov/govbenefits_en.portal. They are a government program to help people find the benefits they are eligible for. There is a confidential questionnaire you can take online to help you determine what is best for your situation.
Make your wishes known. It is important to provide clear instructions about your wishes if something were to happen that prevents you from expressing them yourself, such as if you were unconscious. You can name a health care proxy (also called medical power of attorney) to make decisions on your behalf and state your wishes. Having a health care proxy is particularly important for transgender people, especially if you are concerned that your family might not respect your wishes or your gender identity. Find a person you trust to be your proxy and talk through with them what you would want them to do. You can also create a separate document called a Living Will that gives instructions about end of life care.
- The how-to specifics vary from state to state but there are many resources out there to help you. Do a web search with “health care proxy” and your state or contact your state government for help.
- You do not need an attorney to do this, although if you have any legal questions, you should feel free to consult one.
Know your status. Do you know your HIV status? Transgender people, particularly trans women, are disproportionately impacted by HIV/AIDS. Knowing your HIV status is important because then you can make informed choices with your doctor about your treatment options, which can positively affect your health now. Your doctor should also check for other sexually transmitted infections, which are harmful to your health if left untreated.
- Looking for an HIV testing site? The Center for Disease Control (CDC) has a website to help you find one: http://www.hivtest.org/
- The Center for Excellence in Transgender Health has transgender specific HIV resources. Visit their website at http://transhealth.ucsf.edu/. You can also find more research and resources on their website about more general issues of transgender health.
- Be safe—use a condom when having sex, use clean needles for injections and take care of yourself. Transgender lives are valuable!
Improve your health. Take a look at the way you live your life and identify if there are areas where you could improve your health. Think about things like exercise, the food you eat, your use of substances such as alcohol and drugs, and smoking. Is there an area in your life where you could improve your health? If so, think about steps that you can take that would make that better. You might join a smoking cessation program (which makes it much easier to quit!), getting therapy for your stress levels, buying more vegetables (there are lots of farmers’ markets starting up again this time of year), or going for a walk on your lunch hour. Whatever you pick, you’ll have the satisfaction of knowing that you are taking care of your health. Even little things can have a big impact on your health over time.
Federal Policy Changes needed in health care
- Healthcare Reform. The Administration and Congress should ensure that the healthcare reform debate includes and fairly considers the needs of transgender people including the importance of medically necessary transition-related care.
- Eliminating Health Disparities. Congress should amend the Public Health Service powers and duties to include lesbian, gay, bisexual, and transgender people as a “population marked by health disparities.” If amended, both the National Center for Health Statistics and the Agency for Healthcare Research and Quality should study the specific health needs and disparities of lesbian, gay, bisexual and transgender people.
- AHRQ Research. The Agency for Healthcare Research and Quality (AHRQ) should ensure that its researchers include information about lesbian, gay, bisexual, and transgender people when researching healthcare quality, costs, outcomes, and patient safety.
- Genetic Information Non-Discrimination Act. The Department of Health and Human Services (HHS) should promulgate regulations to clarify that transgender status is protected under the Genetic Information Nondiscrimination Act (GINA) and that transgender status does not fall under the exclusion of “sex” in the Act.
- Provider Conscience Rules. The Department of Health and Human Services should rescind the recently issued “Provider Conscience” regulations that allow health care providers to refuse to treat certain individuals based on the providers’ personal beliefs.
- Medicare. The Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) should allow Medicare coverage for medically necessary transition-related health care.
- Medicaid. The federal government should ensure that Medicaid programs in all fifty states cover medically necessary transition-related care.
- NIH Research. The National Institutes of Health (NIH) should fund research on the efficacy of various transition-related treatments.
- FDA Blood Donation Ban. The Food and Drug Administration (FDA) advisory panel should lift the ban on blood donation by gay men, which has been used to exclude transgender donors regardless of their gender or sexual orientation.
- Public Health Surveys. The Centers for Disease Control and Prevention (CDC) should develop a policy that ensures transgender people are included in all population-wide government public health surveys, especially the National Health Interview Survey and the Behavioral Risk Factor Surveillance System.
- Access to Title X Clinics. The Department of Health and Human Services should develop a model non-discrimination policy that includes sexual orientation and gender identity and expression to be disseminated to all Title X Family Planning Clinics.
- Needle Exchange Programs. Congress should repeal the federal ban on needle exchange and authorize the development of transgender-specific needle exchange programs.
- FQHC Training. The Department of Health and Human Services Health Resources and Services Administration should encourage Federally Qualified Health Centers, also known as 330-funded clinics, to use part of their two percent technical assistance requirement for training around transgender issues.
- SAMHSA Special Populations. The Substance Abuse and Mental Health Service Administration (SAMHSA) and the National Institute of Mental Health (NIMH) should specifically include lesbian, gay, bisexual, and transgender people in the definition of Special Populations.
- Allowability of IRS Deductions. The Internal Revenue Service (IRS) should clarify its policies and guidance publications to make clear the allowance of medical deductions for transition-related care.
The continuing HIV/AIDS epidemic is the number one public health problem that touches transgender people and it extracts an insurmountable human cost. The federal government must swiftly move forward in the fight against HIV/AIDS starting with a comprehensive national AIDS strategy that specifically takes into account transgender people and removes the barriers that limit transgender access to treatment and prevention measures. Inclusion of the policies outlined below will combat HIV/AIDS in the transgender community and will also benefit the general public health.
- Non-Discrimination. The President should issue an Executive Order to clarify that all federal agencies are prohibited from using HIV status as a basis for restrictions or exclusions on applicants and employees.
- National AIDS Strategy. The federal government should create and implement a comprehensive and coordinated national HIV/AIDS strategy that includes provisions that address the impact of HIV/AIDS on transgender populations.
- Increased Funding. Both the President’s budget proposal and the Appropriations process should include an increase in funding for HIV/AIDS prevention, care, treatment, and research, including funding for transgender-specific materials and services.
- Targeted Prevention. The Centers for Disease Control and Prevention (CDC) should develop prevention programs that focus on the communities and populations that are most at risk for HIV, including various transgender populations.
- Separate Population Categories. The Centers for Disease Control should identify transgender people as a category distinct from Men who have Sex with Men (MSM) for provision of HIV/AIDS prevention and treatment funding.
- Immigration Ban. The Centers for Disease Control should eliminate the ban on immigration by individuals who have HIV/AIDS. HIV should be removed from the list of “communicable diseases of public health significance” that is used by the U.S. Citizenship and Immigration Services (USCIS) and the Department of State, which currently prevents foreign nationals from obtaining non-immigrant visas and legal permanent residence.
Trans Health Priorities
There are many respects in which transgender people have the same health concerns as non-trans people. From a public health policy perspective, however, there are areas in which trans people have specific needs that must be addressed more actively and specifically than they generally are at present.
Fortunately, there is a growing number of transgender-identified public health specialists and allies who are addressing these important issues. NCTE is fortunate to be able to work with some of these great people as part of the National Coalition for LGBT Health’s Disparities Working Group.
As part of this working group, a trans Health Task Force, including NCTE Board Member Diego Sanchez and NCTE Executive Director Mara Keisling, has initiated several projects of great importance. These include facts sheets on FTM Trans Health and MTF Trans Health created for LGBT Health Awareness Week, a briefing on LGBT health issues for six presidential campaigns, and a document called “An Overview of the Top U.S. Transgender Health Priorities,” which was drafted and used to educate LGBT health providers and others.
This priorities document was created with input from a variety of knowledgeable trans people as well as allies, and based on an analysis of existent research. Thirteen primary public health priorities were identified and discussed in the document.
- Violence and Murder Prevention
- HIV/AIDS and other STD Prevention and Treatment
- Substance Abuse Prevention and Treatment
- Depression, Suicidal Ideation and Suicide Prevention
- Lack of Health Insurance and Underinsurance
- Lack of Health Insurance Coverage for Trans Health Services
- Gender Identity Disorder (GID) as the Principal Diagnostic Means Determining Access to Trans Health Services
- Lack of FDA approval for Transgender Hormonal Therapy
- Widespread Injection Silicone Use
- The Continuing Misclassification of Sex Reassignment Surgery as "experimental"
- Lack of Training in U.S. Medical Schools for Trans Health Service Delivery and Working with Transgender Patients
- Medical, Mental Health and Substance Abuse Treatment Provider Insensitivity and Hostility to transgender people
- Tobacco Use
NCTE and the authors of this document understand that these are not the only significant health issues facing transgender communities. The issues included were selected because they were significant health issues and they fit into categories from the federal government’s outline for better American health (called Healthy People 2010).
And while each of us may not know trans people who are directly impacted by all of these public health concerns, transgender communities are very broad and varied, and collectively we are impacted greatly by each of these. NCTE will continue to work in coalition on important public health issues like these and others at the national level.