The Supreme Court on Monday turned down an appeal from a Catholic hospital in California that was sued after refusing to perform a hysterectomy for a transgender man.
The court’s denial, issued without comment, sends the lawsuit back to state court for further proceedings against the hospital and avoids, for now, the issue of when claims of religious freedom can trump anti-discrimination laws.
Justices Clarence Thomas, Samuel Alito, and Neil Gorsuch said the court should have taken the case.
The dispute arose when Evan Minton arranged with Mercy San Juan Medical Center in Sacramento to schedule a hysterectomy, which he considered a medically necessary step in his transition. After a nurse called to discuss the surgery and Minton mentioned that he’s transgender, the hospital canceled the appointment.
Minton was able to schedule the operation three days later at a non-Catholic hospital. But he sued Mercy, claiming that it violated a state law guaranteeing full and equal access to public accommodations, regardless of sex, gender, gender identity, or gender expression.
The hospital said it does not discriminate against transgender patients but does refuse to perform certain procedures, including abortion or sterilization, that would violate the Roman Catholic faith. Without the Supreme Court’s intervention, lawyers for the hospital said, the state law “provides no protection whatsoever to religious health care providers that are compelled to allow procedures that violate their faith.”
But Minton, represented by the ACLU, told the Supreme Court that the hospital routinely performed hysterectomies and that it canceled his appointment only after learning he was transgender.
“When I heard the news I remember being so devastated that I collapsed to the ground. I felt distraught and helpless that the hospital was refusing to treat me simply because of who I am,” he told a congressional hearing last year.
The Affordable Care Act, better known as Obamacare, forbids hospitals and medical clinics to discriminate on the basis of sex. The Trump administration said that provision did not apply to LGBTQ patients.
But in May, the Biden administration announced that it will interpret the law as banning LGBTQ discrimination by medical facilities that receive federal funds. The Department of Health and Human Services urged patients who are denied care to file complaints.
The federal courts have yet to work out what the law’s nondiscrimination provision means for hospitals run by religious organizations.
Evan Minton’s lawsuit, which now goes back to the California courts, is based on state law claims, not Obamacare.
The change, which goes into effect in 2023, requires carriers to cover care like hormone therapy, facial feminization, and top surgery.
Colorado to require private health insurance carriers to cover gender-affirming care for transgender patients
COLORADO, USA — At ONE Colorado, Nadine Bridges works to change the lives of LGBTQ Coloradans.
“We just want folks to live their lives and thrive and survive in this world,” the executive director said.
In 2023, Bridges said living will get a little easier for some because of a change in Colorado’s Essential Health Benefits that will require insurance carriers to cover gender affirming care and surgeries for transgender patients.
It’s the first time the federal government has approved a requirement like this in individual and small group health plans, and the decision means specific treatments must be covered if a doctor deems them medically necessary.
According to a Health and Human Services press release, those treatments will include “eye and lid modifications, face tightening, facial bone remodeling for facial feminization, breast/chest construction and reductions, and laser hair removal.”
“I think what people don’t realize is some of these surgeries, like top surgery and electrolysis and facial feminization, some folks feel like that is more cosmetic and there are many in our community who really need that,” said Bridges.
Blair Sagan knows that need.
Three years ago, the 33-year-old paid $10,000 out of pocket to get top surgery, a procedure to remove breast tissue and reshape the chest.
“I was in a very deep depression, and I knew that it had to happen and it changed my life,” Sagan said. “And the feeling after, I want every trans person to have. You know, gender euphoria.”
Sagan said even within trans health care coverage, there are disparities, and to know that many Colorado insurance carriers will no longer be able to call certain care elective or cosmetic is a win for transgender rights.
“There are so many other surgeries that, especially cis-gendered men can get, that are covered,” said Sagan. “And it’s such a fight, it’s such a battle to be able to just have the basics for trans folx.”
Colorado Medicaid does currently cover gender affirming care but it is not a federal requirement for state’s Medicaid programs to do so.
GUNNISON — For the past eight years, my wife, Ky Hamilton, has undergone gender-affirming hormone therapy. As a transgender woman, she injects Depo-Estradiol liquid estrogen into her thigh once a week. This drug has allowed her to physically transition as a woman, and each vial, which lasts around five weeks, was completely covered by insurance.
That was until she lost her job in April 2020 and we switched to a subsidized private health insurance plan in Colorado’s Affordable Care Act marketplace. We discovered that our new insurance from Anthem doesn’t cover Depo-Estradiol and it would cost $125 out-of-pocket per vial. With both of us — and our four pets — depending heavily on Ky’s weekly $649 unemployment check, such medical expenses proved difficult. And as of Sept. 6, those unemployment checks ran out.
“I’m absolutely stressed. I don’t know what to do,” Ky said in August as we tried to find a solution.
Because of Ky’s physical transition as a transgender woman, her body doesn’t make the testosterone it once did. So, without the medication, she would essentially go through menopause. A decline in estrogen levels can also cause transgender women to lose the physical transitions they’ve achieved, resulting in gender dysphoria, which is psychological distress from the mismatch between their biological sex and their gender identity.
Unfortunately, Ky’s experience is shared by many other transgender Americans. The COVID-19 pandemic has caused millions of people to lose their jobs and private health insurance, particularly LGBTQ adults, who reported at higher rates than non-LGBTQ adults that they lost their jobs during the crisis. Consequently, enrollment surged in ACA plans and Medicaid, the state-federal health program for low-income people. Yet many of those plans don’t fully cover gender-affirming care, partly because of conservative policies and lack of scientific research on how crucial this care is for transgender patients.
According to a survey by Out2Enroll, a national initiative to connect LGBTQ people with ACA coverage, 46% of the 1,386 silver marketplace plans polled cover all or some medically necessary treatment for gender dysphoria. However, 7% have trans-specific exclusions, 14% have some exclusions, and 33% don’t specify.
“It’s this whack-a-mole situation where plans, for the most part, do not have blanket exclusions, but where people are still having difficulty getting specific procedures, medications, etc., covered,” said Kellan Baker, executive director of the Whitman-Walker Institute, a nonprofit that focuses on LGBTQ research, policy and education.
Twenty-three states and Washington, D.C., include gender-affirming care in their Medicaid plans. But 10 states exclude such coverage entirely. In 2019, an estimated 152,000 transgender adults were enrolled in Medicaid, a number that has likely grown during the pandemic.
Yet even in states such as California that require their Medicaid programs to cover gender-affirming care, patients still struggle to get injectable estrogen, said Dr. Amy Weimer, an internist who founded the UCLA Gender Health Program. While California Medicaid, or Medi-Cal, covers Depo-Estradiol, doctors must request treatment authorizations to prove their patients need the drug. Weimer said those are rarely approved.
Such “prior authorizations” are an issue across Medicaid and ACA plans for medications including injectable estrogen and testosterone, which is used by transgender men, Baker said.
The lack of easy coverage may reflect the fact that injectable estrogen, which provides the high doses of the hormone needed for transgender women to physically transition, isn’t commonly used by non-trans women undergoing hormone therapy to treat menopause or other issues, Weimer said.
It also may be because cheaper options, including daily estrogen pills, exist, but these increase the risk of blood clots. Estrogen patches release the hormone through the skin but can cause skin reactions, and many people struggle to absorb enough estrogen, Weimer said.
Consequently, many of Weimer’s patients wear up to four patches at a time, but Medi-Cal limits the number of patches patients can get monthly.
While such insurance gaps have existed for long before the pandemic, the current crisis seems to have amplified the matter, according to Weimer. The ACA prohibits discrimination based on race, color, national origin, age, disability and sex in health programs and activities that receive federal financial assistance. The Trump administration significantly narrowed the power of that provision, including eliminating health
insurance protections for transgender people.
However, in June 2020, before the Trump regulations could take effect, the Supreme Court ruled in Bostock v. Clayton County, Georgia, that employment discrimination based on sex includes sexual orientation and gender identity. This landmark decision has served as a crucial tool to address LGBTQ discrimination in many aspects of life, including health care. As of July, for example, Alaska Medicaid can no longer exclude gender-affirming treatment after Swan Being, a transgender woman, won a class-action lawsuit that relied in part on the Bostock decision.
The Biden administration announced in May that the U.S. Department of Health and Human Services Office for Civil Rights will include gender identity and sexual orientation in its enforcement of the ACA’s anti-discrimination provision. The next month, Veterans Affairs health benefits were expanded to include gender confirmation surgery.
But for now, the pressure is still on patients like Ky to fight for their health benefits. Anthem spokesperson Tony Felts said Depo-Estradiol is not on the list of covered drugs for its ACA plans, though many of its private employer-sponsored plans cover it. Because we had one of those ACA plans, Ky had to be persistent. After four months of emails and phone calls — and just before unemployment ran out — Anthem finally authorized her Depo-Estradiol. That brings her out-of-pocket cost to $60 per vial for the next year. It’s still expensive for us right now, but we’ll find a way to make it work.
“The reality is that trans people are more likely to be in poverty and don’t have the time or knowledge to spend four months fighting to get their estradiol like I did,” Ky said.
Alejandra Caraballo, 30, spent three years and countless hours after work — which “felt like a second part-time job” at times — putting together hundreds of documents to get her health insurance to cover her facial feminization surgery.
She even planned to sue her nonprofit employer, the New York Legal Assistance Group, or NYLAG, and the insurance company it used, UnitedHealthcare, in the spring of 2019 for denying the coverage.
Alejandra CaraballoAlejandra Caraballo
“My own clients at NYLAG were getting it covered under Medicaid, no issue,” she said. “And I, having private insurance, was having it consistently denied and, not to mention, working at a place that prides itself on inclusion and diversity and being social justice-oriented in terms of providing direct legal services to low-income New Yorkers.”
She said that she had lobbied for policy change but that when she met with NYLAG’s general counsel, she was told that the organization didn’t view the explicit exclusions for certain gender-affirming operations and voice therapy for transgender people as discrimination.
“It felt really invalidating and just like I wasn’t being heard,” she said, adding that she is a lawyer who knows the case law that affects the issue.
She started preparing her lawsuit, but then, in May 2019, her employer told her that it would be switching insurance plans to Cigna, and she had to start all over again.
After the switch, in July 2019, Cigna approved the first part of her surgery, which took place in October 2019, but when she tried to get the second part covered in June 2020, it denied the claim, she said. The New York Department of Financial Services overturned the decision in August and forced Cigna to cover the surgery, which she had in October.
“I did quite an ordeal in terms of getting this covered, and I say this with the tremendous privilege that I’m an attorney who’s connected in the trans rights movement,” said Caraballo, who is now a clinical instructor at Harvard Law’s Cyber Law Clinic.
NYLAG said that Caraballo was “a valued member of our team” and that it advocates alongside its team members “as they may experience and navigate life’s systematic inequalities and inequities.”
“At NYLAG we aim to create an environment that supports all NYLAG employees during their employment, which includes making available the best options for insurance, qualified by the state of New York,” Jay Brandon, NYLAG’s director of external affairs, said in a statement. “We wish all our former employees the best in their personal endeavors and support Alejandra’s continued fight for equitable coverage from her insurance provider.”
A spokesperson for UnitedHealthcare said the company can’t comment on specific cases. The spokesperson said coverage for the treatment of gender dysphoria may include physicians’ office visits, mental health services, prescription drugs and surgical procedures.
“Our mission is to help people live healthier lives regardless of age, race, ethnicity, sexual orientation or gender identity,” the spokesperson said in a statement. “Our customer service advocates are trained to help people navigate the health care system by matching them with experts who guide them when they have questions, and we have a special gender identity team to support members through their transition.”
A spokesperson for Cigna said gender-affirming treatments “are covered in all of our standard commercial health plans when medically necessary.”
“As this field evolves, we’re seeing more of our clients opt to expressly include additional procedures like facial feminization surgery and voice therapy,” the spokesperson said. “We also regularly evaluate and update our gender dysphoria coverage policies, informed by the latest clinical guidance and expert consensus, including leading organizations like” the World Professional Association for Transgender Health, or WPATH, a nonprofit organization devoted to treating and understanding gender dysphoria.
Caraballo’s experience echoes that of many transgender people who have tried to get gender-affirming care, particularly operations, covered by their insurance — whether it’s publicly or privately funded. Trans people describe months and sometimes years of effort to get their insurance companies to cover care recommended by their doctors.
Majority report being denied care
Although many insurance companies and some politicians describe gender-affirming surgery as cosmetic, major medical organizations say it is medically necessary.
Surgical intervention is one of many treatments for gender dysphoria, which refers to the psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity, according to the American Psychiatric Association.
WPATH, which is considered the governing body on the issue, wrote in a “medical necessity statement” in 2016 that “medical procedures attendant to gender affirming/confirming surgeries are not ‘cosmetic’ or ‘elective’ or ‘for the mere convenience of the patient.’”
“These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition,” WPATH wrote. “In some cases, such surgery is the only effective treatment for the condition,” and for some people, genital surgery, in particular, is “essential and life-saving.”
Despite the medical necessity of gender-affirming care as stated by physicians, many trans people who have insurance — about one-fifth have reported that they don’t — say they have struggled to get coverage.
A report last year from the Center for American Progress found that 40 percent of transgender respondents — and 56 percent of trans respondents of color — said their health insurance companies denied coverage for gender-affirming care, which includes treatments like hormones and surgery. It also found that 48 percent of trans respondents, including 54 percent of trans respondents of color, said their health insurance companies covered only some gender-affirming care or had no providers in network.
Dallas Ducar, CEO and a co-founder of Transhealth Northampton in Massachusetts, said she was shocked by the “endless barriers that exist for patients seeking to transition.”
“For cisgender individuals, hormonal replacement, puberty blockers are really easily accessible, and they’ve been used in the past to treat precocious puberty,” she said. “Hormone replacement therapy has been beneficial for endocrine, cardiovascular conditions, and trans people are burdened with paperwork, psychiatric assessments, insurance pre-authorizations.”
She said that most of the people in power — clinicians, politicians and people who work for insurance companies — are cisgender, meaning they identify with the genders they were assigned at birth, and that they have created systems that have reduced access to quality gender-affirming care.
“Those barriers that exist and that numerous amount of paperwork or assessments that you have to go through are really, really harmful, and they add to the layers of discrimination that exists within the trans community,” she said.
Yearslong battles and hefty loans
Alex Petrovnia, 24, and his partner, who are both transgender men living in central Pennsylvania, faced barriers similar to Caraballo’s when they tried to get UnitedHealthcare to cover their hysterectomies. Petrovnia said that twice — in February and in April — United called them less than 24 hours before their operations and said their claims had been denied. The first time, Petrovnia said, the company said it was because Petrovnia and his partner hadn’t sent the required paperwork, even though Petrovnia said he had faxed it three separate times months in advance.
Alex PetrovniaAlex Petrovnia
Petrovnia had received two letters — one from a doctor and one from a therapist — confirming that a hysterectomy was necessary for his gender dysphoria, but he said the UnitedHealthcare representative told him that he needed a letter from another therapist.
He said that the second time their operations were denied, UnitedHealthcare called them when they were on their way to the hospital — just hours before their scheduled procedures — and said they were required to have been on hormone replacement therapy for one year before they could get hysterectomies. Petrovnia said the policy he had at the time said the requirement was only six months. He wrote about the experiences on Twitter.
He and his partner have been on hormone replacement therapy for a year as of last month, so he said they plan to try to reschedule the procedures for December.
“If they’re willing to just make up the rules and contradict their own rules, it’s very difficult to have hope that it’ll work out, especially since it’s been canceled less than 24 hours in advance twice now,” he said.
ROCHESTER, N.Y. (WROC) — Two local men say they were discriminated against at a Rochester hospital.
Trey Lowery and Cori Smith are transgender men and they say in separate instances, staff at Highland Hospital treated them inappropriately.
When the alleged incidents happen, Lowery and Smith didn’t know each other. But now, they are speaking out together, hoping their stories bring awareness to adequate care and safety for transgender or non-confirming individuals.
Lowery said his incident happened in July of 2021, when he went to Highland Hospital for a bariatric surgery. He wanted to change his life around for his kids and wife, but was left upset by how the staff treated him.
“They made me feel so low,” Lowery said. While his identification shows he is a male, Lowery said many staff members on the surgical floor wouldn’t refer to him as one.
“They begin to call me a she throughout my stay. They never put me as a male, though I corrected them and let them know that I was a male,” Lowery said. “The whole situation was a whole disaster for me. It literally made me feel took my pride in everything away from me.”
Lowery said before his procedure, he was told by staff he had to take a pregnancy test, even though he says he can’t get pregnant.
“As I go in the back area, a patient care tech gives me a cup and says you have to urine for a pregnancy test. I told her that, ‘I am a male, there’s no need for a pregnancy test.’ She laughed in regards to the situation…she thought it was funny,” he said.
Lowery recalls asking a nurse why he was being misgendered.
“She stated, ‘Oh, well, you know, because you are a female, basically you have to go in and do this,’” he said. Lowery said he then heard the nurse laughing with other colleagues about the situation.
Following his experience at Highland, Lowery said he’s been getting help for his mental health. He also said he plans to file a discrimination lawsuit against the hospital.
“He wanted to kill himself because of the situation,” said Cheryln R. Smith, Lowery’s mother. “The way that they treated my son… I didn’t like it at all, but I had to show a little tough love to my son so he would be able to stand up on his two feet and not say that ‘I don’t want to be here anymore.’”
In a statement from Highland Hospital, they said clinical staff don’t necessarily seek permission for each individual test that is run and that’s something they are working to improve.
The hospital wrote in a statement: “Many national organizations, including the American Society of Anesthesiologists and National Institutes for Health, recommend screening for pregnancy as part of preanesthetic evaluation. These recommendations include transgender and gender diverse individuals as they may have reproductive organs. Highland’s policies currently align with those recommendations.“
Shortly after his surgery, Lowery said he received a call from the CEO of Highland, Dr. Steven Goldstein. Lowery said apologized to him for his experience and offered him a job as a spokesperson for transgender people at the hospital. However, Lowery said he did not take the position.
Seven years ago, Cori Smith, who is also a transgender man, said he experienced discrimination at the hospital as well.
Smith had to go into the hospital in 2014 because he had endometriosis and adenomyosis. He had gotten his eggs retrieved, but there had been a complication following the retrieval, which lead him to need emergency surgery.
“They put a female wristbands on me, they put my old name on there, which I don’t know how they still had. I gave them my updated information and said that I am actually a male and they need to put that on, and that my name is Cori. They refused and didn’t do that. They laughed it off,” Smith said.
Smith said he was triaged last and he had to wait for six hours in pain.
“I was screaming so much that it wasn’t until my girlfriend advocated for me and other patients in the waiting room were so annoyed at how loud I was that they finally took me back,” he said.
Once being seen, Smith said an ultra sound showed cysts in his ovaries (HCOs) and that he had a double ovarian torsion. He was brought up for surgery, but that’s when he said he received inappropriate treatment from his doctor.
“He refused to do the surgery. He said I’m not going to help you transition. We’re not going to help you become a man,” Smith said. “He wouldn’t even referenced me as a man. He called me it. He called me she, he called me they,” Smith said.
Smith said the doctor ended up doing the surgery, but he ended up having to have another one shortly afterwards because Smith said it wasn’t done right.
“The trauma that that caused, but also the physical state of my body and my own future, because all of this started because I was thinking of my future, all of this started because I wanted to have children, all of this started because I wanted my eggs retrieved,” Smith said.
Today, Smith has to get nerve blocks and trigger point infections every four weeks to help with the pain, which he said could happen for years to come.
“This all could have been avoided and was supposed to just be a one and done surgery. And it had nothing to do with my transition. It had nothing to do with it,” he said.
Following these instances, Smith filed a discrimination lawsuit against the hospital, which he said got dismissed.
In a statement responding to Smith’s treatment, the hospital wrote:
“UR Medicine believes that Mr. Smith received appropriate medical treatment at Highland Hospital in response to his need for emergency care in November 2014. This is based on a thorough review of the medical record by clinical professionals on Highland’s patient safety team, a review which included interviews with Mr. Smith’s attending physicians and other caregivers.
Leaders of UR Medicine’s quality and patient satisfaction teams reached out to Mr. Smith last summer after he raised a separate concern not specifically related to Highland Hospital. They spoke about his entire experience as a transgender patient in the UR Medicine system. Mr. Smith’s input helped significantly to inform efforts we have already implemented, and others currently underway, to make systems and practices at our hospitals more sensitive to and affirming of the needs of transgender and gender diverse patients, without compromising quality or safety of care.”
However, the hospital also said Smith’s input has helped them in their on-going efforts to make systems and practices at the hospital more sensitive to the needs of transgender patients.
Today, Lowery, Smith and their families are hoping their stories encourage hospitals to take a look at the care they provide for transgender individuals.
“My son does have a chance to be himself, to stand up right for the gay community and transgender, because in today’s world, it doesn’t matter if you’re black, white, orange purple, whether you go with a man, or go with a woman, you are a human being and everyone needs that respect,” Cheryln R. Smith said.
After Smith’s came forward with his complaints, Highland Hospital says they have taken the following steps to support transgender patients, including:
Removing gender from patient wristbands and identification stickers in the hospital
Implementing practices for staff members to assist patients who want to update gender, name, and pronouns in their electronic medical record
Creating a process to make sure hospital billing aligns with a patient’s gender identity
Converting public restrooms to all-gender
Our mandatory annual education provides training about working with transgender and gender diverse individuals, and we offer a number of ongoing trainings to increase affirming and equitable care for transgender and gender diverse individuals.
Highland follows all standards of nondiscrimination set by the Joint Commission, New York State Department of Health, and Centers for Medicaid and Medicare.
An incarcerated transgender man filed a complaint Wednesday against the Virginia Department of Corrections, or VADOC, for denying him surgery and other treatment for gender dysphoria, according to court documents shared with NBC News.
The lawsuit, brought by Lambda Legal, a legal organization that focuses on LGBTQ rights, is among the first filed by an incarcerated transgender man for denial of treatment for gender dysphoria. A number of lawsuits have been filed — and some won — by trans women inmates in recent years.
The plaintiff, Jason Yoakam, was convicted of first-degree murder in 2004 and has since been incarcerated at the Fluvanna Correctional Center for Women in Troy, Virginia. In 2017, VADOC medical providers diagnosed Yoakam with gender dysphoria, which refers to the psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity, according to the American Psychiatric Association.
Despite that diagnosis, medical providers have refused to provide Yoakam with treatment, including mental health services from qualified providers and a bilateral double mastectomy, or surgical removal of the breasts, according to the complaint, which was filed in the U.S. District Court for the Western District of Virginia. Yoakam’s doctors and a transgender health care specialist requested the treatment, the complaint states.
“The only thing I am asking is to be treated fairly and have access to the same standard of healthcare that other incarcerated people receive,” Yoakam said in a statement. “It has been traumatizing, isolating, and stigmatizing to be denied health care services to treat the gender dysphoria that VDOC’s own providers have diagnosed.”
Lambda Legal argues that denying Yoakam surgery and other treatment for gender dysphoria violates the Eighth Amendment’s prohibition on cruel and unusual punishment and the equal protection clause of the 14th Amendment.
Yoakam is also making statutory claims under the Americans With Disabilities Act, due to his gender dysphoria diagnosis; Section 504 of the Rehabilitation Act, which forbids organizations and employers from denying benefits and services to people with disabilities; and Section 1557 of the Affordable Care Act, which prohibits discrimination in federally funded health care facilities.
The complaint lists 10 defendants, including Harold Clarke, director of the Corrections Department; Mariea LeFevers, warden of the Fluvanna Correctional Center for Women; and other mental health providers for the department.
The defendants didn’t immediately respond to NBC News’ request for comment.
Yoakam’s complaint says that from an early age, he “saw himself as a boy and could not understand why people would see him as a girl.” He also lived as a man and was out to his family, friends and co-workers before his incarceration.
In 2017, after he was diagnosed with gender dysphoria by VADOC medical providers, staff at the Fluvanna Correctional Center for Women provided him with a chest binder so he could compress his chest as treatment for his gender dysphoria, and he began hormone therapy, according to the complaint.
“Since he was issued a binder in FCCW, Mr. Yoakam keeps his binder on throughout all hours of the day, except when he must shower,” the complaint states. “He sleeps in his binder. As noted in his medical records, the binder sometimes is so tight that it cuts into Mr. Yoakam’s skin and causes him to bleed. He has also developed scars, rashes, and acne from the binder. These injuries have also led to infections from the binder. Unless he receives chest surgery, Mr. Yoakam will have to continue to use the binder and suffer the resulting injuries.”
The 5-Year Longitudinal Study is First to Examine Post-Surgical Psychosocial Adjustment, Quality of Life and Long-Term Physical and Emotional Wellbeing of Transgender and Non-Binary Patients.
A lot has been said to condemn transgender surgical procedures, often using a couple of subjects who suffered adverse effects. These people are routinely paraded out when republicans introduce anti-trans legislation as ‘witnesses’ in an effort to criminalize transgender healthcare.
The problem being is that there hasn’t been a long-term study in the US to address the overall success or failure of the surgery in actual patients until now.
The Visiting Nurse Service of New York (VNSNY) Center for Home Care Policy & Research has been awarded a $3.4M grant by the National Institute of Nursing Research (NINR) / National Institutes of Health (NIH) to study the psychosocial well-being and quality of life of individuals after gender-affirming surgery. The landmark study will address a significant gap in the current evidence on best practices to support gender minority individuals during a pivotal life course transition.
The VNSNY Research study will be collaboratively co-led by Miriam Ryvicker, PhD., Senior Research Scientist with the VNSNY Center for Home Care Policy & Research and Walter Bockting, PhD., Director of the Program for the Study of LGBT Health at the Columbia University School of Nursing and the New York State Psychiatric Institute / Columbia Psychiatry.
“This funding helps to strengthen the evidence base for improving healthcare access, outcomes and quality of life and mitigating pervasive disparities affecting this population,” said Miriam Ryvicker.
“Fortunately, in recent years, access to gender-affirming surgery has improved considerably in the United States. This study will examine the impact of surgery on the lives of trans and gender nonbinary individuals, and inform the development of post-surgical care and support services,” said Walter Bockting. “Columbia Nursing is proud to partner with the VNSNY on this pioneering effort.”
The goal of this prospective, mixed-method, longitudinal cohort study is to build a rich evidence base on gender identity development and long-term healthcare needs by examining post-surgical changes in quality of life and relationships with healthcare providers among transgender and non-binary individuals who have had a gender-affirming surgery.
THE CONVERSATION — Transgender people continue to be the focus of political culture wars in the U.S. In the spring of 2021, lawmakers in many states sought to limit or ban transgender youth from accessing gender-affirming care. The laws proposed — and in some cases passed — were written to have a direct effect on transgender people’s ability to access physical and mental health care.
For many people, the medical options available to transgender people may seem foreign or new – unless you know someone who is transgender, you may not know about this type of care. So to better understand who is getting this care and the evidence that supports it, in recent months, The Conversation reached out to three experts who work with and study transgender youth medicine. Here is a roundup of what these experts had to say.
1. Medical options available to transgender youth
The first question we sought to answer was: What does medical care look like for transgender youth?
To answer this, we contacted Mandy Coles, a clinical associate professor of pediatrics and co-director of the Child and Adolescent Trans/Gender Center for Health at Boston University and Boston Medical Center. When young people want to see a doctor and have questions about their gender, they go to someone like Coles.
In her article, Coles explains that medical care for transgender youth who suffer from gender dysphoria — when a person’s gender identity does not match the sex assigned at birth – is much more than just hormones or surgery. Social support can have as big an impact on health as physical interventions and “an important first step is to help parents become allies and advocates,” says Coles.
But, for many of her patients, physical interventions – including puberty blockers, hormone treatments or surgery – are the best way they can align their physical bodies with their gender identity. For transgender people seeking care who haven’t started puberty or are still in its early stages, puberty blockers are often an initial treatment. As Coles explains, “These medications work like a pause button on the physical changes caused by puberty. They are well studied, safe and completely reversible.”
Puberty blockers are only one option available to transgender youth before other, more serious interventions. Taking testosterone, estrogen or other drugs can produce changes in a person’s body that help them look more masculine, feminine or nonbinary – whichever it is the person wants. Every patient is different and “my colleagues and I personalize their treatments to meet their specific need,” says Coles.
Surgery is the most permanent treatment available. It comes with risks and lies at the center of much of the political fighting around transgender care, but as one patient told Coles, gender-affirming care “literally saved my life. I was free from dysphoria.”
2. Younger people are seeking care earlier
With an explanation of what kind of medical care exists, the next question is: Who is getting this care and when?
If you have the sense that young people today are more likely to transition than, say, 20 years ago, in a sense you would be correct. But it is a bit more complicated than simply saying more young people are transgender than older people, says Jae A. Puckett.
Puckett, an assistant professor of psychology at Michigan State University, recently surveyed nearly 700 trans people and published a paper exploring generational differences in when and how fast people reach milestones of their transgender identity and how this relates to mental health. Milestones include identifying as trans, living in an affirmed gender some or all the time and, for some, accessing trans medical care.
Puckett wrote a story for The Conversation that explains that younger generations are more diverse in gender than older generations. Nearly a quarter of Gen Z participants “identified as nonbinary, whereas only 7.4% of boomers identified this way,” Puckett writes. Another interesting generational difference is the age at which people began to pass through the milestones of coming out. On average, people in every generation realized they “felt different” at around 10 to 13 years old. But “boomers reported reaching the other major milestones later than younger groups,” Puckett explains. “For example, boomers were, on average, around age 50 when they were living in their affirmed gender all the time. In contrast, Gen X was 34, millennials were 22 and Gen Z was 17.”
Better access to medical care and greater social acceptance today, compared with the past, might be one reason for this disparity, they write.
Puckett sees a similar trend in how fast people made transitions. “Gen Z and millennials also reported much shorter gaps between reaching milestones. For instance, the boomers group reported an average 24-year delay between starting to identify as trans and living in their affirmed gender. There was just a two- and three-year gap for Gen Z and millennials, respectively.”
3. Uncertainty in care
This increase in young people seeking transgender care means more doctors are being asked to provide it. At the bottom of the political and legal fight across the U.S. around transgender medicine, a fundamental – and often avoided – medical question remains: Does this care work?
stef m. shuster is an assistant professor of sociology at Michigan State University. They recently wrote a book exploring the emergence of trans medicine over the last century and how it is practiced today. In an article for The Conversation, they explain how the contentious social and political fights over transgender care are drowning out much needed nuance in research as well as the care transgender people receive.
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“Blocking people from accessing gender-affirming care creates increased risks for social isolation, suicide ideation and depression,” writes shuster. But they also explain that “little scientific evidence exists to support the use of current trans medical treatments, therapy or decision-making that meets evidence-based standards.”
The key phrase there is “evidence-based standards.” One of the reasons for this lack of evidence that care works is pretty simple, according to shuster. “Randomized controlled trials have been implausible, given that only 0.6% of the population identifies as trans or nonbinary.” This isn’t to say that doctors are flying blind. As Mandy Coles explains, there is a good and ever-growing amount of evidence gathered in other ways to support many types of interventions. But compared with other medical interventions, guidance is murky, says shuster. As they put it: “How might someone who is trained to manage illness and disease ‘treat’ someone’s gender identity, which is neither an illness nor a disease?”
This lack of clear clinical guidelines is compounded by a lack of training. A study in 2016 found that most medical providers only get one day of training on transgender issues. All this adds up to medical providers feeling a lot of uncertainty in the care they give, shuster found in their research.
So what happens next? shuster acknowledges that some portion of the concerns voiced by lawmakers are legitimate. But bans on transgender medical care or polarizing political fights aren’t going to help people that currently experience very high rates of depression, anxiety, self-harm and suicide. The way forward, shuster argues, is through more funding for studies on transgender care and more training for medical providers that are facing complicated situations.
Secretary of Veteran Affairs Denis McDonough (Photo courtesy of Veterans Affairs)
Secretary Denis McDonough is expected to announce that transgender veterans will be offered gender confirmation surgery for the first time according to the Military Times.
“[This is ] allowing transgender vets to go through the full gender confirmation process with VA by their side,” McDonough said in prepared remarks for an event at the Orlando VA Healthcare System in Florida. “We’re making these changes not only because they are the right thing to do, but because they can save lives.”
The National Center for Transgender Equality estimates there are more than 134,000 transgender veterans in America today, and another 15,000 transgender individuals serving in the armed forces.
VA officials estimate that around 4,000 veterans nationwide will be interested in the surgeries. Total cost of the program is not yet known. The department also could not say when surgeries will be available, since officials must first go through a formal rule change process.
McDonough said making the change “will require changing VA’s regulations and establishing policy that will ensure the equitable treatment and safety” of transgender veterans.
“There are several steps to take, which will take time. But we are moving ahead, methodically, because we want this important change in policy to be implemented in a manner that has been thoroughly considered to ensure that the services made available to veterans meet VA’s rigorous standards for quality health care.”
In a statement, House Veterans’ Affairs Committee Chairman Mark Takano, D-Calif. and the first openly gay minority individual elected to Congress hailed the move.
“Veterans in need of gender confirmation surgery should not have to seek healthcare outside of the VA health system or navigate complicated processes to get the care they need,” he said. “VA must be inclusive of all veterans who have served, regardless of their identity.”
Senate Veterans Affairs Committee Chairman Jon Tester, D-Mont., similarly praised the expansion of health care offerings for transgender veterans.
“Every service member and veteran deserves equal access to quality care from VA, and this includes our LGBTQ+ veterans,” he said in a statement. “We must reaffirm our commitment to making VA a more welcoming place for everyone who fought to protect our freedoms.”
The GOP is more than ready for a war on vets now that it is clear legislating against trans children is a fail.
House Veterans’ Affairs Committee ranking member Mike Bost, R-Ill., blasted the announcement as the White House trying to win “the culture wars.”
“This announcement clearly has more to do with advancing a radical liberal agenda than serving veterans,” he said. “It is a disgrace. This administration should rethink their priorities immediately.”
“I worry about what might happen to my patients if these bills are passed and worry about going to jail myself.”
Dr. Stephanie Ho, a family medicine physician in Fayetteville, Arkansas, said she’s had state legislators in her exam room before.
Ho, who has provided gender-affirming care to transgender people in the state since 2015, is also an abortion provider, so she is familiar with lawmakers’ restricting the care she provides. She said she wasn’t surprised when the Legislature overrode Gov. Asa Hutchinson’s veto of a bill last month that would ban puberty blockers, hormones and surgery for transgender minors.
“I think that it’s kind of ridiculous that we’ve gotten to the point that we’re letting politicians dictate how health care is delivered and what kind of care can be given to whom,” said Ho, a fellow with Physicians for Reproductive Health.
“I think the last thing I’ve ever wanted, being an abortion provider or somebody who provides gender-affirming care, is to have a politician in the back of my mind in the exam room making me think about ‘Oh, I wonder if I should do this, if it’s OK,’” she said. “They’re essentially trying to practice medicine without a license. And that’s incredibly wrong.”
Arkansas was the first state to pass a ban on transition care for minors. Tennessee Gov. Bill Lee last week signed a similar bill barring prepubertal youths’ access to transition care like hormone therapy. Advocates say no doctors in the state provide hormone therapy for prepubertal youths, The Associated Press reported.
So far this year, state legislatures have considered 35 bills to ban or limit gender-affirming care for trans minors, according to the Human Rights Campaign. Physicians say that the bills negatively affect their patients’ health before they even become law and that they require doctors to go against medical standards of care. Legal experts say the bans could also open providers and hospitals up to lawsuits or put them at risk of losing federal funding.
Ho is trying to support her patients as best she can until Arkansas’ law takes effect this summer.
“It’s just a matter of making sure that my patients know that, whether I can provide them hormones or not, we’re still here for them to support them in any way that we can,” she said. “Of course, I’m going to practice within the bounds of the law, whether I agree with it or not, because me being in jail doesn’t help any of my other patients at all.”Creating ‘contingency plans’
Some physicians, like Dr. Izzy Lowell, who founded a telemedicine practice called QMed in Atlanta in 2017, started planning for the bills months ago.
Dr. Izzy Lowell, second right, founder of QMed.Bonnie Heath
In April, Alabama’s Senate passed a bill that would have made it a felony for doctors to provide minors with gender-affirming care. The bill died Monday after the House missed the deadline to vote on it. Lowell said that when it first passed, the minor patients she treats in Alabama were scared and frustrated.
“It was clear that the state of Alabama was coming after transgender teens, and we talked about some contingency plans,” she said. “Based on each case, I tried to give them as many refills as possible and told them: ‘Go pick up as much of your medicine as you can. I don’t know when I’ll see you again.’”
Lowell is licensed and practices in 10 states via telemedicine, so she also talked with her legal team and with patients in states considering bans about how her patients could continue care should their states ban it. She said her patients’ parents would have to drive to other states, which would “place an extraordinary burden on these families.”
“If they were, for example, able to get over the border into Tennessee or South Carolina and sit in a parking lot somewhere, I could see them technically with my South Carolina license or Tennessee license or my North Carolina license and perhaps find a local pharmacy there and have them pick up the prescription, but it would be a day’s worth of driving for them to get somewhere where I could see them legally,” she said.
Many minors whose parents don’t have the time or money to drive out of state would be forced to stop transition care if their states passed laws like Arkansas’, which comes with potentially life-threatening health risks, physicians say.
Major medical organizations, including the American Medical Association, the American Academy of Pediatrics, the Endocrine Society and the American Psychological Association, support gender-affirming care for trans youths and oppose efforts to restrict access.
Supporters of the Arkansas bill argue that transition care for minors is “experimental” and that trans minors often change their minds about their genders and detransition later in life. Medical experts say neither of those claims are backed by scientific evidence. On the contrary, research has found that access to gender-affirming care such as puberty blockers reduces the risk of suicide among trans youths.
Ho said the danger is evidenced by what happened when Arkansas’ bill passed through one legislative chamber. Dr. Michele Hutchinson, a physician at the Arkansas Children’s Hospital Gender Spectrum Clinic, testified before the state Senate in March that there were “multiple kids in our emergency room because of an attempted suicide, just in the last week,” after the House passed the bill.
Ho said that “since then, I have had one of my own patients attempt suicide,” adding that she has talked to her patients about what would happen if a judge doesn’t block Arkansas’ law from taking effect. The law also bars her from referring her patients to other physicians who provide gender-affirming care. Unless her patients were able to leave the state, they would be likely to lose access to hormones, so she talked to them about what that would mean.
Lowell said forcing people who were assigned female at birth to stop testosterone would cause them to suffer symptoms of low testosterone, which include inability to concentrate and low energy. “They would start doing badly in school most likely, until their bodies started producing estrogen a few months later, and then they would restart their periods, restart breast growth, and it would undo all of the changes that we tried to achieve with testosterone.”
If people assigned male at birth were forced to stop taking estrogen, it “would be like going through instantaneous menopause,” Lowell said. For about a year, they could have symptoms like hot flashes, night sweats, irritability and mood swings, among other issues, such as negative impacts on emotional well-being.
Doctors worry that minors who already receive and rely on transition care would get hormones illegally if they had to. Dr. Ricardo Correa, a board member of GLMA: Health Professionals Advancing LGBTQ Equality, treats trans veterans in Phoenix, where, he said, trans people have traveled to the border to buy hormones illegally when they can’t get them. He said state bans would worsen the problem.
“It will just create chaos in the system from black markets that are going to start selling this kind of medication in that state,” he said.
Lowell said that hormone therapy is safe when it is monitored by a doctor but that using it without medical supervision could cause health problems, such as liver failure, kidney failure or heart problems.
“There’s very serious consequences of completely unmonitored, sort of black market medication use in this situation,” she said.‘A form of medical malpractice’
Legal experts and advocates say that in addition to having dangerous health impacts, bans on gender-affirming care for transgender youths could expose health care providers to legal and regulatory problems.
Valarie Blake, a law professor at West Virginia University specializing in health care law, said there’s “a pretty strong case” that Arkansas’ law is discriminatory under Section 1557 of the Affordable Care Act, which protects against discrimination based on sex.
The Biden administration announced this month that it would interpret Section 1557 to protect against discrimination based on sexual orientation and gender identity — reversing a Trump-era policy that cut protections for transgender people.
Hospitals and physicians receiving federal funding, such as Medicare and Medicaid payments, are required to comply with laws like Section 1557, Blake said; otherwise, they risk losing the funding.
Arkansas’ law could trigger that risk by allowing physicians and hospitals to prescribe puberty blockers and hormones to cisgender minors for precocious puberty but not transgender teens.
“If the reason that they’re not doing it for transgender teens is because of the fact that they’re transgender, then there’s a very good case that the reason that they’re refusing the treatment is based on the gender identity and not anything else,” Blake said.
“It really puts health care workers in an untenable position when the federal government makes it plain that this is discrimination and has the money to back it up to basically say, ‘We can pull away all of the resources,’ and yet the state persists,” she said.
The American Civil Liberties Union argued in a lawsuit it filed Tuesday against Arkansas that the trans health restrictions are unconstitutional, but Blake said that’s not set in stone.
“We don’t have clear precedent on the books yet to suggest that LGBTQ categories are fully protected in that manner, which is why we’ve been seeing various kinds of Equal Rights Amendment-type laws trying to work their way through Congress,” she said, referring to the Equality Act, a bill that would protect LGBTQ people from discrimination in housing, employment, public accommodations, education and other areas of life.
The bill passed the House in February, but it has stalled in the Senate. “If something like that passes, then suddenly Arkansas as a state is in big trouble,” Blake said.
Lowell said thinking about the potential legal issues “keeps me up at night.” Physicians are required to give patients several months’ warning when they can’t see them anymore and to do their best to find other providers who can see them if they’re unable to.
But laws like Arkansas’ bar physicians from referring patients to other providers for transition care. “In this case, I can’t do any of those things, and I just have to say, ‘Bye,’ and ‘I’m not allowed to see you anymore,’” she said. “That’s patient abandonment, which is a form of malpractice.”
Lowell said that when the first restrictions were introduced several months ago, she felt angry and anxious all the time.
“I worry about what might happen to my patients if these bills are passed and worry about going to jail myself,” she said. “I struggle with the question of what I would do: continue to support my patients and risk going to jail for years or follow these hateful laws? Thankfully, I have not had to answer this question yet, but I will never abandon my patients.”
