"There are simply are not enough physicians comfortable with treating transgender patients," according to Joshua D. Safer, MD, FACP, associate professor of medicine at Boston University School of Medicine (BUSM). To begin to address this issue, BUSM has created a medical school elective that combines the standard approach of teaching about transgender medical topics with sensitivity and appropriate terminology with evidence-based hands-on patient care.

"We have seen that lack of knowledgeable medical providers remains the most reported barrier to good care for transgender patients. Direct care experiences with transgender patients not only increases the confidence of medical providers in providing care, but more importantly provides the patient with a better experience," added Safer, who also is medical director of the Center for Transgender Medicine and Surgery at Boston Medical Center.

Transgender individuals are medically underserved in the U.S. and face many documented disparities in care due to the providers' lack of education, training and comfort. When educating medical professionals regarding transgender medicine much attention has focused on terminology and on health care disparities suffered by transgender individuals. Specific transgender medicine content in a medical school curriculum has demonstrated that it increases a students' willingness to treat transgender patients. Still, those same students are less comfortable with transgender care relative to care for lesbian, gay, and bisexual (LGB) patients.

BUSM students who participated in the standard transgender care curriculum were offered the opportunity to participate in a subsequent clinical elective providing direct care to transgender individuals. Students were surveyed before and after their elective experience regarding knowledge and comfort with transgender medical care.After completing the elective, students who reported "high" comfort increased from 45 percent to 80 percent and students who reported "high" knowledge regarding management of transgender patients increased from 0 to 85 percent. Even motivated students who already were interested in transgender care and who already rated themselves well with transgender care saw large improvements in their scores after the direct patient care experience.

According to the researchers, it is insufficient to limit health care provider training to cultural sensitivity and to didactic teaching alone. Direct patient care experiences are necessary in transgender medicine.

"Previously, we have piloted and demonstrated the benefit of teaching transgender medicine in a format similar to how other medical topics are taught, that is, with the current science and evidence-based approaches. We have demonstrated that benefit above what is seen with students who only receive the standard teaching. The circumstance is improved further, when the students have direct care experiences," explained corresponding author Safer.

Safer believes the existing medical teaching model using evidence-based teaching along with direct patient care experiences works well for transgender medicine. "Opportunities to mandate such teaching should be sought for all medical schools."

Transgender patients often travel long distances and pay more for less-than-competent medical care. But as doctors embrace virtual treatment models, those problems may soon be obsolete.

 

M, who is non-binary and transgender, first sought care for gender dysphoria at their local Planned Parenthood clinic in South Carolina. (Because M has not disclosed their transgender status at work, they requested anonymity for this story.) The staff there was very caring, they said, but the clinic was underfunded and understaffed, with a long waiting list for follow-up appointments. "It was almost like musical chairs," said M, "with more people than seats." When M began taking hormone therapy for gender transition, delays in care led to month-long lapses in hormone prescriptions, resulting in an emotional and physical roller coaste 

The demand for affirming, competent transgender care far outsrips what’s available, and in rural areas, physicians able to provide that care are often fewand far between. By bringing doctors as close to patients as their nearest high-speed internet connection, telehealth offers a potential solution to that gap.

On the whole, transgender people travel further and receive less insurance coverage for their healthcare than do other sexual minorities. A study of rural sexual minorities found that 14 percent of transgender and non-binary people lived more than an hour's drive from their primary care providers, compared to only 5 percent of their gay, cisgender counterparts. And respondents to the 2015 US Transgender Survey said they were more likely to travel long distances for transition-related care than for routine care.

Other studies have show that transgender people were much more likely than cisgender people to have no health insurance, and about a quarter of those responding to a question about barriers to care reported the cost of gender-confirmation therapy (including hormonal and/or surgical therapy) was the main problem in not receiving it.

Once they make it into a provider's office, transgender patients are likely to have a negative experience related to their transgender status. According to the US Transgender Survey, one third of respondents who had seen a healthcare provider in the past year reported having a negative experience with a provider related to being transgender, and almost a quarter said they'd avoided seeking needed health care due to fear of being mistreated on the basis of their gender identity.

The American Academy of Family Physicians and other associations of primary care physicians are increasingly encouraging their members to provide transition-related care to patients with gender dysphoria. But many unspecialized physicians hesitate, citing fear of making mistakes and lack of knowledge, and in some cases, acknowledging bias.

As a result of all of these factors, transgender people living in rural and exurban areas are often faced with a vacuum of physicians willing to perform the bread-and-butter work of transition-related care: prescribing and adjusting hormone replacement therapy and related medication, ordering and reviewing laboratory results, responding to concerns about medication side effects, and monitoring patients' overall health within the context of transition. And while medical educators are beginning to catch up with the demand for trans-competent doctors, there’s still a long way to go.

A transgender activist who made waves last year for confronting Caitlyn Jenner is running for public office. 

Following the resignation of California Assemblyman Sebastian Ridley-Thomas, Ashlee Marie Preston announced Dec. 30 that she plans to run for the District 54 seat. If elected, she would represent Century City, Westwood and a number of other Los Angeles neighborhoods. 

"As someone directly impacted by the issues that often diminish the quality of life, I have an acute understanding of which policies must be put into play in order to move progress forward for the constituents of the 54th district and beyond. I believe in prioritizing people over politics,” Preston, who previously served as the editor-in-chief of Wear Your Voice magazine, said in a press release cited by The Advocate. “We are more than poll percentage points; we are real people with real stories.”

“I fully intend to continue honoring those experiences, and advocating for those who don’t have a seat at the table,” she added. 

Preston gained widespread attention after she was seen confronting Jenner at a Trans Chorus of Los Angeles event in August. The activist, who has reportedly served on the boards of the Transgender Service Provider Network and the Human Rights Campaign, blasted Jenner, a longtime Republican, for her support of President Donald Trump

“You’re a fucking fraud,” Preston told Jenner at the time. “It’s really fucked up that you continue to support somebody ... that’s erasing our fucking community. And you support it!”

In an interview with HuffPost after the incident, Preston said she believed that Jenner “owes the [transgender] community an apology” for backing Trump, who has rescinded federal guidance on protections for trans students against discrimination and attempted to ban trans recruits from the U.S. military. 

“Caitlyn Jenner is a text book case on cognitive dissonance and her vote against her own supposed interests made that evident,” Preston said. “Her commentary and actions have carried real consequences for the transgender community; people who aren’t afforded the same protections and privilege as she has.”

In September, Preston was named one of The Root’s 100 Most Influential African-Americans of 2017. If elected, she has said she plans to address issues of police brutality, trans discrimination and immigration. 

The U.S. Centers for Disease Control is reportedly banning a list of seven words or phrases in official documents, sparking a flood of reaction on social media platforms.

Policy analysts at the CDC, based in Atlanta, Georgia, were told about the list of prohibited words at a meeting Thursday with senior CDC officials, according to an unnamed analyst who attended the meeting as reported by The Washington Postnewspaper.

The banned words are "diversity," "entitlement," "evidence-based," "fetus," "science-based," "transgender," and "vulnerable."

The meeting was led by Alison Kelly, a top official in the CDC's Office of Financial Services, according to the analyst who the Post said remained anonymous because the person was not authorized to speak publicly about agency affairs. The analyst said Kelly did not explain why the words were being forbidden.

The Planned Parenthood Federation of America, a non-profit group that provides reproductive health care, said on Twitter the action sends strong messages about the administration of President Donald Trump.

"It’s clearer than ever: this administration has disdained women’s health, LGBTQ people, and science since day one."

David Reiss, an internationally recognized psychiatrist, tweeted that the administration's decision is counterproductive and outside the boundaries of traditional Washington politics.

"This is an attack on reality. Censoring names, Trump attempts to disappear knowledge, people & rational discourse. This is not politics or partisan but a takeover of society by authoritarian kleptocrats. Resist or Collaborate. No other options."

Legal Lambda is a legal organization that advocates on behalf of bisexuals, gay men, lesbians, transgender people and people who have contracted HIV. The group responded on Twitter with disbelief.

"Unbelievable. You cannot erase us, @realDonaldTrump..."

Unprecedented

The analyst, described by the Post as a "longtime CDC analyst" who helps write descriptions of the agency's work for the administration's annual budget proposal, could not remember past incidents of words being banned from budget documents because they were deemed controversial.

"In my experience, we've never had any pushback from an ideological standpoint," the analyst told the Post.

Others in the meeting reacted with disbelief, the analyst said.

The Trump administration has grappled with how to address issues such as abortion rights, gender identity and sexual orientation. Several federal agencies have altered some federal policies and how they gather information about bisexual, gay, lesbian and transgender citizens.

The Department of Health and Human Services has eliminated questions about gender identity and sexual orientation in two surveys of older people. The agency has also deleted information about LGBT people from its website.

On many occasions, the Trump administration has dismissed science-based findings in favor of opinion - particularly regarding climate change. Trump has not said if he believes in climate science and numerous members of his administration have denied facets of scientific findings related to climate change.

The Environmental Protection Agency has eliminated references to climate change on its website and has prohibited its scientists from presenting scientific reports on the topic.

The Office of Management and Budget, which produces the president's budget and monitors federal agencies for compliance with the president's policies, has not responded to requests for comment, nor has the CDC, the Post reported.

Many of the responses on Twitter were triggered by comments from Democratic Congressman Ted Lieu, who blasted the Trump administration for reportedly banning the words.

"The @realDonaldTrump Administration is making America stupid again. Centers for Disease Control and Prevention banned from using "science-based" and "evidence-based" terms. Are we now going to use Voodoo & leeches to treat diseases?..."

When Dr. Maurice Garcia was a young surgical intern in San Francisco in the early 2000s, he regularly encountered transgender patients who had horror stories about their encounters with doctors.

Once, a transgender woman came to him distressed that she couldn’t find a surgeon to remove her testicles. Garcia couldn’t fathom why she was having such a difficult time finding someone to perform a simple and common surgery routinely done for people with testicular cancer. He thought it was especially odd because there were significant medical benefits to the procedure; removing the testicles meant the woman could stop taking certain hormones and lower her dosage of other hormones. 

“[She was] told, ‘I’m not a transgender surgeon, you have to find someone else,’” Garcia recalled. “Or, ‘I don’t believe in that.’” 

These kinds of roadblocks moved some patients to seek gender-affirming surgery in Mexico, Thailand or elsewhere, where procedures were cheaper but surgical standards might be lower. When they returned to San Francisco with serious complications from botched procedures, neither Garcia nor his colleagues at the University of California, San Francisco, knew how to manage the injuries.

A Knowledge Gap In Transgender Care

Currently, medical schools devote only an average of five hours of their curriculum to teaching “LGBT-related content,” according to a 2009-2010 survey of deans representing 150 medical schools in North America. This is woefully inadequate to prepare doctors to see and treat the approximately 1.4 million American adults who identify as transgender, and may explain why members of the medical community appear to have such a strained and fraught relationship with their transgender patients. 

Garcia wanted to make things better for his patients. So he sought permission from his superiors to learn more about transgender care and bring the knowledge back to UCSF. He went to the U.K. for a year and put together a curriculum on transgender surgery, training under the guidance of experienced surgeons. When he returned, he established UCSF’s first gender-affirming surgery program.

Now, three years later, he’s brought his expertise to Cedars-Sinai Medical Center in Los Angeles, where he established the hospital’s Transgender Surgery and Health Program — the second such academic medical center to offer gender-affirming surgery on the West Coast, as The New York Times first reported. 

Garcia wanted to make things better for his patients. So he sought permission from his superiors to learn more about transgender care and bring the knowledge back to UCSF. He went to the U.K. for a year and put together a curriculum on transgender surgery, training under the guidance of experienced surgeons. When he returned, he established UCSF’s first gender-affirming surgery program.

Now, three years later, he’s brought his expertise to Cedars-Sinai Medical Center in Los Angeles, where he established the hospital’s Transgender Surgery and Health Program — the second such academic medical center to offer gender-affirming surgery on the West Coast, as The New York Times first reported. 

Garcia believes that academic programs like these are key to helping not just transgender patients in San Francisco and Los Angeles, but patients all over the world. Unlike doctors at private clinics, where it’s thought that the majority of gender confirmation surgeries are conducted, those at academic centers also gather research to be published in peer-reviewed journals that will help deepen the field of genital surgery — perhaps discovering techniques that could help a wounded veteran or cancer survivor retain some measure of fertility, sexual or urinary function.

And most health care professionals, Garcia thinks, would benefit greatly from basic training about transgender patients. He hopes that the research he conducts at his center, as well as the expertise he builds as he develops a model for transgender care, will also help change the dialogue among medical professionals about how to compassionately and competently treat transgender patients.

Performing more gender confirmation surgeries at academic centers is also important because it fills an important gap in medical education, said Dr. Loren Schechter, director of the Center for Gender Confirmation surgery at Weiss Memorial Hospital in Chicago. 

“One of the things that’s lacking in medical schools is gender education,” he said. “When academic medical centers are performing the surgeries, you’ve got exposure to medical students ― the next generation of doctors.” 

Garcia also plans to take the center’s goals a step further by establishing a fellowship program for urology surgeons who want to gain specialty training in transgender surgery. This fellowship, set to launch next summer, is part of a growing movement. The Icahn School of Medicine at Mount Sinai in New York and Weiss Memorial Hospital in Chicago were the first to offer year-long fellowships in transgender surgery in August, and Hahnemann University Hospital in Philadelphia just announced the launch of its new fellowship program for surgeons in November.

Garcia hopes that the spread of fellowship programs in the U.S. means that doctors interested in the field can train at home, as opposed to traveling abroad like he had to when he couldn’t find other experts to mentor him. 

“Private practice is a very lucrative business,” he said. “There isn’t a natural incentive to train people who will then compete with you.” 

The Growth Of Transgender Surgery Centers In The U.S.


 

Cedars-Sinai Medical Center is part of a growing trend. By adding a transgender surgical program, the hospital now joins other academic medical centers, like UCSF, the Cleveland Clinic, Boston Medical Center, Oregon Health and Science University and Mount Sinai Hospital in New York.

And one advantage big academic medical centers have over smaller private clinics is the bureaucratic power they bring to bear on issues like health coverage. In addition to bringing gender confirmation surgery to Southern California, Cedars-Sinai’s program also accepts patients who are on Medi-Cal and Medicare, opening up access to crucial treatment that was generally available only from expensive private practice clinics. The hospital’s experience dealing with health insurance companies can also spare patients a lot of heartache and money.  

Nikolai Miles, a 26-year-old security guard in Thousand Oaks, California, decided to get a double mastectomy back in 2014 — a standard part of the series of surgeries that transgender men can get to affirm their identity. He went to a private practice in San Francisco that required him to pay all the money ― $8,500 ― upfront, while assuring him that they were going to work with his insurance to get as much of the operation covered as possible.

When he was recovering from the procedure, he got the shocking news that his clinic hadn’t bothered getting prior authorization for the surgery from his health insurance company, and that not a single dollar of his deposit would be reimbursed. Miles said that if he had known that his surgery would not be partially reimbursed, he never would have gone through with it.

″It was pretty crazy, and there were unfortunately a lot of aggravating curse words,” Miles recalled. “I wasn’t as appropriate on the phone as I should have been. It was a stressful moment, but there was no going back from it.”

There are no hard numbers on how common Miles’ experience was. What we do know is transgender people are less likely to have health insurance than the general population, and gender affirmation surgeries can cost tens of thousands of dollars out of pocket. Despite the costs, those surgeries are up almost 20 percent since the American Society of Plastic Surgeons began counting them in 2015. The group estimated that transgender people had more than 3,200 surgeries of some kind in 2016 to help them transition.

Despite Miles’ financial setback, he continued to research clinics that could help him continue his transition, and in the beginning of 2017, a therapist suggested he contact Garcia at Cedars-Sinai. Garcia’s office worked with Miles for over six months to communicate with his health insurance company about the process, getting authorization for the surgeries beforehand and ensuring that they would be covered. 

“I thought for so long that I was never going to have bottom surgery, because it was so expensive,” he said. “As soon as Dr. Garcia said he was going to work with insurance, I felt like I was going to fall off my chair.”

So far, Miles has had a scrotoplasty and a phalloplasty, and is recovering from his most recent surgery on Nov. 1. Because he just turned 26 and can no longer be on his grandmother’s insurance plan, he’s figuring out how to pay for his third and final surgery. While he’s stressed about it, he’s thankful that surgeries that could have cost him anywhere from $60,000 to $100,000 out of pocket — quotes from private practice clinics that all refused to work with insurance — have cost him only about $1,500.

“It’s enough, in itself, to give anybody goosebumps,” Miles said.

It’s this kind of comprehensive care that Garcia and his colleagues strive for at Cedars-Sinai. Whether it’s providing help navigating health insurance companies, connecting people with previous patients who have gone through similar procedures, or even offering a makeup session to transgender women before they return home, Garcia aims to offer patient-centered care that takes care of the whole person, not just their body.

“It’s about making people feel whole, and recognizing it’s a whole person we’re taking care of, not just the genital area.”

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