Providing healthcare for transgender individuals is as much about inclusivity as it is about clinical expertise.
Most likely, you already care for transgender individuals in your hospitals or clinics but don't collect data about patients' gender identity or sexual orientation.
The "not counting" of these individuals represents just the beginning of missed opportunities in best serving their needs.
While it's become more common in recent years for hospitals and health systems to launch service lines dedicated to gender-affirming healthcare, Boston's Fenway Health is among the pioneers.
The Fenway Community Health Center (later shortened to Fenway Health in 2009) was founded in 1971 by students of Northeastern University as a drop-in center serving the elderly, and the lesbian, gay, bisexual, and transgender (LGBT) community.
In 2001, Fenway Health launched The Fenway Institute, a nonprofit interdisciplinary center dedicated to ensuring cultural competence in healthcare for the LGBT community through research and evaluation, training and education, and policy and advocacy.
Today, Fenway counts a patient visit total of more than 150,000 per year.
And with dozens of new transgender patients coming to the organization each month, they now account for about 3,000 patients, Alex S. Keuroghlian, MD, MPH, director of education and training programs at The Fenway Institute, says.
Success key No. 1: Create the right environment
Creating a formalized, multidisciplinary program to address the healthcare needs of transgender individuals involves many moving parts, but the most difficult and critical step has nothing to do with business plans or balance sheets, says Keuroghlian, who is also an assistant professor of psychiatry at Harvard Medical School.
"The hardest part is creating an inclusive, affirming healthcare environment for transgender people," he says.
"As prescribers, we're pretty adept at learning how to prescribe a new medication, reading about the dosing and any lab work that needs to go along with the medication, learning about the potential side effects, and running with it. The harder part is the structural competency and training of both clinical and nonclinical staff to work with transgender people."
A key piece of that training—for everyone from the clinical care team to front-desk personnel and security guards—involves instruction around effective, sensitive communication.
In particular, employees must be taught not to make assumptions about people's gender or pronouns by which they prefer to be addressed.
The physical environment should be designed thoughtfully as well, says Keuroghlian. "What posters and pamphlets are in the waiting room? What kind of reading materials are being used?"
Hiring practices matter, too, in order to have a workforce that reflects the diversity of the community served. "Are there openly transgender people working there? Are there nondiscrimination policies that explicitly name gender identity and expression, and are known by staff and patients?" he says.
Success key No. 2: Recruit caring, committed people
Most important, the team you recruit must be a caring one, says Joni Steffens, APRN, CSC, director of CentraCare Health's Gender Medicine program in Central Minnesota, which opened in July 2017, after two years of planning.
"The clinicians and our care team are passionate and committed to this patient population. This is not [just] a job for any of us," Steffens says. "It is really something that drives us every day, and we're all committed to making it matter."
The program's team of six includes four medical providers, a behavioral health professional, and a gender medicine patient navigator.
Together, these individuals provide a comprehensive, integrated model of care that includes primary care, urology, OB-GYN, and behavioral health in one physical space.
"Bringing all of these services together is a bit unique, particularly if you are outside of an academic or urban setting," she says.
For patients in the community of St. Cloud, getting care in the Twin Cities requires hours of driving each way.
"We will provide primary care not only to our transgender individuals but to offer a medical home to the LGBTQ community in general. Our specific transgender services include hormone management, behavioral healthcare, and referrals for surgery."
CentraCare's sexual medicine clinic was already up and running, so relationships with support staff, urologists, and other professionals were already established, she adds.
"The hardest part is creating an inclusive, affirming healthcare environment for transgender people."
Fenway Health also employs a full-time transgender health advocate to address challenges with insurance coverage and reimbursement.
According to the 2015 U.S. Transgender Survey, which included anonymous online responses from more than 27,000 transgender individuals across the country, 55% of respondents have had coverage denied for gender-affirming surgery, while 25% of those who sought coverage for hormones were denied.
"Our advocate's job all day, every day, is to deal with these challenges and file appeals to ensure that we get coverage for the gender-affirming care that we're providing," Keuroghlian says.
Success key No. 3: Work with your EHR
As part of its mission to provide integrated care, all of the clinicians working with CentraCare's Gender Medicine program use the same electronic health record.
"Fortunately, we're all on the same EHR. Technology can be a great tool, but sometimes there are barriers within the EHR itself," Steffens says.
While the vendor she works with has been focused on accommodating gender medicine workflows, Steffens says, not all products are set up to collect information about a person's sexual orientation, gender identity, gender marker change, name pronunciation, and correct pronouns, to name a few gaps.
"So foundational are names and pronouns," she says. "From the very start, it's crucial to interact with patients in a friendly and inclusive way, from the first phone call, throughout their visits, and across the continuum."
Part of The Fenway Institute's work is to advise EHR vendors on these issues—and training individuals on how to collect and use the information.
"We work with vendors of EHRs to build in anatomical inventories that track body modifications and retained organs that people have, so that preventive cancer screening is based on the actual organs in someone's body," says Keuroghlian.
But more fundamentally, registration staff must be trained to ask patients for their current gender identity as well as their sex assigned at birth.
"A lot of people aren't going to identify as transgender unless you ask both of those questions," he says. "It's called the two-step process."
Both steps are necessary, he explains, because oftentimes a transgender woman, if simply asked her gender, will say she is a woman—and vice versa for a transgender man. "And second, they may not want to out themselves in that way."
Even with the two-step process and a robust EHR, if staff aren't trained to be effective and affirming in their communication, that data collection "is not going to go very well," says Keuroghlian.
This means that the right technology must be paired with humanity, cultural competence, and humility, he says. "You want people to just have to tell you once what their pronouns are and for that to get transmitted throughout. You don't want people to get misgendered over and over again, because they're really not going to come back at that point and you'll lose people."
That said, Keuroghlian recommends "checking in with some regularity about people's name, pronouns, and sexual orientation and identity because those evolve throughout a person's life."
Debra Shute is the Senior Physicians Editor for HealthLeaders Media.