Keshav Tyagi - MPHc Protecting the Health of the Transgender Population

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"The Need for a Non-Discrimination Statement to Protect the Health of the Transgender Population in the State of Massachussetts," by Keshav Tyagi, Keck School of Medicine, University of Southern …

"The Need for a Non-Discrimination Statement to Protect the Health of the Transgender Population in the State of Massachussetts," by Keshav Tyagi, Keck School of Medicine, University of Southern California, Master of Public Health Program

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  • 1. ! ! ! T h e $ K e c k $ S c h o o l $ o f $ M e d i c i n e $ o f $ t h e $ U n i v e r s i t y $ o f $ S o u t h e r n $ C a l i f o r n i a $ M a s t e r $ o f $ P u b l i c $ H e a l t h $ P r o g r a m $ The$Need$for$a$Non,Discrimination$ Statement$to$Protect$the$Health$of$the$ Transgender$Population$in$the$State$of$ Massachusetts$ Keshav$Tyagi$ PM$508$,$Dr.$Cousineau$ Spring$ 14$
  • 2. Introduction* In! 2010,! the! Obama0Biden! Administration! passed! the! Patient! Protection! and! Affordable! Care! Act,! also! known! as! the! ACA! (U.S.! Department! of! Health! and! Human! Services).! It! was! enacted! with! the! intent! of! increasing! the! quality,! affordability,! and! accessibility!of!health!care,!expanding!public!and!private!insurance!coverage,!and!reducing! health!care!costs!across!the!country.!Outlined!in!the!ACA!are!two!sections:!Section!2706,! the!“Nondiscrimination!in!Health!Care”!clause!(Integrative!Healthcare!Policy!Consortium),! and! Section! 1557,! the! “Civil! Rights! Provision,”! (U.S.! Department! of! Health! and! Human! Services).!Together,!they!ban!discrimination!in!healthcare!based!on!sex!and!gender.!! For!those!identifying!as!transgender,!these!protections!originally!meant!access!to! care! for! many! long0standing! health! concerns.! This! population! suffers! from! issues! like! access!to!culturally!competent!care,!hormone!therapy,!substance!and!alcohol!abuse,!and! mental!health!issues!like!depression,!(Vanderbilt!University!School!of!Medicine).!They!also! have! a! disproportionately! high! rate! of! suicide! in! comparison! to! both! the! general! population,!and!the!highest!rates!of!HIV!infection!(National!Center!for!Transgender!Health).! Additionally,!this!population!endures!judgment!and!discrimination!by!doctors!and!health! insurance!providers!(Massachusetts!Transgender!Political!Coalition).! However,!the!ACA!does!not!outline!or!mandate!state!requirements!for!either!clause.! As!such,!it!is!through!each!state’s!discretion!as!to!how!these!policies!are!enforced.!In!the! state!of!California,!the!Department!of!Managed!Health!Care,!or!DMHC,!responded!to!this! choice! by! releasing! a! non0discrimination! statement! barring! discrimination! based! on! gender,! gender! identity,! and! gender! expression! (California! Department! of! Managed! HealthCare).!This!influenced!both!the!delivery!of!care,!as!well!as!insurance.!In!response,! Kaiser! Permanente! dropped! their! policies! traditionally! used! to! marginalize! those! identifying! as! transgender.! Kaiser! Permanente! shepherded! the! first! three! test! cases! for! fully! covered! gender0confirming! therapy! (both! hormone! therapy! and! surgery! (Stroumsa! 31),!and!became!the!first!plan!in!the!nation!to!include!coverage!for!such!procedures!in!its! health! insurance! policy! (Valentine).! Since! then,! the! states! of! Colorado,! Oregon,! Vermont! and!Connecticut,!and!Washington!DC,!have!also!barred!this!discrimination!(Murtha).!! However,! states! like! Massachusetts! have! not! followed! this! trend.! While! discrimination!towards!transgender!people!has!been!barred!in!this!state!since!2011,!this!
  • 3. policy!enforces!employment!and!housing!equity,!and!does!not!currently!extend!to!health! care! (GLAD! Answers).! As! a! result,! this! population! has! substantial! difficulties! accessing! quality! care,! contributing! to! higher! health! risks.! In! a! study! done! by! the! Massachusetts! Department! of! Public! Health,! 8%! of! those! sampled! self0reported! that! they! did! not! have! health! insurance,! 17%! did! not! have! a! personal! physician,! and! 33%! did! not! believe! themselves!to!have!excellent!health.!On!average,!transgender!individuals!in!Massachusetts! reported!depression!and!anxiety!for!an!average!of!8!days,!and!31%!had!considered!suicide! (Mass!Equality).!Despite!these!findings,!not!much!policy!work!has!been!done!here!to!level! these! disparities.! As! a! result,! this! population! still! endures! these! problems,! with! roots! derived!from!both!health!care!settings!and!insurance!coverage.! Transgender*Discrimination*in*Massachusetts*–*Public*Health*Implications* According! to! the! Massachusetts! Transgender! Political! Coalition,! this! population! predominantly! suffers! from! two! major! predicaments,! even! after! the! passing! of! the! ACA.! The!first!issue!is!difficulty!locating!providers!and!insurance!sensitive!to!and!respectful!of! transgender!health!issues.!Many!patients!have!reported!harsh!and!abusive!language!at!the! hands!of!a!health!care!professional,!and!blame!from!these!same!caregivers!for!their!own! debilitating!health!conditions.!Additionally,!those!living!outside!urban!areas!have!difficulty! accessing! competent! doctors,! who! are! concentrated! in! urban! cities! like! Boston! and! Worcester!(Fenway!Health).!Aside!from!transgender!health!services,!this!population!also! suffers! from! discrimination! and! denial! of! basic! care,! like! in! emergency! rooms! (Massachusetts! Transgender! Political! Coalition).! The! issue! is! the! predominant! lack! of! respect!and!consideration!for!transgender!patients!in!this!state,!encapsulating!both!gender0 confirming!therapy!and!basic!health!services,!and!manifesting!through!delivery!and!access.! The! second! major! issue! is! the! inability! to! secure! and! pay! for! needed! services.! Transgender! individuals! are! wary! to! disclose! their! status! because! they! fear! exclusion! (Valentine),! and! potentially! a! loss! of! health! coverage! (Murtha).! Many! health! insurance! plans,!like!Harvard!Pilgrim!Care!Group!in!Massachusetts,!include!policies!to!discriminate! against!transgender!patients,!barring!them!from!gender0confirming!therapy!by!classifying! it! as! medically! excessive! (Harvard! Pilgrim! HealthCare).! Although! the! American! Medical! Association! has! recently! joined! the! movement! to! support! gender0confirming! therapy!
  • 4. inclusion! within! public! and! private! insurance,! health! plans! in! Massachusetts! actively! do! not,!further!marginalizing!this!population!(Human!Rights!Campaign).!! Generally,!if!a!policy’s!language!is!vague!enough,!they!can!choose!to!deny!services! unrelated! to! gender0confirming! therapy,! simply! because! one! identifies! as! transgender.! Additionally,!this!inexplicit!language!permits!a!hostile!medical!environment,!spanning!care! delivery! and! coverage.! In! a! 2011! survey! by! Lambda! Legal,! out! of! 6000! respondents! sampled,! 19%! reported! being! refused! health! care! services! based! on! their! status,! 28%! reported! verbal! abuse! from! a! health! professional,! and,! 33%! postponed! seeking! medical! care!after!this!treatment!discrimination!(New!York!City!Bar;!Lambda!Legal;!Human!Rights! Campaign).! This! data! explains! that! despite! how! a! segment! of! the! US! population! suffers! disproportionately! high! rates! of! mental! illness,! substance! abuse! and! addiction,! chronic! disease,!these!issues!continue!because!they!are!not!comfortable!to!go!to!medical!facilities! and!receive!the!care!they!need,!because!the!environment!is!not!receptive!to!them.! Another! method! exploited! by! health! insurance! plans! to! discriminate! against! this! population! involves! utilizing! a! loophole! in! the! ACA.! While! expanding! public! and! private! insurance!was!intended!to!make!it!easier!to!attain!health!insurance!coverage,!to!receive! legalized! benefits! like! premium! assistance,! one’s! chosen! gender! in! his! or! her! health! insurance!policy!must!match!the!gender!marked!on!his!or!her!social!security!card.!Social! security,!however,!requires!physician!documentation!for!gender!change!(National!Center! for! Transgender! Equality).! Through! this! loophole,! health! insurance! plans! justify! not! covering!services!based!on!how!official!documentation!of!the!patient’s!sex!was!not!matched! by!social!security!administration!and!the!health!policy!(Murtha).! Cadence!Valentine,!one!of!the!first!three!test!cases!by!Kaiser!Permanente!to!undergo! fully! covered! gender! confirming! therapy,! offered! personal! insight! into! the! overarching! effects! of! the! lack! of! consideration! for,! and! overall! understanding! of,! the! transgender! population! and! specific! health! needs.! In! therapy,! for! example,! she! cited! how! many! individuals!spend!much!of!the!session!educating!the!professional!about!what!it!means!to!be! transgender,! due! that! professional’s! lack! of! knowledge.! She! explained! how! although! transgender!individuals!have!the!highest!risk,!as!well!as!rates,!of!HIV!infection,!many!are! not! in! treatment! or! on! medication.! She! cites! this! trend! as! a! direct! result! of! the! cultural! incompetency!and!insensitivity!of!providers!and!insurance!plans.!Lastly,!she!also!explains!
  • 5. how!many!misconceptions!and!incorrect!terminology!are!utilized!in!health!care,!which!is! perceived!as!offensive!to!transgender!individuals,!and!has!detrimental!effects.!For!example,! many! professionals! termed! a! transgender! individual! as! “transgendered.”! This! term,! according! to! Valentine,! is! regarded! as! a! dehumanizing! (Valentine).! While! Valentine! is! fortunate! to! have! received! quality! care! from! culturally! competent! providers,! many! transgender!individuals,!especially!in!Massachusetts,!do!not!have!that!access,!and!equity! for!this!population!has!a!long!way!to!go!in!terms!of!political!enforcement!and!advocacy.! Policy*Alternatives! ! One! possible! action! to! address! this! issue! in! the! Massachusetts,! as! well! as! other! states,! is! to! have! the! Massachusetts! Executive! Office! of! Health! and! Human! Services! (EOHHS)! deliver! a! non0discrimination! statement,! similar! to! the! one! passed! by! the! California!Department!of!Managed!Care.!This!would!clearly!enforce!that!health!insurance! policies!are!not!permitted!to!uphold!discriminatory!language,!and!facilitate!the!delivery!of! health!services!outlined!in!the!ACA!(Forbes).!This!would!be!a!positive!alternative,!because! it! eases! the! reception! of! non0judgmental! care! and! coverage! by! health! professionals,! in! health!care!facilities,!and!through!insurance!plans.!At!minimum,!it!would!ensure!essential! health!benefits!are!justly!delivered,!and!grant!transgender!individuals!fair!access!to!quality! care.!While!the!Massachusetts!EOHHS!would!need!to!debate!if!the!full!spectrum!of!gender0 confirming!therapy!should!be!considered!as!medically!necessary!in!insurance!policies!later! on,!the!first!step!is!to!ensure!this!population!can!access!the!same!type!and!quality!of!care!as! the!general!population.! ! Another! action! to! consider! is! incorporating! transgender! health! as! a! part! of! continuing!medical!education.!Much!discrimination!against!this!population!stems!from!a! general!lack!of!understanding,!awareness!and!education!about!health!as!it!relates!to!those! identifying! as! transgender.! The! lack! of! knowledge! allows! for! the! development! bias! and! prejudice,! and! paving! the! way! for! their! marginalization.! This! is! also! emphasized! by! the! dearth! of! physicians! who! are! comfortable! with! providing! care! to! transgender! people! (Stroumsa!33).!Education!is!desperately!needed.!It!should!emphasize!primary!care,!as!well! as! aligned! disciplines! like! endocrinology,! urology,! obstetrics! and! gynecology,! plastic! and! reconstructive! surgery,! and! emergency! medicine.! Additionally,! it! would! be! beneficial! to! incorporate!education!in!medical,!physician!assistant!and!nursing!school!curriculum,!so!as!
  • 6. to!reform!current!health!education!and!include!this!population!in!the!spectrum!of!minority! care! and! cultural! competency! (Stroumsa! 34).! Ultimately,! influencing! medical! education! does! not! solely! affect! transgender! individuals! in! Massachusetts;! it! influences! education! across!the!country.! ! A! third! policy! action! requires! developing! and! distributing! national! surveys! and! health! data! sets! to! gather! information! about! transgender! health.! This! can! be! done! by! incorporating! questions! about! gender! identity! and! expression! on! current! and! existing! health!surveys!(Stroumsa!37).!This!is!a!necessary!step!towards!establishing!a!foundation!of! knowledge!and!statistics!to!respond!to!the!health!and!needs!of!the!transgender!population.! The! information! gathered! could! be! used! to! develop! culturally! competent! care,! inform! health! educators! and! health! professionals! on! the! population’s! demographics! and! health! trends,!and!enhance!the!practice!of!medicine!to!advocate!and!consider!transgender!health! within!the!spectrum!of!patient!care!and!health!insurance.!Ultimately,!accumulation!of!this! data!can!be!utilized!in!Massachusetts,!outside!states,!and!in!further!national!health!reform.! Final*Policy*Recommendation* While!all!of!these!policy!actions!should!be!considered!and!implemented!over!time,! the! more! practical! approach! is! issuing! a! non0discrimination! statement,! barring! discrimination!based!on!gender,!gender!identity,!and!gender!expression.!As!a!result!of!this! declaration! in! Massachusetts,! a! foundation! for! developing! education! about! transgender! health!issues,!and!accumulation!of!health!statistics!for!this!population,!will!be!established.! This!action!will!facilitate!a!progressive!and!culturally!competent!health!care!system!that! fairly!includes!transgender!individuals,!and!prohibits!unfair!discrimination.! It! is! important! to! note! that! while! this! policy! action! has! been! enacted! in! several! states,!its!effects!have!not!officially!been!qualified!or!quantified.!!However,!its!provision! heralds!protection!and!security!in!health!care,!for!a!population!that!has!not!experienced!it.! Dr.!Ted!Eytan,!at!the!first!ever!Kaiser!Permanente!LGBT!Health!Symposium,!describes!the! impact! of! this! decision! for! transgender! individuals! in! California.! In! his! words,! “a! marginalized!and!invisible!population!in!health!care!was!now!‘visible,’!and!seen!as!worthy! of!care,”!(Eytan).! ! !
  • 7. Works$Cited$ California!Department!of!Managed!HealthCare.!Gender!Non0Discrimination!Requirements.! Statement.!Sacramento:!California!Department!of!Managed!HealthCare,!2013.! Executive!Office!of!Health!and!Human!Services.!Health!and!Human!Services.!00!00!2014.!4! April!2014!<http://www.mass.gov/eohhs/>.! Eytan,!Ted.!Clinicians!from!the!future!practice!the!medicine!of!inclusion!–!Kaiser! Permanente!LGBT!Health!Symposium.!15!April!2013.!4!April!2014! <http://www.tedeytan.com/2013/04/15/12965>.! Fenway!Health.!Transgender!Health!Fact!Sheet.!Fact!Sheet.!Boston:!Fenway!Health,!2014.! Forbes.!Essential!Health!Benefits!Under!the!Affordable!Act!Act.!11!October!2013.!3!April! 2014!<http://www.forbes.com/sites/investopedia/2013/10/11/essential0health0benefits0 under0the0affordable0care0act/>.! GLAD!Answers.!What!You!Need!to!Know!ABout!MAssachusetts'!Transgender!Rights!Law.! Presentation.!Boston:!Gay!and!Lesbian!Advocates!and!Defenders,!2013.! Harvard!Pilgrim!HealthCare.!Our!Plans.!1!January!2014.!3!April!2014! <https://www.harvardpilgrim.org/portal/page?_pageid=213,38301&_dad=portal&_schem a=PORTAL>.! Human!Rights!Campaign.!Health!Insurance!DIscrimination!for!Transgender!People.!1! January!2014.!3!April!2014!<https://www.hrc.org/resources/entry/health0insurance0 discrimination0for0transgender0people>.! Integrative!Healthcare!Policy!Consortium.!"Frequently!Asked!Questions!about!Section! 2706."!Integrative!Healthcare!Policy!Consortium.!Conifer:!Integrative!Healthcare!Policy! Consortium,!2013.!00.! Kaiser!Permanete.!Accountable!Care!Organizations!Explained.!23!August!2013.!3!April! 2014!<http://www.kaiserhealthnews.org/stories/2011/january/13/aco0accountable0 care0organization0faq.aspx>.! Mass!Equality.!A!survey!of!health!issues!comparing!LGBT!persons!with!their!heterosexual! and!non0transgender!counterparts.!Survey.!Boston:!Massachusetts!Department!of!Public! Health,!2009.! Massachusetts!Transgender!Political!Coalition.!U.S.!Patient!Protection!and!Affordable!Care! Act.!14!February!2014.!3!April!2014!<http://www.masstpc.org/issues/health0care/>.! Murtha,!Tara.!The!Problem!with!Obamacare!for!Some!Transgender!Policholders.!12!March! 2014.!5!April!2014!<http://rhrealitycheck.org/article/2014/03/12/problem0obamacare0 transgender0policyholders/>.! National!Center!for!Transgender!Equality.!Transgender!People!and!the!Social!Security! Administration.!Report.!Washington!DC:!National!Center!for!Transgender!Equality,!2013.! National!Center!for!Transgender!Health.!Preventing!Transgender!Suicide.!Washington:! National!Center!for!Transgender!Equality,!2010.! New!York!City!Bar;!Lambda!Legal;!Human!Rights!Campaign.!Transgender0Affirming! Hospital!Policies.!Policies.!New!York!City:!Lambda!Legal,!2011.! Stroumsa,!Daphne.!"The!State!of!Transgender!Health!Care:!Policy,!Law!and!Medical! Frameworks."!The!American!Journal!of!Public!Health!104.3!(2014):!31038.! U.S.!Department!of!Health!and!Human!Services.!Affordable!Care!Act!Nondiscrimination! Provisions!Applicable!to!Insured!Group!Plans.!Notice.!Washington!DC:!IRS,!2011.! —.!"Patient!Protection!and!the!Affordable!Care!Act."!Bill.!2009.!
  • 8. Valentine,!Cadence.!The!State!of!Transgender!Health!Keshav!Tyagi.!21!February!2014.! Vanderbilt!University!School!of!Medicine.!Key!Transgender!Health!Concerns.!Nashville,!00!00! 2012.! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !