Friday, January 08, 2016

The Doctor Will See You Now

For a lot of trans people those words create an uneasiness, we never know what to expect. Will be thrown out of the office, will the doctor give us the best care or just give us lip service to get us out of their office? We wonder if insurance will cover us or will they deny us coverage?
OCR Enforcement under Section 1557 of the Affordable Care Act Sex Discrimination Cases

Section 1557 of the Affordable Care Act prohibits discrimination on the basis of race, color, national origin, sex, disability, or age in certain health programs and activities. The HHS Office for Civil Rights (OCR) is responsible for accepting and investigating complaints under Section 1557.

Section 1557 is the first federal civil rights law to prohibit sex discrimination in covered health programs and activities. Section 1557’s sex discrimination prohibition extends to claims of discrimination based on gender identity or failure to conform to stereotypical notions of masculinity or femininity. Below are a few case examples that highlight OCR’s enforcement results in complaints alleging sex discrimination.
They go on to list several case histories and one them is about a trans case…
A transgender individual alleged that the Colorado Women’s Wellness Connection Program denied coverage of her mammogram because she transitioned from male-to-female rather than female-to-male. The Wellness Program provides funding to health care facilities to cover mammograms and gynecological screenings for low-income and under-insured women throughout Colorado. The Wellness Program itself was funded primarily by the National Breast and Cervical Cancer Early Detection Program, administered by the Centers for Disease Control and Prevention (CDC). Under the Program, CDC’s position was to cover only individuals who were genetically female. OCR accepted the complaint for investigation because Section 1557 prohibits discrimination in health care programs based on sex, which includes gender identity. Subsequent to OCR’s investigation, CDC issued guidance for all its grantees, including the Wellness Program, to clarify that recipients of CDC’s grants can cover mammogram services for transgender women who have taken or are taking hormones. OCR confirmed that the Wellness Program adopted the CDC’s new guidance and formally notified all of its sub-grantees of the policy change.
I know of a number of cases where trans men have been to that Ob/Gyn doctor didn’t want to treat them because it would make their other patients uncomfortable having a man in the waiting room or that they didn’t know how to medically treat a trans patient. As if the trans men uterus and ovaries mutate when they transition.

The other problem that we’re starting to have is because of the switch to electronic medical records.
Electronic medical records and the transgender patient: recommendations from the World Professional Association for Transgender Health EMR Working Group

Transgender patients have particular needs with respect to demographic information and health records; specifically, transgender patients may have a chosen name and gender identity that differs from their current legally designated name and sex. Additionally, sex-specific health information, for example, a man with a cervix or a woman with a prostate, requires special attention in electronic health record (EHR) systems. The World Professional Association for Transgender Health (WPATH) is an international multidisciplinary professional association that publishes recognized standards for the care of transgender and gender variant persons. In September 2011, the WPATH Executive Committee convened an Electronic Medical Records Working Group comprised of both expert clinicians and medical information technology specialists, to make recommendations for developers, vendors, and users of EHR systems with respect to transgender patients. These recommendations and supporting rationale are presented here.
They then list some of the problem areas such as,
Transgender people may have preferred names and/or pronouns that differ from those listed on government-issued documents or health insurance policies. Furthermore, transgender people may obtain name and/or sex/gender designation changes on identity or other documents (eg, passport, birth certificate, driver's license, financial accounts, etc) at various stages of their transition. In the USA, specific guidelines exist for identity document changes both at the federal level as well as state by state. Failing to be identified by the preferred name and pronoun in a medical setting has been shown to impact patient satisfaction and quality of care for transgender people.11* For example, a patient with an outwardly female appearance may be called by a male name in a crowded medical office reception area, or a patient listed as female who has a male appearance and identity may be referred to with a feminine pronoun by a healthcare provider unfamiliar with the patient's history and preferences. This may negatively impact the patient–provider relationship, as well as put patients at risk for verbal or even physical abuse from other patients in the waiting area. A recent non-peer reviewed report on transgender discrimination showed some 28% of respondents had experienced harassment in a clinic setting and that 2% had been subject to physical abuse.12 It may also lead to the avoidance of care or loss of retention of the patient if they feel that their gender identity is not being acknowledged or respected. A qualitative study of HIV+ low income transgender women of color found that culturally sensitive practices influenced linkage to a variety of healthcare services.13

In addition to concerns about demographic information such as listed versus preferred name, gender, and pronouns, providers require a means to maintain an accurate record of what organs a patient may or may not have; this record cannot be limited or defined by the patient's assigned or apparent sex/gender as entered into the EHR. For example, a patient may have been assigned female at birth, and have transitioned to male through the use of testosterone and surgical removal of the breasts; they may also have obtained a court ordered name and sex or gender change and are registered in the EHR system under a male name and gender. However, since this patient still has a cervix, ovaries, and uterus, health care providers will require the ability to enter pelvic exam findings and gynecologic review of systems, and to order a cervical pap smear within the EHR system. EHR products that restrict or pre-populate an individual encounter with sex-specific history, exam, or ordering templates will prevent this patient's provider from accurately and efficiently documenting their care.
My last insurance company had a hard time with me getting a PSA test; they used to reject the claim saying that I was female and shouldn’t have a PSA test.

It is nice to see that WPATH and other organizations are working to make healthcare for us less of an ordeal.

*For the footnotes see the article.

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