Understanding the Well-Being of LGBTQI+ Populations (2020) / Chapter Skim
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12 Coverage, Access, and Utilization of Evidence-Based Health Care
12 Coverage, Access, and Utilization of Evidence-Based Health Care
Pages 349-394
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From page 349... ...
This chapter first reviews the literature on access to care, insurance coverage, and health services utilization in SGD populations. It then discusses in detail three topics that are particularly critical to ensure that clinical and policy approaches to health care for SGD populations are evidence based: gender-affirming care for transgender people, conversion therapy targeting sexual orientation or gender identity, and early genital surgeries for infants with intersex traits.
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From page 350... ...
It then discusses other insurance coverage issues for SGD people, followed by what is known about health services utilization in SGD populations, including considerations of care quality and health professions training. Discrimination in Health Care and Health Insurance Coverage Despite cultural and legal shifts such as the nationwide expansion of marriage equality for same-sex couples, discrimination against LGBT people in health care and coverage remains pervasive in the United States.
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From page 351... ...
. Similarly, people with intersex traits may avoid routine health care due to previous negative experiences with medical providers (Lambda Legal, 2018)
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From page 352... ...
In addition to requiring equal access to health care services and health insurance coverage, the regulation clarified that such actions as refusing to use a transgender person's correct name and pronoun, assigning a transgender person to a hospital room or other facility on the basis of their sex assigned at birth, or excluding coverage for all care related to gender affirmation constitute discrimination (insurance coverage for gender-affirming care is covered in more detail below)
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From page 353... ...
Health Insurance Coverage Several factors have changed the landscape of health insurance coverage for LGBT people over the past decade. In addition to the nondiscrimination protections described above, these factors include marriage equality for same-sex couples and the implementation of coverage expansions under the ACA.
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From page 354... ...
. Among transgender people, 39 percent of 2015 USTS respondents reported having a disability, compared with 15 percent of the general population (James et 10 See: https://williamsinstitute.law.ucla.edu/visualization/lgbt-stats/?
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From page 355... ...
Access to care for people living with HIV is one of the many reasons that Medicaid expansion or broader health system reform, such as "Medicare for All" or another form of universal coverage, is a critical health issue for SGD populations. Medicaid is also an important source of health insurance coverage for transgender people for both income and medical reasons.
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From page 356... ...
. This trend is likely related to a combination of a growing transgender population in the United States, improved coding practices that make it easier to identify transgender people and gender-affirming medical services in data sources such as insurance claims, and removal of barriers to insurance coverage for these services.
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From page 357... ...
It is important for researchers, care providers, and policy makers to develop and evaluate targeted efforts to address social determinants of health and meet social needs for SGD people. The experiences of SGD patients have also not been fully explored in the context of new care delivery models intended to improve quality, coordinate care, and restrain costs, such as accountable care organizations and patient-centered medical homes (National LGBT Health Education Center, 2016)
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From page 358... ...
, which oversees the community health centers program and the Ryan White program, funds the National LGBT Health Education Center at Fenway Health, a federally qualified community health center located in Boston that specializes in serving LGBTQ people and people living with HIV.12 The National LGBT Health Education Center provides a variety of downloadable resources and continuing medical education modules on 11 See https://www.aamc.org/what-we-do/mission-areas/diversity-inclusion/lgbt-health-resources. 12 See https://www.lgbthealtheducation.org.
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From page 359... ...
Important factors identified in this project included providing transgender-specific cultural and clinical competency training for the health care workforce; addressing social determinants of health, such as housing, as part of the provision of health care services; and recognizing the central role that gender-affirming services and personal empowerment can play in improving care and outcomes for transgender people living with HIV, particularly transgender women of color (Health Resources and Services Administration, n.d.; Rebchook et al., 2017)
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From page 360... ...
Psychosocial support for gender affirmation typically focuses on reducing emotional distress and supporting decision making regarding social, legal, and medical steps. Some young transgender people and their families opt for medication to delay the onset of puberty.
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From page 361... ...
. A number of professional medical organizations have joined WPATH in recognizing that gender-affirming care is medically necessary for transgender people because it reduces distress and promotes well-being, while withholding care increases distress and decreases well-being (American Academy of Family Physicians, 2012; American Academy of Pediatrics, 2018; American College of Nurse Midwives, 2012; American College of Obstetricians and Gynecologists, 2011; AMA, 2008; American Psychiatric Association, 2018; American Psychological Association (APA)
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From page 362... ...
This aspect of the regulation remains contested in court, but it is expected that the original regulation's specific protections for transgender people will be found to be well within the scope of federal law and the agency's authority (Keith, 2020)
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From page 363... ...
. Some countries have further underscored that transgender identity is not a pathology by recognizing gender affirmation as fundamental to the human right to self-definition and removing requirements that transgender people seeking gender-affirming medical care present with a diagnosis such as gender dysphoria (Arístegui et al., 2017)
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From page 364... ...
Hormone therapy with testosterone or estrogen is a common genderaffirming treatment for transgender adults and older adolescents. Though limited by heterogeneity of methodology, regimen, and outcomes measures, systematic reviews and meta-analyses consistently find that genderaffirming hormone treatment is associated with significant reductions in gender dysphoria, psychological symptoms, and psychiatric diagnoses and with improved markers of well-being, including quality of life, interpersonal functioning, psychological adjustment, sexual function, body satisfaction, and self-esteem (Costa and Colizzi, 2016; Dhejne et al., 2016; Keo-Meier et al., 2015; Murad et al., 2010; Nguyen et al., 2018; Rowniak, Bolt, and Sharifi, 2019; White Hughto and Reisner, 2016)
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From page 365... ...
. Surgeries involving the genitals or secondary sex characteristics can also improve health and well-being among transgender people and are an important and medically necessary aspect of gender-affirming care (Bailey, Ellis, and McNeil, 2014; Castellano et al., 2015; Murad et al., 2010; Passos et al., 2020; Wernick et al., 2019)
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From page 366... ...
As noted above, available evidence generally indicates that genderaffirming medical interventions, including surgeries, are associated with improvements in gender dysphoria, mental health, and quality of life for transgender people. Evidence also suggests, however, that mental health conditions can persist after treatment: for instance, a 2011 Swedish registry study of 324 patients who had undergone gender-affirming surgeries between 1973 and 2003 found increased rates of suicide attempts and psychiatric hospitalizations relative to population controls (Dhejne et al., 2011)
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From page 367... ...
For example, the Center of Expertise on Gender Dysphoria at the Free University Medical Center in Amsterdam published results from 43 years of clinical care in which regret was reported in only 14 patients (0.5%) of the more than 5,300 patients who underwent gonadectomy as part of gender affirmation (Wiepjes et al., 2018)
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From page 368... ...
Overall, however, the evidence indicates that gender-affirming interventions, including social affirmation, hormonal treatment, and surgeries, are medically necessary for reducing distress and improving the health and well-being of transgender people. CONVERSION THERAPY Efforts to change sexual orientation or gender identity, which initially gained traction in the 1960s and which are often referred to as conversion or reparative therapies, assume that non-cisgender and non-heterosexual identities are abnormal.
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From page 369... ...
The available evidence suggests that sexual orientation and gender identity conversion efforts are ineffective and dangerously detrimental to the health of SGD populations, especially for minors who are unable to give informed consent. As of early 2020, 20 states, the District of Columbia, Puerto Rico, and a number of municipalities had outlawed sexual orientation and gender identity conversion therapy for minors (Move
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From page 370... ...
, a narrow or absent vaginal opening, or presence of partially fused labia or a partially separated scrotum. This section focuses primarily on early genital surgery for children born with obvious genital diversity, which remains the most contentious area of clinical care -- and increasingly, health law and policy -- for persons with intersex traits (Dalke et al., 2020)
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From page 371... ...
Early genital surgeries primarily seek to align genitalia with assigned sex. Feminizing surgeries reduce the size of a clitoris, shape a vulva, or create or lengthen the vagina of a child assigned female.
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From page 372... ...
have very low risk of testicular malignancy in childhood or adolescence, do not develop masculine secondary sex traits in puberty, and derive a high bone health benefit from endogenous hormone production; in these cases, it is generally recommended to defer gonadectomy until after puberty. Individuals with gonadal dysgenesis (in which gonads do not fully develop into ovarian or testicular tissue)
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From page 373... ...
Importantly, a large systematic review and meta-analysis found that only two studies surveyed 46,XX female CAH patients' satisfaction with surgery, of which the majority were satisfied (Almasri et al., 2018)
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From page 374... ...
. Notably, there are no objective scales validated to assess sexual function in women with intersex traits.
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From page 375... ...
. Of note, as discussed in Chapter 11, evidence indicates greater rates of psychological distress for individuals with intersex traits than the general population, but there is very little research exploring why.
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From page 376... ...
Some intersex traits, such as complete AIS, complete gonadal dysgenesis, and proximal hypospadias without DSD, are associated with very low likelihood of gender dysphoria (Meyer-Bahlburg et al., 2016)
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From page 377... ...
, and reduction of parental distress is often cited as a benefit of early genital surgery. However, there have been no studies examining experiences of bullying among children with intersex traits, and thus no evidence is available to indicate that surgery reduces the risk of bullying.
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From page 378... ...
. Of note, while the statement committed to pausing all genital surgeries that were not medically necessary, it did indicate that there may be a difference in approach for individuals with intersex traits who have CAH relative to people who do not.
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From page 379... ...
Ensuring access to care for SGD populations includes building supportive and protective structures at all levels, from the broad societal level to the level of individual provider practices. At the societal level, laws that guarantee access to health care services, health insurance coverage, and public health programs for all, regardless of sexual orientation, gender identity, and intersex status, are critical to the health and well-being of SGD people.
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From page 380... ...
Entities that provide resources and guidance on affirming health care policies and environments for SGD populations include the Academy of Physician Assistants, GLMA: Health Professionals Advancing LGBTQ Equality, Association of American Medical Colleges, American Psychological Association, American Academy of Pediatrics, American Medical Association, National LGBT Health Education Center, and The Joint Commission. CONCLUSION 12-2: Gender-affirming care, including puberty delay medications, mental health services, hormone therapy, and surgeries, is associated with improved mental and physical health for transgender people.
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From page 381... ...
. At the intersec tion of sexual orientation, race/ethnicity, and cervical cancer screening: Assessing Pap test use disparities by sex of sexual partners among Black, Latina, and white U.S.
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From page 382... ...
. Report of the American Psychological Association Task Force on Appropriate Therapeutic Responses to Sexual Orientation.
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From page 383... ...
. Inclusion of sexual orientation and gender identity in stage 3 meaningful use guidelines: A huge step forward for LGBT health.
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From page 384... ...
. Protecting children with intersex traits: Legal, ethical, and human rights considerations.
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From page 385... ...
. Gender dysphoria and XX congeni tal adrenal hyperplasia: How frequent is it?
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From page 386... ...
. The Affordable Care Act and health insurance coverage for lesbian, gay, and bisexual adults: Analysis of the Behavioral Risk Factor Surveillance System.
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From page 387... ...
. Profound health-care discrimination experienced by transgender people: Rapid systematic review.
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From page 388... ...
. An exploration of family therapists' beliefs about the ethics of conversion therapy: The influence of negative beliefs and clini cal competence with lesbian, gay, and bisexual clients.
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From page 389... ...
doi: 10.1111/j.1365-2265.2009.03625.x. National LGBT Health Education Center.
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From page 390... ...
. Quality of life after gender affirmation surgery: A systematic review and network meta-analysis.
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From page 391... ...
. The informed consent model of transgender care: An alternative to the diagnosis of gender dysphoria.
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From page 392... ...
. Paying for prevention: Challenges to health insurance coverage for bio medical HIV prevention in the United States.
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From page 393... ...
. Conversion therapies and access to transition related healthcare in transgender people: A narrative systematic review.
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