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Accessing Gender-Affirming Health Care: Tips for Navigating the System

Here’s how to advocate for yourself in the healthcare system, find quality providers and pay for gender-affirming care.

Interacting with the healthcare system can be daunting for transgender, gender nonconforming and nonbinary people. Of the 20,000 transgender adults surveyed in a 2020 study published in SSM - Population Health, 23 percent reported that they avoid health care because they anticipate discrimination.

These fears may be heightened for gender-diverse individuals who are Black, indigenous and people of color (BIPOC) or who have disabilities, as they frequently face multiple forms of stigma in healthcare settings.

“Many trans-identified people are disconnected from health care in general,” says Jason Schneider, MD, associate professor at Emory University’s School of Medicine, who specializes in primary care for LGBTQIA+ people. This is due in part because of prior experiences with discrimination or structural barriers to affordable health care.

The first thing to know if you’re considering gender-affirming therapy is that advocacy groups around the country are fighting for more rights and protections as well as more sensitive and culturally competent care.

Noah Lewis, director of the Trans Health Project at the Transgender Legal Defense and Education Fund (TLDEF), says that although there is “a historical legacy of discrimination” in health care, we have come a long way since the early 2000s. Today, for example, federal law requires that most insurance plans cover gender-affirming care.

Of course, many factors will determine the kind of access you have to treatment, as well as the quality and sensitivity of that care. Here are some key questions to ask as you navigate the healthcare system.

What healthcare providers do I need?
When it comes to general preventive health and wellness, routine exams and referrals to other specialists, gender-diverse people have the same needs as people who are cisgender. That starts with finding a culturally competent and knowledgeable primary care provider

Locating primary care providers isn’t always easy and can require some research. The same goes for finding specialists who should be seen regularly for screenings, such as gynecologists, as well as board-certified surgeons who have experience providing gender-affirming surgeries.

Resources that can help include:

  • OutCare, which has a directory of culturally competent providers in the United States
  • The Campaign for Southern Equality, which has compiled a “Trans in the South” directory of trans-affirming health and legal providers in the southern U.S.

How do I know if a healthcare provider is right for me?
According to a 2020 report from the Center for American Progress, 1 in 3 transgender people have had to teach their healthcare providers about gender-diverse individuals in order to receive appropriate care. So, once you know which providers you need, how can you tell which ones will provide inclusive, affirming and knowledgeable care?

No matter the specialty, all providers and staff members (including nurses and front desk staff) should establish and maintain an affirming atmosphere. Do they respect your name and pronouns? Will they discretely handle a name discrepancy in your insurance or identification documents? These are questions you can ask directly, over the phone or via email if necessary.

Dr. Schneider says that there are also often visual cues that indicate that an office is a welcoming place: “For example, pride flags and images of people representing a diversity of gender expressions.” Although there is no tool that’s perfect for helping you find the right provider, Schneider notes that the Human Rights Campaign’s Healthcare Equality Index can help you identify “institutions and healthcare systems that have made extra efforts to be inclusive.”

If your journey of gender affirmation does not follow a binary path, ask providers if they have experience with nonbinary patients. They should follow your lead and not assume that you have certain gender or transition goals because of your pronouns or gender expression.

What steps do I need to take to pursue gender-affirming treatment?
Your provider’s requirements for initiating gender-affirming therapy will vary depending on the treatment you’re seeking and the criteria they follow. Many providers adhere to the guidelines outlined by the World Professional Association for Transgender Health (WPATH) Standards of Care (SOC).

The WPATH SOC, for example, requires you to obtain at least one letter from a mental health provider indicating a diagnosis of “persistent” gender dysphoria in order to get chest or genital surgery. Gender dysphoria refers to the distress someone might experience when they feel their gender identity doesn’t align with their physical or physiological characteristics. Not all transgender, gender nonconforming and nonbinary people experience gender dysphoria, but it remains a requirement for obtaining many gender-affirming treatments.

If you are considering facial feminization or top surgery (surgery to reduce or remove breasts), you’ll likely need to obtain one letter from a mental health provider. Bottom surgeries (gender-confirming genital surgery) typically require letters from two different mental health providers.

Because obtaining these letters can be time-consuming and difficult for many patients, the Gender Affirming Letter Access Project (GALAP) offers resources that can lessen this burden. This group of transgender, nonbinary and allied mental health clinicians in the U.S. maintains a database of mental health providers who have taken the GALAP pledge stating they "believe in an informed consent model where clients can affirm their gender identity without the steep cost of sessions with mental health professionals and reductionist clinical practices." These providers can be expected to provide (after a free consultation) a letter for gender-affirming treatment at no cost.

GALAP also offers instruction for healthcare providers on how to write these letters and explains how prospective patients can vet therapists before asking for a letter.

What about accessing gender-affirming hormone therapy?
While the WPATH SOC also recommends an assessment from a mental health professional before initiating gender-affirming hormone therapy (GAHT)—and providers have traditionally followed this framework—more and more providers today use an informed consent model.

Informed consent essentially means that a provider will discuss the risks, benefits and limitations of hormone therapy directly with a patient before prescribing. The patient considers these variables as well as the potential impact that treatment will have on their life. They can ask follow-up questions, then will typically sign a consent form if they choose to proceed with treatment. This shared decision-making model is the norm in nearly all other situations in which a patient is pursuing medical treatment.

Some providers may use the informed consent model alone or blend it with some parts of the WPATH SOC. As you seek providers for your care, ask them whether they incorporate informed consent into their process of initiating therapy.

Although mental health professionals are not required to be part of the informed consent process, many providers make them available to support patients over the course of treatment, and it can be very helpful to take advantage of this resource.

Given the varied and evolving requirements for gender-affirming treatment, it may be complicated and confusing to navigate the process. Having a primary care provider who has experience working with gender-diverse people can make the process go more smoothly and without unnecessary delays in care.

How will I pay for gender-affirming treatments?
As many people who have sought gender-affirming care know, the costs of transition and gender affirmation can be high.

Masculinizing top surgery, breast augmentation and genital surgeries, for example, generally cost several thousands to several tens of thousands of dollars. Having health insurance that covers gender-affirming services can go a long way toward reducing these costs, but out-of-pocket charges for covered treatments can add up. And if you are one of the nearly 33 million Americans under age 65 who reported being uninsured in 2019, you might be wondering how to even begin pursuing gender-affirming care.

The good news is that there are a number of financial support options beyond health insurance:

  • Point of Pride provides grants for services like electrolysis (a type of permanent hair removal) and GAHT, as well as non-medical products like chest binders and shapewear.
  • Jim Collins Foundation and Stealth Bros Support Fund provide financial support for specific surgeries.
  • Folx Health provides microgrants for half or full coverage of GAHT for certain periods of time.
  • Plume provides 12 months of free GAHT and medications via Point of Pride.

As you journey through the healthcare system, it can help to find common cause with others following a similar path. Connecting with other gender-diverse people, whether online or offline, and making use of the support systems created by organizations, advocates and activists are all helpful ways to keep tabs on logistics and stay fortified emotionally. Having an affirming and culturally competent primary care provider can also help you anticipate and prepare for challenges that may crop up.

Medically reviewed in June 2021.

Sources:

Kcomt L, Gorey KM, Barrett BJ, McCabe SE. Healthcare avoidance due to anticipated discrimination among transgender people: A call to create trans-affirmative environments. SSM Popul Health. 2020;11:100608.
National Center for Transgender Equality. 2015 U.S. Transgender Survey.
Krahn GL, Klein Walker D, Correa-De-Araujo. Persons with disabilities as an unrecognized health disparity population. Am J Public Health. 2015; 105(Suppl 2): S198-S206.
Tolbert J, Orgera K. Key facts about the uninsured population. Kaiser Family Foundation. 2020.
Crank JA. Informed consent model for gender affirming hormone therapy. Affirm: A Blog From the Center For Transgender Health. Johns Hopkins Medicine.
UCSF Transgender Care. Surgery referral assessment requirements.
Centers for Disease Control and Prevention. Patient-Centered Care for Transgender People: Recommended Practices for Health Care Settings. Page last reviewed April 1, 2020.
National Center for Transgender Equality. National Transgender Discrimination Survey: Full Report. September 11, 2012.
Mosser S. How to check your surgeon’s credentials. Gender Confirmation Center.
Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674-697.
Timothy Cavanaugh, MD, Ruben Hopwood, MDiv, PhD, and Cei Lambert, MFA. Informed Consent in the Medical Care of Transgender and Gender-Nonconforming Patients. AMA Journal of Ethics. November 2016.
UCSF Transgender Care, Department of Family and Community Medicine, University of California San Francisco. Hair removal. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. Deutsch MB, ed. June 2016.
Stanford University. How U.S. Health Insurance Works. Stanford Vaden Health Services.

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