Health Care Access for Trans Patients: a Panel Discussion

By CHAMONIX ADAMS PORTER

December 3, 2011

On November 11, three of the nation’s leading voices for healthcare access for transgender people spoke at Yale, and lent valuable insight to future healthcare professionals and transgender rights activists. The panel, a part of the ninth annual  Trans/Gender Awareness Week at Yale, featured a pediatrician, a psychotherapist, and a specialist in institutional support of transgender people.

Dr. Ralph Vetters, a pediatrician at Sidney Borum Jr. Health Center in Boston spoke about his work with clients aged 12 to 29, some of whom identify as transgender or genderqueer. Margot Metiner (BR ’00), a psychotherapist who specializes in transgender and queer issues, discussed the relationship between transgender people and mental health professionals. Finally, Samuel Lurie spoke about his experience as an activist for transgender equality, specifically through his business, which trains health and social service providers in providing quality care for transgender clients.

As Meitner was quick to point out, improvement of health care for transgender people is of vital and immediate importance. She cited statistics from the National Gay and Lesbian Task Force, explaining that 29% of transgender people have been victimized or harassed in a health care setting. In these settings, half of transgender people had to educate their providers about their needs, 19% were refused service, and 2% were physically assaulted. These sobering numbers helped to show just how groundbreaking the work of the panel is.

Meitner first spoke about transgender people and mental health. Current regulations require two letters from psychotherapists for genital reassignment surgery. This often puts the psychotherapist in a gatekeeper role, meaning that the client feels that they must in some way prove themselves. People with mental health problems may feel that they cannot discuss these without risking their chance at the letters. People with non-binary identities may feel that they have to conform to fully male or female roles to be considered “truly” transgender.

Meitner and Vetters were pleased to say that in neither of their practices did the therapist assume this role. For Meitner, the focus was on the right to self-identification. Metiner cited her single most important role as “to let people know they don’t need to see me.” In non-surgery treatments, Meitner said that her job is to provide “an utterly non-judgmental presence.” She described therapy as a safe place for experimentation with gender, dress, names, and pronouns. She aims to reflect the identities that the clients see in themselves. Vetters’ practice operates under an informed consent model, in which the clients make the majority of decisions about their own bodies. Instead of the physician deciding if the patient qualifies for treatment, she or he makes sure that the patient understands the risk and helps them decide if the choice is right for their circumstances.

Lurie next spoke about his role as an activist for transgender health. Discrimination during his own transition 15 years ago spurred him to take action to improve health care services for transgender people. He told the iconic story of Tyra Hunter, an African-American transwoman who was injured in a car accident in Washington DC in 1996. As paramedics worked to save Hunter’s life, they cut off her skirt, revealing male genitalia. They dropped her on the ground and ceased all efforts to help her. Although she was eventually taken to a hospital, she died. A later court case ruled that her death was the result of the deliberate negligence of the paramedics.

This story, Lurie reminded the audience, was seared into the collective unconscious of transgender people across the country. Fear and mistrust permeate relations between transgender people and medical professionals, meaning that discriminatory treatment within the healthcare system is all the more devastating.

Lurie firmly noted that his work extends far beyond changing the ways in which hormones and genital reassignment surgeries are administered. The objective is rather to make all health care—from emergency services to gynecology—more accessible and safe for transgender people.

Dr. Vetters described some of the ways in which his pediatric practice had helped to make these changes manifest. Because many transgender young people have not legally changed their names, and as many older documents may reveal names that are no longer used, his office places a sticker upon all of the folders of patients who prefer names that are not on their medical files. Additionally, stickers are used to indicate patients’ preferred pronouns. Even in these seemingly small ways, Vetters manages to make the existing healthcare system work better for transgender people.

In order to explain how his practice works with young transgender people, Vetters divided his clients into three categories: pre-pubescent children, adolescents younger than 18, and adolescents 18 and older.

Among pre-pubescent children, he stated, gender expression is incredibly fluid. Children’s expression and perception of their own genders can drastically change year to year or even month to month. Among this population, Vetters estimates that 1% will maintain a transgender or gender variant identity into adulthood. Puberty is often an extremely stressful and dysphoric time for these young people, and accordingly sometimes the best practice is to medically halt the onset of puberty. This process is never simple and varies greatly between cases. While identifying the children who need this treatment is difficult, getting it to them is even more difficult. Although Children’s Hospital Boston has some of the most advanced pediatric endocrinology in the nation, including the Gender Management Service (GEMS) clinic, he noted that the treatment is prohibitively expensive for most families.

This remains a challenge with adolescents under 18, who, although they are more aware of their gender identity, cannot act on their own. Even with the support of their parents (no mean feat) the cost of treatment is incredibly high and rarely covered by insurance. Vetters expressed frustration at the fact that although the DSM currently identifies “Gender Identity Disorder” as a sickness, insurance companies will not pay for the hormones or surgeries that transgender people need. While he described the classification of transgender identity as a mental illness as a “pretty repugnant misnomer,” Vetters felt that this double standard of care is indicative of profound transphobia within the medical system.

All three panelists expressed frustration that patients’ transgender identity was often brought to the forefront in conversations about unrelated treatments. Lurie stated that medical students were often trooped in to observe transgender people, exacerbating their already vulnerable states. Meitner added that she has had many clients seek out therapy elsewhere for grief or depression, but end up referred back to her simply because of their identities. A clear message of the panel was that transgender health extends far beyond hormones and surgery.

The panel ended with words of encouragement and advice for students looking towards careers in health care and young activists. Lurie encouraged students to “think of nitty-gritty concrete things” such as whether Yale’s health facilities had gender-neutral bathrooms. He encouraged training within professional organizations, and urged students to speak in favor of improved transgender health care on and off campus.

All of the panelists were aware that their work is saving lives and that the future leaders in the room have the potential to do so as well. Lurie reminded the audience that 41% of transgender people in one health care survey had attempted suicide. By improving the healthcare system, professionals can change the lives of their patients by allowing them to safely remain healthy as well as express their identities entirely on their own terms. Vetters was firm in this stance, stating “I believe it is a human right.”

Chamonix Adams Porter is a freshman in Yale College.  She is a a staff writer for Broad Recognition.