Community and Compassion: Providing Safe Care for Transgender Patients

By Matt Phillion

For transgender patients, accessing affirming and comprehensive healthcare can often be challenging.

Community organizations have come to play a crucial role in bridging gaps in transgender healthcare, emerging as allies in providing essential support networks and medical resources. These local and national support groups, educational resources, and advocacy services work to provide a holistic view of transgender healthcare, working to ensure that patients are able to safely access quality care. They collaborate with healthcare providers to ensure that medical professionals are equipped to provide competent care.

“The community has done an incredible job to get us here,” says Angela Rodriguez, MD, founder of ART Surgical, a boutique practice specializing in gender-affirming care. “The struggle that keeps me up at night now is the polarization of care. I have colleagues who have received threats for doing their job, taking care of illness. Healthcare should be driven by data. And the politicization of this causes a horrible effect on a very vulnerable population.”

Community groups have done such good work, Rodriguez notes, out of necessity.

“Practicing in California, it’s a very privileged place in that there have been a number of community driven centers and other organizations that make it easier for the patient,” she says. “Navigating the system can be incredibly difficult. If you listen to some individuals on television, it can be misleading. Some people are under the impression you are able to access gender-affirming surgical care services promptly and undergo an operation within 24 hours. This is simply false and far from reality. There are many roadblocks to gender-affirming care. In order for a patient to see a surgeon there is an average of two to three years, they have to see a primary care physician, a mental health therapist—sometimes two—and an endocrinologist. This is leaving aside the burden of the administrative aspects of dealing with insurance companies, exclusion of services and denials. The first thing some of my patients bring to the office is a binder with all documentation.”

Navigating the healthcare landscape is complex for the simplest of needs, and for patients seeking gender-affirming care, that complexity expands exponentially, she notes.

“You have to have an education in how to access care, and we need to do more,” says Rodriguez. “It is happening, though at a slower pace than we want.”

A truism in healthcare is that it helps to connect with the patient in an environment where they feel safe or comfortable, and so Rodriguez says she’s often connected with people online to provide education, answer questions, and explain steps and requirements in spaces not usually associated with healthcare, such as Facebook groups, to ensure there’s access to education about how to receive quality care.

“This is especially important for those patients who don’t have access to the same level of care everyone else does: people who may have language issues, lack of insurance, or an inability to access care in general,” she says. “Our different professional societies are extremely passionate about educating the population in general, giving talks about access to care and providing opportunities for patients to ask questions.”

The convergence of providers and community help with areas where tools and resources might be scarce, Rodriguez says.

“In my time in gender-affirming care, I’ve seen people come from the immigrant population with some basic training to help as a translator, and nurses who are part of the trans community stepping forward to help,” she says.

Communication and understanding

Part of the way the community can and does step up, Rodriguez says, is discussing shared experiences and opening up the lines of communication.

“Even I as a physician struggle to have other physicians understand my healthcare needs,” says Rodriguez. “Everybody encounters this, even if you’re in the profession, but this patient population has a very specific level of need.”

It’s only in recent years that there’s been an opportunity to speak openly about transgender care, Rodriguez explains.

“There was this incredible segment of the population nobody knew existed or were ignored for years,” she says. “That presents a problem: the demand for physicians who are qualified and trained on these procedures and treatments are few. There’s a mismatch.”

Even highly trained physicians coming out of other surgical specialties require ramping up, Rodriguez explain. Because of this, transgender patients often arrive even more prepared and educated than the average patient out of necessity, she says.

“I love my patients because when they come to me, they’ve done so much research already,” she says.

But no amount of research can make up for that lack of available physicians and other necessary providers. Take behavioral health, for example, Rodriguez says.

“We are failing patients in the U.S. on all fronts when it comes to mental health. And for gender-affirming care, we base the treatment on the diagnosis of gender dysphoria,” she explains. “Gender dysphoria means there is incongruence between their gender identity and their sex assigned to them. The diagnosis, that feeling of being incongruous between the body and mind, is key. If someone comes to me without seeing a mental health therapist, it’s a long way for me to send them back to the beginning of the line so they can obtain a diagnosis from a proper specialist.”

Some surgeries require two letters, from two different mental health therapists, Rodriguez explains.

“Some in the community feel this is gatekeeping, but it’s necessary,” she says. “What I’ve learned through years of doing this is I can speak very well about the surgery and complications, but not as good a job about guiding people to the next step.”

This is where navigators come in, Rodriguez says.

“A navigator can help with next steps, forming a bond with the patient and being available to help them sail through the sometimes endless requirements from insurance company and from providers,” she says. “But having the patient evaluated by a mental health provider early in the process is very important as I cannot take the next steps without a proper diagnosis.”

A holistic view

In taking a big picture view of what this unique patient population needs for safe, quality care, Rodriguez notes there are distinct differences in process.

“The typical surgical practice is a bit of an assembly line,” she says. “You come to me already diagnosed, you’ve already had the necessary tests, and we book a day to operate. But the transgender population doesn’t work that way. They have unique needs, unique comorbidities, often multiple mental and physical comorbidities to consider.”

The patient population benefits from having a bit more of a relationship with their surgeon to ensure the line of communication is clear.

“I pride myself on doing this because I’ve been doing plastic surgery for 20 years and I’ve seen many cases. I’ve had a patient come in from the doctor’s office fixated on a particular part of their surgery, and sometimes the patient is not fully able to express what they need or want.”

Longer consultations and more time to talk can enable surgeons like Rodriguez to provide the highest quality of care through better communication and greater understanding of what the patient expects and needs from the procedure.

“Sometimes it takes one, two, three conversations to get the message across, but the patient needs to know they are going to be heard,” she says.

Rodriguez brings up the old saying about how a society can be judged by how it treats its most vulnerable members.

“That’s what reflects who we are as a people,” she says. “We need more communication, more understanding, but it all starts with education and exposure.”

She points to some devastating figures for why this level of care is so important.

“This population is four times more likely to commit suicide, and there are outcomes that show that there are not only mental health but physical benefits to care,” she says. “What we need to do is treat the patient holistically and make sure the person becomes a functional member of society. It’s not a trend when you have 50,000 surgeries between 2016 and 2019. For anyone to make this change, the need to make this change is extremely powerful. And if it improves the way they function as part of society, it’s important.”

The conversation in the public eye is often about surgical solutions, but 50% of the patient population doesn’t look for surgery, Rodriguez notes.

“They may need mental health therapy, they may need hormone replacement therapy, they may need other medications, surgery is only performed when dysphoria persists despite all other measures,” says Rodriguez. “The real issue is how do we provide healthcare for the transgender community? How do we help them to live their lives with dignity and compassion?”

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.