Breaking Health Disparities for Transgender Patients
Does a transgender patient’s preferred pronoun make its way from the patient’s registration form all the way into the exam room? How does a health center evaluate if a patient is a good candidate for a gender reassignment treatment? How does the center assess for gender identity? What about health education -- are trans-specific resources available for patients in Spanish? Federally Qualified Health Centers (FQHCs) that serve migratory workers across the country, just like all health facilities, are recognizing transgender patients in their exam rooms. And each health center is at a different stage in incorporating best practices for transgender and gender nonconforming patients. Many are actively seeking to improve their approach. Last year, the National LGBT Health Education Center launched a Project ECHO, entitled TransECHO, seeking to bolster FQHCs’ efforts to better serve their trans patients. Such support has proven to be incredibly popular.
“Without much promotion, we had 111 organizations apply for 25 spots. It’s a testament to the hunger that’s out there to learn more about transgender health and how to provide the best possible care,” explained Alex Keuroghlian, MD, MPH, Director of the National LGBT Health Education Center, a program of the Fenway Institute and a National Cooperative Agreement program with HRSA. He’s also the Division of Education and Training Programs at The Fenway Institute, a practicing psychiatrist and Assistant Professor of Psychiatry at Harvard Medical School’s Massachusetts General Hospital campus. The National LGBT Health Education Center has just begun to accept applications for year two of TransECHO, and Dr. Keuroghlian is looking forward to welcoming a second cohort of clinicians from Federally Qualified Health Centers across the country to work and learn together on the topic of trans health. (TransECHO is designed for all FQHCs, not just those funded to serve agricultural workers. The program focuses on all trans patients, not trans agricultural worker patients.)
“It’s not something that clinicians are trained to do,” Dr. Keuroghlian noted, “and health systems are not set up in a way that accommodates transgender people. Plus, there’s a huge range of health disparities faced by members of the transgender community.” Many transgender agricultural workers seek to leave behind serious threats and debilitating discrimination in their country of origin to start anew in a more accepting culture. But, in their new country, transgender agricultural workers experience overlapping and at times overwhelming health disparities like cultural and linguistic barriers and fear over immigration status, in addition to those common among trans people, such as pervasive and overt discrimination in housing, employment, and in interactions with law enforcement. Both trans people and agricultural workers also often struggle with poverty which only exacerbates general health disparities. Among the overall trans population, suicide attempt rates hover at 41 percent (compared to 1.6 percent of the general population).
“It’s part of our mission at the Fenway Institute to improve the quality of care and reduce health disparities for the LGBT community,” Dr. Keuroghlian explained, so TransECHO is a natural extension of their work. TransECHO’s expansive approach encompasses all parts of the trans patient’s health center experience. Special attention is given to the design of the health system, from determining how best to welcome the patient, to evaluating an informed consent model, to minimize gatekeeping. Dr. Keuroghlian explained that “there’s a history in the health care field of requiring a lot of onerous assessments to really reassure clinicians that the patient is in fact transgender before care is initiated,” which may not align with the FQHC’s ethical policies or with established best practices in medical decision making for trans patients. Defining clear and evidence-based protocol streamlines the process and assures the patient gets the best quality care. TransECHO equips FQHCs to accomplish this.
Like in typical ECHO projects, the cohort meets monthly for a year, in two-hour sessions via Zoom, a popular virtual platform where participants and experts can see and speak to each other, “like Hollywood Squares,” Dr. Keuroghlian relates. Fenway Institute’s leading experts on trans health lead a didactic presentation which fits into the 12-month curriculum, followed by a discussion facilitated by experts. Case consultations allow clinicians to present real-life challenging cases and get guidance on how to best care for these patients from both the experts and from other health centers who may have experienced similar situations. Dr. Keuroghlian recalls that updates from cases that were presented during case consultations were particularly powerful, as clinicians reported breakthroughs in care, in which patients felt “relief and affirmation through the health care that the FQHC has provided them, [as a result of] our ECHO project,” he concluded.
Last year, to whittle down the application pool, the National LGBT Health Education Center chose participants that were geographically diverse and prepared to incorporate the lessons learned. This second-year cohort will go through an equally rigorous selection process to assure that the FQHCs chosen will have the biggest impact, based on their readiness to provide this kind of care, the size of their catchment -- how big a population they’re caring for, and how undeserved the catchment is -- the extent to which they are able to commit to both primary care and behavioral health clinicians to participate, and the demonstrated level of buy-in from the FQHC’s leadership. Additionally, the group will weigh the geographic areas already represented in the first year cohort, committing to ongoing greater spread with the second year cohort’s health center locations.
“It’s been a really rich learning environment,” Dr. Keuroghlian proudly related. “The ECHO model is a really exciting way to scale up” the National LGBT Health Education Center’s work in reducing health disparities for transgender or gender nonconforming patients. “This expertise hasn’t really been disseminated in rural areas before.”
The National LGBT Health Education Center is accepting applications for the 2017/2018 TransECHO. The new session begins October 11th. Visit https://www.lgbthealtheducation.org/transecho/ to learn more and apply.
The National LGBT Health Education Center has a wealth of resources for health centers wishing to improve their approach to caring for transgender patients. View webinars and other materials at: https://www.lgbthealtheducation.org/topic/transgender-health/.
More resources are available at UCSF’s Center of Excellence for Transgender Health, including patient-facing fact sheets in Spanish.