Transgender discrimination in health care: What families should know

rainbow and transgender flag lanyards from boston children's
(Photo: Michael Goderre/Boston Children's)

Earlier in June, the U.S. Department of Health and Human Services finalized a regulation that would eliminate some protections for transgender patients against discrimination by clinicians, hospitals, and health insurance companies. Our understanding is that this change is being challenged in court, as such discrimination isn’t just hurtful — it can also be harmful to trans patients. To better understand the effects of health care discrimination on trans kids and adults, and how Boston Children’s Hospital works to maintain access for trans patients, we spoke with Elizabeth Boskey, a social worker in the Center for Gender Surgery at Boston Children’s Hospital.

What does this new regulation mean for trans patients?

The creation of the Affordable Care Act was designed to increase access to health care for all Americans. However, it alone was not sufficient to address care disparities for transgender patients. In the spring of 2016, a regulation that explicitly forbade health care providers who accept federal funds from denying care based on gender identity was added. It was that regulation that was recently changed. If allowed to stand, this change has the potential to increase the discrimination and health disparities experienced by transgender people.

What are some examples of health care discrimination involving trans patients?

Trans people have historically experienced many types of discrimination in health care. In the 2015 U.S. Transgender Survey, which included 27,715 trans adults, one third reported having a negative experience with a health care provider in the last year — everything from verbal harassment to being refused necessary medical care. One out of every seven people reported that their providers asked them unnecessary questions about their gender identity or transition. One out of four reported that they had to educate their providers about transgender people in order to get proper care.

Other discrimination occurs in the context of health insurance. In the survey mentioned above, 25 percent of survey respondents reported issues using their health insurance related to their gender identity or expression. More than half of those were denied coverage for transition surgery and a quarter were denied coverage for hormones.

Similar types of discrimination have also been reported for transgender youth and adolescents. One study found that less than one third of patients seeking puberty blockers got their medication covered by insurance. Young transgender individuals are also more likely to report worse health and fewer preventive care visits than their cisgender peers.    

How can discrimination affect trans patients?

Discrimination in health care can have both direct and indirect effects on trans patients. When someone is refused treatment necessary medical care it can have a direct effect on their health. Lack of access to gender-affirming care can also have substantial direct effects on someone’s well-being. However, there are indirect effects as well. When someone is misgendered or verbally harassed at a doctor’s office, they may be less likely to seek out routine, or even urgent, care, and that reluctance can have long-term consequences for individuals as well as increasing the health care disparities known to affect transgender youth and adults. In the 2015 U.S. Transgender Survey, almost one in four people reported not getting necessary care in the previous year.

What is Boston Children’s doing to support gender-diverse patients?

Fortunately, Massachusetts and many other states have enacted their own protections against health care discrimination. If you find that your health care coverage does not cover any portion of transgender medical care, make an appointment to talk with Boston Children’s Patient Financial Services to discuss your options. 

What can families do to help protect their gender-diverse kids from health care discrimination?

The two most important things families can do to protect their gender-diverse kids is to know their rights and be a good advocate. Rights vary from state to state, but Massachusetts prohibits discrimination on the basis of gender identity and requires access to many forms of public accommodation on the basis of gender identity. That means your child’s gender identity should be respected when they’re seeking care, and they should be treated like any other child who shares their gender.

As for being a good advocate, consider reaching out to doctor’s offices in advance to see if they have experience working with gender-diverse kids, and be clear about what your child will need to feel safe at their appointment. Encourage providers who don’t yet provide gender-affirming care to educate themselves, rather than expecting you or your child to educate them. If a provider or staff member behaves inappropriately, reach out to the facility and let them know about the problem. All facilities should be able to provide you with a patient’s bill of rights that lets you know who the appropriate person is to contact.

You can also take the following steps:

  • When calling for an appointment, let the team know when your child’s affirmed name or gender are different from what is on their insurance card. That information can then be entered into the system, although it may not be available for all providers.
  • Clearly indicate on any intake paperwork your child’s affirmed name and pronouns.
  • If your child has legally changed their name or gender markers, make certain their insurance company has that updated information. Then let the medical records department know so that the information can be updated across the system.
  • If an insurer denies care because they think it is inappropriate for your child’s gender, reach out to your provider and let them know they will need to resubmit the charges with a modifier to indicate they are appropriate.
  • Remind providers that most of the care they’re offering has nothing to do with your child’s gender identity, and that they should not treat them any differently from a cisgender child.  

Learn more about Boston Children’s gender service

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