How To Start A Transgender Clinic

Acknowledgements

This manual was developed in collaboration between the Transgender Law Center’s Health Care Access Project and Christopher Roebuck, MPH (Medical Anthropology Program, UCB-UCSF). Roebuck’s research was funded in part by the California HIV/AIDS Research Program (#D07-B-409). The Transgender Law Center takes sole responsibility for any and all errors. The Transgender Law Center thanks all of the funders whose support made this publication possible, including:

• The California Endowment
• The California Wellness Foundation
• The Evelyn and Walter Haas, Jr. Fund
• Horizons Foundation
• Kicking Assets Fund of Tides Foundation
• Liberty Hill Foundation
• Transgender Law Center Staff
• Danielle Anderson-Castro, Policy Advocate
• Masen Davis, Executive Director
• Ben Lunine, Staff Attorney
• Mila Pavlin, Operations Manager
• Kristina Wertz, Legal Director

Transgender Health Care Access Project

How to Start a Transgender Clinic

Transgender people are severely underserved by current health services. In many health care settings, transgender and gender non-conforming individuals experience discrimination, mistreatment, and overall lack of knowledge about transgender related medical issues. These factors place transgender people at increased risk of serious health problems.

Fortunately, we find ourselves at a time when greater access to transgender-appropriate care is becoming possible. In communities across the nation, transgender individuals, family members, health care providers, and local leaders are working together to develop health programs that are affordable, comprehensive, and culturally competent. It is in this spirit of possibility that this booklet is created.

After interviewing community members, advocates, and providers, we have developed a series of guiding questions and answers that have proven helpful in the initial planning of transgender-appropriate health services in the United States. We recommend a community-driven model of care that is comprehensive and multi-disciplinary.
This approach unites primary care, transgender specific medical care, and psychosocial services with active community participation in program development.

We offer this booklet as a tool. We hope it will enable communities to organize their unique capacities in order to provide affordable, quality health care to transgender and gender non-conforming people, a community that has long lacked access to adequate care.

I . Pre-Planning

What is transgender health care?

Comprehensive transgender health care encompasses two approaches: primary care and medical care specifically related to transgender issues, such as hormonal therapy and surgical procedures. Primary care includes screening for common diseases (cancer, diabetes), assessing symptoms and diagnosing illness, treatment of acute illness
and the management of chronic diseases. Primary care also incorporates health promotion, risk reduction, and referrals for other health and social issues, including mental health services, housing, and employment.

Hormonal therapy has been shown to profoundly increase the quality of life for transgender individuals. For many transgender people, hormonal therapy is a way to bring the body into greater congruence with gender identity. Integral components of hormonal therapy include assessing the patient’s health status, needs, and values as well as prescribing appropriate hormones and monitoring any potential side-effects.

Providing competent transgender health care also means being aware of the diversity of ways in which transgender individuals identify, often outside the binaries of male and female. This means being aware of the many ways in which gender transition may occur. This includes people who take hormones or have surgeries as well as those who do not.

It is important to underscore that transgender populations experience severe social inequities. Many transgender people are economically and socially vulnerable and experience multiple forms of oppression and discrimination, particularly transgender people of color, immigrants, sex workers, and those who have a gender expression that is fluid or outside the gender binary. It is important that providers take into consideration the
constellation of life factors which may impact patients’ health and wellbeing.

What are your community’s health needs?

Perhaps the most important step in establishing relevant transgender health services begins with a community health assessment which identifies the health needs of the local community, the resources that are available, and the state of current programs. A community health assessment enables providers to develop a targeted and appropriate program while preventing duplication of services. Also identifying existing organizations that offer transgender related programs can facilitate the development of collaborative partnerships necessary for sustaining community-wide participation in the delivery of relevant health and social services.

There are a variety of ways of conducting community health assessments ranging from interviews with key leaders to more comprehensive epidemiological studies. Attached examples of needs assessments can be found in Appendix A.

I I . Planning & Development

What kind of medical care and health services will you provide? What sorts of referrals to other organizations will be necessary?

After assessing the demographics and health issues of the local community, consider what kind of programs will best fit your local needs and resources. Successful program models typically combine primary care, hormonal management, and basic psychosocial services that emphasize the broader health and transition-related concerns faced by transsexual, transgender, and gender non-conforming persons. Given that many health-related studies
have documented that transgender (MTF) women represent a community particularly at-risk for HIV/AIDS, it is highly recommended that clinics include active HIV prevention and AIDS care services; in addition, providers should explore targeted programs to address the health care needs of transgender youth and adolescents.

Pre-planning should also consider how patients will be referred to outside organizations for services the clinic may not be able to provide, such as mental health services, case management, housing, employment, and surgical procedures. The local community health assessment will prove helpful in identifying and building relationships with other organizations offering relevant services.

Where will transgender services be provided?

It is important to consider how transgender services will be organized and what kind of space these services will occupy. Current transgender health services are offered in one of two ways, either as a transgender-specific clinic or integrated into existing programs. The latter includes stand-alone clinics within local public health departments as well as services offer by LGBT, HIV/AIDS, and family-planning organizations.

How will services be funded?

Certainly one of the most vital issues facing any clinic is the question of how to fund services and programs. A number of strategies are available to finance transgender health services, including funding as part of a broader public health department at the city or county level, financial support from foundations, funding as part of a larger not-for-profit organization such as Planned Parenthood, or a combination of approaches. Many programs offer sliding scale payment for low-income individuals as well as include third party reimbursements, such as payment from private insurance companies and Medi-Cal.

What will the hormonal treatment protocols be?

Hormonal therapy, such as estrogen, anti-androgens, and testosterone, is often a significant part of gender transition. The effects of hormones allow transgender individuals a sense of congruity between internal understandings of gender identity and the body. For these reasons, it is extremely important that transgender health programs develop guidelines for the administrating of hormones. Issues to consider include what kinds pharmaceuticals will be used, at what dosages, when hormonal therapy may begin, and how informed consent is given.

In our review of peer-reviewed literature and clinical guidelines, there is agreement on the basic guidelines for hormonal therapy. Examples of treatment protocols and list of peer-reviewed studies which have examined hormonal regimes and sides effects are included as Appendix B.

In general, hormonal therapy is best administered in the context of a complete approach to health that includes comprehensive primary care and coordinated psychosocial services. However, we do not recommend a one size fits all approach for transgender patients. Instead, medical care and hormonal therapy should be flexible, taking into consideration each individual’s preferences, goals, and values. Also baseline protocols should be modified to address changing conditions, emerging issues, and clinical research.

What kind of patient intake procedures will you use?

As infrastructure and clinical guidelines are developed, it is important to consider what kinds of administrative practices are necessary. How are patients going to be enrolled and what kinds of intake processes you will have? Intake processes usually include a general health history with attention to urgent needs.

Initial assessments may be conducted by a semi-structured interview, standardized questionnaire, or a combination of both. We recommend a flexible approach that first identifies immediate risks to the health and safety of the patient, such as abuse and or violence, unsafe living or working conditions, hunger, suicide, and untreated physical/mental health conditions.

Experience has shown that patients should be allowed to use their chosen name, which might be different than their legal name, and to self-identify their gender and sexual identities, such as male, female, MTF, FTM, genderqueer, straight, lesbian, gay, etc. Thus, intake forms might need to be rewritten in order to include “chosen name” in addition to legal name, as well as a third blank option for sex/gender where someone can more accurately describe their gender and sexuality. These practices will allow you to create a welcoming environment for your transgender and gender non-conforming patients.

We have attached a sample intake questionnaire in Appendix C.

What kinds of sensitivity training will be provided to staff?

Alongside the development of transgender appropriate intake and administrative procedures, it is important to develop guidelines for the training of staff to ensure that a non-discriminatory and welcoming environment is provided. This is especially important for front-line staff members who are the patients’ first contact with clinic services. Staff should be able to interact effectively with transgender people, families, and friends. They should have familiarity with commonly used terms and the diversity of identities within the transgender community and allow individuals to self-identify their gender and sexual orientation. As well, they should be able to respond appropriately to the disclosure of gender concerns, personal names, and pronoun usages. The Transgender Law Center offers provider education and literature, see Appendix D.

Of particular concern for many transgender patients is the confidentiality of their gender status and related health issues. Thus, all staff should maintain the privacy of their transgender and gender non-conforming patients, and not disclose the gender status of patients unless it is directly relevant to care.

We recommend that ongoing training about emerging issues within the transgender and gender nonconforming environment be part of regular staff education.

What kinds of things can your clinic do to provide a welcoming environment??

It is important to display transgender-positive cues at your site. Posters, buttons, stickers, and literature about transgender people can demonstrate that you are a transgender-friendly organization. Transgender Law Center has many brochures and pamphlets available to providers, and the Massachusetts Department of Health’s LGBT Health Access Project has samples of posters that promote an inclusive and welcoming environment. See GLBhealth.org and Appendix E for examples of transgender-friendly outreach materials

I I I . Evaluations & Sustainability

How are you going to evaluate your services?

Evaluation is a way to measure the success of your services, identify unmet needs, and characterize the health and needs of your clients. It enables you to determine if your program is working, in what ways, and with what kinds of consequences.

Program evaluation can be conducted in a number of ways, ranging from interviews with key leaders to patient surveys.

We recommend that the evaluation process solicit active community participation. Members of the community should be included in the design, implementation, and analysis of the evaluation. By so doing, the skills and knowledges that transgender people bring to the table are acknowledged. In addition, involvement in the evaluation process can a further train and empower community members. These activities can build community capacity and contribute to the sustainability of your program.

What are the ways in which the success of your clinic be guaranteed over the long run?

Some of the last issues to address concern how to maintain funding for your programs, how to increase community participation, and how to sustain collaborative partnerships with other organizations and service providers. Addressing these three areas – funding, participation, and partnerships – will go a long way in helping your services flourish over time.

We have found that services incorporating a community-based, peer-driven model of care have been the most successful and viable. A network of advocates and organizations focusing on social change has created safe and healthy environments for transgender and gender non-conforming people while providing a base of grassroots advocate support needed to secure public and private funding for transgender-specific services.

I V. Conclusion

Although transgender people are chronically underserved within current healthcare systems, awareness of transgender health needs and culturally appropriate standards of care are steadily increasing. Transgender clinics provide an important vehicle to meet the targeted needs of this emerging community. For additional information about starting a transgender clinic, please contact the Transgender Law Center.

References

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2. Herbst JH, Jacobs ED, Finlayson TJ, McKleroy VS. 2008. Estimating HIV prevalence and risk behaviors of transgender persons in the United States. AIDS and Behavior 12
3. Edwards JW, Fisher DG, Reynolds GL. 2007. Male-to-Female transgender and transsexual clients of HIV service programs in Los Angeles County. American Journal of Public Health 97.
4. Hines S. 2007. Transgendering care: Practices of care within transgender communities. Critical Social Policy 27.
5. Bockting W, Avery E.2006. Transgender Health and HIV Prevention: Needs Assessment Studies from Transgender Communities Across the United States. New York, NY: Informa HealthCare
6. Dahl M, Feldman J, Goldberg JM, Jaberi A. 2006. Physical aspects of transgender endocrine therapy. International Journal of Transgenderism. 9.
7. Feldman J, Goldberg J. 2006. Transgender medical care. International Journal of Transgenderism 9.
8. G oldberg J. 2006. Training community-based clinicians in transgender care. International Journal of Transgenderism
9. Meyer I, Northridge M. 2006. Health of Sexual Minorities: Public Health Perspectives on Lesbians, Gay, Bisexual and Transgender Populations. New York, NY Springer Press.
10. Nemoto T, Sausa L, Operario D, Keatley J. 2006. Need for HIV/AIDS education and intervention for MTF transgenders: Responding to the challenge. Journal of Homosexuality51.
11. Newfield E, Hart S, Dibble S, Kohler L. 2006. Female-to-male transgender quality of life. Quality of Life Research
12. Melendez RM, Exner TA, Ehrhardt AA, Dodge B et al.. 2006. Health and health care among male-to-female transgender persons who Are HIV positive. American Journal of Public Health 96.
13. Zians J. 2006 The San Diego County Transgender Needs Assessment Report. Family Health Centers of San Diego.
14. Bockting WO, Robinson BE, Forberg J, Scheltema K. 2005.Evaluation of a sexual health approach to reducing HIV/STD risk in the transgender community. AIDS Care 17.
15. Kenagy GP. 2005. Transgender health: Findings from two needs assessment studies in Philadelphia. Health and Social Work 30.
16. Kenagy GP, Hsieh CM.2005. The risk less known: female-to-male transgender persons’ vulnerability to HIV infection. AIDS Care
17. Nemoto T, Operario D, Keatley J, Nguyen H. 2005. Promoting health for transgender women: transgender resources and neighborhood space (TRANS) program in San Francisco. American Journal of Public Health 95
18. Nemoto T, Operario D, Keatley J. 2005. Health and social services for male-to-female transgender persons of color in San Francisco – International Journal of Transgenderism 8.
19. G oldberg J. 2004. First year report: Transgender Health Program. Vancouver, BC: Vancouver Coastal Health Authority. (online at http://www.vch.ca/transhealth/resources/library/thpdocs/0407yearend.pdf ).
20. Hibbs D. 2004. Hormone replacement and the treatment of the transgender Patient: a critical literature review.
    Caring For The Vulnerable: Perspectives in Nursing Theory. edited De Chesnay M. San Francisco: CA, Jones & Barlett.
21. Lev AI. 2004. Transgender Emergence: Therapeutic Guidelines for Working With Gender-Variant People and Their Families. New York: Haworth Clinical Press.
22. Lurie S. 2004. Identifying training needs or health care providers related to treatment and care of transgendered patients. International Journal of Transgenderism 7.
23. Nemoto T, Operario D, Keatley J, Han L, Soma T. 2004. HIV risk behaviors among male-to-female transgender persons of color in San Francisco. American Journal of Public Health 94.
24. Nemoto T, Operario D, Keatley J, Villegas D. 2004 . Social context of HIV risk behaviors among male-to-female transgenders of color AIDS Care 16.
25. Reback CJ, Simon P. 2004. The Los Angeles Transgender Health Study: Creating a research and community collaboration. Preventing AIDS: Community-science collaborations. New York, NY: Haworth Press.
26. X avier J, Hitchcock D, Hollinshead S et al. 2004. An Overview of US Trans Health Priorities: A Report by the Elimination Disparities Group. Washington, DC: National Coalition for LGBT Health.
27. Clements-Nolle K, Bachrach A. 2003. Community based participatory research with a hidden population: The transgender community health. Community-based Participatory Research for Health. edited Minkler M, Wallerstein N. San Francisco, CA: Jossey-Bass Press.
28. Moore E, Wisniewski A, Dobs A. 2003. (Clinical Review) Endocrine treatment of transsexual people: a review of treatment regimens, outcomes, and adverse effects. The Journal of Endocrinology & Metabolism 88.
29. Kopal, L. 2003. Recommendations for a transgender health program. Vancouver, BC: Vancouver Coastal Health Authority (online at http://www.vch.ca/transhealth/resources/library/thpdocs/0304kopalareport.pdf ).
30. Levy A, Crown A, Reid R. 2003. (Review) Endocrine intervention for transsexuals. Clinical Endocrinology 59
31. Tangpricha, V., Ducharme, S. H., Barber, T. W., & Chipkin, S. R. 2003. Endocrinologic treatment of gender identity
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32. Kenagy GP. 2002. HIV among transgendered people. AIDS Care 14.
33. X avier J & Simmons, R. 2002. The Washington, DC Transgender Needs Assessment Survey. Washington, DC: HIV AIDS Administration, District of Columbia.
34. Bockting W, Kirk S. 2001. Transgender and HIV: Risks, Prevention, and Care. New York, NY: Haworth Press.
35. Clements-Noelle K, Marx R, Guzman R, Katz M. 2001 HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: Implications for public health intervention. American Journal of Public Health 91.
36. G ay and Lesbian Medical Association.2001. Healthy People 2010 bisexual, and transgender (LGBT) health. San Francisco, CA: GLMA
37. Kellogg TA, Clements-Noelle K, Dilley J, Katz MH, McFarland W. 2001. Incidence of human immunodeficiency virus among male-to-female transgendered persons in San Francisco. Journal of Acquired Immune Deficiency Syndrome 28.
38. Kammer N, Mason T, Connors M, Durkee R. 2001.Transgenders, HIV/AIDS, and substance abuse: from risk group to group prevention. Transgender and HIV: Risks, Prevention, and Care. ed Bockting W, Kirk S. New York: Haworth Press.
39. Lombardi, EL. 2001. Enhancing transgender health care. American Journal of Public Health 91.
40. Meyer, IH. 2001. Why lesbian, gay, bisexual, and transgender public health? American Journal of Public Health 91.
41. Lombardi EL, Wilchins RA, Priesing D, and Malouf D. 2001.Gender violence: transgender experiences with violence and discrimination. Journal of Homosexuality42.
42. Oriel K. 2000. (Clinical Update) Medical care of transsexual patients. Journal of the Gay and Lesbian Medical Association. 4-194. [with response from Karasic D].
43. Simon PA, Reback CJ, Bemis CC. 2000. HIV prevalence and incidence among male-to-female transsexuals receiving HIV prevention services in Los Angeles County. AIDS 14.
44. Simon P, Bemis C, Gatson B. 2001. HIV Risk behaviors of male-to-female transgenders in a community-based harm reduction program. International Journal of Transgenderism 3 (online at www.symposion.com/ijt).
45. Bockting WO, Rosses BRS, Coleman T. 1999. Transgender HIV prevention: community involvement and empowerment. International Journal of Transgenderism 3 (online at www.symposion.com/ijt).
46. Clements-Nolle K, Katz M, Marx R. 1999. The Transgender Community Health Project: Descriptive Results. San Francisco, CA: San Francisco Department of Public Health.
47. Clements K, Wilkinson W, Kitano K, Marx R. 1999. Transgender and HIV: risks, prevention, and care. International Journal of Transgenderism 3 (online at www.symposion.com/ijt).
48. Krammer N, Mason T, Connors M, Durkee R. 1999. Transgender health and social service needs in the context of HIV risk. International Journal of Transgenderism 3 (online at www.symposion.com/ijt).
49. Lombardi, E. 1999. Integration within a transgender social network and its effect upon member’s social and political activity. Journal Homosexuality3.
50. Bockting, WO. Robinson BE, Rosser BRS. 1998. Transgender HIV prevention: A qualitative needs assessment. AIDS Care 10.
51. Futterweit W. 1998. Endocrine therapy of transsexualism and potential complications of long-term treatment. Archives of Sexual Behavior 27.
52. Israel GE, Tarvar DE. 1997. Transgender Care: Recommended Guidelines, Practical Information, and Personal Accounts. Philadelphia, PA: Temple U Press.
53. van Kesteren P , Asschemen H, Megens J, Gooren L. 1997. Mortality and morbidity in transsexual subjects treated with cross-sex hormones. Clinical Endocrinology 47.
54. Asscheman H, Gooren L. 1992. Hormone treatment in transsexuals. Journal of Psychology & Human Sexuality 5
55. Asscheman H, Gooren L, Eklund P. 1989. Mortality and morbidity in transsexual patients with cross-gender hormone treatment. Metabolism 38.

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Study	Year	FTM Standard Therapy	MTF Standard Therapy
Van Kesteren, Asscheman, Megens, Gooren Free University Hospital, Amsterdam, The Netherlands *Largest TG Health Study to-date: 293 FTM, 816 MTF	1997	Parenteral Testosterone esters 250mg, intramuscular, every 2 weeks Or: Oral Testosterone undecanoate 160mg per day	Ethinyl esterdiol 100μg, oral, daily And: Cyproterone acetate 100mg, oral, daily [40-years old and over + high incidence of venous thromboembolism: transdermal Estradiol]
Moore, Wisniewski, Dobs (Review Artical) School of Medicine, The Johns Hopkins Baltimore, MD	2003	“Recommended Hormonal Treatment Regimen:” Testosterone esters, 200mg, every other week, intramuscular Or: Testosterone (patch), 5g, transdermal, daily	“Recommended Hormonal Treatment Regimen:” Ethinyl estradiol, 100μg, oral, daily Or: Conjugated estradiol (equine estrogen), 2.5mg, oral, daily [40-years old and over: transdermal Estradiol] [If estrogen doses reach twice above recommendations, add Spironolactone, Cyproterone acetate, or GnRH agonists to minimize estrogen requirement]
Levy, Crown, Reid (Review Artical) University Research Center for Neuroendocrinology Bristol University Bristol, UK	2003	“Sustanon” 250mg, intramuscular, every 2 weeks Or: Testosterone enanthate (“Primoteston Depot”), if patient is sensitive to peanut (arachis) oil, 100mg	“Estraderm TTS” 50 or 100 (delivering 50 or 100 μg estradiol per 24hours transdermally when applied 2x weekly, reduced to 50 μg per 24-hours “post-gender reassignment surgery”) Or: Oral Ethinylestradiol 100-150 μg daily in divided doses (50 μg twice a day or three times a day, reducing to 50 μg daily “post-surgery”) Or: Oral estradiol valerate (“Progynova”) 4- 6mg daily (2mg twice a day or three ties a day, reducing to 1- 2mg “postsurgery”) Often in combination with: Spironolactone 100-300mg, oral, daily Or: Cyproterone acetate 50-100mg, oral daily
Oriel (REVIEW ARTICLE) University of Wisconsin, School of Medicine Madison, Wisconsin	2000	Testosterone 150-200mg, intramuscular, every 2 weeks	“Estrogen dosing range:” Conjugated Estrogen, 0.625 – 2.5mg, oral, daily Or: Estradiol (“Estrace”) 1-2mg, oral, daily Or: Esterified Estrogens (“Estratab”) 0.0625-5.0mg, oral, daily Or: Estinyl estradiol (“Estinyl”) 0.05-.5mg, oral, daily Often in combination with: Spironolactone 200-400mg daily (usually discontinued after “gender reassignment surgery”)
Futterweit Mt. Sinai School of Medicine New York, NY	1998	Standard treatment regimen: Testosterone esters (cypionate or testosterone enanthate), 250-400mg, intramuscular, every 2 to 3 weeks	Standard treatment regimen: Ethinyl estradiol, 100 μg, oral, daily Or: Conjugated estrogen (“Premarin”), 1.25-2.5mg, orally, daily And (initially): Medroxyprogestrone acetate (“Provera”) 5-10mg, oral, daily for 10-days per month
Israel and Tarver San Francisco, CA	1997	Testosterone cypionate or testosterone enanthate 200mg, intramuscular, 2-times month Or: Transdermal testosterone, 2-patches, 2.5mg, daily (for 5mg daily)	Conjugated estrogen (“Premarin”) 1.25-2.5mg, oral, daily Or: Synthetic ethinyl estradiol (“Estrace”) 0.1-0.5mg, oral, daily Or: Estradiol valerate (“Delestrogen”), 15-80mg, intramuscular, monthly Or: Estradiol undecanoate, 200-800mg, monthly Or: Estradiol cypionate, (“Depo-Estradiol”) 1-5mg per week Or: Estradiol Benzoate, 0.5-1.5mg two-three times per week [Patients over 40-years old: Transdermal estradiol (“Estraderm”) 50-100mg 2x per week] “Frequent Supplement:” Progesterone (“Provera”) 2.5-10mg, oral, daily Or: Micronized natural progesterone, 100-400mg, 2x day “Commonly prescribed supplement:” Spironolactone 200-600mg, oral, daily Or: Cyproterone acetate (“Anandron,” “Androcur”), 50- 100mg, oral, daily
Asscheman & Gooren Free University Hospital, Amsterdam, The Netherlands	1992	Testosterone ester (“Testoylron” or “Sustanon”) 200- 250mg, intramuscular, every 2 weeks Or: Testosterone undecanoate, 160-240mg, oral, daily	Antiandroge ns: Lueprorelin (“Lucrin depot”) or Triptorelin (“Decapepty 1-CR”) 3.75mg, injection, every 4weeks Or: Spironolactone (“Aidactone”) 100m-200mg, oral, daily, Or Flutamide (“Eulexin”) 250mg, orally, 3x day Or Cyproterone acetate (“Androcur”) 100-150mg, oral, daily Or: Medroxyprogesterone (“Provera”) 5-10mg, oral, daily Or “Depo-Provera”, 150mg, intramuscular, daily Or “Farlutai”, 5-10mg, oral, daily Or “Farlutai depot”, 100mg, intramuscular, monthly ESTROGENS: Standard Treatment: Ethinyl Estradiol (“Lynorai”) 100μg, oral, daily, Or Conjugated Estrogens (“Premarin”) 5-10mg, oral, daily, Or 17ß estradiol (“Progynova”) 2-4mg, oral, daily Or (“Progynon depot”) 10mg, intramuscular, every 2- weeks to 100mg every month Or (“Estraderm TTS”) 50-100 μg, transdermally, daily, Or: Estriol (“Synapause”) 4-6mg, oral, daily
Asschemen, Gooren, Eklund Free University Hospital, Amsterdam, The Netherlands	1989	Testosterone ester 250mg, intramuscular, every 2 weeks Or: Testosterone undecanoate 120-160mg, orally, daily OR: Both, but not simultaneously	Ethinyl esterdiol 100μg, oral, daily And: Cyproterone acetate 100mg, oral, daily,
Meyer, Webb, Stuart, Finkelstein, Lawrence, Walker The University of Texas, Medical Branch Galveston, TX	1986	Testosterone ester 250mg, intramuscular, every 2 weeks Or: Testosterone undecanoate 120-160mg, orally, daily OR: Both, but not simultaneously	Ethinyl esterdiol 100μg, oral, daily And: Cyproterone acetate 100mg, oral, daily,
Meyer, Webb, Stuart, Finkelstein, Lawrence, Walker The University of Texas, Medical Branch Galveston, TX	1986	“A satisfactory hormonal regimen:” Testosterone cypionate 200mg, intramuscular, every 2-weeks	“A satisfactory hormonal regimen:” Ethinyl estradiol, 0.1-0.5mg, oral, daily Or: Conjugated estrogen, 7.5-10mg, oral, daily
Meyer, Finkelstein, Stuart, Webb, Smith, Payer, Walker The University of Texas, Medical Branch Galveston, TX	1981	“Best treatment regimen seems to be:” Testosterone cypionate 200mg, intramuscular, every 2-weeks,	“Best treatment regimen seems to be:” Ethinyl estradiol, 0.1mg, oral, daily
Benjamin, Harry	1969	Testosterone 200-250mg, intramuscular, once a week	Ethinyl Estradiol (“Estinyl”) 0.5mg 3x day Or: Conjugated Estrogen (“Premarin”) 5mg per day Or: Estradiol Valerate (“Delestrogen”) 30-40mg and Hydroxyprogesterone caproate (“Delalutin’) 30-60mg every 2 weeks

Progesterone therapy is rarely – if ever – discussed

References:

1. P van Kesteren, H Asschemen, J Megens, L Gooren. 1997. Mortality and morbidity in transsexual subjects treated with crosssex
2. hormones. Clinical Endocrinology 47:337-342
3. E Moore, A Wisniewski, A Dobs. 2003. (Clinical Review) Endocrine treatment of transsexual people: a review of treatment
4. regimens, outcomes, and adverse effects. The Journal of Endocrinology & Metabolism 88(8):3467-3473
5. A Levy, A Crown, R Reid. 2003. (Review) Endocrine intervention for transsexuals. Clinical Endocrinology 59:409-418
6. K Oriel. 2000. (Clinical Update) Medical care of transsexual patients. Journal of the Gay and Lesbian Medical Association. 4(4)185- 194. [with response from Dan Karasic (UCSF)]
7. W Futterweit. 1998. Endocrine therapy of transsexualism and potential complications of long-term treatment. Archives of Sexual Behavior 27(2):209-226
8. G Israel, D Tarver. 1997.Transgender Care: Recommended Guidelines, Practical, and Personal Accounts. Philadelphia, PA: Temple University Press
9. H Asscheman, L Gooren. 1992. Hormone treatment in transsexuals. Journal of Psychology & Human Sexuality 5:39-59
10. H Asscheman, L Gooren, P Eklund. 1989. Mortality and morbidity in transsexual patients with cross-gender hormone treatment. Metabolism 38(9)869-873
11. W Meyer, A Webb, C Stuart, J Finkelstein, B Lawrence, P Walker. 1986. Physical and hormonal evaluation of transsexual patients: a longitudinal study. Archives of Sexual Behavior 15(2):121-138
12. W Meyer, J Finkelstein, C Stuart, A Webb, E Smith, A Payer, P Walker. 1981. Physical and hormonal evaluation of transsexual patients during hormonal therapy. Archives of Sexual Behavior 10(4)347-356
13. H Benjamin. 1969. Suggestions and guidelines for the management of transsexuals. in Transsexualism and Sex Reassignment. edited R Green, J Money. Baltimore, MD: The Johns Hopkins University Press

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Appendix D: Provider Education Materials

10 Tips for Working with Transgender Individuals

An Information and Resource Publication for Health Care Providers

The Health Care Access Project is funded by grants from The California Endowment, The California Wellness Foundation, and the Liberty Hill Foundation.

A guide for health care providers

As a health care provider, you likely encounter and serve a population that is diverse with regards to race, nationality, immigration status, socioeconomic status, sexual orientation, gender identity, HIV status, medical condition, and disability, among other issues. At the Transgender Law Center, we recognize that many health care providers are eager to provide a safe, welcoming treatment environment for members of the transgender community, yet may not have had the opportunity to access information about the needs and experiences of
this marginalized population. With this barrier in mind, we have created this pamphlet so that we may work in partnership with providers to improve quality of care and provider-patient outcomes.

Introduction to the Transgender Community

Gender identity, a characteristic that we all possess, is our internal understanding of our own gender. The term “transgender” is used to describe people whose gender identity does not correspond to their birth-assigned sex and/or the stereotypes associated with that sex. A male-to-female transgender individual is a transgender woman and a female-to-male transgender individual is a transgender man. There are also gender nonconforming people who do not identify as transgender and some individuals in the transgender community who do not identify as male or female.

For many transgender individuals, the lack of congruity between their gender identity and their birth sex creates stress and anxiety that can lead to severe depression, suicidal tendencies, anti-social behavior, and/or increased risk for alcohol and drug dependency. Transitioning— the process that many transgender people undergo to bring their outward gender expression into alignment with their gender identity— is a medically necessary treatment strategy that effectively relieves this stress and anxiety.

Transgender people are medically underserved.

Access to affordable and appropriate health care is central to avoiding negative health consequences, yet most insurance companies exclude gender identity-related care and services, including mental health therapy, hormonal therapy, and surgeries. In addition, many transgender people have had multiple negative experiences in health care settings in the care of providers and office staff who have lacked the information necessary to provide sensitive services. Discrimination in the provision of services causes transgender people to delay or avoid necessary health care services, including health care that is not transition- related, often to the point of putting their overall health at severe risk.

The following are ten suggestions for improving
services for transgender people:

1. Welcome transgender people by getting the word out about your services and displaying transgender-positive cues in your office. You can utilize LGBT community centers, services, newspapers, and Internet resources to advertise your services. Posters, buttons, stickers, and literature about transgender people can demonstrate that you are transgender-friendly. You can rewrite your intake form to include “chosen name” in addition to “legal name,” as well as a third, blank option for “sex/gender” where someone can more accurately describe their gender. And single-use restrooms are a welcome addition for many, including transgender people.
2. Treat transgender individuals as you would want to be treated. You can show respect by being relaxed and courteous, avoiding negative facial reactions, and by speaking to transgender clients as you would any other patient or client.
3. Remember to always refer to transgender persons by the name and pronoun that corresponds with their gender identity. Use “she” for transgender women and “he” for transgender men, even if you are not in the patient’s presence.
4. If you are unsure about a person’s gender identity, or how they wish to be addressed, ask politely for clarification. It can be uncomfortable to be confused about someone’s gender. It can also feel awkward to ask someone what their gender is. However, if you let the person know that you are only trying to be respectful; your question will usually be appreciated. For instance, you can ask, “How would you like to be addressed?” “What name would you like to be called?” “Which pronoun is appropriate?” In order to facilitate a good provider-patient relationship, it is important not to make assumptions about the identity, beliefs, concerns, or sexual orientation of transgender and gender non-conforming patients.
5. Establish an effective policy for addressing discriminatory comments and behavior in your office or organization. Ensure that all staff in your office or organization receives transgender cultural competency training and that there is a system for addressing inappropriate conduct.
6. Remember to keep the focus on care rather than indulging in questions out of curiosity. In some health care situations, information about biological sex and/or hormone levels is important for assessing risk and/or drug interactions. But in many health care situations, gender identity is irrelevant. Asking questions about one’s transgender status, if the motivation for the question is only your own curiosity and is unrelated to care, is inappropriate and can quickly create a discriminatory environment.
7. Keep in mind that the presence of a transgender person in your treatment room is not always a “training opportunity” for other health care providers. Many transgender people have had providers call in others to observe their bodies and the interactions between a patient and health care provider, often out of an impulse to train residents or interns. However, like in other situations where a patient has a rare or unusual finding, asking a patient’s permission is a necessary first step before inviting in a colleague or trainee. For transgender patients, in particular, it is often important to maintain control over who sees you unclothed. Therefore, when patients are observed without first asking their permission, it can quickly feel like an invasion of privacy and creates a barrier to respectful, competent health care.
8. It is inappropriate to ask transgender patients about their genital status if it is unrelated to their care. A person’s genital status—whether one has had surgery or not—does not determine that person’s gender for the purposes of social behavior, service provision, or legal status.
9. Never disclose a person’s transgender status to anyone who does not explicitly need the information for care. Just as you would not needlessly disclose a person’s HIV status, a person’s gender identity is not an item for gossip. Having it known that one is transgender can result in ridicule and possible violence towards that individual. If disclosure is relevant to care, use discretion and inform the patient whenever possible.
10. Become knowledgeable about transgender health care issues. Get training, stay up to date on transgender issues, and know where to access resources.

For medical and mental health protocols, you can learn about the World Professional Association for Transgender Health’s Standards of Care for the treatment of gender identity disorders by visiting www.wpath.org. These internationally recognized protocols are intended as flexible guidelines. Clinical departures may be warranted based on patient characteristics, the provider’s evolving sensibilities, or research protocol.

You can view the Tom Waddell treatment protocols at www.dph.sf.ca.us. These comprehensive guidelines reflect the expertise of this San Francisco community clinic, which has been providing transition-related hormone therapy and primary care for low-income transgender individuals since 1993.

With attention to these guidelines, you can provide a vital service to a medically underserved population. By enhancing your knowledge and skills and demonstrating culturally competent behavior with transgender people, you will be on your way to building trust with individuals in the community by providing the respectful care that they need and deserve.

Thank you for doing your part to ensure healthcare access for all!

Transgender Health and the Law:

Identifying and Fighting Health Care Discrimination

Health Care Access

Like most people in the United States, transgender and gender non-conforming people have great difficulty securing affordable, comprehensive health care. The situation is compounded by systemic discrimination and health care providers’ lack of basic cultural competency on transgender issues. Gender identity discrimination in the form of ignorance, insensitivity, and outright bigotry is alienating and keeps people from accessing medically necessary care, such as hormone therapy, surgery, and mental health services. Health care injustice has life-long effects on people’s ability to learn, work, and care for themselves mentally and physically.

What is Gender Identity Discrimination?

Gender identity discrimination in health care settings occurs when you are denied equal access to health care and services, and/or you are subjected to a hostile or insensitive environment because you are, or are perceived to be, transgender or gender non-conforming. Such discrimination may be compounded with discrimination based on other characteristics (i.e. race, sex, sexual orientation, disability, etc.). Some examples of gender identity-related health care discrimination are: 1) being denied complete or partial health insurance coverage; and 2) inappropriate treatment from health care providers, facilities, or community-based organizations.

Discrimination in Private Health Insurance^[1]

Denial of Coverage

Many transgender people have their applications for health insurance denied when they disclose their transgender status or transition-related medical history (such as hormone level tests) to a potential insurer. Such denial of coverage is most common when applying for a private individual plan, but could also happen when applying for employer-based and other group plans. If your application for coverage is denied on the basis of your transitionrelated medical history or transgender status, you may have some legal recourse. Depending on the reason given for the denial, you may be able to take action against the insurance company. Contact TLC for suggestions on filing an appeal.

Reference

[1] This section of this pamphlet pertains particularly to private health insurance. TLC has a separate publication on public health insurance titled: Medi-Cal and Gender Reassignment Procedures.

Treatment Exclusion for Transgender-Related Care and Services

Most health insurance policies still specifically exclude transgender-related care and services. This often means that you will not be covered for procedures like: hormone therapy, transition-related surgery, and/or gender identityrelated mental health services. While the legality of such exclusions is not yet clear, you do have options other than filing a lawsuit. If you are denied coverage under one of these exclusions, you should file a timely appeal with your insurance company. Filing such an appeal can be time-consuming, but it generally costs little, if any, money. Even if you do not prevail, the information you provide about the medical necessity of the procedures you have requested helps educate the insurer about transgender health issues, thus advancing transgender access to health care. TLC can give you some suggestions on how to file a comprehensive appeal.

If transgender-related care and services are not specifically excluded in your policy, your insurance company might still deny the claim on the basis that these procedures are considered cosmetic or experimental. However, in deciding cases related to Medi-Cal, California courts have etermined that transition-related procedures are neither cosmetic nor experimental. If your insurance company has used this explanation to justify denial of coverage, contact TLC about appealing the decision.

Treatment Exclusion for Non-Transgender Services

Unfortunately, some insurance companies broadly interpret language excluding transgender-related care and services to deny coverage for non-transition-related procedures for transgender individuals. Insurers justify these exclusions by stating that your current medical problem is somehow related to your transition. For example, the insurer might argue (often times without any proof) that liver damage or blood clotting results from hormone therapy. Or, they may refuse to cover expenses related to a defective breast implant on the basis that the implant was “elective surgery.” While the law is unclear in this area, such a denial is likely a violation of your policy. If your insurance company has used this explanation to justify denial of coverage, contact TLC about appealing the decision.

Treatment Exclusion for “Gender-Specific” Services

Because the U.S. health care system largely overlooks the needs of transgender people, certain health care services are believed to be accessed only by men and other services only by women. This system of binary gender designation can be problematic for transgender health care recipients. Sometimes, transgender patients will have trouble scheduling certain appointments (such as an FTM getting a gynecological appointment) or making sure that they receive thorough examinations (such as an MTF having to remind her primary care physician to test her for prostate cancer).

And all too often, transgender people are denied coverage for medically necessary procedures because their documented gender does not correspond to the “gender-specific” service. Female-to-male transgender people, in particular, may have difficulty obtaining gynecological services or treatment for gynecological cancers. If you experience a denial of this sort, you should not hesitate to appeal it. Contact TLC if you would like assistance preparing your appeal.

Should I Change My Gender Marker on My Current Insurance?

Because of such problems, many transgender people are rightfully concerned about changing the gender marker in their medical records to reflect their gender identity. Changing the gender marker on your insurance is likely to alert the insurance company that you are transgender, and could possibly jeopardize your benefits. We urge you to contact TLC before doing so.

Which Gender Marker Should I Use When I Sign Up With A New Insurer?

The unfortunate reality is that regardless of what your gender marker is in your health records, it is possible that you will face denial for gender-specific procedures. FTMs who list their gender as male may have no trouble receiving testosterone, but may not be able to access gynecological services, or vice versa. Similarly, MTFs who designate female in their medical records may access female hormones but not care for prostate or testicular cancer. If you want to discuss what avenue might be best in your situation, contact TLC.

Discrimination by Providers of Health Care and Services

In addition to being denied health insurance coverage, you may experience gender identity-related health care discrimination when seeking care and services from doctors, nurses, hospital staff, and/or other health care providers (such as acupuncturists, chiropractors, or mental health therapists). Gender identity discrimination can also occur in residential/long-term care facilities (such as mental health or drug treatment facilities) and public health community-based organizations (such as HIV prevention agencies).

Discriminatory conduct can include: inappropriate name or pronoun use, invasive inquiries about your genitalia or transgender status, denial of access to the restroom or housing facility that corresponds to your gender identity, use of epithets, and/or hostile or intimidating behavior.

Some examples of discrimination are: being forced to revert to the gender you were assigned at birth in order to access health care, or having a dentist or ear/nose/throat doctor ask questions about your genitals.

Since most medical schools and other health care training programs do not educate their students on transgender health issues, this kind of inappropriate behavior happens too often. While state law is not explicit on this issue, such conduct is likely illegal. If you experience this kind of discrimination, you can contact TLC or you can contact one of the following agencies:

• The Department of Fair Employment and Housing is the state agency that investigates complaints of discrimination, including discrimination in public accommodations. They can be reached at 1- 800-884-1684. You can find out more information about them at www.dfeh.ca.gov.
• The Medical Board of California is the state agency that licenses and investigates misconduct of a variety of health care professionals in California (see a list of which professionals at www.medbd.ca.gov). The Board can also accept discrimination complaints against health care professionals and will send an advisory letter to a professional when a complaint is filed. To file a complaint, call 1-800-633-2322.

Appendix E: Outreach Materials

Transgender, gay, lesbian, and bisexual people deserve the same care as everyoneelse . Thousands of health care providers in Massachusetts agree . They’re working to eliminate barriers to health care access , so everyone can be treated well . And stay well .

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