What is Gender Affirmation Care? On Treating the Whole Person

A conversation with Melina Wald, PhD, Clinical Director of the Gender Identity Program at Columbia University Irving Medical Center, on using an evidence-based approach to health care that is focused on instilling pride and celebration of gender diversity.

Before we begin, for family members, loved ones, folks who may not yet know, will you define the term Gender Dysphoria?

Absolutely. Gender dysphoria is essentially discomfort related to gender. Often physical, but it can also be social, that arises from an incongruence in someone's gender—how or what they know their gender to be, their sex assigned at birth, and how others perceive their gender.

When a patient makes an appointment with a physician in the Gender Identity Program, where does the process begin?

So, if a patient starts their care by coming to the clinic, which is housed within the Department of Psychiatry, then the first thing is scheduling an intake. And typically, folks who come into our clinic are looking for psychotherapy or come to us because they want to establish a relationship with a provider that's going to be able to provide the letter and documentation that is required for gender-affirming medical interventions.

What is the intake experience like?

Someone from our team will meet with them and conduct an interview of what their needs are, what they're looking for. Oftentimes, again, because we're in the Department of Psychiatry, it's not just related to gender dysphoria or aspects of their identity with respect to gender. So, we also like to get a complete picture of the person with respect to mental health and life satisfaction. Goals that the person has that we might be able to assist within therapy.

And from there, we co-develop a plan with the patient to identify what they may need and what treatment could look like both from our end, with respect to psychotherapy, and then also with respect to referrals for other medical interventions, like hormone therapy or surgery.

Are there other avenues for starting the referral process outside of psychiatry?

For adults, there are more and more providers that are willing to provide hormone therapy without a letter from a mental health provider. For surgery, the WPATH Standards of Care is a very important resource to use [WPATH stands for The World Professional Association for Transgender Health].

I would say probably all reputable surgeons still practice under the WPATH Standards of Care, which indicate that a letter is required from a qualified mental health provider for readiness for surgery.

The requirements for letters and documentation vary state by state; is that correct?

They do, care is not equal in that regard, and 2021 has been devastating for trans youth seeking care in several states.

More and more providers for adults are willing to start folks on hormone therapy under what's known as the informed consent model, which would not require a letter from a mental health provider. So, there are places like Callen-Lorde or Planned Parenthood, for example, that use an informed consent model to start an adult on hormone therapy.

There are also nurse practitioners, primary care providers, or endocrinologists that also practice with that model and don't require a letter or any sort of meeting or established relationship with a mental health provider.

Is there any kind of database that keeps track of physicians who are, for lack of a better word, safe for trans and non-binary folks, and knowledgeable about gender-affirming care?

That’s where WPATH comes in again. It has both a certification process and also a list of providers who are members. So that's one way that folks can be sure that they're seeing someone who's well-versed and informed in working with the trans population.

Let’s jump to insurance coverage and financial burden. The American Medical Association reports that 25 percent of those who seek hormone therapy are denied by their insurance companies. And then 55 percent of people who seek surgical therapy are denied nationwide.

You know, I can speak for New York, and here I do not think hormone therapy is much of an issue getting covered by most insurances.

And this is specifically after the law changed where Medicaid in New York started to cover gender-affirming medical interventions. So after that, a lot of insurances had to follow suit. And again, that's specific to New York State; although, Obamacare has also changed the landscape for coverage of gender-affirming health care. Certainly, I would imagine that those numbers are accurate across the rest of the country and may potentially even more concerning in some states, especially for folks who are under 18.

I would say, typically, in New York, insurance will cover hormone therapy. I've had maybe one or two situations where the doctor had to do a peer-to-peer or something like that for hormone therapy, but that's rarely the case.

What about for surgical treatment?

Sadly, for surgery, I think it's more common. And, in particular, many insurance companies are lagging behind in terms of coverage for non-binary folks. I've had situations, for example, where I've written a letter for someone who identifies as non-binary, has gender dysphoria, and needs top surgery. And the way that the insurance plan is written, we find out later, is that top surgery is only available for folks who identify as transmasculine.

And so, we've had to go back and forth and do an appeal. Sometimes the language that's written in these policies is a bit dated and non-inclusive of folks across the spectrum who might need surgery. So that often is an issue.

The other place where Dr. Rohde [Chief, Division of Plastic Surgery] and I have found that appeals are often needed is for folks under age 18.

How does that work for children and adolescents, can they pursue treatment on their own? How much do their families need to be involved?

When you hit a certain age you can keep your medical records private, but if the child (even an adult child) is going through their parent’s insurance, their parents are going to be aware of the diagnosis and the fact that we're putting in a request for a particular gender-affirming intervention.

Also, we wouldn't necessarily recommend it. I can think of some exceptions, but oftentimes we would want parents to be on board with hormones or surgery for a child so that they can help in the aftercare and in preparation, especially for surgery.

We want to involve the parents and the family in a decision, and help give them all the information that they may need to best understand, or to best make a decision that's right for themselves, the kid and their body.

With adolescents, we focus more on ensuring that they understand the permanence and that they're able to provide consent. So I think that's maybe heightened for children, although certainly, that's part of the process with adults as well—to ensure that they understand all of the potential risks and benefits.

Are there any avenues for kids who may be desperate to seek treatment but are living in an environment that does not affirm their identity?

In cases like that, where it's very, very clear that the adolescent is under significant distress, and is going to be helped by access to a gender-affirming medical intervention, the only option would be for legal emancipation, which is obviously something that needs to be thought about really carefully. There are certainly scenarios in which that happens, but outside of that, the current laws and our hospital policies indicate that a parent has to consent.

With discriminatory legislation in states across the country attempting, and at times succeeding, to limit or ban access to gender-affirming treatments for trans youth, how has that affected your work at the clinic?

I think it actually has a huge impact on the population and the folks that we're working with. There's research evidence that shows when there are discriminatory laws that are passed, even if they're states away, it can really impact folks who maybe aren't impacted legally by the law, but are certainly impacted by the language within the law or the discrimination that then gets publicized in the media.

And I would say, I work with a lot of children and adolescents who are very scared that it could happen in New York. Or who maybe are thinking about going to college, or are not going to live in New York their entire lives and are really concerned about what that means. And so unfairly, they have to make those types of decisions with the threat of access to their medical care in mind.

There's an increase in anxiety, in dysphoria, and in depression, among folks that we see, related to a lot of the legislation. Not just around banning access to gender affirming medical interventions, also around banning trans people from participating in sports. 

Is there a general treatment path folks take when starting gender affirmation care, or is that fairly individualized? For instance, is hormone therapy always recommended before surgery?

No, you know, I would say it’s really individualized. Historically, in trans healthcare, there was this kind of track that was developed or this progression where the medical profession would expect someone, for example, to socially transition and live in the gender that they know themselves to be for a specified amount of time, sometimes years long. And then start hormone therapy. And then after starting hormone therapy, obtain access to surgery. And we really don't practice in that way anymore.

There's a lot more recognition around, first of all, the fact that gender identity is much more diverse than was previously thought, even in the medical field, which is often catching up to what the trans community already knows about themselves. We've also caught up to understanding that folks have different needs in terms of what helps mitigate their dysphoria. For some people, that will include hormone therapy or surgery, and it will not for other people.

That being said, there are sometimes medical reasons that we recommend starting hormone therapy first for folks who are interested in both hormone therapy and surgery. Because they may be able to get certain effects that they need, and then the surgery becomes an easier process.

As someone who is also a patient at Columbia, I’ve noticed that intake forms I’ve filled out in one office or another only have male or female gender options. How do you deal with that?

Yeah, it’s really a shame, but it’s still the case. Certainly, part of our mission in the gender identity programs was to start to change measures, intake procedures, and educate clinicians, not just within our clinic, but other clinics across the larger Psychiatry Department and CUIMC system.

In terms of other efforts that I know about in NYP and Columbia, there are different committees that work on increasing awareness and practices. So, it sounds like there's work to be done, which is complicated by each office or clinic using their own forms.

With our transition to Epic [electronic medical record system], I think there has been a big change in allowing patients more agency to be able to identify their gender, the gender that is accurate for them, and to also clearly state their pronouns. And the format of Epic allows providers to see that a lot more clearly than in some previous systems we've had. So that, I think, has been a really positive change.

But we're always catching up. As an example; in moving to Zoom, it took a lag before Epic was able to allow folks to have their chosen name, rather than their legal name, show up on their Zoom window when they came to a visit. And, obviously, that was incredibly dysphoric for people, especially in a group therapy session. So we're still always trying to catch up to those types of things, unfortunately.

There is more and more medical research confirming that access to gender-affirming care significantly improves health outcomes overall and mental health. What do you want folks to know about that data?

Oh yeah, there is significant research among children, adolescents, and adults that demonstrates that access to gender-affirming therapy and gender-affirming interventions—whether those are what we consider social interventions, like being able to use your name and pronouns, or being able to join a team or an activity that's aligned with your gender or being able to wear clothing or adornments that are aligned with your gender or gender-affirming medical interventions, like hormones and surgery—significantly improve mood and anxiety. 

And oftentimes, actually, social interaction too. People start to feel more comfortable engaging with others and become more social.

We’re going to link to part 2 on gender-affirming surgical interventions with Dr. Rohde at the end of this interview, so let’s close out on the topic of collaboration—how do you work together with surgeons?

Generally, for patients interested in surgery, we refer them to surgeons we recommend, that we collaborate well with, and that we know have good results, like Dr. Rohde and our team here.

And we'll encourage folks to set up a consultation with more than one surgeon, just to get different opinions and impressions, and ensure that they feel they have a good rapport with the surgeon and are comfortable with them.

From there, if they've selected a surgeon, I'll typically reach out to the surgeon and let them know that a patient of mine has just completed a consultation. And attach a letter with what I know is typically required from the WPATH Standards of Care for that individual. Then the surgeon and I will continue to coordinate around the needs that the patient may have.

Any closing thoughts?

You know, one last thing I want to add is that there is a misconception around how children receive gender-affirming care. And much of it, many conversations you hear, politically motivated, are designed to scare people. But this is a thoughtful, careful process that involves the family and the needs of that specific patient. And it saves lives.

Read Part 2 of this interview on Top Surgery with Dr. Christine Rohde here.

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