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Transgender health
The past, present and future of transgender medical services in the area

12/14/17
By Ryan Lessard news@hippopress.com



 Kerry Anne Garnick is a 21-year-old transgender woman who lives with her parents in Hudson. She is on the waitlist to have gender reassignment surgery in Boston, an option she first heard about from her endocrinologist in Amherst. 

“I was excited. I was looking for a place to … get on the waitlist as fast as possible,” Garnick said.
As part of the process, she’s obtained letters of recommendation from two therapists, another from her endocrinologist, and just last week got a letter from an electrologist for hair removal. Her surgery is covered by her Anthem insurance; it would have been upward of $30,000 if she had to pay out of pocket. 
 
Access and affordability
Just five years ago, Dr. Joshua Safer at Boston Medical Center would have called it the dark ages for transgender health care in the region and the country. But many things have changed in just the past few years. 
In September 2016, BMC started performing the first male-to-female gender reassignment surgeries in New England. Safer, an endocrinologist, is the medical director of the hospital’s Center for Transgender Medicine and Surgery.
“Up until we got our program going, the patients had to travel out of state. … The nearest places to get your genital surgeries were Philadelphia and Montreal,” Safer said. “Really, there were only only half a dozen well-known places nationally and maybe a dozen total places. … It was a huge addition to the landscape, basically, that we could even do this at all, here in Boston. So the majority of the population of New England has at least reasonable driving access.”
Other medical services such as hormone therapy, breast reduction or augmentation surgeries, facial feminization surgeries, orchiectomies (the removal of the testes) and hysterectomies (removal of the uterus) had already been available at the hospital for the past several years.
The addition of genital surgery is a big deal for New Hampshire’s transgender community, for whom many can now drive to the hospital or take public transportation.
In the meantime, many of the barriers in insurance coverage have fallen away in the past few years as private carriers such as Harvard Pilgrim and Anthem have started to offer plans for transgender medical care that include reassignment surgeries. 
On Jan. 1, 2017, federal rules kicked in that prohibited discrimination by insurers on the basis of someone’s transgender identity, according to the New Hampshire Insurance Department, though they doesn’t specify any particular procedures, and in New Hampshire it’s not required that a carrier provide transgender reassignment-related coverage.
More recently, New Hampshire lifted a ban on Medicaid coverage for gender reassignment surgery, alternatively known as gender affirmation or confirmation surgery. That was a change by the Joint Legislative Committee on Administrative Rules at the request of the health department, which cited the federal rules as its reason for lifting the ban.
And in the past few years Dartmouth-Hitchcock has expanded its transgender medical offerings through its transgender clinic led by a team of three endocrinologists. 
Dr. John “Jack” Turco is the director of the clinic, which has locations in Lebanon, Bedford and Manchester. He said he’s been seeing individual trans patients since the 1980s, but the clinic has become more formalized in the last four or five years and their new adolescent clinic began about two years ago.
“We’re seeing them as endocrinologists mostly to initiate hormone therapy as adolescents and adults,” Turco said.
Their services also involve clinical social workers and psychologists, and the team helps patients who are very young and assists parents with navigating the options available. 
In the coming years, Turco hopes Dartmouth will be the first hospital in the state to offer gender affirmation surgery like the kind offered at BMC.
“We’re hoping to evolve into doing vaginoplasty,” Turco said.
 
The trans community
Transgender people in New Hampshire, which includes trans men, trans women and nonbinary transgender individuals, are a small minority in the state. According to a June 2016 report by the Williams Institute, there’s an estimated total of about 4,500 transgender people in the state, of which 650 are age 18 to 24, 3,100 are 25 to 64 and 750 are 65 and older. There’s an estimated 1.4 million in the whole country, which is just over the total population of New Hampshire.
Overall, the Dartmouth-Hitchcock clinic sees about 500 transgender patients, split roughly evenly between women and men. About a fifth of them are children, who can be as young as 8 years old in some cases, though most are 12 or older.
Dr. Nancy Charest, a pediatric endocrinologist with the Dartmouth clinic, said she sees about five new patients each month.
The clinic’s third endocrinologist, Dr. Benjamin Boh, said the biggest change has been the influx of young patients.
“We are seeing more adolescents. We are seeing patients in general in younger ages who are interested in medical transition,” Boh said.
Adult patients tend to present at different points in their life, but he thinks the growing cultural understanding of transgender identity among parents has made it possible for more young people to pursue transgender care.
Kristine Stoddard, the director of Bi-State Primary Care Association, said the most recent data from federally subsidized community health centers in New Hampshire reported 22 trans men and 13 trans women patients in the last year. Health centers were just required to start tracking transgender data in March 2016, so numbers are expected to increase.
 
Room for improvement
The new gender confirmation surgery in Boston is unique for a few reasons, according to Safer. The procedure is conducted by a two-man team: urologist Dr. Robert Oates and plastic surgeon Dr. Jaromir Slama. They studied the procedure at the University of Michigan and the University of Maryland and had visiting surgeons supervise the initial surgeries. Now, Safer said the Boston team has become some of the most proficient vaginoplasty surgeons in the country.
“Because they come at it as surgical experts in their own right, prior to doing this, they actually have thought of different approaches than were standard among those doing these surgeries elsewhere,” Safer said.
They have done nearly 30 operations so far, averaging about two per month. About 500 people have expressed interest and patients are coming from all over New England. That means Boston Medical Center doesn’t have the capacity alone to meet the demand, Safer said.
“There’s no doubt that, as a region, one surgeon doing surgeries every couple of weeks is insufficient,” he said.
He would like to expand the program there by training more surgeons and would like to see other hospitals, such as in New Hampshire, offer more services, including reassignment surgery, as well. 
Additional training for primary care settings would also help reduce barriers for trans people in New Hampshire. Linds Jakows, the campaign director for Freedom New Hampshire, a transgender advocacy group, said they’ve heard recent examples of people being turned away from primary care doctors who wouldn’t take them on, even to care for unrelated issues, because the doctors stated they never had a trans patient before.
“That’s discrimination. That’s completely unacceptable,” Jakows said.
Jakows, who is a nonbinary transgender person, hopes the transgender nondiscrimination bill will pass this year and prevent that sort of thing from happening.
And while carriers have begun to cover procedures that were not covered before, it’s still hit or miss with certain procedures. Usually, this has to do with policies that delineate between procedures that are seen as cosmetic versus medically necessary.
Anthem doesn’t cover breast augmentation, as a general rule, nor does it cover facial feminization surgery. Harvard Pilgrim says it covers some of the essential elements of feminization. But neither cover laser hair removal, which is needed before genital surgery.
“It’s just frustrating because it’s a necessity of the procedure that costs a lot of money most people don’t have,” Garnick said.
Garnick is opting for electrolysis, which she said costs about $60 per session. After all the sessions needed in a year, Safer estimates the costs range from $500 to $1,000.
“But as we expand this to the general population, there are going to be a lot of people who don’t have those kinds of resources,” Safer said.
And having extra savings could preclude people from getting covered under Medicaid, he said. 





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