By Ariel Makower
Department of Medicine Communications Intern
Montefiore Einstein
Physicians take an oath to do no harm. Regardless of this pledge, there are communities that continue to struggle to access healthcare, including those who identify as transgender and gender non-binary (TGNB). These groups face unique challenges including social persecution, mistreatment by providers, and lack of medical coverage from insurance companies. In fact, the 2015 Nationwide Transgender Survey Report noted that 23% of respondents did not see a doctor when they needed to due to a fear of mistreatment.
At Montefiore Einstein, providers recognize this health care inequity and are committed to making patients who are in the TGNB community feel welcome by taking a multidisciplinary approach, receiving training/education, and providing care.
Primary Care
Robert Beil M.D., a graduate of the Montefiore internal medicine program, is a strong advocate for patients who identify as transgender. As a gay man starting his career in the early 1990s when the AIDS epidemic was still raging in New York City (and across the world), he was nervous about specializing in AIDS care. “AIDS was a death sentence. There were still limited treatments doctors could offer,” says Dr. Beil.
The AIDS epidemic has impacted certain members of the LGBTQIA+ community more than others; 6.7% of those who identify as both Black and transgender are living with HIV. This is more than 20 times higher than the rate in the United States population (0.3%) and five times higher than the rate found in Black people living in the U.S. (1.3%) [Source: Transequality.org - “U.S. Transgender Survey”]. The high rates of HIV in the transgender community are connected to their participation in commercial sex work. Some transgender women believe that sex work is their only viable career option, and this belief stems from discrimination that is deeply rooted and ingrained in our society, spanning across interpersonal, intrapersonal, institutional, and systemic domains. [Source: J. Trauma Association, “Transgender women and the sex work industry: roots in systemic, institutional, and interpersonal discrimination.”]
Advancements in Health Advocacy but not for the Transgender Community
In the 1980s and 1990s health advocacy efforts for the LGBTQIA+ community were focused primarily on treatment of cisgender gay men and they were fairly successful. However, the same advancements in providing equitable health care were not seen for people who are transgender. New York State went so far as to specifically disallow the use of any state funds to cover gender affirming care. As a result, patients identifying as TGNB frequently resorted to buying hormones via the underground, unlicensed market. At Montefiore Einstein, Dr. Beil and a few others found themselves in a unique position to make a significant difference.
The Birth of Montefiore Einstein’s TransWellness Centers
In 2014, Dr. Beil gathered a multidisciplinary group of providers, including: Vafa Tabatabaie M.D. (endocrinology); Renee Reopell, M.S.W.; Jules Chyten-Brennan M.D. (general internal medicine); Teresa Benacquista M.D. (plastic and reconstructive surgery); Caryn Weiss N.P.; Beth Drzewiecki, M.D. (urology); Octavia Lewis, M.P.A.; and Donna Futterman, M.D. (pediatrics) who formed an unofficial committee called the Transgender Health Working Group. They tried to find a way to pool resources, increase training, and start teaching people about transgender advocacy and care. That same year, Medicare and Medicaid began covering gender affirming healthcare. This change in policy prompted the creation of the TransWellness Centers. With Dr. Beil as its director, the TransWellness Centers provide comprehensive care to Montefiore Einstein’s patients who are transgender across the entire healthcare system. Since its inception, the number of patients in this program has grown from 50 in 2014 to approximately 1,000 today. Read more about the TransWellness Centers.
Patients who are Transgender Find Their Voice
In addition to experiencing barriers to healthcare, there are a lot of special procedures and therapies that are not done in most academic medical centers because of the novelty of the field. Many patients who identify as TGNB struggle with the mismatch between their gender identity and their voice. To address this, an additional area of care at Montefiore Einstein focuses on gender affirming voice therapy, a fairly new field in medicine.
Rachel Kominsky, M.D., is a laryngologist leading the otorhinolaryngology department’s gender affirming voice care team at Montefiore Einstein. Each week, the department’s division of laryngology sees new patients who are TGNB, many of them local to the Bronx.
Gender affirming voice therapy can be provided for patients transitioning from both male to female and female to male. Most of the patients who seek out gender affirming voice care are transitioning from male to female, as female to male patients who are prescribed testosterone often have their voices deepen as a result of their hormonal therapy. Patients meet with a physician specializing in voice care, called a laryngologist, to evaluate the health of their voice box. If requested, patients can also undergo a glottoplasty, which is a surgery that will raise a patient's pitch about 20 to 30 hertz. Then patients spend time with speech language pathologists who will teach them how to use their voice in a way that reflects their gender identity.
Mehak Noorani CCC-SLP, Logan Walsh CCC-SLP, and Molly Sheehan CCC-SLP are the speech pathologists who work closely with patients on creating the voice that best fits them. This process includes education on characteristics of speech patterns for both males and females, pitch, resonance, prosody, volume, resonance, and articulation - all areas that target voice and speech production. Therapy is collaborative and the therapists encourage patient-led desires. According to Dr. Kominsky, multiple studies show that providing gender affirming care significantly decreases psychological distress and the need for mental health care, especially in those who undergo gender affirming surgery. It also significantly increases patients’ quality of life.
Facial Feminization
As the director of transgender surgery at Montefiore Einstein, Andrew Lee M.D., is the go-to person for facial feminization surgery (FFS), which are cosmetic procedures that change someone’s morphology from a traditional male face to a female one. This includes alteration of the forehead, jaw, lips, cheeks, nose, and eyebrows, as well as hairline and Adam’s apple reduction. Dr. Lee has extensive experience and training in FFS; during his career he has performed approximately 150 surgeries. See examples of Dr. Lee’s work.
When a person's body aligns with their gender identity and expression, they are much less likely to experience harassment and violence. Nearly half (47%) of respondents in the 2015 Nationwide Transgender Survey Report reported that they experienced some form of violence or harassment because of being transgender. In the way Dr. Lee describes it, undergoing these surgeries sounds like a rebirth process where people are reintroduced to themselves and become the positive change that they want to see. In a lot of ways these patients are limited by their body dysphoria and the surgeries can impact all aspects of their lives, not just their faces.
Staff Training
Key to transgender care is staff and provider training on inclusivity of those who identify as TGNB. On February 24, 2023, Christian Huygen, Ph.D., executive director, and Parker Jordan, L.M.S.W., executive director and director of community engagement, respectively, for the Rainbow Heights Club, conducted a training session for the department of medicine’s division of endocrinology about creating a welcoming and affirming environment for patients who are transgender.
In this training, the facilitators sought to answer the overarching question: how can we as healthcare professionals be more effective and affirming in our treatment of the LGBTQIA+ community?
Throughout the training, there was an emphasis placed on verbal and nonverbal communication in relation to the LGBTQIA+ community. Participants examined the languages and tools needed to provide good care and to ensure that patients feel safe and are treated with respect. There were approximately 30 people in attendance, including the Department of Medicine Chair Yaron Tomer, M.D., physicians, nurse practitioners, medical assistants, administrative support, and front desk personnel.
Words and Terminology Matter
When addressing patients who are TGNB, all staff – from the greeters to the clinical staff– should be mindful. It is important for staff to know the proper use of the terms sex, gender, and sexual orientation. While sex is often decided based on external genitalia, gender is a bit more subjective, as it’s the way someone identifies. It’s their sense of self. For those whose gender and sex align, they are cisgender; if they are discordant, they are transgender. Other terms include agender, where gender categories don’t apply, non-binary, where someone is on the gender binary spectrum, and gender fluid, where gender identity is not fixed.
In addition, understanding the patient’s stage and type of transitioning (social, medical, and legal) is a crucial aspect.
Social transitioning incorporates the use of pronouns. A good way to honor someone’s pronouns and make them feel at ease is for staff to introduce themselves, provide their names and pronouns, and ask the patient what they would like to be called. This way, you start off by creating a safe space where identity and pronouns are seen, heard, and honored.
Medical transitioning includes hormone and/or voice therapy and/or surgery. This is often referred to as gender affirming care.
Legal transitioning includes a legal name change, a gender marker change, or a change on identification documents such as birth certificates and driver's licenses.
Additional recommendations from the Rainbow Heights Club:
- Every facility should have a nondiscrimination policy displayed and materials that show diversity, such as rainbow stickers in the waiting room.
- Intake forms should request the patient’s legal name, chosen (preferred) name, sex, gender, and an option for committed relationship.
Training, advocacy, and education regarding proper care for the LGBTQIA+ community is necessary because according to the 2015 National Transgender Survey, 50% of respondents had to teach their provider about Transgender Care [Source: Transequality.org - “Injustice at Every Turn”]. With little to no education around this topic in medical school education, it’s time to start advocating for the LGBTQIA+ community, both medically and socially. The features discussed throughout the training help make an open and accepting space where people from different backgrounds and identities can feel safe and comfortable. The basic principle for offering affirming care is to start where the client is, help them feel as if they belong, and help them feel safe.
Read more about Montefiore Einstein’s LGBTQIA+ care.
Posted on: Friday, May 05, 2023