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Health Equity for Transgender and Gender Non-Binary Patients

Highlights | Trans and non-binary care

  • Many trans and non-binary people face healthcare barriers.
  • Providing respectful, medically informed gender-affirming care is essential for their overall health.
  • UW Medicine’s Transgender and Gender Non-Binary Health Program seeks to do just that.
  • The program’s team members work to coordinate care and assist with creation of new service lines.
  • They also train providers and staff regarding both gender-affirming and clinically appropriate care.
  • Trans and non-binary patients can access services including a primary care, hormone management and gender-affirming surgeries.

As of 2015, Washington state was home to 33,000 adults who identify as transgender or gender non-binary, according to the National Transgender Survey from that year.

Many trans and non-binary people have had negative experiences in healthcare. That’s a problem, especially considering that they are also more likely to experience poverty, unemployment, homelessness and violence.

“Many people who are gender diverse don’t seek medical care because they’re afraid how they’ll be treated or had a bad experience before. As a further tragic consequence, they don’t receive preventive care and may wait to treat significant health conditions,” says Corinne Heinen, MD, a family medicine physician who sees patients at UW Medicine Primary Care at Belltown.

It is vital that healthcare organizations not only provide a supportive environment but also have the expertise to treat gender diverse patients.

Enter UW Medicine’s Transgender and Non-Binary Health Program, for which Heinen is the physician lead. The program’s goal is to create a safe, supportive space in which trans and non-binary people can receive affirming, respectful care that is coordinated with all their providers across the UW Medicine system.

Humble beginnings

Heinen is no stranger to gender affirming care: She’s been providing it since the early 1990s at the UW Medicine Primary Care at Belltown and at Harborview Medical Center’s Madison Clinic.

Her journey to create the Transgender and Gender Non-Binary Health Program began in 2016, when she appealed to leadership for funding. The program then became official as part of the Care Transformation initiative, which also saw the creation of UW Medicine’s Healthcare Equity program, now the Office of Healthcare Equity (OHCE).

Heinen’s first goal was to educate primary care providers and patient-facing staff on how to work with gender diverse patients, such as using someone’s correct name and pronouns as well as having an appreciation for their life experiences.

Special collaborations

Another main goal was working closely with specialty services, so referrals are a smooth process for patients.

“Many specialists had been providing care to trans patients already but it was word of mouth, which made it hard for primary care providers to know to whom to refer,” says Heinen.

Heinen collaborates regularly with specialists from surgery — including plastic surgery, gynecology and urology — and mental health care or, as Heinen prefers to call it, brain health.

“A lot of gender diverse patients have gone through traumatic events and intense discrimination. Rates of post-traumatic stress disorder for example are extremely high. Some of that arises from seeking medical care and being maltreated, rejected or neglected. We’re trying to reform the system so anyone who comes in and is gender diverse can feel comfortable,” she says.

A core team of surgeons and specialists collaborate to make these services possible. The team includes Russell Ettinger, MD, a craniofacial plastic surgeon; Alexander Skokan, MD, a trauma and reconstructive urologist; Alson Burke, MD, an OB-GYN; Lorena Alarcon-Casas Wright, MD, an endocrinologist; Hunter Wessells, MD, a urologist and chair of the Department of Urology; and Shane Morrison, MD, a plastic surgeon returning to Seattle this fall after doing a fellowship in gender-affirming surgery at the University of Michigan.

These collaborations are essential not just for ensuring patients can access care easily, but to make sure their experience is consistent and that all providers they see have the correct information about them.

Growing the program

In 2019, Sean Johnson, LSWAIC, joined UW Medicine under OHCE as the program operations specialist for the Transgender and Gender Non-Binary Health Program.

Now that the relationships between specialties have been established, Heinen, Johnson and colleagues have developed a monthly Trans Health Ally meeting to go over cases. They continue to do trainings, too.

Despite the small team and need for more resources, Heinen and Johnson have ushered in a bunch of service offerings.

Currently, the program offers many gender-affirming services, from hormone management and fertility care to orchiectomy and hysterectomy to chest masculinization and breast augmentation.

And beginning later this year, patients will be able to access vulvovaginoplasty services for the first time. (This is colloquially called “bottom surgery” but not everyone uses that term.)

Aside from direct care for patients, the team also does behind-the-scenes work to make UW Medicine’s patient and work environments — and the broader community — more inclusive, working toward ensuring faculty and staff badges list pronouns to creating gender-neutral bathrooms to providing consultations and trainings for outside organizations.

Looking ahead

Johnson has a lot of goals — and sees many opportunities — for the program’s expansion. First, getting more resources is key, since currently he and Heinen are solely responsible for the program’s organization.

One relationship he would like to further build is with mental health care, partly because it’s more necessary for patients than ever after the pandemic, and because sign-off from a mental health specialist is required for coverage of all gender-affirming surgical care, such as vulvovaginoplasty.

“For top surgery, the patient needs a letter from their doctor and from a brain health specialist, which can be a master’s level person like a social worker. For genital reconstruction, the patient needs a letter from a doctorate-level psychiatrist or psychologist as well,” Heinen explains.

Insurance companies are required under Washington state law to cover medically necessary procedures for trans patients, but the process is not foolproof and Johnson is working on looking more in-depth into surgical billing codes and how to make sure patients can get reimbursed.

Heinen and Johnson also want to see the program offer metoidioplasty and phalloplasty soon, as well as facial feminization and masculinization. Another goal is to have a designated site and day for gender-affirming care to take place (currently, the plan is to establish this at UW Medical Center – Northwest).

Plus, they continue to work on making existing types of care more inclusive to trans patients, such as by renaming women’s health and men’s health services.

While Johnson sees many opportunities for growth in in the future of gender affirming care delivery, he is motivated by the buy-in he has witnessed from people across UW Medicine.

“People are better informed and more vocal and more attentive to trans patients. It’s been amazing. Our admin staff and providers working with patients are the ones hounding the system to hurry up and build this program. I’ve felt supported by them. From my lived experiences as a trans person, I wasn’t expecting that. The overwhelming majority of people have been supportive,” Johnson says.

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