Gender-Affirming Healthcare: Supporting Members with Evidence-based Treatment Across Disciplines
by Micah Hoffman, MD, DABPN, FAPA
AllMed Behavioral Health Medical Director
An estimated 1.4 million Americans now identify as transgender, with an additional 1.2 million U.S. adults identifying as nonbinary.1 As these numbers continue to grow, developing clear policies and procedures around gender-affirming healthcare is becoming imperative for plans and medical professionals. At AllMed, our deep bench of board-certified physicians, with expertise in more than 120 specialties and subspecialties, can help your team sort through the relevant considerations to ensure that transgender and gender diverse (TGD) members receive optimal, plan-aligned care.
Multidimensional Care Calls for Multidisciplinary Expertise
Gender-affirming healthcare, as defined by the World Health Organization, encompasses a range of social, psychological, behavioral, and medical interventions “designed to support and affirm an individual’s gender identity” when it conflicts with the gender they were assigned at birth.2 Far from one-size-fits-all protocols or guided steps, these interventions come in many forms. Treatments may include hormone therapy, surgery, facial hair removal, interventions for the modification of speech and communication, and behavioral adaptations. All of these procedures have been defined as medically necessary by the World Professional Association for Transgender Health.3 The primary goal is to help TGD people align the emotional, interpersonal, and biological aspects of their lives with their gender identity.
Like many medical therapies and treatments, the types and methods of gender-affirming care that are appropriate in a given scenario depend on a variety of factors, including a person’s age and condition. For children, care might be as simple as using a different name or the correct pronouns. For adolescents, it may involve taking drugs to delay puberty or receiving hormone therapy. As people get older, they may opt for surgery.
As plans and providers gain experience with gender-affirming care, a coordinated care model is emerging as the most effective way of providing treatment. This approach brings together specialists from a variety of disciplines who collaborate to ensure that the member receives appropriate care that aligns with plan policies. Such a team would likely include physicians with expertise in adult or child/adolescent psychiatry and family medicine and might also include plastic surgeons and urologists, among others. Each specialist brings unique and relevant expertise to a case.
Specific Considerations Across Disciplines
As with most medical journeys, a member seeking gender-affirming care would likely begin with a primary care physician. Ideally, this physician would be involved throughout the individual’s journey, initially helping to identify appropriate resources and create a team of specialists and, ultimately, assisting with follow-up, ensuring that the member continues to receive necessary treatment to meet their physical and mental health care needs. Depending on the setting (rural vs. urban), the primary care physician may provide more direct care in terms of prescribing.
For an adult seeking treatment, a psychiatrist would first consider whether the individual has been diagnosed with gender dysphoria. If so, then it’s essential to understand whether they have been or are currently being treated. Further, the physician would evaluate whether the individual is receiving care for any psychiatric disorders or substance abuse problems. From the psychiatrist’s point of view, ensuring that the member has the capacity to understand and have reasonable expectations of treatment, that any co-occurring issues are under control, and that continuing care is in place are paramount.
Children and adolescents bring their own unique issues to gender-affirming care. A child or adolescent psychiatrist would focus on understanding the systems within which the young person exists—family, school, community—and how best to help bolster strengths and mitigate harms within those systems. For young members, the most important component of care can be education for the member and the people around them to help normalize and de-pathologize gender diversity or gender behaviors. Crucial, too, is a consideration of how the decisions being made today may impact the young person’s long-term future. What will the member’s reproductive options be? How will their care impact the family’s insurance coverage? Will they be exposed to bullying at school as a result of their choices? Evidence regarding these issues informs AllMed reviews, which are completed in accordance with state and federal regulations pertaining to this evolving topic.
When a member expresses a desire for plastic surgery, several additional factors come into play. First and foremost, taking the time to understand the member’s goals and set reasonable expectations of what the surgery can accomplish becomes especially critical. Then, beyond ensuring that the patient is clinically evaluated and psychologically fit for surgery, the surgeon may ask the member to complete one year of hormone therapy and facial hair removal before taking the next step. These treatments can make a huge difference. After all these steps have been completed, if the member is still certain that surgery is the goal, then the final two stages are the surgery and post-op care.
Lastly, when evaluating members for bottom (urology) surgery, which is irreversible, particularly stringent standards apply. A urologist would typically follow the current WPATH guidelines and would want to be certain that the member has strong behavioral health support. In addition, the surgeon would want to confirm that ongoing logistical support is in place, both for post-operative wound care and ongoing wellness.
Careful evaluation and support from physicians with specialized knowledge are essential to optimal gender-affirming care. Leveraging the expertise of AllMed specialists helps ensure that your members receive the right care at the right time within the parameters of their plan.
In my next article, I’ll recap a recent discussion among members of the interdisciplinary AllMed gender-affirming care panel about anticipated changes in the upcoming release of the World Professional Association for Transgender Health (WPATH) Standards of Care 8 and how the new standards might be integrated into plan policy. Check back in this space in the coming weeks.