Navigating health-care system more complicated for transgender people

The Philadelphia Trans-Health Conference is taking place this weekend. Though some say transgender health issues get a little more attention now than they did when the annual conference began 10 years ago, navigating the health-care system as a transgender person still presents unique challenges.

Sex-reassignment surgeries and hormones are rarely, if ever, covered by insurance companies. But even access to routine medical care can be compromised by fear of discrimination or medical providers’ lack of knowledge.

‘She didn’t know what I was going through’

Yvonne Paulovic likes to say she has always been a woman from the collarbone up.

“I identify as female, I always have,” Paulovic said. “At least since I became conscious of the fact that there was a difference in gender, which was about the age of 6.”

Paulovic lives in Point Pleasant in Bucks County and works as a photo lab technician. She lived as a male for most of her life, but came out publicly about 10 years ago. Later, she decided to start taking estrogen, but her doctor did not know the right dosages to prescribe and said she could not help her.

“I would tell her that I was going through this stuff, and could I have hormones,” but she said no, Paulovic said. “Basically she didn’t understand what I was going through.”

Paulovic asked around and eventually found a new, trans-friendly doctor she is very happy with, and she has been taking hormones since 2007. A chronic and lifelong testicular pain, though, got to be too much to handle.

“I used to go to the doctor and they’d say, ‘Well, you have a hernia,’ they’d check it and say ‘No you don’t,’ and that was it,” Paulovic said. “After I started taking hormones, I said, you know, this is ridiculous, I gotta find somebody.”

Eventually she was referred to a urologist who said Paulovic’s testicles had to be removed. Her doctor said the procedure was medically necessary, but the claim was denied by her insurance company because Paulovic’s insurance card identifies her as female.

Paulovic has enlisted the help of a lawyer, who said with a fight she can usually get the decision reversed in this kind of case. Health providers recommend trans clients do something Paulovic did not–retain the gender marker on their insurance cards that match with their body parts, not necessarily with how they see themselves. Even if that advice is heeded, though, this kind of problem can crop up.

“It’s not an easy system to navigate if you’re not trans,” said Dane Menkin, a certified nurse practitioner at the Mazzoni Center, a health center in Philadelphia that caters to gay and transgender clients. “Anything that makes you different is just going to make that system more complicated to navigate.”

In a 2009 survey, more than a quarter of transgender respondents said they had been denied care because of their gender identity. Three-quarters said they were afraid medical personnel would treat them differently if they sought care. Menkin said that can have serious implications for long-term health.

“It’s really about screening and prevention, and that’s the way it is whether we’re talking about diabetes or transgender medicine,” Menkin said. “We don’t have a very high death rate in this country for women of cervical cancer because of pap smears, because we screen, but that’s just not true for transmen, because they’re just not going to go get paps.”

Menkin said the same thing holds true for mammograms and prostate exams.

‘It’s almost as if trans people don’t exist’

What effect on health outcomes this lack of screening and other factors has on the trans population is not well understood. Jae Sevelius, of the Center of Excellence for Transgender Health in San Francisco, said anecdotally, health outcomes for trans people are generally worse than for the average population. But there is a lack of data on this particular subset of the population.

“There’s a lot that we don’t know about trans health because a lot of the big health-related surveys and epidemiology just does not include trans people,” Sevelius said. “On a national level, it’s almost as if trans people don’t exist.”

Sevelius was pleased when a government report released earlier this spring called for more research on lesbian, gay, bisexual and transgender health outcomes. The report also recommended inclusion of sexual orientation and gender identity questions on national health surveys.