Access to quality health care has been historically complicated and challenging for people whose sense of identity and gender does not correspond with their sex assigned at birth. Over the years, specialists throughout Montefiore have provided care for transgender and non-binary (TGNB) patients. But until recently, the Montefiore Health System did not have a comprehensive patient-centered program to meet the health care needs of this underserved community.
“A lack of medical care used to mean that people who wanted to transition turned to back-alley methods, such as street hormones and silicone injections,” said Robert Beil, MD, a general internist and AAHIVM HIV specialist at Montefiore and an Assistance Professor of Medicine (General Internal Medicine) at Einstein, who has been working with transgender patients throughout his medical career.
Today, thanks to the collaborative efforts of Dr. Beil and other forward-thinking Montefiore Einstein clinicians, the piecemeal and fragmented delivery of health care services to TGNB people is becoming a thing of the past. An interdisciplinary, community-based approach to caring for this vibrant but vulnerable patient population is taking shape in the Bronx and changing lives.
The movement to streamline transgender health care at Montefiore Einstein began in earnest a little over five years ago, when like-minded faculty, medical students and House Staff began meeting once a month to discuss opportunities and gaps in quality care for TGNB patients. Recognizing the potential benefits to the Bronx community of dedicated trans care nearby, they established a Trans Health Working Group (THWG), and started working toward their wish list: A program that would integrate primary care, hormonal treatment, mental health services, HIV care, adolescent medicine and other relevant specialties; increase capacity for gender-affirming surgery; create a network of referrals for subspecialty care; offer cultural competency education throughout the system; promote research; and establish links to local nonprofit social and health-related organizations.
This summer, their vision gave rise to Montefiore’s fledgling Trans Health Program (a name still in progress). In July, the program worked with the departments of Medicine, Urology, Plastic and Reconstructive Surgery and Family and Social Medicine to bring on its first dedicated professional staff: A Transgender Health Coordinator and a Clinical Director (set to begin in October), who will help guide interdepartmental collaboration and strengthen community connections. They will develop cultural competency education at Montefiore Einstein that demystifies some of the psychosocial issues affecting TGNB people. To increase health care workers’ comfort level in caring for patients with trans experience, the trainings will address such nuances as how to ask and use patients’ preferred names and gender pronouns regardless of their stage in the legal transition and cover such functional questions as how to remain current without the evolving capacity of EPIC to record and prompt correct use of names and pronouns.
"This initiative evolved out of the fact that many of us were, for many years, doing transgender health care, but not in an organized, coordinated fashion," said Dr. Beil, who is also Medical Director of the Montefiore CICERO Program and of the Transgender Health Program. In 2014, Dr. Beil and Jules Chyten-Brennan, DO, then a General Internal Medicine Resident, created an advisory committee and began formalizing their discussions about the complexities, opportunities, and gaps in care for transgender and gender non-conforming patients. Today, the Trans Health Working Group is a thriving, all-volunteer interdisciplinary body that includes representation from a wide range of disciplines. These include: primary care in the Montefiore Medical Group (MMG); endocrinology; HIV/AIDS; adolescent pediatrics - seeing children and adolescents and providing pubertal blockade; family medicine; urology; plastic surgery; the Oval Center; Adolescent AIDS Program (AAP) Umbrella program, psychiatry; psychology; obstetrics and gynecology; social work; IT support, among others. They are joined by an enthusiastic cohort of Einstein medical students, some of whom have taken time off from school to provide programmatic and research support to the program. "We had a core group who wanted to build support for trans health care and we brought an insider's understanding of what it would take for that to happen,” Dr. Beil added.
Dr. Beil credits the Montefiore Medical Group and President and CEO Steven Safyer, MD, for his ongoing support for his early encouragement of the plastic surgery and urology departments to start providing essential surgical components of trans health care. The Human Rights Campaign also recognized remarkable strides being made at Montefiore and Einstein, recently awarding the institution Leader Status for LGBTQ health care, based, in part, on the work of the Health Equality Index committee, run by Alana Murphy, which added gender identity to the patient bill of rights, changed the bed assignment policies and EPIC, HIM and HR policies that effect TGNB people- both clients and associates.
The Right to Quality Health care
Trans health care at Montefiore has grown during an extraordinary era of expansion for transgender rights: In 2014, an explicit ban on Medicare from covering trans health in most states was overturned. A year later, New York became the ninth state to allow its Medicaid program to cover gender affirmation surgery, and many private insurance companies soon followed suit. By 2016, the Affordable Care Act made clear that health care discrimination against LGBT people – particularly trans gender and gender non-binary people – was unlawful. The trans community, historically seen as fringe, has increasingly become mainstream in the media, in political discourse, and in health care settings.
“We are definitely living through history it is one of those times you can see history happening when you’re in the thick of it,” said Dr. Chyten-Brennan, who moved in June to California to become Director for Transgender Care for the Santa Clara Valley Medical Center.
With the changes in law came opportunities for Montefiore, said Vafa Tabatabaie, MD, an Assistant Professor in the department of Medicine (Endocrinology ) who has been part of the Trans Health Working Group since its inception: “When I was a fellow, a patient would come to our clinic and we would say, this is something that needs multi-disciplinary care, but we didn’t have that network. Now we have that network,” she said.
Training the Next Generation
Dr. Tabatabaie did not see any TGNB patients during her 2009 Internal Medicine residency at Montefiore, and encountered only a handful of patients as a fellow in endocrinology two years later. Now, in her role as Endocrinology Fellowship Program Director, Dr. Tabatabaie is part of a sea change at Montefiore; she ensures that all young physicians develop ease in working with TGNB patients. In April, she and Dr. Beil, for the first time, included a formalized didactic lecture in the care of transgender patients as part of the Endocrine fellowship program curriculum. The joint session between pediatric and adult endocrinology clinicians included information on transitioning patients from the adolescent program into adult care.
“Part of our role as endocrinology is to manage specific endocrine-related issues that may come up in primary care of TGNB patients,” said Dr. Tabatabaie, who estimates that 20 to 30 patients receive trans-specific care in the endocrine department at any one time, and that many more get hormones through primary care doctors experienced in delivering TGNB care. “I think one of the areas where we have made significant strides and we need to keep strengthening is the network of providers -- increasing the ability, knowledge and comfort level in providing trans care across all departments.”
Outreach and Opportunity
Educational outreach will be a key part of the job ahead for Octavia Lewis, MPA, who started July 1 as Montefiore’s first Transgender Health Coordinator. She will work alongside a new Clinical Director slated to begin in October. “So far, a lot of what I have been doing is getting a feel and understanding of the landscape of those who are already working with our population, and seeing how I can best help integrate our services,” said Ms. Lewis, a woman of trans experience and a graduate of the Audre Lorde Project Trans Justice Community School with a background in managed care. “I am excited to be in the inception of this program and to be a part of its infancy stage. It’s a big opportunity for the community. To know that these doctors are working, day in and day out, to make sure that people here in Bronx have the same quality care and access to care as they have in other boroughs is inspiring.”
An Open Door
Montefiore’s Trans Health Program will continue growing to meet the surge in demand from the community. Trans-specific patients have increased more than eight-fold in recent years, from under 50 to nearly 450 across a range of departments, said Dr. Beil. Waitlists are long – particularly for surgery.
“We are trying to stay very true to our Montefiore mission in serving the underserved,” said Beth Drzewiecki, MD, Surgical Director of Transgender Care and an Associate Professor of Urology, who, along with Lawrence Draper, MD, Assistant Professor of Plastic Surgery and other colleagues in plastic surgery and strong backing from their departments, has undergone trans-specific surgical training since 2016 -- most recently they travelled to the University of Ghent Hospital, Belgium, in April. She and Dr. Draper performed the first vaginoplasty at Montefiore two years ago and she has since performed 14 trans-specific surgeries on patients aged 20 to 68.
“To have all those surgeons in a room come together in a collegial manner to talk about how to best care for trans people, to really be willing to talk about their experiences, the problems they face as gender surgeons, and their techniques. It’s a very open door,” remarked Dr. Drzewiecki, about the feeling of camaraderie at conferences of the World Professional Association for Transgender Health.
Groggy and Grateful
While some gender-affirming procedures, such as the orchiectomy, or castration, are relatively straightforward, others, such as phalloplasty and metoidioplasty, are more intensive, she said.
“Without question, these are the most emotional kinds of operation I do,” said Dr. Drzewiecki, listing some of the steps the patients go through even before reaching the operating table: hair removal, hormones, hysterectomies for trans males, mental health counseling. “I find it so rewarding when people wake up from anesthesia. They are groggy, but yet they are so, so grateful.”
Researching the Population
In addition to providing clinical care to the trans community, research around trans health care is ongoing. Viraj Patel, MD, MPH, a clinician-investigator in the Division of General Internal Medicine and assistant professor of Medicine (GIM), is working on building an algorithm to track the transgender population throughout the institution and looking at HIV outcomes among people who are transgender.
The data is discussed by Trans Health Working Group -- which continues to meet the second Tuesday of every month. Research also guides the Trans Health Program in its work to thoughtfully grow capacity and educate the clinical care community.
“What we find in the institution is that people are interested in learning how to work with folks and how to make care better for our TGNB clients,” said Dr. Beil. “We want to continue to provide compassionate and high-quality care, while increasing capacity of the sites and departments where people get transition health care specifically.”
Times Have Changed
Dr. Beil marveled at how things have changed, describing a patient, he’s seen since the early 1990s -- a Latina Bronx resident whose life was defined by discrimination, poverty and struggles to access care that required her to go underground, scraping together $2,500 to pay out of pocket for an orchiectomy in Philadelphia, from a doctor who did the procedure in his office and sent her to a hotel room to recuperate.
She was nearly 60 years old when last year she was able to get a breast augmentation and vaginoplasty at Montefiore, through the Trans Health Program. “As you would guess, she was over the moon about having access to these procedures. It wasn’t even in her worldview that it would ever happen,” said Dr. Beil.
He contrasted her experience with another patient, who is now just 19 years old. Thanks to recent, historic shifts in trans care and Montefiore’s increasingly vibrant interdisciplinary program, she has found all the quality care she needs in her own neighborhood: Montefiore clinical staff provide her with hormonal transition care, mental health care and sexual health care with HIV pre-exposure prophylaxis (PrEP). She is already in the process of accessing breast augmentation and she is on track to have completed bottom surgery by the time she is 23, he said.
“These are all parts of the comprehensive health care she needs in order grow into the fully realized healthy female adulthood she envisions for herself,” Dr. Beil said. “Trans people need anything that a large institution has to offer. We’re working to make Montefiore Health System ready and able to deliver whatever they need.”
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