Approach to the provision of transgender health care in a veteran population.

Transgender patients often experience health disparities, including higher rates of psychiatric comorbidity, tobacco and substance use disorders, higher suicide risk, and reduced access and initiation of medical and mental health services. In 2011, the Department of Veterans Affairs (VA) health care system released a directive outlining the provision of transgender health care services. Since 2011, the number of transgender veterans seeking services has increased. To address these health care disparities and ensure competent comprehensive medical and mental health care for this population, an interprofessional team collaborated to develop the first formalized Transgender Healthcare Clinic at the VA Loma Linda Medical Center. The team consisted of an endocrinologist, primary care provider, clinical pharmacist, psychologist, and social worker. Each member of the team plays a key role in the management of mental and medical health care for transgender veterans. After implementation of the Transgender Healthcare Clinic and its respective model for appointments, access to gender transition-related health care has improved and expanded. Although the role of the clinical pharmacist is well established in this clinic, the addition of a psychiatric pharmacist to the transgender health care team could improve patient care through the integration of an expert understanding of behavioral and pharmacologic aspects facing transgender individuals. The psychiatric pharmacist is trained with the unique skill set required to address these concerns and facilitate the optimal management of co-occurring mental illnesses commonly seen in this patient population. Further research focusing on the integration of psychiatric pharmacists into transgender health care teams is needed.

Background

Transgender is a term used to describe people whose gender identity or gender expression differs from that usually associated with their sex assigned at birth1 (see Table 1 for a full definition of terms). Transgender individuals often experience discrimination and social stigmatization, which can lead to emotional pain and other psychiatric illnesses, such as anxiety or depression.1,2 Some transgender individuals experience distress or discomfort related to a lack of congruency between their assigned sex at birth and their gender identity. According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5),2 if these feelings of discomfort persist for at least 6 months and interfere with daily functioning, a patient may receive a diagnosis of gender dysphoria (see Table 2 for full DSM-5 criteria for gender dysphoria in adults). This is a change from the DSM-IV-TR classification of “gender identity disorder.” The change in diagnostic terminology highlights the current need to reduce stigma associated with this diagnosis. Health professionals can assist gender dysphoric patients by upholding their gender identity and discussing the various treatment options available. Treatment options may include: changes in gender expression (living in the preferred gender role), hormonal treatment (to masculinize or feminize the body; may include reversible and nonreversible effects), surgical options to change primary and/or secondary sex characteristics, and psychotherapy aimed to support the individual in expressing or exploring the preferred gender identity and alleviate dysphoria. It is important to note that not all patients require hormones or surgery to alleviate their dysphoria; treatment should be highly individualized.1,2

TABLE 1

Definitions and keywords (modified from Veterans Health Administration Directive 2013-003)1-3,7

TABLE 2

Diagnostic and Statistical Manual of Mental Disorders, 5th edition2 diagnostic criteria for gender dysphoria in adolescents and adults

Prevalence

The prevalence of transgender individuals in the general population is unknown. Most prevalence statistics have narrowly focused on subsets of transgender individuals with gender dysphoria (previously known as gender identity disorder) or those who have undergone sexual reassignment surgery.3,4 Because of fear and stigmatization, rather than seeking professional medical treatment, patients often self-medicate with nonprescribed hormones or surgical interventions from unqualified individuals.1 This leads to inaccurate and underestimated prevalence statistics among the general population. This also holds true for the veteran population.3,4

Transgender Care Among Veterans

Although prevalence data are difficult to obtain among veterans who use Veterans Health Administration (VHA) services, it is possible to identify the subset with transgender-related diagnostic codes (eg, Gender Identity Disorder) in administrative data.4 Some studies4,5 found prevalence rates 3 to 5 times higher in veterans than in the general population. The number of veterans with transgender-related diagnostic codes has been increasing since 2008, with a notable increase after 2011.6 In 2011, the VHA created a national policy on transgender care with the release of a directive entitled “Providing Health Care for Transgender and Intersex Veterans,” now VHA Directive 2013-003.3 The purpose of this directive is to establish policy for delivering respectful, competent, health care services for transgender and intersex veterans who are enrolled in the Department of Veterans Affairs (VA) health care system or otherwise eligible for VA care. Transgender and intersex veterans are entitled to all services included in the VA's medical benefits package, including but not limited to: mental health care, hormone therapy, preoperative evaluation, and medically necessary postoperative and long-term care following sex reassignment. The VA does not provide sex reassignment surgery for the explicit purpose of transitioning from one sex to another. The VHA directive mandates staff members address the veteran based on the veteran's self-identified gender. Additionally, the directive states all transgender veterans have the right to receive health services free from discrimination, similar to any other veteran seeking treatment, and reiterates VA's zero-tolerance for harassment. Following the 2011 VHA Directive, centers nationwide were left with challenges relating to the implementation of, and access to, comprehensive transgender health care services.

Purpose

Prior to the implementation of the Transgender Healthcare Clinic at VA Loma Linda Medical Center, the care for a transgender veteran was often uncoordinated, resulting in discordant treatment plans. To address the delivery of transgender health-related services, including improving the lack of competent and comprehensive medical and mental health care, fragmented access to care and resources, and the lack of staff education on transgender care, an interprofessional team with expertise and interest for transgender health collaborated to develop the first formalized Transgender Healthcare Clinic at VA Loma Linda Medical Center.

Description of Innovative Service

In March 2011, VA Loma Linda Medical Center established an interdiscplinary Transgender Healthcare Clinic, which includes an endocrinologist, primary care provider, clinical pharmacist, psychologist, and social worker. Each member of the team plays a key role in the management of mental and medical health care. Patients are referred to this clinic through the process of a consult entered in the veteran's electronic medical record. This clinic provides veterans with improved access to specialty transgender health care and various appointment modalities, including individual and group medical appointments, along with telephone appointments. The veteran is evaluated conjointly by the entire transgender health care team during these visits, and individualized treatment plan and goals are established.

Role of Mental Health Provider

The key responsibilities of mental health providers working with transgender individuals are outlined by the World Professional Association for Transgender Health Standards of Care,1 and include: (1) assess for gender dysphoria; (2) provide information regarding options for gender identity and expression, and possible medical interventions; (3) assess, diagnose, and discuss treatment options for coexisting mental health concerns; and (4) when applicable, assess eligibility, prepare, and refer for hormone therapy and/or surgery. Guidelines1,7 recommend anyone seeking transition-related medications or services, including cross-sex hormone therapy (CSHT), first complete a thorough mental health evaluation to establish or confirm the diagnosis of gender dysphoria. Part of this evaluation includes determining the stability of comorbid psychiatric conditions along with assessing the individual's capacity to make an informed medical decision.

Role of Medical Provider

When considering treatment with CSHT, guidelines1,7 recommend the patient's medical practitioner first complete a thorough medical risk and benefit evaluation. This includes a comprehensive review of past and current medical history, as well as assessing potential future risks of CSHT. The medical practitioner reviews the reversible and irreversible effects of CSHT and discusses risks, realistic expectations, limitations, and benefits associated with medically managed transitioning.

Role of Pharmacist

Part of the medical assessment process is to ascertain understanding of the therapeutic plan and obtain the veteran's consent to treatment with CSHT. The clinical pharmacist plays a crucial role in the consent process in answering drug-related medication questions related to case-specific CSHT. The clinical pharmacist is responsible for reviewing drug-drug pharmacokinetic and pharmacodynamic interactions, with special attention given to the medications that may be affected when used in combination with CSHT as well as medical conditions that can be exacerbated by hormone therapy. As part of the pretherapy assessment, the pharmacist will identify contraindications, address precautions, and ensure medical risk factors have been addressed and are controlled prior the initiation of CSHT.

Clinical Impact

Following implementation of the Transgender Healthcare Clinic at VA Loma Linda Medical Center and its respective model for appointments, there has been a demonstrated improvement in access to gender transition–related health care and familiarity of covered services. Prior to clinic implementation, veterans had very limited, if any, access to providers with expertise and competence in transgender-related care within the facility. A clinic specifically designated to provide specialty care to transgender veterans was not available. Patients were also largely unaware of which transition-related health care services were included under VHA benefits. After the transgender clinic was established, veterans were provided with various forms of access to comprehensive, transition-related health care services provided by an interprofessional team of experts in transgender medicine and mental health. Veterans now have a choice of various appointment modalities, including group, telephone, and individual sessions, and are able to identify a set team to oversee their care. In addition, implementation of a secure e-mail messaging system has allowed for expedited, direct communication between the veteran and all members of the transgender health care team. Veterans are also informed of available VHA services and treatments with respect to transitioning. A formal evaluation of the Transgender Healthcare Clinic at VA Loma Linda, including a patient satisfaction survey, is ongoing.

The Transgender Healthcare Clinic addressed the issue of care continuity by providing a “one-stop shop” for all medically necessary gender transition–related needs and services, along with closing the gap between specialty care, primary care, and mental health. The entire transgender health care team is present at each appointment and is able to address any medical, pharmacologic, social, and psychologic aspects that may be of concern. The team also acts as a liaison for communication to the primary care provider and other mental health providers involved in the care of the veteran should any issues arise outside the scope of transgender-related services.

It is well documented8-11 that the lack of knowledge, skill, and sensitivity to provide gender transition–related services has been a barrier to seeking health care and respective services. Upon the advent of the Transgender Healthcare Clinic at VA Loma Linda, veterans were given a venue in which to feel safe and comfortable seeking gender transition–related needs without stigma or discrimination. They know their clinicians are experienced, competent, and compassionate about their situation and overall health.

Although the role of the pharmacist is well established in this clinic, the addition of a pharmacist with mental health expertise would serve to provide improved care through the integration of an expert understanding of behavioral and pharmacologic aspects facing transgender individuals.

Future Implications

Transgender patients experiencing gender dysphoria are more likely to experience stigmatization, discrimination, and victimization, which may limit patients from seeking treatment.2,8-11 Access to health services, including mental health services, may be limited further by barriers such as institutional discomfort or inexperience working with this population.2 Qualified mental health professionals with experience in providing care for transgender veterans may not be readily available. Although not all psychiatric pharmacists have experience with transgender patients, they do have specialized training, which allows them to effectively evaluate medication-related needs while demonstrating compassion, empathy, and respect for patients with psychiatric illnesses. The psychiatric pharmacist, as a member of the interdisciplinary team, can improve access to care by providing medication management visits for patients that require frequent titration of medication or closer monitoring. Transgender veterans with gender dysphoria commonly have multiple mental health diagnoses, including substance abuse and tobacco use, along with higher suicide rates.4,5 Psychiatric pharmacists have the unique skill set needed to address these concerns and facilitate the optimal management of co-occurring mental illnesses commonly seen in this patient population. Further research focusing on the integration of psychiatric pharmacists into Transgender Healthcare Clinics is warranted.