A Kinder, Gentler Approach to Transgender Care

The part of the transgender population wishing to transition genders can be subject to some of the most rigorous pre-qualification requirements of any medical procedure. A Boston organization thinks there's a better way.

The Standards of Care issued by the World Professional Association for Transgender Health are intended only as guidelines. Yet, most providers treat them as requirements, especially those providers who lack extensive experience serving transgender people who are therefore nervous about the whole subject.

Fenway Health, a community health center serving greater Boston, has accumulated enough experience working with transgender clients to adopt a kinder, gentler approach, and the results have been impressive. Ruben Hopwood, a PhD candidate in counseling psychology at Boston University, is the Coordinator of Fenway's Transgender Health Program.

Hopwood calls Fenway's approach a "patient centered, harm reduction" model. The patient centered part means that Fenway trusts its clients when they present themselves as transgender, instead of requiring the lengthy series of behavioral health sessions suggested by the Standards before the clinician can officially agree that the person is transgender and recommend a treatment.

Fenway's intake and screening session involves a typical behavioral health evaluation, an exploration of the client's lifetime gender identity development and an orientation to Fenway's team-based care approach. Clients are then required to undergo a physical examination and blood analysis, either by a Fenway doctor or with their existing primary care provider. This assessment of the client's physical health is the sole basis upon which the client's suitability for hormone therapy will be determined.

In roughly half the cases where hormone therapy is approved, six months of behavioral health monitoring will be recommended or required to help manage the impact of hormone treatment on life situations or co-existing mental health issues.

The harm reduction part of the treatment model applies for clients who had already been taking hormones on their own, usually securing them over the Internet without a doctor's involvement. Fenway's doctors take over medical management of the client's hormone therapy in order to avoid unwise levels and combinations of medications, remove the need to share injection needles, and monitor the patient's ongoing health.

The number of transgender clients receiving health services has tripled since Fenway started using the new approach in 2007. But more than the numbers, Hopwood says it is "most exciting to witness the profound and miraculous positive changes in people's lives that have occurred. People who had been seeing other providers for years, and who had been told by them that they would not succeed because of co-existing conditions, have succeeded because we believed who they were and addressed their gender issues first."

Fenway Health is also home to another innovative program -- the Navigator Project. Alex Solange is one of the Navigators serving the transgender community. Potential clients call Solange when they don't know where to turn to access transgender care and support.

Some callers are just seeking to join his waiting list-only peer support group to meet other transgender people. Others are seeking to undertake a gender transition, and for those in stable situations, Solange refers them to Fenway's in-house Transgender Health Program.

But all too often his callers are homeless, having lost housing or employment due to the discrimination that transgender people face so often in this country, or because family have outright rejected them. Solange is firm in his belief homelessness does not provide a stable environment for transitioning genders, so he works with social service agencies to secure housing and repayment of debts before any medical services are arranged.

Depending on the needs of the client, Solange may also make referrals within or outside of Fenway for behavioral health or substance abuse services, as well as for legal support and insurance assistance.

Once clients are "in care," Solange interfaces with providers so they know what to expect. And he keeps after his clients to make sure they keep their appointments.

The Navigator's services are free. Clients find Solange by word of mouth, through internal referrals and from his outreach to different groups and conferences. He knows where his potential clients go.

Solange provides ongoing services to around 50 clients a month and guesses that he conducts about 350 encounters per month. He believes his work demonstrates "the life changing things that people can do if they have support." He's proud of clients who came to him homeless three years ago, who are now completely stable and happily living fully in their true genders.

The patient centered, harm reduction approach. Health navigation. Two innovative approaches that are changing the face of transgender health care.

Note: Herman is a non-compensated member of the Board of Fenway Health, a non-profit community health center.