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Queer and trans individuals as a community have historically faced discrimination when seeking healthcare services. Whether during a time when homosexuality was categorized as a mental illness, queer and trans people were arrested or sent to conversion therapy, or in the modern age of “acceptance” where continued malpractice and insensitivity take place, it has always been a challenge to receive health services. This discrimination can take many forms, from legal attacks like the ones described in the Government Action archive, to the hostile culture of certain medical providers. Jonathan Santos-Ramos, the Director of Community Engagement and Strategic Initiatives at Callen-Lorde Community Health Center in New York City, explained the experience of queer and trans individuals in an interview we conducted with him in May of 2020. Callen-Lorde provides LGBTQ-specific, sensitive, and quality health care to residents of New York City. Patients often come to Callen-Lorde with a history of traumatic experiences from other medical settings. 


“LGBTQ specific health is extremely important, because unfortunately our current sort of general medical system doesn't really support the nuances of queer health. Specifically around trans care or the insensitivity that we saw in the HIV epidemic. That stigma, and unfortunately those experiences, are still very much alive today. So the bulk of the patients who seek our care have either not found care that was inclusive of all their identities or have unfortunately experienced some sort of trauma in the medical field or with medical professionals. So they really come to us as we provide sort of trauma informed care, recognizing that the folks who come through the door have so many levels of trauma that may have happened to them.”

Jonathan Santos-Ramos, Director of Community Engagement and Strategic Initiatives at Callen-Lorde Community Health Center



A New York Times article detailing the challenges that community health centers are facing during the pandemic highlighted Callen-Lorde’s work, and reiterated a similar narrative. Anthony Fortenberry, a chief nursing officer with Callen-Lorde, had observed this trauma in his work.


I would tell them that they needed to go to the E.R., Fortenberry recalls of some transgender patients. They would say: ‘Absolutely not. I would rather die than be misgendered or mistreated. It is not worth going through the trauma.’ According to a 2017 poll, 18 percent of L.G.B.T.Q. Americans say that fear of discrimination has kept them from seeking medical care.

Mattathias Schwartz, "A Shadow Medical Safety Net, Stretched to the Limit"



Insensitive care is life-threatening. It is not just a matter of affecting individual mood or self-esteem; this is pervasive trauma that has a tangible effect of discouraging at-risk LGBTQ individuals from seeking treatment when they need it. During a global health crisis, this should be alarming to all of us. 


While Callen-Lorde can provide some of this sensitive care to people who may otherwise go untreated, they are at absolute capacity and employees still say that more is needed. The community health center was brought on to work in two isolation hotels, one targeted to treat adults in the shelter system who are symptomatic or have tested positive for COVID-19, and another specifically for LGBTQ homeless youth. However, even with Callen-Lorde straining to cover the gaps in care, there is not nearly enough infrastructure to support everyone. The isolation hotel staff was quickly running short on gowns, masks, and other necessary equipment. While community members pitched in to help create makeshift gowns, there was a clear lack of support on the state and federal levels. Callen-Lorde does not have the capacity to treat the entire LGBTQ population of New York, meaning the rest of the burden falls on the hospital system.


Mount Sinai, a prominent health system and hospital network in New York City, is one of these institutions that many LGBTQ New Yorkers will be required to turn to. In an effort to increase the number of patients they could treat during the pandemic, Mount Sinai partnered with Samaritan’s Purse, an evangelical Christian humanitarian aid organization founded by Franklin Graham. Graham is the son of televangelist Billy Graham, and the family has a legacy of bigotry. In 1993, Bill Graham claimed that AIDS was a “judgment of God.” In April of 2019, Franklin Graham tweeted at then-presidential candidate Pete Buttigieg, “As a Christian I believe the Bible which defines homosexuality as sin, something to be repentant of, not something to be flaunted, praised or politicized.”


At the end of March 2020, Samaritan’s Purse put up their medical tents in Central Park to the vocal support of Mount Sinai President David L. Reich. Reich told hospital staffers to consider the tents “an extension of Mount Sinai.” The tents stayed up for about a month, concluding their work in early May 2020 after numbers began to decline.


Mount Sinai’s collaboration with Samaritan’s Purse sends a strong message to LGBTQ New Yorkers: you are not safe here. Let us remember the words Anthony Fortenberry relayed to us: “I would rather die than be misgendered or mistreated.” How many LGBTQ New Yorkers did not feel comfortable going to Mount Sinai for medical attention because they knew they could be mistreated? How many died?


The problem of discrimination and insensitivity in healthcare should matter to all of us, because it kills. We cannot tell the LGBTQ population that if they want sensitive healthcare they should just go to specialized centers like Callen-Lorde. That system cannot hold them all. More importantly, they shouldn’t have to be exiled to the outer corners of the healthcare system because the mainstream medical field refuses to change. As a global health crisis takes lives every day by the thousands, we are justifiably examining the way our health coverage must be expanded. However, we must also consider that changing the delivery of this care could save lives, too.


 

Interview with Jonathan-Santos Ramos


"A Shadow Medical Safety Net, Stretched to the Limit"


"The Soul Crushing Legacy of Billy Graham"


"Treating Coronavirus in a Central Park 'Hot Zone'"

On March 14th, 2020, the U.S. Surgeon General Jerome Adams tweeted that hospitals and healthcare systems should consider stopping elective procedures until the U.S. is able to flatten the curve. For many trans people, this meant that their gender-affirming surgeries and appointments for hormone replacement therapy (HRT) were cancelled or postponed indefinitely. This was done in an effort to limit the risk of exposure to COVID-19 and to save medical supplies, hospital beds, and doctors for only the most urgent cases. While necessary, this move raises an important question: what counts as an essential medical service?



For transgender people, gender affirming surgeries are often necessary and life-saving. Both scientific research and the lived experiences of trans people confirm that these surgeries are medically necessary. However, most health insurance carriers currently consider gender-affirming surgeries to be cosmetic procedures, and over 30 states allow insurance providers to exclude transition related services from coverage. Clearly, transition related procedures are far from cosmetic. Arguably, these procedures are not even elective, since, as licensed clinical social worker and psychotherapist Laura A. Jacobs notes in an interview with NBC, “existing daily in a body that doesn’t match your sense of self isn’t just uncomfortable, it’s traumatic”. In many cases, states and insurance carriers fail to recognize this fact.


Trans people face significant barriers when accessing healthcare, including "financial barriers, discrimination, lack of cultural competence by providers, health systems barriers and socioeconomic barriers”. Because of this, the cancellation and postponement of transition-related care has been devastating for many trans people, many of whom have fought for years to be able to schedule and fund these procedures.


In a NBC News video report, a trans man named Jaceon Coronado narrates his experience with having his top surgery postponed indefinitely. Jaceon notes that while on paper the surgery was considered medically necessary, he was told by his case manager that the procedure would be considered elective because of the pandemic. Jaceon notes that he cannot shake the sad feeling that has come over him since his surgery was cancelled. In the same news report, licensed clinical social worker and psychotherapist Laura A. Jacobs notes the detrimental impact of these cancellations on the mental health of trans patients.


“I know that some people often question whether these surgeries are cosmetic or just superficial. But far from that, these surgeries have well documented and real critical outcomes and improvements in outcomes for these communities. It’s not just a daily inconvenience to live in a body that feels inauthentic. It is daily and ongoing suffering and trauma. Being told that their surgeries are postponed is just another instance of them having to live in that dysphoria place, that place of trauma.”

Laura A. Jacobs, Licensed Clinical Social Worker and Psychotherapist and board chair at Callen-Lorde Community Health Center, a New York-based LGBTQ health center



A second trans man named Benton Sorensen also narrates his personal experience with having his top surgery postponed in a YouTube video. Benton describes being scheduled with a new surgeon and the lack of communication from his medical providers. He describes a phone call with the surgical center, saying “I didn’t even know the [new] surgeon’s name...they didn’t have any answers for me”.


Benton also describes a moral dilemma he faced when considering whether he would want to go ahead with the surgery or not if given the opportunity:

“I’d been having this moral debate with myself about whether or not I would even proceed if they said it was a go-ahead. I just don’t know if I could deal with potentially taking a bed, taking the resources from somebody who really needs it”

Benton Sorensen, YouTube Creator



In addition to transition-related medical services like gender-affirming surgeries and HRT, doctors faced the difficult decision of suspending other medical services as well. The line between elective and non-elective quickly becomes blurry. ABC News reported that doctors are now having to decide “whether to proceed or postpone prostate surgeries, colonoscopies, skin cancer removals and a range of other procedures that could mean life or death for their patients”. When it comes to deciding which procedures to cancel and which to go ahead with, doctors and healthcare institutions may look to the government to provide guidance.


On March 18th, the Centers for Medicare and Medicaid Services (CMS) released their recommendations for non-emergent, elective medical services. The CMS defined non-essential surgeries and procedures as those that could be deferred, such as non-emergent, elective and preventive medical services. They also recommended a tiered framework “to prioritize services and care to those who require emergent or urgent attention to save a life, manage severe disease, or avoid further harms from an underlying condition.”


“CMS, in collaboration with medical societies and associations, recently created recommendations to postpone non-essential surgeries and other procedures. This document provides recommendations to limit those medical services that could be deferred, such as non-emergent, elective treatment, and preventive medical services for patients of all ages."

Centers for Medicare & Medicaid Services


The CMS defines “Tier 3” medical services as services that would result in harm to the patient if they were withheld. The examples the CMS give include situations where the patient is showing symptoms of COVID-19. It is clear that withholding gender-affirming care also has a real potential to cause harm to transgender patients. Preventing harm in the present context primarily means preventing the harm caused by COVID-19 infection. Treating and preventing other forms of patient harm is deemed to be less essential.


The Johns Hopkins Center for Transgender Health released a message to their transgender patients defining what is meant by “elective surgery” and emphasizing the importance of gender-affirming surgeries.


“In discussions you may hear the term “elective surgery” used, which refers to procedures that can be rescheduled to a future date, as the timing of these cases is flexible and is unlikely to significantly impact the patient’s health outcome in the short term. This term in no way downplays how critical and important these surgeries are for our patients.”

Johns Hopkins Center for Transgender Health




 

U.S. Surgeon General's Tweet


NBC News Report: "Trans surgeries postponed indefinitely amid coronavirus pandemic"


Healthcare Laws and Policies Map


Barriers to Health Care for Transgender Individuals https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4802845/


NBC News Video Report: "Trans Surgeries Put On Hold During Coronavirus Outbreak"

YouTube Video: "I was supposed to have top surgery today."


ABC News Report: "As COVID-19 bears down, doctors confront difficult choices on elective surgeries" https://abcnews.go.com/Health/covid-19-bears-doctors-confront-difficult-choices-elective/story?id=69693791


Centers for Medicare & Medicaid Services "Non-Emergent, Elective Medical Services, and Treatment Recommendations" https://www.cms.gov/files/document/cms-non-emergent-elective-medical-recommendations.pdf


Ambulatory Surgery Center Association "State Guidance on Elective Surgeries"


Johns Hopkins Center for Transgender Heatlh

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