Download Gender identity

Doran Stamps, RN, BSN, CHC, CPHRM
The Intersection of
Gender Identity and
Healthcare
Why do healthcare institutions
need to address gender identity?
• The right thing to do
• 70% of transgender individuals report experiencing
discrimination in healthcare
• 19% of transgender or non-conforming individuals
report being refused healthcare due to their status
• 41% of transgender individuals reported they had
attempted suicide (compared with 1.6% of the general
population)
• Compliance with Non discrimination Section 1557 of
the ACA
Key Parts of Section 1557 of the
Affordable Care Act
• Protecting individuals against sex
discrimination
• Ensuring Meaningful access for Individuals
with Limited English Proficiency
• Ensuring Effective Communication with and
Accessibility for individuals with disabilities
• Coverage of health insurance in
marketplaces and other health plans
Protections Against Sex
Discrimination
Includes discrimination based on:
• An individual’s sex
• Pregnancy, childbirth and related conditions
• Gender identity
• Sex stereotyping; including that an individual
must identify as either male or female
Protections
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Individuals cannot be denied health care or health coverage based on their sex, including
their gender identity and sex stereotyping.
Women must be treated equally with men in the health care they receive and the insurance
they obtain.
Categorical coverage exclusions or limitations for all health care services related to gender
transition are discriminatory.
Individuals must be treated consistent with their gender identity, including in access to
facilities. However, providers may not deny or limit treatment for any health services that are
ordinarily or exclusively available to individuals of one gender based on the fact that a person
seeking such services identifies as belonging to another gender.
Sex-specific health programs or activities are permissible only if the entity can demonstrate
an exceedingly persuasive justification, that is, that the sex-specific health program or activity
is substantially related to the achievement of an important health-related or scientific
objective.
While the final rule does not resolve whether discrimination on the basis of an individual's
sexual orientation status alone is a form of sex discrimination under Section 1557, the rule
makes clear that OCR will evaluate complaints that allege sex discrimination related to an
individual’s sexual orientation to determine if they involve the sorts of stereotyping that can be
addressed under Section 1557. HHS supports prohibiting sexual orientation discrimination as
a matter of policy and will continue to monitor legal developments on this issue.
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Examples of sex discrimination (from the OCR’s education slide deck)
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Multiple staff at a hospital created a hostile environment for a
transgender woman because she was transgender. She was also required
to share a room with a male patient.
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A pharmacist would not provide a flu vaccine to a woman and questioned
her about her non-gender-conforming clothing and hairstyle.
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Staff at a hospital’s emergency department ridiculed a male patient who
arrived after sustaining injuries in a domestic incident. Staff did not
evaluate the patient under a domestic violence protocol because he was
male.
Gender Identity
An individual’s internal sense of gender,
which may be female, male, neither, or a
combination of female and male, and which
may be different from an individual’s sex
assigned at birth.
The way an individual expresses gender
identity is frequently called “gender
expression”, and may or may not conform to
social stereotypes associated with a particular
gender. A transgender individual is an individual
whose gender identity is different from the sex
assigned to that individual at birth.
What is gender identity?
Gender identity is one's personal experience of
one's own gender. This is generally described as
one's private sense of being a man or a woman,
consisting primarily of the acceptance of
membership into a category of people: male or
female. All societies have a set of gender
categories that can serve as the basis of the
formation of a social identity in relation to other
members of society.
Gender Categories
• 1. Male
• 2. Female
• 3. Female to Male (FTM)/Transgender Male/Trans
Man
• 4. Male to Female (MTF)/Transgender
Female/Trans Female)
• 5. Genderqueer, neither exclusively female nor
male
• 6. Additional gender category or Other please
specify
• Decline to answer
Other terms
Cisgender: A term used to describe someone
whose gender identity aligns with the sex assigned
to them at birth.
Androgynous: Identifying and/or presenting as
neither distinguishably masculine nor feminine
Bigender: Someone whose gender identity
encompasses both man and woman. Some may feel
that one side or the other is stronger, but both sides
are present
Gender fluid: A person who does not identify with a
single fixed gender, and expresses a fluid or unfixed
gender identity. One’s expression of identity is likely
to shift and change depending on context
Gender non-conforming: A broad term referring to
people who do not behave in a way that conforms
to the traditional expectations of their gender, or
whose gender expression does not fit neatly into a
category.
Genderqueer: A term for people who reject
notions of static categories of gender and
embrace a fluidity of gender identity and often,
though not always, sexual orientation. People
who identify as genderqueer may see
themselves as being both male and female,
neither male nor female or as falling completely
outside these categories.
Two-spirit: A term that refers to historical and
current First Nations people whose individual
spirits were a blend of male and female. This
term has been reclaimed by some in Native
American LGBT communities to honor their
heritage and provide an alternative to the
Western labels of gay, lesbian, bisexual, or
transgender.
Gender Affirming Surgeries
• For Affirmed Women
• For Affirmed Men
• Breast Augmentation
Facial Feminization (FFS)
Gluteal and hip
augmentation
Orchiectomy
Vaginoplasty
Labiaplasty
Clitoroplasty
• Chest Construction, also
known as “Top Surgery”
(Mastectomy)
Hysterectomy
Bilateral Oophorectomy
Metoidioplasty
Phalloplasty – Stage 1
includes: Vaginectomy,
Urethroplasty & Forearm
Pre-Lamination
Phalloplasty – Stage 2
includes: Scrotoplasty &
Glansplasty
Hormone Therapy
• MTF: Estrogen and anti-androgens
spironolactone
• FTM: Testosterone
What do we do?
Strategies to improve health care for gender nonconforming patients and to comply with Section
1557 requirements:
• Use the patient’s identified gender
In the demographics- EHR
When addressing the patient
On wristbands and labels
Follow the Fenway guidelines (MTF, FTM, etc.)
•Understand that gender nonconformity is not a
disorder
•Gender identity is not binary (male, female)
•Gain knowledge of transgender medical care
needs
•Room according to gender identity- (no charge for
accomodation of gender by using a private room)
•Identify and use the patient’s preferred pronouns
• Include gender identity in Non
Discrimination and Patient’s Rights
policies
• Provide role specific transgender care staff
training
The EHR
• Not currently standardized nor mandated, but
this is coming.
• EHR requirements have been made a part of
Meaningful Use requirements. All EHR
systems certified under Stage 3 of
Meaningful Use will allow users of record to
record, change and access structured data
on sexual orientation and gender identity.
These requirements are slated to take effect
in 2018.
Suggested questions
•  Female to Male (FTM/Transgender
Male/Trans Man
•  Male to Female (MTF/Transgender
Female/Trans Woman
•  Genderqueer, neither exclusively male
nor female
•  Additional gender category/Other
please specify__________________
•  Decline to answer
• What sex were you assigned at birth on
your birth certificate?
•  Male
•  Female
•  Decline to answer
• Record name and preferred pronoun in
EHR
• Registration records, in additions to Legal
Name fields, should include a field for
Name in Use. Nickname, alias or similar
fields can be used.
Pronouns
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 She/her/hers
 He/him/his
 They/them/theirs
 Patient’s name
 Decline to answer
 Unknown
Sexual Orientation
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 Lesbian or Gay
 Straight (not Lesbian or Gay)
 Bisexual
 Something else
 Don’t know
 Choose not to disclose
Federal Enforcement of Section
1557 (from OCR slide deck)
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The U.S. Department of Health and Human Services (HHS), Office for Civil Rights (OCR) enforces
Section 1557 as to programs that receive funding from HHS.
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OCR is a neutral, fact-finding agency that receives, investigates and resolves thousands of
complaints from the public alleging discrimination in health services and health coverage.
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When OCR finds violations, a covered entity will be required to take corrective actions, which may
include revising policies and procedures, and implementing training and monitoring programs.
Covered entities may also be required to pay compensatory damages.
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When a covered entity refuses to take corrective actions, OCR may undertake proceedings to
suspend or terminate Federal financial assistance from HHS. OCR may also refer the matter to the
U.S. Department of Justice for possible enforcement proceedings.
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Section 1557 also provides individuals the right to sue covered entities in court for discrimination
if the program or activity receives Federal financial assistance from HHS or is a State-based
Marketplace℠.
Enforcement
• Violations and failure to address compliance
issues can result in suspension or loss of
federal funding and may include payment of
compensatory damages.
• Individuals can bring individual or class
actions claims directly against covered
entities in federal court.
• Rumble v. Fairview Health Services
Resources
• Fenway Institute National LGBT Health
Education Center:
http://www.lgbthealtheducation.org/
• Lambda Legal
• OCR website (Section 1557 educational
tools) www.hhs.gov/ocr
Questions?
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