Transgender Health Care in the Current Climate: A Q&A with Robbie Goldstein, MD, PhD

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On Friday, June 12, 2020, the U.S. Department of Human Health Services finalized a rule on Section 1557 of the Affordable Care Act, allowing providers to refuse care to patients who identify as gay, lesbian, bisexual, transgender, non-binary or queer, effectively removing nondiscrimination protections for patients in the LGBTQ community. Three days later, the U.S. Supreme Court issued a landmark ruling to expand employment discrimination protections for LGBTQ employees. The new policy and ruling also come amidst the COVID-19 pandemic and the Black Lives Matter protests continuing around the country.

In this Q&A, Robbie Goldstein, MD, PhD, medical director of the Massachusetts General Hospital Transgender Health Program, discusses what all of this means for the LGBTQ community in Massachusetts and beyond, and how providers can create affirming spaces for transgender and nonbinary patients.

Q: How does this new policy change affect transgender health care?

Goldstein: I want to be both optimistic and realistic. Massachusetts has amazing laws on the books that protect people based on gender identity and sexual orientation in health care. And we have some of the best health care regulations. So, people living in Massachusetts and who have Massachusetts-based insurance should not see any change in their coverage or care independent of what happens with the ruling.

But, the realistic part is that many people we see at Mass General have insurance that is provided through different states, either because their employer is from a different state or they themselves live in a different state, and they're coming to Mass General for their care. It is for those individuals that we are most concerned. Someone who maybe gets their insurance through their employer in Oklahoma may have a harder time obtaining coverage for the gender-affirming care that we might provide.

It becomes our responsibility to advocate and fight for those people who may not be able to get care. That's where both local and national advocacy are going to be important. There's an argument to be made that we should be enacting a two-prong strategy of building up the laws in each state to protect folks no matter where they live, and then also trying to bring down the federal regulations that are denying care.

Q: How was transgender health care already being impacted by COVID-19

Goldstein: COVID-19 has been really challenging, especially for transgender folks. It has played out in many ways. Trans folks are no longer able to go to support groups and get out of the house to places where they feel affirmed. Some are struggling to get the medications that they were taking because they need injections in a health care setting, which we can't do because of the new restrictions. Many people have been on the road to surgery and those surgeries have been delayed or halted, and nothing's been rescheduled yet. There have been many roadblocks for trans and binary folks during the process of COVID, which made the isolation harder.

And then during this past month, this national awakening to the racial injustice and the need to change our system hit trans folks incredibly hard. Trans women of color experience violence at a higher rate than any other group in our country. There is no other group that experiences gun violence, police brutality and all of the things that we're talking about in this national Black Lives Matter conversation. As the country has begun to talk about racial injustice, the trans community has come out to say: "We are here. We are part of this conversation, and we are not just black women. We are not just trans women. We are a group that has all of this intersectionality and it is important for us to be there and to be a part of the conversation."

Q: What sorts of measures is Mass General taking to ensure the transgender community is getting access to the support they need?

Goldstein: The Transgender Health Program has always tried to meet patients where they are and affirm them for who they are. We very quickly turned to virtual visits and figured out ways that we could get people in for injections. And we've done everything we can to help people maintain a connection to health care during COVID. I think that we've done a little bit better in sort of managing some of the roadblocks by just being very present for our patients and making sure that we can answer them, respond to their questions, figure out the next best path that they can do what they were doing before.

We have really tried to build into our program a racial justice mission. We've tried to make our space gender-affirming, racially affirming and ethnically affirming for everyone who wants to walk in the door. In the most recent experience over the past few weeks, we have been trying to talk with our patients and make sure that they know we're here to talk through whatever's going on.

We're also showing our support for them by being out in the community. That means partnering with groups like the Trans Club of New England and First Event, which is the largest organization and conference for the transgender community in New England. We work with groups like the AIDS Action Committee, the Boston Living Center - Victory Programs and BAGLY to make sure that we're supporting people in the way that we have to. We are a part of this community and we are an affirming space for them.

Q: What does creating an affirming space within the hospital look like?

Goldstein: You can think about it in the physical space and making sure that there are affirming signs, rainbow ribbons and trans flags, that your forms are gender neutral and that you are prepared to ask people their name and pronouns. You can think about it as how health care providers act in the exam room. And are they ready to have a question or a conversation around gender identity and sexual orientation? You could think about it as openness to prescribing gender-affirming hormones or knowing how to get someone gender hormones. At its core, it's about being open to having the conversation around gender identity and recognizing that gender identity is something that we have to talk about separate from sex.

Q: What makes Mass General a leader in transgender health?

Goldstein: We came to this work later than many other institutions did, but we came to this work with the full support of hospital administration, clinicians across the hospital and the community. We did this right by investing in this work, making sure we were building not just a safe clinical space, but a safe hospital. And because of that, we have woven into the fabric of the institution the idea that trans people deserve a safe space to receive care just like everybody else.

The Transgender Health Program exists administratively within the Department of Medicine, but it is very much a multidisciplinary practice. We meet regularly with the Departments of Surgery, including the Division of Plastic Surgery, Urology and OB/GYN to make sure that we are coordinating surgical care. We have collaborations with MassGeneral Hospital for Children and are now seeing children and adolescents. We work with the Department of Psychiatry and their gender identity program to make sure that people have the support they need and mental health care. We work very closely with Social Work and Nursing and Patient Care Services to make sure the other floors of the hospital and departments have the support that they need. So this is very much a hospital-wide initiative.

We have also worked hard to expand across Mass General Brigham. We work with clinicians at Brigham & Women's Hospital, Cooley Dickinson and the other institutions across the system and across New England. We've built a collaboration called the New England Gender C.A.R.E. Consortium in an effort to advocate for our patients and to build a community so we can all work together.

Q: What advice do you have to physicians in treating transgender patients, especially in places with different regulations than in Massachusetts?

Goldstein: I would say to those who agree with us at Mass General, that gender-affirming care is health care, please continue to provide that care, to make your space affirming, to welcome your patients and to give them the tools they need to succeed.

To those people who don't agree with us and feel that gender-affirming care is not a requirement of being a health care provider, I would say look at the evidence and look at the data. Gender-affirming care is lifesaving care. It is the best tool we have to prevent suicide, violence and trauma against the transgender community. And we as health care providers should be in the business of using evidence and data to make people live a healthy life.

Q: All of this has happened within the month of June, which is traditionally Pride month. How does that fit into this context?

Goldstein: Pride allows us the opportunity to stop for a second, in normal years, and acknowledge the work that we do every single day. Pride month is not the only time of the year when this hospital or the Transgender Health Program or any of us does the work of caring for LGBTQ patients. It is, however, the moment when we get to reflect on how we do that work all year. That's really important because we are committed to the trans community year-round. We are committed to the broader LGBTQ community year-round. And we're going to continue to work for folks outside of June. But in June we get to stop for a second and recognize the work that is being done, the community that is stronger because of that work and all the people here at Mass General who do the work every single day to make this place better for LGBTQ folks.

View all COVID-19 updates

Learn more about the Transgender Health Program at Mass General