According to The Kaiser Family Foundation, 26 states have passed bans on gender-affirming healthcare. This includes Utah, where S.B. 16 bans puberty blockers and gender-affirming hormones for minors.

The Human Rights Campaign defines gender-affirming care as “a range of services, including mental health care, medical care and social services … [that] helps transgender and non-binary people live openly and authentically as their true selves.”

It is a treatment for gender dysphoria, which “happens when one’s gender identity does not match their sex as assigned at birth.”

The American Medical Association, the American Academy of Pediatrics and Endocrine Society recognize gender-affirming care as medically necessary and provide guidelines for care. Many other medical associations have made statements in support of transgender healthcare.

The U’s Transgender Health Program 

University of Utah Health houses the Transgender Health Program, a comprehensive center for gender-affirming care that spans across multiple specialties. 

The program’s website provides information on services for adults as well as youth. For adults, services offered include primary care and hormone therapy, gender-affirming surgery, fertility services, voice therapy, hair reduction, mental health counseling and pelvic floor rehabilitation.  

The clinic for trans youth, the Adolescent Gender Management and Support Clinic, lists behavioral health, nutrition wellness, family planning and coordinated care as services currently available.

Ariel Malan is the outreach network and development specialist at the U’s Transgender Health Program.

Malan said the program is the only comprehensive, multidisciplinary gender health program in the Mountain West, meaning it serves not only people in Utah but also patients from surrounding states such as Idaho, Colorado and New Mexico. It is one of just a “handful” of other gender health programs in the country. 

“Our mission really is to provide comprehensive, compassionate, evidence-based care for gender diverse people,” Malan said. “We are very involved in research on the health of transgender people in our communities and we’re also involved with … educating healthcare providers and healthcare professionals and staff members on best practices.” 

The program is not contained in one physical clinic, but spread throughout clinics and hospitals in the community. Malan said to help patients navigate the wide range of services that are available, the program has a team of patient coordinators. 

Malan said gender-affirming care does not entail one set, “linear path” but can look differently to different people. 

“We’re trying to move away from this idea that transition is this, you start with hormone therapy, you end with surgery and there’s like this start and end date even,” Malan said. “Getting services that make you feel more aligned in your gender — that’s gender-affirming care, for anyone.” 

She said gender-affirming healthcare is not experimental, but rather evidence-based and well supported by research. 

“This care has existed for over 100 years and there is an extensive amount of research that has been conducted on both adolescent and adult populations receiving this care, and we continue to see the positive impacts that access to this care will provide to people’s quality of life,” Malan said. 

Malan said students who want to use trans health services can have a conversation with their health insurance to determine what services are covered. Most often, primary care is a good place to start. 

“Many trans folks are not connected or have a primary care provider because it is so difficult to find a gender-affirming provider … so sometimes just getting connected to a primary care provider and then going from there is a really great step,” Malan said. 

Malan said providers in the program follow WPATH Standards of Care, are typically pursuing continuing education credits on transgender health and have indicated to the program that they want to see trans patients as part of their practice.

Adult patients do not need a letter of support from a mental health provider in order to start hormone treatment. All surgical services require one to two letters of support.

The student health insurance plan at the U covers some of the services provided by the center. Janis Gibson, health coverage case manager at the Student Health Center, described possible costs in a written statement.

Gibson said hormone replacement therapy medications are covered the same as any other prescription medication, falling into three tiers depending on the medication: Tier 1 with a $15 copay, Tier 2 with a $40 copay and Tier 3 with an $80 copay.

She said most providers at the Student Health Center provide gender-affirming care, with a $15 copay for each visit.

Gender-affirming surgery is also covered the same as any other surgery. If done at U of U Health, insurance pays for 80% and the student pays for 20%, in addition to a $250 deductible.

Gender-Affirming Care: Student Experiences 

Quail Reed is a senior at the U majoring in history and Asian studies. She is trans and uses healthcare services at the U. 

At her first appointment, Reed received a formal gender dysphoria diagnosis and information on hormone replacement therapy. She had to wait one month before starting estrogen. 

“You have your initial appointment where they say, ‘Yeah, you can do this thing,’ but they won’t give you a prescription or anything,” Reed said. “They force you to wait a longer amount of time, which I’m sure comes out of this idea where … you’ve got to know it for sure.” 

Malan said at the first consultation, a provider would typically ask questions about the patient’s medical history and gender journey, as well as complete a physical exam and lab work. They would take some time to discuss the medication, including risks and benefits, and give the patient information to take home. It will then usually be the second appointment when the patient could actually start taking hormones. 

Reed said they have had a mostly positive experience with trans healthcare at the U. However, there was one incident in which her doctor forgot to prescribe a refill for her estrogen, which made her feel as though her medication was viewed as not “necessary.” 

“I think there’s kind of this sense, not overtly, almost implicitly, that it’s like, HRT isn’t a necessary thing,” Reed said. “I was off estrogen for a week, and I had the worst headaches of my life, and I was calling and pleading and trying to get a hold of my doctor … like, this is keeping me functioning, both mentally and physically.” 

Reed also described months-long gaps between appointments, and moments that indicate knowledge on trans health may not be prioritized in medical education. For example, part of her treatment is a testosterone blocker called spironolactone, which also has the effect of lowering blood pressure. Since Reed already has low blood pressure, the dosage couldn’t be raised too high. 

When Reed asked if there were any alternative hormone blockers, she said her doctor was not immediately aware of other options. 

Reed said it can also be confusing navigating the trans healthcare services available due to the nature of being spread out in different departments and requiring referrals. She considered doing voice training and received a referral, but was confused about where to go. She said it would be easier to navigate if there was one centralized point for trans healthcare. 

“Why are the speech therapy people that are doing this specifically, in a different area than the people who are doing gender-affirming surgeries?” Reed said. “I don’t expect one doctor to have all the answers, that’s not how that works, but the fact that it takes so long to get between all of the departments makes it harder to figure all of that out.” 

Lee Bateman is a freshman at the U majoring in geographic information science and gender studies. He is trans and has not yet used medical gender-affirming care, but recently began talking to his parents about the idea and checking what would be covered by their health insurance. 

Bateman said the idea of medically transitioning can feel “daunting,” particularly irreversible procedures like top surgery and some effects of testosterone. He said anxiety over the legislation on gender-affirming care is part of the reason he is looking into this process now.

“There’s a Republican majority and everything and one of the hot-button issues that Republicans seem to really be focusing on is trans healthcare … so in a couple of years, I don’t know what things I might or might not have access to,” Bateman said. “Part of me is like, ‘Oh if I get top surgery sooner rather than later, like, they can’t un-surgery me.’” 

Trans Disparities in Health 

Research indicates trans people face physical and mental health disparities compared to their cisgender peers. This includes high rates of depression, anxiety, eating disorders, self-harm and suicide.

Effectiveness of gender-affirming care has also been established by research. One 2022 study among trans youth demonstrated 60% lower odds of moderate or severe depression and 73% lower odds of suicidality after youth received puberty blockers and hormones.

According to the 2022 U.S. Transgender Survey, which surveyed 92,329 trans people in the US, 98% of respondents receiving hormone treatment reported being “a lot more satisfied” or “a little more satisfied” with their life.

More than one-third of respondents in the survey were experiencing poverty and almost one-third had experienced homelessness in their lifetime. Research suggests limitations to employment, education and housing due to discrimination contribute to negative health outcomes for trans people. 

Malan said many patients who use trans healthcare also need help finding non-medical resources to help with issues such as food and housing insecurity, so patient navigators try to stay aware of community resources that are available. They also provide referrals to mental health services. 

Education for Healthcare Providers 

Malan said one opportunity for medical students at the U is a fourth year medical school elective which allows students to get rotations with the transgender health program and visit the different clinic sites to see what different providers and specialties do for the trans patient population. 

For medical providers who are out of school, Malan said there are free Continuing Medical Education classes that can be found online. Another opportunity available for providers is the Mountain West Transforming Care Conference. The conference will be held from May 8-10 in Springdale, Utah and will provide education and networking opportunities for primary care and mental health providers focused on LGBTQ+ health. 

Malan said medical doctors who complete a residency in family medicine at the U will be provided education on gender-affirming hormone therapy and work with trans and gender-diverse patients. 

The trans health program can be contacted at transgenderhealth@hsc.utah.edu. 

a.khatri@dailyutahchronicle.com 

@a_khatri_news