How gender affirming surgeries have been impacted by the pandemic

Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.

AMA Chief Experience Officer Todd Unger speaks with LGBTQ health experts on the impact COVID-19 has had on transgender individuals awaiting gender affirming surgeries. Learn more at the AMA COVID-19 resource center.

Speakers

• Jesse M. Ehrenfeld, MD, MPH, LGBTQ health expert and immediate past chair, AMA Board of Trustees
• Maya Green, MD, MPH, regional medical director, South, Howard Brown Health
• Loren S. Schechter, MD, director, Center for Gender Confirmation Surgery, Weiss

Unger: Hello, this is the American Medical Association's COVID-19 update. Today we're talking about the impact of COVID-19 on transgender individuals, awaiting gender affirming surgeries. I'm joined today by Dr. Jesse Ehrenfeld, immediate past chair of the AMA Board of Trustees and an LGBTQ health expert in Milwaukee. Dr. Loren Schechter clinical professor of Surgery at the University of Illinois at Chicago and director of the Center for Gender Confirmation Surgery at Weiss Memorial Hospital in Chicago. And Dr. Maya Green, regional medical director, South, at Howard Brown Health in Chicago, who is actually in a mobile COVID-19 testing unit immediately as we talk. So I'm Todd Unger, AMA's Chief Experience Officer in Chicago.

On March 18, CMS announced that all elective surgeries and non-essential procedures should be delayed due to the COVID-19 pandemic. Dr. Ehrenfeld, gender affirming surgeries are technically labeled as elective or nonessential and were put on hold. Is this label accurate?

Dr. Ehrenfeld: So, thanks Todd. The language describing this care is unfortunately misleading. We know that gender affirming medical and surgical care is an essential component of care for transgender persons. And access to this care has been consistently shown to improve the health and long-term well-being of transgender persons. When these procedures are labeled as elective or not essential, it is more reflection of the acuity of the issue being addressed and the resources that are needed to perform the procedures. As some gender affirming surgeries require ventilator support or blood products, some were postponed to ensure that resources were available to take care of people with severe COVID-19 infections.

Unger: Dr. Schechter?

Dr. Schechter: Well, thank you very much, and I appreciate the opportunity to be on the panel today and hope everyone is healthy and safe. And I agree with Dr. Ehrenfeld, people often conflate elective with cosmetic for example. Gender affirming surgeries are medically necessary procedures. They improve quality of life, function, well-being across multiple domains. So they are absolutely essential services. From the surgical perspective, because of the pandemic, we were forced to triage based on acuity. Really emergent or urgent procedures, meaning immediate threat to life or limb. Unfortunately, many procedures, many surgical procedures are elective, and that includes cancer operations. So we were forced for about three months to shut down. Luckily and fortunately over the past 10 days or so, we've been able to resume surgery, and it's going quite well.

Unger: Dr. Green, what are some of the potential consequences of delaying procedures like this?

Dr. Green: Oh, potential consequences are enormous, right? Everything from delayed manifestation of a person who one is, to the mental health impact, to the societal impact that our gender nonconforming and transgender population experience when walking in the street. It's basically, like, we're in the middle of pandemic, right? In the middle of pandemics, historically groups that have historically been overlooked and underserved always bear the brunt of it. This is just one of the examples, right? To be in this space where gender affirming or life affirming surgery is deemed nonessential is just one of the examples how marginalized populations are further marginalized unfortunately, during pandemics.

Dr. Ehrenfeld: Let me just jump in and say, I agree with Dr. Green, but people are feeling isolated now more than ever. I'm experiencing that. I'm sure you're all experiencing that. Our patients are experiencing that. My transgender patients who in many cases have been waiting years and years, getting ready for procedures to happen, suddenly everything's on hold. And unfortunately, we're starting to see some increased substance use and abuse as a result of some of these isolation challenges. That's a result of the behavioral health experience that I think a lot of us are under right now.

Dr. Schechter: Yeah. The intense preparation for surgery and then the cancellation has been quite disruptive to people's lives. As you can imagine, people who may prepare almost for a lifetime for surgery and then to have it taken away from them in quite an abrupt fashion has been very disruptive. We're trying to get back on track. We're not operating at 100% as of yet because of some limitations associated with COVID. But we are adjusting to the situation and ramping up.

Unger: Insurance coverage for these procedures was an issue long before the pandemic. Has this become further complicated by COVID-19, Dr. Schechter?

Dr. Schechter: So over the last, perhaps, five to 10 years, certainly since the passage of the Affordable Care Act, access to care has been expanded dramatically. Probably 85%, maybe 90% of the individuals for whom I care are now covered by insurance. And that's distinct. It was almost 90% were not covered 15-20 years ago. I would say though, that the insurance companies have made some accommodations by allowing, for example, some of our precertification or predetermination to be extended. So we haven't had to go through what can be quite a cumbersome process. Now having said that, there's a tremendous amount of flux and uncertainty in the health care environment. As time marches on and there are potential changes to laws or policies that may be adverse to coverage. That certainly has not been helped by delays associated with COVID.

Dr. Ehrenfeld: I'll just add that, coverage still isn't great. There are 30 states where transition related care, by law, can be excluded from coverage, which is crazy. People often travel long distances to get highly specialized care that's medically indicated. And I do worry about 17% of LGBTQ adults don't have any kind of health insurance compared to 12% of non-LGBTQ adults living in the country. So we still in spite of gains that we saw under the affordable care act have a higher uninsurance rates amongst LGBTQ people.

Dr. Green: Yes. And then if you think about another thing that people are experiencing is, for the population I work with, I work on the South and West sides of Chicago. And so a lot of my patients who identify as gender nonconforming or transgender were in service industries and work at companies where there were high layoffs. And so even in spaces where they were able to have that insurance, now that's not the case. And so there is, for my patients, a lot of nervousness about what's to come, what changes they can expect, whether or not insurance will be instituted at that same level. It's really, you spoke to what other ramifications has this decision been causing. It's really causing things on a whole public health level.

Dr. Schechter: Yeah. And just to add to that, the postoperative care is so important. Especially with many of the more complex procedures. So having a safe environment in which to recuperate is so important and that plays into, as Dr. Green has just indicated, housing, the ability of someone's support system, family, friends, loved ones to care for people. Some individuals for our more complex procedures, we send to skilled facilities for a week or two to recover prior to going home. That has been delayed because many of those facilities now are caring for COVID positive patients.

Unger: So how have you all been getting creative and addressing transgender individual needs during the pandemic while also following state guidelines? And now that states are loosening restrictions, are these surgeries moving forward?

Dr. Schechter: So early on we began with virtual consults, whether by phone and then expanded into web-based consults. We care for, almost two thirds of our patients travel from outside of Chicago. So, we're familiar with coordinating care from far away places, remote places, even international. But the ability to travel even for an office appointment has been dramatically reduced. So now, what we're trying to do is still move the process along, by obtaining the necessary assessments and so forth. And then scheduling confirmatory or final consults several days before the anticipated date of surgery. So it's a bit more work on our end to coordinate with primary care and so forth, get testing done remotely, so people don't have to travel twice to see us.

Dr. Ehrenfeld: One thing I would just jump in and say is that, like any medically indicated health care, people shouldn't put off in delay care because of a concern about COVID. It's important that people seek the health care that they need. And I do worry that people are delaying, putting things off, whether it's related to a transgender surgery or not. Probably the safest place to come now is to see a health care provider, whether that's in a clinic setting or a hospital where we understand what the precautions are that need to be taken. And so I would just make sure that we get the message out there that people shouldn't be putting out the care that they need.

Dr. Green: Yes. If I can just quickly dovetail off of that, and looking at the way we're communicating that, right. When we look at gender nonconforming and transgender population, that's a population that historically details like that weren't written for or communicated to. So we've got some work to do in that area. In addition to the things we're doing, Dr. Schechter mentioned telehealth. I know where I work, Howard Brown, we have mobile primary care, which will go to someone's house. We also have mobile integrative health, which is mobile psychiatry services. And we also have telehealth, integrative health, mental health support, where someone can have a telehealth visit or a call.

And then we have to remember, when we're talking to people, distributing things like pamphlets, important things like post-surgery, if you have to pack for a long term, don't forget things like dilators and things like that. How did you test binding? Those things that really supportive of our population pre- and post-surgery at this time, and then collaborating with organizations that are doing it more local, safe spaces for our population to come and talk about support when they can't, when they're having these barriers to care that are not allowing them to actualize who they are right now, yeah.

Dr. Ehrenfeld: There is guidance that's been issued about when it's appropriate to resume non-urgent services. All of the guidance from CMS, American College of Surgeons, CDC can be found on the AMA website and the COVID-19 center.

Unger: Well, thank you all very much for being here today. Dr. Green, you are a first time a person who's ever been speaking to us from a mobile unit. So thanks for taking the time to do it. Dr. Ehrenfeld, Dr. Schechter, thanks for your perspective today. We'll be back tomorrow with another COVID-19 update. And as Dr. Ehrenfeld mentioned, for COVID-19 resources, visit the AMA site at ama-assn.org/COVID-19. Thanks for joining us and take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.