But in cases where patients don’t have an established relationship with a mental health provider, recommendations can take months or even years to obtain, said Nicolosi, who uses they/them pronouns. People who identify as transgender or gender-expansive may have trouble finding an affirming therapist, and even when they do, many clinicians have long waitlists, they added.
“If they’re not already enrolled in mental health care services with an affirming provider, that’s a whole other step they have to go through first,” Nicolosi said. “That’s just an extra hurdle for folks.”
Discrimination and bias
It’s even more critical for transgender and gender-expansive people to find providers that are trained in gender-affirming care, as many have experienced discrimination from the wider medical system.
Anthony Fortenberry, deputy executive director at Callen-Lorde, said that discrimination and fear of coming out to a provider are among the biggest challenges that gender-expansive people face.
When providers “deadname” patients—or use their government name instead of the name they chose for themselves—or seem uncomfortable, patients don’t feel accepted or safe. That can create health care access issues, Fortenberry said.
Dr. Jeffrey Birnbaum, a pediatrician who cares for transgender patients at SUNY Downstate Medical Center in East Flatbush, said that other infrastructural barriers, such as nuances in electronic medical records, can cause harm. Medical records may not have accurate fields for a patient’s chosen name, for example, which adds to confusion about how to refer to them.
Changes such as updating medical record systems are slowly becoming more prevalent, Birnbaum said. But there’s still a need to educate providers within the mainstream medical community on how to care for patients who are transgender and gender-expansive, he added.
“I think the bigger issue is that providers and facilities view it as something that’s really complicated,” Birnbaum said. “I think treating diabetes is a lot more complicated than transgender care.”
At SUNY Downstate, Birnbaum runs a clinic for transgender patients called Health & Education Alternatives for Teens. He said that making patients feel accepted within the health system is integral to the provision of care.
“Patients are motivated to be on treatment,” Birnbaum said. “They become very closely connected to care because, among other things, we validate them as human beings.”
New York state prohibits health insurers from denying transgender patients coverage for gender-affirming care. But before it was largely covered by insurance, patients in New York resorted to other measures to start transitioning, said Dr. Andrew Lee, director of transgender surgery at Montefiore, who specializes in facial feminization and masculinization.
This included going to nonlicensed providers and getting industrial-grade silicone injected into the face to aid in feminization or masculinization, he said. According to the Food and Drug Administration, silicone injections can lead to long-term pain, injections and serious injuries.
“Even now I see patients who maybe 10 years ago got silicone injected into their faces,” he said. “Many of my patients now deeply regret it, and it’s very difficult to correct once it’s in the face.”
He noted that even though coverage has improved, some patients have difficulty getting their procedures covered by commercial insurance and will often switch to Medicaid.