A Blueprint for Planning and Implementing a Health Program

1 Anna M. Morenz, MD ABSTRACT 3 Hilary Goldhammer, SM Transgender and -diverse people face multiple barriers to accessing appro- Cei A. Lambert, MFA4 priate health care, including denial of service, harassment, and lack of clinician knowledge. This article presents a blueprint for planning and implementing a 4,5 Ruben Hopwood, MDiv, PhD transgender health program within a primary care practice in order to enhance the Alex S. Keuroghlian, MD, MPH2,3,6 capacity of the health care system to meet the medical and mental health needs of this underserved population. The steps described, with emphasis on elements 1Department of Medicine, University of specific to transgender care, include conducting a community needs assessment, Washington, Seattle, Washington gaining commitment from leadership and staff, choosing a service model and 2Harvard Medical School, Boston, treatment protocols, defining staff roles, and creating a welcoming environment. Massachusetts 3National LGBT Health Education Center Ann Fam Med 2020;18:73-79. https://doi.org/10.1370/afm.2473. at The Fenway Institute, Fenway Health, Boston, Massachusetts ransgender and gender-diverse people have a that 4 Transgender Health Program, Medical differs from the one traditionally associated with the they were Department, Fenway Health, Boston, assigned at birth. These identities may include trans feminine, Massachusetts T trans masculine, and non-binary identities. A high prevalence of suicide 5 The Danielsen Institute at Boston Univer- attempts, HIV infection, substance use disorders, and other health inequi- sity, Boston, Massachusetts ties affect the transgender and gender-diverse community,1-4 and numer- 6 Department of Psychiatry, Massachusetts ous barriers such as harassment and impact the commu- General Hospital, Boston, Massachusetts nity’s access to care.1,4-6 Many transgender and gender-diverse people seek medical interventions to affirm their gender identity,1 but few primary care programs provide gender-affirming hormone therapy, surgical referrals, or wrap-around services to an increasingly visible transgender and gender- diverse population. As educators and clinical experts on , we field numerous requests from primary care organizations to help with planning and implementing transgender health programs. In this article, we respond to those requests by presenting a “blueprint” that can be adapted by primary care practices of different sizes and settings. Our flexible recommendations are based on expertise gained from operat- ing (1) a transgender health program integrated within an urban health center that has served over 6,000 transgender and gender-diverse primary care patients,7 and (2) a national center funded and authorized by the US government to provide technical assistance on the implementation of over 150 transgender health programs in communities across the nation.8

NEEDS ASSESSMENTS For organizations with the resources to conduct a formal needs assess- ment, we offer several recommendations below. Practices without such Conflicts of interest: authors report none. capacity may forgo the needs assessment and instead begin providing gender-affirming medical treatments for transgender and gender-diverse patients after accessing relevant training and guidelines, and by building a CORRESPONDING AUTHOR referral network for surgeries and other external services. Alex S. Keuroghlian, MD, MPH The Fenway Institute 1340 Boylston Street Community Needs Boston, MA, 02215 A needs assessment with the surrounding transgender and gender-diverse [email protected] community helps tailor services to the local setting while ensuring inclu-

ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 18, NO. 1 ✦ JANUARY/FEBRUARY 2020 ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 18, NO. 1 ✦ JANUARY/FEBRUARY 2020 PB 73 TRANSGENDER HEALTH PROGRAM sion of gender-diverse voices. In areas with defined and gender-diverse community; if this is not possible, the engaged transgender and gender-diverse populations, team can attempt to assemble and meet regularly with using traditional assessment methods, such as focus a community advisor or group. groups, community leader interviews, and/or town forums may suffice. Offering light meals for participants shows consideration for those who may be experiencing ORGANIZATIONAL BUY-IN homelessness or unemployment. To assess patient per- Starting a new program, especially one focused on a ceptions of your organization’s current competence in stigmatized population, can generate staff concerns serving transgender and gender-diverse patients, prac- and resistance. To gain buy-in from leadership and col- tices can place comment boxes in waiting rooms and ask leagues, champions can generate enthusiasm for the about gender identity on patient satisfaction surveys. program through staff presentations that emphasize The state health department may also have information how offering transgender health care can position the on transgender health disparities and needs. In less open organization at the vanguard of reducing disparities, communities, hosting online focus groups and/or anony- and how gender-affirming care aligns with the princi- mous surveys through social media sites may yield more ples of medical ethics, such as beneficence and justice. robust findings. The Supplemental Appendix provides Other strategies include holding question-and-answer examples of published community needs assessments sessions with staff and inviting a panel of transgender and of sample assessment questions (Supplemental and gender-diverse people to share their personal Appendix, available at http://www.AnnFamMed.org/ experiences seeking health care (alternatively, showing content/18/1/73/suppl/DC1/). films with transgender themes and holding a discussion afterwards). Champions can enhance motivation among Organizational Capacity and Needs colleagues by conducting follow-up presentations that It is also important to assess existing capacity and demonstrate ways in which the ideas and interests of needs within your organization and in the surround- staff members are being integrated into the program. ing area. Taking informal polls at staff meetings and Cost concerns can be alleviated by explaining regional conferences, on message boards, or in discus- that several US medical professional societies support sions with human resource executives and diversity and insurance coverage for transgender health care,10 and inclusion committees can help uncover who is already that a large percentage of transgender and gender- providing medical or mental health care for transgen- diverse patients require multiple visits per year (eg, for der and gender-diverse patients, who has training or hormone therapy and surgical referrals) and often have experience, and who has a strong interest in learning. strong networks who can bring in additional patients, An internal organizational needs assessment9 and ongo- even from outside the usual catchment area. Given the ing discussions with leadership can help assess other volume of need and the lack of care options elsewhere, areas of need and opportunity within the organization. it is likely these services could be revenue-neutral if For example, does the electronic health record software not revenue-generating. accommodate collecting information on gender iden- tity? How do staff currently self-report their comfort and knowledge in transgender health care? Are there SERVICE MODELS ways to incorporate staff training on sensitive and Depending on the setting, needs, and resources of effective communication with transgender and gender- each organization and community, a transgender diverse people into regular diversity training? Are there health program can be as streamlined as 1 or 2 clini- clinic hours that can be used for transgender health? cians providing hormone therapy within a welcoming primary care practice, or as comprehensive as a “one- stop shop” within an academic hospital offering the full PLANNING AND IMPLEMENTATION TEAM range of gender-affirming services, including primary Interested personnel can form a planning and imple- care, endocrinology, gynecology, mental health, voice mentation team with a minimum of 2 “champions” who therapy, and surgical care. Many programs start with a meet regularly and lead the change effort. Typically, small core team of primary care clinicians who initiate at least 1 champion is a primary care clinician. It is and monitor hormone therapy, supported by an admin- helpful for the other champion to have a nonclinical istrative staff person who is well-versed in gender- position, and for at least 1 of the champions to have a inclusive language and insurance navigation, and who decision-making role in the organization to help facili- can help clinicians coordinate referral services as tate support from leadership. Ideally, the team consists needed. Programs may also initially tailor services for of people who represent the local transgender and a subset of the local transgender and gender-diverse

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Figure 1. Suggested components of a comprehensive transgender health program.

Inclusive environment and trauma-informed care Community advisory board and ongoing needs assessment Continuous quality improvement and research on evidence-based practices

Gender-af rming primary care Case management Hormone therapy Housing referrals and advocacy Surgical care coordination Administrative support Legal services or referral Integrated behavioral health care or referral Insurance navigation Food security services or referral HIV/STI screening and treatment Program coordination Partnerships and networks with community organizations Fertility preservation and assisted reproduc- tive services or referral

STI = sexually transmitted infection.

community (eg, transgender and gender-diverse ostracizing or unequal in quality. For embedded pro- women of color) shown to have the greatest need grams, it is important that all clinicians demonstrate during the assessment phase. Some teams eventually adequate understanding and respect for gender diver- expand to other clinicians and build more comprehen- sity in cases of urgent care situations when a transgen- sive, integrated programs that provide an ideal model der or gender-diverse patient’s primary care clinician is of care. This model includes in-house services most not available.11,12 relevant to the local transgender and gender-diverse All transgender health programs can benefit from community, possibly aligning primary medical care developing broad relationships with external agencies, with mental health counseling, substance use disorder community-based organizations, and individual practi- treatment, HIV and sexually transmitted infection tioners who provide a range of services and can func- (STI) prevention and treatment, obstetrics and gyne- tion as a network for knowledge-sharing and referrals. cology, case management for accessing basic needs These connections can include , , bisexual, like food and housing, legal and advocacy services transgender, , , and asexual (LGBTQIA+) for insurance coverage and name and gender change community centers, AIDS service organizations, sub- on identity documents, and/or options or referrals for stance use disorder treatment centers, departments of fertility preservation and assisted reproduction (Figure public health, mental health practitioners, endocrinolo- 1). Because transgender health is understudied, some gists, and surgeons. When building referral systems, programs have formed research arms to contribute to it can be helpful to develop a memorandum of under- the development of evidence-based practices.7 Before standing that defines the terms and responsibilities of expanding, program teams can use continuous quality each organization in order to meet expectations and improvement methods to evaluate and adjust their sys- maintain accountability. In addition, ongoing com- tems and clinical practices accordingly. munication via in-person feedback, web acknowledg- Typically, transgender health programs are either ments, and handwritten thank-you notes about how (1) embedded within existing primary care settings so these services improve outcomes can go a long way that transgender and gender-diverse patients see spe- toward nurturing relationships with partner organiza- cific clinicians during regular office hours in the same tions. See Table 1 for examples of transgender health space as all other patients; (2) fully integrated so that program models. all clinicians are prepared to care for transgender and gender-diverse patients, or (3) offered as a separate, dedicated program that has a different location or TREATMENT PROTOCOLS AND CLINICAL designated practice times (eg, after hours). A separate TRAINING program might be chosen if transgender and gender- After years of referring transgender and gender-diverse diverse patient safety or confidentiality is a concern, or patients to specialty clinics and endocrinologists, if logistical or cultural barriers currently prevent incor- transgender health experts have come to agree that poration within the mainstream clinical practice. If the gender-affirming hormone therapy can be safely deliv- program is separate, it is vital that it does not become ered as part of routine care by a trained primary care

ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 18, NO. 1 ✦ JANUARY/FEBRUARY 2020 ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 18, NO. 1 ✦ JANUARY/FEBRUARY 2020 74 75 TRANSGENDER HEALTH PROGRAM clinician.14,15 Furthermore, most adult patients do not treatment and if any existing mental health conditions require mental health counseling in order to receive are reasonably well-controlled.16 Patients need only hormone therapy; rather, the primary care clinician be referred to a mental health specialist to address can determine if the patient has the capacity to make untreated psychiatric or substance use disorders.14 This an informed medical decision about gender-affirming approach, which is part of an -based model, avoids unnecessary and prolonged barriers to potentially Table 1. Examples of Transgender Health Program Models life-saving treatment. Although no single stan- Reisner SL, Bradford J, Hopwood R, et al. Comprehensive transgender healthcare: ​the gender dard of treatment exists, several affirming clinical and public health model of Fenway Health. J Urban Health. 2015;​92(3):​ 584-592.7 evidence-based protocols offer Fenway Health was one of the first primary care organizations to integrate transgender health, recommendations for hormone and was a pioneer in developing the informed consent model for gender-affirming medical therapies as well as general pre- care. This article tells the history of the program and its growth over a 20-year period. Also discussed are details on transgender patient demographics and Fenway’s research, education, ventive and mental health care and training program. (Table 2). Primary care clinicians Reisner SL, Radix A, Deutsch MB. Integrated and gender-affirming transgender clinical care and can learn to safely and effec- 12 research. J Acquir Immune Defic Syndr. 2016;72(Suppl​ 3):S235-S242.​ tively provide hormone therapy, In this article, the authors present a gender-affirmative integrated clinical care and participa- tory community research model designed to address HIV prevention and care disparities for preventive care, and surgical transgender people. An appendix briefly describes 3 exemplary models of gender-affirmative follow-up through basic training clinical care located in Boston, MA, New York, NY, and San Francisco, CA. and practice. Despite common . How to Start a Transgender Clinic. Oakland, CA: Transgender Law Center; concerns that transgender health 2008. https://transgenderlawcenter.org/resources/health/how-to-start-a-transgender-clinic.13 This free online booklet offers research-based advice for planning, developing, evaluating, and care is complicated, it is in fact sustaining a transgender health clinic. Appendices and case examples from several transgen- as straightforward as managing der health programs across the United States provide additional insight and practical tools for implementing programs. common chronic diseases. The general approach to gender- CA = California; MA = Massachusetts; NY = New York. affirming hormone therapy first requires counseling patients on the benefits and potential risks of Table 2. Clinical Guidelines and Training Resources treatment, including options for Publisher Title and URL fertility preservation. Typically, the next step involves delivering The Center of Excellence Guidelines for the Primary and Gender-Affirming Care of Transgen- for Transgender Health, der and Gender Nonbinary People. https://transcare.ucsf.edu/ estradiol for feminizing treat- University of California guidelines ment, or testosterone for mascu- San Francisco World Professional Asso- Standards of Care (SOC) for the Health of , Transgen- linizing treatment. Therapy may ciation for Transgender der, and Gender Nonconforming People, V.7. https://wpath.org/ also consist of an additional med- Health (WPATH) publications/soc. ication to suppress endogenous Deutsch MB, Feldman JL. Updated recommendations from the world professional association for transgender health standards hormones, particularly in the case of care. Am Fam Physician. 2013;87:89-93. of feminization. Once therapy Training in WPATH Standards of Care. https://wpath.org/about-gei. has begun, clinicians track prog- The Fenway Institute, Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health, 2nd Fenway Health Edition. Philadelphia, PA: American College of Physicians; 2015. ress toward desired effects and https://acponline.org/acp-newsroom/american-college-of- monitor for potential side effects. physicians-publishes-second-edition-of-the-fenway-guide-to-- health Although only a handful of National LGBT Health Education Center’s continuing education clinical training programs offer programs and publications, including Transgender Health Project transgender health care within ECHO. http://lgbthealtheducation.org their existing standardized cur- Endocrine Society Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. https:// ricula, several continuing edu- endocrine.org/topics/transgender-medicine cation programs are available American Academy of Recommended Curriculum Guidelines for Family Medicine Resi- Family Physicians dents: Lesbian, Gay, Bisexual, Transgender Health (Table 2). Sometimes a core team https://www.aafp.org/dam/AAFP/documents/medical_education_ (eg, a physician, nurse, and men- residency/program_directors/Reprint289D_LGBT.pdf. tal health clinician) initially trains Transgender Law Center Publications and TransLine (medical consultation service) and Project Health http://transgenderlawcenter.org/resources/health together and then meets regularly Campaign Health Equality Index’s online training and resources. to discuss cases. A program can http://hrc.org/hei/staff-training-overview also begin with a single clini- The Safe Zone Project Safe Zone Training Curriculum. https://thesafezoneproject.com cian who gradually trains others

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within the organization through shadowing opportuni- ies, and cases in which a patient’s anatomy necessitates ties, consultation, and didactic learning. different screening than what may be assumed based on the gender marker in their identifying documents or health records.19 Clinicians often need to appeal for STAFF TRAINING AND COMPETENCIES insurance coverage with a rationale for care. For larger It is very important for all patient-facing staff (clinical programs, it may be necessary to hire a program coor- and nonclinical) to receive a foundational level of train- dinator or to train care navigators to help advocate for ing in and effective communication treatment coverage. with transgender and gender-diverse patients.8 Key competencies include using patients’ correct names and pronouns, maintaining confidentiality of gender ELECTRONIC HEALTH RECORDS identities, avoiding assumptions about gender, being Collecting and recording patient data on gender iden- open to nonbinary gender identities, and avoiding tity (and ) in the electronic health questions not pertinent to care.12,17,18 In order for the record (EHR) has been recommended as critical for program to be truly inclusive, the workplace culture providing patient-centered care and reducing health must ensure that chatter behind closed doors does not disparities.20,18 Although all EHR systems certified for differ from patient-facing language. Suggested roles Meaningful Use are now required to have the capacity and corresponding competencies for staff members to record gender identity, many systems still require are presented in Table 3. The roles of a program’s staff adjustments. Ideally, the EHR will also allow for a will vary depending on the patient population size and the breadth of services offered. For most pro- Table 3. Suggested Staff Roles and Competencies for a Primary Care grams, many of the roles can be Transgender Health Program combined or provided through referrals, and existing staff can be Staff Member Suggested Roles and Competencies trained in the competencies. Primary care/family • Provides hormone therapy according to standards of care If hiring new staff, programs medicine clinician • Provides routine primary care based on anatomy and behavior, (eg, physician, nurse not identity should aim to hire transgender practitioner, physician assistant) • Coordinates surgical care; provides perioperative and post- and gender-diverse employees, operative care some of whom may identify them- • Does not assume all patients want masculinizing or feminizing selves during the needs-assessment treatment process. Career marketing mate- • Supports patients with nonbinary gender identities • Is open to alternative strategies for anatomy-based procedures, rials ought to state that person- such as a self-administered cervical swab for human papilloma- nel of all gender identities and virus testing expressions are sought; employee • Participates in shared decision making with patients • Is nonjudgmental when addressing substance use, silicone injec- policies should explicitly protect tion, sex work, and other stigmatized behaviors against discrimination based on Behavioral health clini- • Helps patients navigate social, personal, and familial aspects gender identity or expression. At cian (eg, licensed of gender identity and expression, but does not act as a - social worker, licensed keeper to medical gender affirmation the same time, programs ought to mental health coun- • Writes letters of support for surgeries and other gender-affirming take caution against unconsciously selor, psychologist) procedures when required by insurance providers or surgeons tokenizing or transgen- • Offers counseling and support groups for transgender and der and gender-diverse staff, or gender-diverse communities expecting these staff to educate • Provides counseling and treatment for substance use disorders Case manager/nurse • Develops and maintains relationships with gender-affirming local their colleagues or become public agencies; navigates referrals spokespersons unless they wish to Front desk/patient ser- • Talks to patients with no assumptions about gender identity serve in this role. vice representative • Communicates sensitively with patients about dissimilarities between name and gender on insurance documents, legal iden- tification, and medical records Medical assistant/nurse • Ensures that gender and name information is communicated COVERING FINANCIAL seamlessly from front desk to clinicians COSTS OF CARE Program director/coor- • Oversees program operations, schedules and leads team meet- dinator (for programs ings, manages the budget, supports patients with insurance Common barriers to coverage of with large transgender issues and name changes, ensures all staff are trained, helps with and gender-diverse surgical authorizations and other paperwork, and helps with financial costs are insurance poli- patient populations) recruitment of staff and patients cies that exclude gender-affirming hormone therapy and/or surger- Note: Roles can be combined or provided through referrals.

ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 18, NO. 1 ✦ JANUARY/FEBRUARY 2020 ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 18, NO. 1 ✦ JANUARY/FEBRUARY 2020 76 77 TRANSGENDER HEALTH PROGRAM patient’s name (which may differ from the name on CONCLUSION insurance or identification documents) and correct pro- Creating a transgender health program provides a nouns to be collected at patient registration, recorded much-needed service for an underserved popula- and displayed in the EHR for all staff to see before tion that experiences significant health inequities. A interacting with the patient, and will also include ana- program that offers community-tailored medical and tomic inventories, as well as procedures and medica- mental health services, case management, legal advo- tions specific to gender affirmation.21-23 cacy, and more, will provide a unique opportunity to holistically improve wellness and quality of life for transgender and gender-diverse people. As more pro- INCLUSIVE, TRAUMA-INFORMED grams develop globally, staff can join the growing and ENVIRONMENTS passionate network of clinical practice teams who are To create more welcoming care environments, committed to health care, innovation, and equity for organizations can offer clearly labeled all-gender transgender and gender-diverse communities. restrooms and prominently post nondiscrimination To read or post commentaries in response to this article, see it policies that include gender identity and expression. online at http://www.AnnFamMed.org/content/18/1/73. Intake forms may need modifications to include the full range of gender identities and sexual orienta- Key words: transgender health program; transgender service model; tions, chosen names, pronouns, and names on insur- gender-affirming care; hormone therapy protocol; gender identity; health care access; primary care; ; clinical practice 12,23 ance and legal documents. Because transgender guidelines; transgender; gender-diverse communities and gender-diverse people experience high levels of trauma and stress related to minority status, it is also Submitted October 22, 2018; submitted, revised, May 3, 2019; accepted recommended to adopt a trauma-informed approach. May 21, 2019.

Trauma-informed care for transgender and gender- Supplemental materials: Available at http://www.AnnFamMed. diverse people means recognizing that patients may org/content/18/1/73/suppl/DC1/. need interventions to address their trauma, and may need additional choices and autonomy to engage in References particular kinds of medical care,24-26 such as a self- administered cervical swab for human papillomavirus 1. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi 27 M. The Report of the 2015 U.S. Transgender Survey. Washington, testing among trans masculine people. Transgender DC:​ National Center for Transgender Equality; ​2016. https:​// and gender-diverse patients may also react with strong transequality.org/sites/default/files/docs/usts/USTS-Full-Report- emotions if something occurs during a primary care Dec17.pdf. Published Dec 2016. Accessed Jul 11, 2018. encounter that reminds them of a past traumatic expe- 2. Baral SD, Poteat T, Strömdahl S, Wirtz AL, Guadamuz TE, Beyrer rience or leaves them feeling threatened.28 C. Worldwide burden of HIV in transgender women: ​a systematic review and meta-analysis. Lancet Infect Dis. 2013;​13(3):​214-222. 3. Keuroghlian AS, Reisner SL, White JM, Weiss RD. Substance use and treatment of substance use disorders in a community sample of PROGRAM COSTS AND FUNDING transgender adults. Drug Alcohol Depend. 2015;​152:​139-146. Most programs need minimal start-up funding. Free 4. The Institute of Medicine. The Health of Lesbian, Gay, Bisexual, and or low-cost trainings and resources can be accessed Transgender (LGBT) People: ​Building a Foundation for Better Under- through online learning platforms, local university standing. Washington, DC: ​National Academies Press; ​2011. LGBTQIA+ programs, or public health departments 5. Bradford J, Reisner SL, Honnold JA, Xavier J. Experiences of transgender-related discrimination and implications for health: ​ (Table 2). Clinicians can also include transgender results from the Virginia Transgender Health Initiative Study. Am health training within their continuing medical J Public Health. 2013;103(10):​ 1820-1829.​ education budget. Program champions can deliver 6. Safer JD, Coleman E, Feldman J, et al. Barriers to healthcare for promotional and informational messages via existing transgender individuals. Curr Opin Endocrinol Diabetes Obes. 2016;​ 23(2):​168-171. channels, such as the organization’s website, newslet- 7. Reisner SL, Bradford J, Hopwood R, et al. Comprehensive trans- ters, and social media platforms; champions can also gender healthcare: ​the gender affirming clinical and public health set up interviews with local journalists and can give model of Fenway Health. J Urban Health. 2015;​92(3):​584-592. presentations to the community at local LGBTQIA+ 8. Ard KL, Keuroghlian AS. Training in sexual and gender minority gathering places. Some costs may be incurred if health - expanding education to reach all clinicians. N Engl J Med. electronic health records require extensive modifica- 2018;​379(25):​2388-2391. tions, or if new restroom signage is needed. Common 9. Goldhammer H, Maston ED, Kissock LA, Davis JA, Keuroghlian AS. National findings from an LGBT healthcare organizational needs funding sources include public health departments, assessment. LGBT Health. 2018;5(8):​ 461-468.​ foundations/private donations, and large nonprofit 10. Stroumsa D. The state of transgender health care: ​policy, law, and organizations. medical frameworks. Am J Public Health. 2014;104(3):​ e31-e38.​

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11. Hinrichs A, Link C, Seaquist L, Ehlinger P, Aldrin S, Pratt R. Trans- 21. Deutsch MB, Buchholz D. Electronic health records and transgender gender and gender nonconforming patient experiences at a family patients—practical recommendations for the collection of gender medicine clinic. Acad Med. 2018;​93(1):​76-81. identity data. J Gen Intern Med. 2015;30(6):​ 843-847.​ 12. Reisner SL, Radix A, Deutsch MB. Integrated and gender-affirming 22. The National LGBT Health Education Center. Ready, Set, Go! Guide- transgender clinical care and research. J Acquir Immune Defic Syndr. lines and Tips For Collecting Patient Data on Sexual Orientation and 2016;72(Suppl​ 3):S235-S242.​ Gender Identity. Boston, MA: ​The Fenway Institute, Fenway Health; ​ 2018. www.lgbthealtheducation.org/publication/ready-set-go- 13. Transgender Law Center. How to Start a Transgender Clinic. Oakland, guidelines-tips-collecting-patient-data-sexual-orientation-gender- CA: ​Transgender Law Center; ​2008. https:​//transgenderlawcenter. identity. Published Jan 2018. Accessed Sep14, 2018. org/resources/health/how-to-start-a-transgender-clinic. 23. Grasso C, McDowell MJ, Goldhammer H, Keuroghlian AS. Planning 14. Coleman E, Bockting W, Botzer M, et al. Standards of care for the and implementing sexual orientation and gender identity data col- health of transsexual, transgender, and gender-nonconforming lection in electronic health records. J Am Med Inform Assoc. 2019;​ people, version 7. Int J Transgenderism. 2012;​13(4):​165-232. 26(1):​66-70. 15. White Hughto JM, Reisner SL. A systematic review of the effects of 24. Machtinger EL, Cuca YP, Khanna N, Rose CD, Kimberg LS. From hormone therapy on psychological functioning and quality of life in treatment to healing: ​the promise of trauma-informed primary care. transgender individuals. Transgend Health. 2016;1(1):​ 21-31.​ Womens Health Issues. 2015;25(3):​ 193-197.​ 16. Smith WB, Goldhammer H, Keuroghlian AS. Affirming gender 25. Brezing C, Ferrara M, Freudenreich O. The syndemic illness of HIV identity of patients with serious mental illness. Psychiatr Serv. 2019;​ and trauma: ​implications for a trauma-informed model of care. Psy- 70(1):​65-67. chosomatics. 2015;56(2):​ 107-118.​ 17. Goldhammer H, Malina S, Keuroghlian AS. Communicating with 26. Substance Abuse and Mental Health Services Administration. patients who have nonbinary gender identities. Ann Fam Med. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed 2018;16(6):559-562. Approach. Rockville, MD: ​Substance Abuse and Mental Health Ser- 18. Deutsch MB, Green J, Keatley J, Mayer G, Hastings J, Hall AM; ​ vices Administration;​ 2014. World Professional Association for Transgender Health EMR Work- 27. Reisner SL, Deutsch MB, Peitzmeier SM, et al. Comparing self- and ing Group. Electronic medical records and the transgender patient: ​ provider-collected swabbing for HPV DNA testing in female-to-male recommendations from the World Professional Association for transgender adult patients: ​a mixed-methods biobehavioral study Transgender Health EMR Working Group. J Am Med Inform Assoc. protocol. BMC Infect Dis. 2017;​17(1):​444. 2013;20(4):​ 700-703.​ 28. Reisner SL, White Hughto JM, Gamarel KE, Keuroghlian AS, Mizock 19. Learmonth C, Viloria R, Lambert C, Goldhammer H, Keuroghlian L, Pachankis JE. Discriminatory experiences associated with post- AS. Barriers to insurance coverage for transgender patients. Am traumatic stress disorder symptoms among transgender adults. J Obstet Gynecol. 2018;​219(3):​272.e1-272.e4. J Couns Psychol. 2016;​63(5):​509-519. 20. The Joint Commission. Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: ​A Field Guide. Oak Brook, IL:​ The Joint Commission; ​2011.

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