Novel studies published in the Men’s Health Issue of American Association for Clinical Chemistry‘s journal Clinical Chemistry suggest that hormone therapy for transgender people increases the risk of blood clots less than birth control pills and does not increase the risk of cardiovascular disease at all. These preliminary results could help more transgender individuals to access essential hormone therapy by increasing physician comfort with prescribing it.
Obstacles to Therapy
All major medical associations agree that transgender individuals need to be able to express their gender in ways with which they feel comfortable and that this is the most effective treatment for psychological distress caused by incongruence between sex assigned at birth and gender. For many transgender individuals, expressing their gender involves physically changing their body through medical steps such as taking hormone therapy. However, transgender patients often experience difficulty getting hormone therapy prescriptions, to the point that 1 in 4 transgender women have to resort to illegally obtaining cross-sex hormones. Part of this is because existing research on transgender hormone therapy is limited and conflicting, which has led to some physicians denying patients this treatment out of concern that it could significantly increase the risk of health problems such as blood clots and cardiovascular disease.
A team of researchers led by Dina N. Greene, PhD, of the University of Washington in Seattle has now estimated that in transgender women prescribed estrogen, blood clots only occur at a rate of 2.3 per 1,000 person-years. While this is higher than the estimated incidence rate of blood clots in the general population (1.0-1.8 per 1,000 person-years), it is less than the estimated rate in premenopausal women taking oral contraceptives (3.5 per 1,000 person-years), which means that it is an acceptable level of risk. In order to determine this, Greene’s team performed a systematic review of all studies that have included the incidence rate of blood clots in transgender women receiving estrogen therapy, identifying 12 that were most relevant. The researchers then used meta-analysis to combine the results of these 12 studies and calculate a risk estimate that is based on all available evidence to date.
“Documenting the risks associated with hormone treatment may allow for prescribers to feel more comfortable with prescribing practices, allowing for better overall management of transgender people,” said Greene. “Our data support the risk of thrombotic events in transgender women taking estrogen therapy being roughly comparable to the risk of thrombotic risks associated with oral contraceptives in premenopausal women. Given the widespread use of oral contraception, this level of risk appears to be broadly accepted.”
In a second study, a team of researchers led by Guy G.R. T’Sjoen, MD, PhD, also conducted a systematic review of all studies that have measured risk factors for cardiovascular disease in transgender people taking hormone therapy. The researchers identified 77 relevant studies in this area and found that the majority of them report no increase in cardiovascular disease in either transgender men or women after 10 years of hormone therapy. The studies that did indicate a higher cardiovascular disease risk for transgender women in particular mainly involved patients using ethinyl estradiol, a now obsolete estrogen agent, and are therefore no longer valid.
T’Sjoen’s team does state that their results are not conclusive due to the small sample sizes and relatively short duration of the studies in this area (and Greene’s team included a similar caveat for their work). However, it is important to look at Greene and T’Sjoen’s studies in the context of transgender research as a whole. The field only began to receive National Institutes of Health funding in 2017 and is also lagging due to the fact that transgender patients often aren’t identified in medical databases that provide data for research. In light of this, these studies are significant not only because they suggest that transgender hormone therapy is safe, but also because they underscore the need for longer-term, large scale studies involving this underserved population.
Source: Press release
HRC Releases 12th Annual Healthcare Equality Index
The HRC Foundation released its 12th annual Healthcare Equality Index (HEI), which scores health care facilities on policies and practices dedicated to the equitable treatment and inclusion of their LGBTQ patients, visitors and employees.
The HRC Foundation released its 12th annual Healthcare Equality Index (HEI), which scores health care facilities on policies and practices dedicated to the equitable treatment and inclusion of their LGBTQ patients, visitors and employees.
A record 680 health care facilities actively participated in this year’s survey, and, even as Trump-Pence continue their assault on LGBTQ-inclusive health care, 406 of them received HRC’s coveted “Leader in LGBTQ Health Care Equality” designation after earning a top score of 100. In addition, the HRC Foundation proactively researched key policies at 1,000 non-participating hospitals across the nation.
The 12th edition of the HEI assesses participants on four criteria: Non-Discrimination and Staff Training, Patient Services and Support, Employee Benefits and Policies, and Patient and Community Engagement.
In Texas, only six facilities received the “Leader in LGBTQ Health Care Equality” designation. This compared to the top three states — California with 81 facilities, New York with 74 facilities and neighboring New Jersey with 25 facilities. North Carolina stood out in the South region with 24 facilities earning the top scores.
In Austin, the People’s Community Clinic was the only facility to earned the top score of 100. “At People’s Community Clinic, we not only believe that everyone should be treated with dignity and respect, we make a real effort to ensure that our patients—especially those who identify as LGBTQ—feel welcome,” says the clinic in a Facebook post. This was People’s Community Clinic’s first year on HRC’s HEI.
The only other Austin facility to be rated this year was the Austin/Travis County Health and Human Services Department’s RBJ Health Center. This year, as it did the previous two years, it scored an 80 on the index. The last time the center qualified for the “Leader in LGBTQ Health Care Equality” designation was in 2016.
Metropolitan Methodist Hospital in San Antonio earned the top score for its fourth year in a row. “Our mission statement is serving humanity to honor God by providing exceptional and cost effective health care accessible to all. To the staff at Metropolitan Methodist Hospital this means providing the very best for every patient regardless of their background and we’re very proud of the HEI leader designation which shows our sensitivity, knowledge and commitment to the needs of LGBT patients and community,” said Greg Seiler, CEO at Metropolitan Methodist Hospital.
The remaining four facilities in Texas were all part of the U.S. Department of Veterans Affairs. The VA El Paso Health Care System in El Paso, the VA Michael E. DeBakey Medical Center in Houston, the VA South Texas Health Care System in San Antonio and the VA Central Texas Veterans Health Care System in Temple all earned the “Leader in LGBTQ Health Care Equality” designation with scores of 100.
The most improvement came from the VA El Paso Health Care System which went from a score of 35 in the 2017 to a score of 85 in the 2018 index, to a perfect score of 100 this year. The VA Central Texas Veterans Health Care System in Temple went from a score of 65 in 2017 to an 85 in 2018 and a 100 this year. This is Houston’s VA Michael E. DeBakey Medical Center’s second year earning a score of 100 and the VA South Texas Health Care System in San Antonio’s third year.
The release of the 2019 HEI comes as the comment period closes on a regulation proposed by the Department of Health and Human Services (HHS) that would strip away explicit health care protections on the basis of gender identity, effectively targeting transgender and gender non-conforming people’s access to critical care. Under the Obama administration, these landmark protections were added under Section 1557 of the Affordable Care Act, the first time sex was covered as a protected characteristic in health care.
“As the Trump-Pence administration continues to attack the most fundamental rights of LGBTQ people, including rolling back non-discrimination protections in the Affordable Care Act and promoting a license to discriminate in health care, it is more important than ever that health care institutions stand with the LGBTQ community,” said HRC President Alphonso David. “The health care facilities that participate in HRC’s Healthcare Equality Index are making clear that they stand on the side of fairness and are committed to providing inclusive care to their LGBTQ patients. Going beyond inclusive non-discrimination policies, these health care facilities are adopting best practices in the areas of LGBTQ patient care and support, employee policies and benefits, and LGBTQ patient and community engagement. We commend all of the HEI participants for their commitment to providing inclusive care for all.”
In the 2019 report, an impressive 406 facilities earned HRC’s “LGBTQ Health Care Equality Leader” designation, receiving the maximum score in each section and earning an overall score of 100. Another 148 facilities earned the “Top Performer” designation for scoring from 80 to 95 points. With 81% of participating facilities scoring 80 points or more, health care facilities are demonstrating concretely that they are going beyond the basics when it comes to adopting policies and practices in LGBTQ care.
The remarkable progress reflected in the 2019 HEI includes:
- Over half of HEI participants now have written gender transition guidelines;
- 75% of hospitals surveyed offer trans-inclusive benefits — an impressive eight percentage point increase over last year, and numbers that bring them on par with their corporate counterparts, as measured by HRC’s 2019 CEI;
- A 35% increase in training hours recorded — clocking in at more than 94,000 hours of LGBTQ care training provided;
- A 60% increase in the number of HEI participants whose electronic health records capture a patient’s sexual orientation, and a 40% increase in the number of HEI participants whose electronic health records capture a patient’s gender identity.
Of the 1,000 hospitals that didn’t actively participate in the HEI but were included based on HRC Foundation research, only 67% have patient non-discrimination policies that include both sexual orientation and gender identity, and only 62% were found to have an LGBTQ-inclusive employment non-discrimination policy. The equal visitation policy, in place at 90% of facilities that didn’t actively participate, is the only aspect in which this group comes close to matching the rate of the participating facilities.
Texas’ Low HPV Vaccination Rates Keeping Cervical Cancer Rates High
The state’s approach stands in stark contrast to that of Australia, where leaders have successfully pushed a nationwide program that has made a sizable dent in cervical cancer rates.
This article originally appeared in The Texas Tribune
One was the state of Texas, where lawmakers rejected a mandate to vaccinate adolescent girls against human papillomavirus, or HPV, a near-ubiquitous sexually transmitted infection that causes cervical cancer. For more than a decade since, the number of Texas adolescents vaccinated against HPV has remained low.
On the other side of the globe, Australia, a country with roughly the same size population and economy as Texas, was taking a radically different approach. Public health leaders there rolled out a nationwide program that offered the HPV vaccine to girls for free at their schools. The program, though optional, proved popular, and it later expanded to boys. Vaccine coverage grew rapidly, with up to 80% of teens becoming immunized over the next decade.
Now, 12 years after Texas and Australia first veered onto wildly different courses regarding HPV prevention, their gap in health outcomes has widened demonstrably. Australia is on track to become the first country to eliminate cervical cancer, perhaps within a decade. Texas, meanwhile, has hardly made a dent in its rate of cervical cancer — which remains one of the highest in the United States, with an incidence comparable to that of some developing countries.
Medical experts in both Texas and Australia say the results underscore the effectiveness of widely available vaccines and cancer screenings.
“From the beginning, I think the [Australian] government successfully positioned the advent of HPV vaccination as a wonderful package that had a beneficial effect for the population,” said Karen Canfell, a cancer epidemiologist with the Cancer Council Australia. “It was celebrated for that reason, and it was a great public health success.”
Local cancer experts say Australia seized a golden opportunity Texas missed out on. “They embraced the vaccine at that time, and our fear kind of began around then,” said Lois Ramondetta, a professor of gynecologic oncology at MD Anderson Cancer Center in Houston. “Really, vaccination in general has just gone down the tube since then.”
Texas is at half of Australia’s vaccination rate for adolescents — and is lagging behind most other U.S. states. Only about 40% of Texans between 13 and 17 years old were up to date on their HPV vaccinations in 2017, according to the U.S. Centers for Disease Control and Prevention. That’s compared with the national average of 49%.
Cervical cancer rates remain significantly higher in Texas as well. In 2016, the age-adjusted rate of new cervical cancer cases in the state was 9.2 per 100,000 women, according to the CDC and National Cancer Institute. Women in only four other states — New Mexico, Alabama, Florida and Kentucky — were found more likely to develop cervical cancer.
Because it takes several years for persistent HPV infection to manifest as precancerous lesions on the cervix, not all of Texas’ high cancer rate can be attributed to low vaccine rates. But experts say the best way for the state to significantly reduce its cervical cancer rates is to boost HPV immunization.
Researchers in Australia estimate the country will see fewer than 4 new cases of cervical cancer per 100,000 women each year by 2028, as long as vaccination rates remain high among adolescents and adult women receive regular cancer screenings.
The success of those programs has positioned Australia as the “first country that is likely to eliminate cervical cancer as a public health issue,” researchers wrote in a study published by medical journal The Lancet late last year.
An estimated 99.7% of cervical cancer cases are caused by the group of viruses known as HPV. Cervical cancer is the fourth most commonly occurring cancer in women. Study after study has found the HPV vaccine to be safe and effective.
Some Texas policymakers say it’s time to revisit the state’s vaccination requirements in light of Australia’s success.
“This is a preventable disease, and we should and can be doing more,” said state Rep. Jessica Farrar, a Houston Democrat who has advocated for more robust HPV vaccine coverage. “Here we are 12 years later, and look where we could’ve been, but because of certain beliefs, we’re suffering from cancers that could have been avoided.”
Texas’ last effort to expand HPV vaccine coverage, supported by an unlikely cast of characters, fell wildly short.
“We did not want to be the first”
On a Friday afternoon in February 2007, just months after the U.S. government approved a vaccine to protect adolescent girls against HPV, then-Gov. Rick Perry — a Republican — stunned the political establishment by announcing an executive order: Texas would become the first state in the nation to require all 11- and 12-year-old girls entering the sixth grade to receive the vaccination. Doing so, Perry wrote, had “the potential to significantly reduce cases of cervical cancer and mitigate future medical costs.”
Public health advocates were as elated as they were surprised. Farrar, who had authored a bill that would have similarly required adolescent girls to receive the HPV vaccination, said she was caught unawares by Perry’s proclamation but quickly voiced her support for it. Kathy Miller, executive director of the left-leaning Texas Freedom Network and a veteran of the state’s long-running debate over policies regarding sexual health and education, said she was “completely shocked … but applauded [Perry] for his out-of-character decision to listen to the science and the health care experts.”
Their optimism was short-lived. Pressure from evangelical groups and members of a nascent anti-vaccine political movement to repeal the executive order mounted, while government watchdogs accused the Texas governor of being too cozy with pharmaceutical lobbyists; his former chief of staff, Mike Toomey, had gone on to become a lobbyist for Merck, the manufacturer of the Gardasil HPV vaccine.
Within weeks, Texas lawmakers revolted against Perry’s order — and with support from Democrats and Republicans, the Legislature voted overwhelmingly to torpedo the mandate.
“We did not want to be the first in offering young girls for the experiment to see if this vaccine is effective or not,” state Rep. Dennis Bonnen, the Angleton Republican who authored the bill overturning Perry’s order, told The New York Times. (Bonnen, now the Texas House Speaker, did not respond to emailed questions.)
The blowback would haunt Perry for years. When he unsuccessfully ran for president in 2011, the executive order spawned attacks from primary competitors on the right. Perry ultimately called the order a mistake, saying, “If I had to do it over again, I would have done it differently.”
Lessons from Down Under
Australian leaders took pains to avoid a mandate in their rollout of the vaccine program.
As it is in Texas, HPV vaccination for students in Australia is optional. But unlike Texas, where parents are generally expected to have their children vaccinated on their own time, Australia decided to bring the vaccine directly to the kids — by offering the shots at school.
“Relying on people to go to their pediatricians … it’s harder to reach kids that way,” said Divya Patel, an assistant professor at the University of Texas System Population Health Initiative who has studied HPV vaccination in Texas.
Another reason the Australian schools-based program has been so well-received: It’s free.
“Vaccines in schools is by far the most effective way to do it,” said Ian Frazer, a professor of medicine at the University of Queensland who helped develop the HPV vaccine. “Free public health programs work really well if you publicize them well.”
Medical experts also praise Australia’s national cervical cancer screening program, which maintains a registry of people who have received cervical cancer screenings and encourages women to be tested every five years from age 25 to 74.
Australia faced some initial anti-vaccine opposition to its schools program, but an effective public awareness campaign helped overcome the opposition. Frazer, the Brisbane-based co-creator of the technology behind the HPV vaccine, was named Australian of the Year in 2006 for his research breakthrough. The same year, Janette Howard, the wife of Australia’s prime minister, disclosed that she had survived cervical cancer.
“What I think has been successful here is a pretty good public understanding of the importance of the vaccine and its key role in cancer prevention, not only for girls but also for boys,” said Canfell, the Australian epidemiologist.
The U.S. Centers for Disease Control and Prevention recommends that boys receive the HPV vaccine at age 11 or 12, but boys’ vaccination rates have lagged behind girls’. Only 36% of adolescent boys in Texas were up to date on HPV immunization in 2016, according to federal data.
In 2015, 406 Texas women died of cervical cancer, according to the Texas Department of State Health Services.
The state’s health department acknowledges the effectiveness of the HPV vaccine; a July report from the agency found that the “burden of cervical cancer can be reduced through efforts to screen all women at risk and to increase use of the HPV vaccination.”
The agency actually has the authority to implement a requirement for all students except those with a “conscientious objection” to receive an HPV vaccination before entering the sixth grade.
But a spokesperson for the agency said it typically waits for orders from state lawmakers before changing vaccine rules.
“We’ve also received clear direction from the Legislature that it wants to be involved in decisions about immunization requirements, so outside of an emergency situation, it’s unlikely we’d make a change without legislative action,” agency spokesman Chris Van Deusen said in an email. The most recent change to students’ vaccine requirements, the addition of the meningococcal disease immunization, came in 2013 after the Legislature passed a new law requiring it.
In 2017, researchers from the University of Texas System found the Lone Star State continued to have one of the lowest rates of HPV vaccine coverage in the nation.
“Despite the remarkable cancer prevention opportunity HPV vaccination provides, Texas has fallen behind the rest of the country in adopting this practice,” the researchers wrote.
The Texas Tribune is a nonpartisan, nonprofit media organization that informs Texans — and engages with them – about public policy, politics, government and statewide issues.
Disclosure: The University of Texas System has been a financial supporter of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune’s journalism. Find a complete list of them here.
Trump Administration Rule Would Undo Health Care Protections For LGBTQ Patients
Supporters of the rule say it would strengthen health care professionals’ freedom of conscience, but opponents say it “empowers bad actors to be bad actors.”
This article originally appeared in Kaiser Health News.
A new Trump administration proposal would change the civil rights rules dictating whether providers must care for patients who are transgender or have had an abortion. Supporters of the approach say it protects the freedom of conscience, but opponents say it encourages discrimination.
The sweeping proposal has implications for all Americans, though, because the Department of Health and Human Services seeks to change how far civil rights protections extend and how those protections are enforced.
Roger Severino, the director of the HHS Office for Civil Rights, has been candid about his intentions to overturn an Obama-era rule that prohibited discrimination based on gender identity and termination of a pregnancy. In 2016, while at the conservative Heritage Foundation, he co-authored a paper arguing the restrictions threaten the independence of physicians to follow their religious or moral beliefs.
His office unveiled the proposed rule on May 24, when many people were focused on the start of the long Memorial Day holiday weekend.
The rule is the latest Trump administration proposal to strip protections for transgender Americans, coming the same week another directive was proposed by the Department of Housing and Urban Development that would allow homeless shelters to turn away people based on their gender identity.
The public was given 60 days to comment on the HHS proposal. Here’s a rundown of what you need to know about it.
What would this proposal do?
Fundamentally, the proposed rule would overturn a previous rule that forbids health care providers who receive federal funding from discriminating against patients on the basis of their gender identity or whether they have terminated a pregnancy.
The Trump administration proposal would eliminate those protections, enabling providers to deny these groups care or insurance coverage without having to pay a fine or suffer other federal consequences.
That may mean refusing a transgender patient mental health care or gender-confirming surgery. But it may also mean denying patients care that has nothing to do with gender identity, such as a regular office visit for a bad cold or ongoing treatment for chronic conditions like diabetes.
“What it does, from a very practical point of view, is that it empowers bad actors to be bad actors,” Mara Keisling, executive director of the National Center for Transgender Equality, told reporters.
The proposal would also eliminate protections based on sexual orientation and gender identity from several other health care regulations, like non-discrimination guidelines for the health care insurance marketplaces.
Does it affect only LGBTQ people?
The proposal goes beyond removing protections for the LGBTQ community and those who have had an abortion.
It appears to weaken other protections, such as those based on race or age, by limiting who must abide by the rules. The Trump proposal would scrap the Obama-era rule’s broad definition of which providers can be punished by federal health officials for discrimination, a complicated change critics have said could ease requirements for insurance companies, for instance, as well as the agency itself.
And the proposal erases many of the enforcement procedures outlined in the earlier rule, including its explicit ban on intimidation or retaliation. It also delegates to Severino, as the office’s director, full enforcement authority when it comes to things like opening investigations into complaints lodged under the non-discrimination rule.
Why did HHS decide to change the rule?
The Obama and Trump administrations have different opinions about whether a health care provider should be able to refuse service to patients because they are transgender or have had an abortion.
It all goes back to a section in the Affordable Care Act barring discrimination on the basis of race, color, national origin, age, disability or sex. President Barack Obama’s health officials said it is discrimination to treat someone differently based on gender identity or stereotypes.
It was the first time Americans who are transgender were protected from discrimination in health care.
But President Donald Trump’s health officials said that definition of sex discrimination misinterprets civil rights laws, particularly a religious freedom law used to shield providers who object to performing certain procedures, such as abortions, or treating certain patients because they conflict with their religious convictions.
“When Congress prohibited sex discrimination, it did so according to the plain meaning of the term, and we are making our regulations conform,” Severino said in a statement. “The American people want vigorous protection of civil rights and faithfulness to the text of the laws passed by their representatives.”
Much of what the Office for Civil Rights has done under Severino’s leadership is to emphasize and strengthen so-called conscience protections for health care providers, many of which existed well before Trump was sworn in. Last year, Severino unveiled a Conscience and Religious Freedom Division, and his office recently finalized another rule detailing those protections and their enforcement.
The office also said the proposed rule would save about $3.6 billion over five years. Most of that would come from eliminating requirements for providers to post notices about discrimination, as well as other measures that cater to those with disabilities and limited English proficiency.
The rule would also save providers money that might instead be spent handling grievances from those no longer protected.
The office “considers this a benefit of the rule,” said Katie Keith, co-founder of Out2Enroll, an organization that helps the LGBTQ community obtain health insurance. “Organizations will have lower labor costs and lower litigation costs because they will no longer have to process grievances or defend against lawsuits brought by transgender people.”
Why does this matter?
Research shows the LGBTQ community faces greater health challenges and higher rates of illness than other groups, making access to equitable treatment in health care all the more important.
Discrimination, from the misuse of pronouns to denials of care, is “commonplace” for transgender patients, according to a 2011 report by advocacy groups. The report found that 28% of the 6,450 transgender and gender non-conforming people interviewed said they had experienced verbal harassment in a health care setting, while 19% said they had been refused care due to their gender identity.
The report said 28% had postponed seeking medical attention when they were sick or injured because of discrimination.
Critics fear the rule would muddy the waters, giving patients less clarity on what is and is not permissible and how to get help when they have been the victims of discrimination.
Jocelyn Samuels, the Obama administration official who oversaw the implementation of the Obama-era rule, said that for now, even though the Trump administration’s HHS will not pursue complaints against those providers, Americans still have the right to challenge this treatment in court. Multiple courts have said the prohibition on sex discrimination includes gender identity.
“The administration should be in the business of expanding access to health care and health coverage,” Samuels told reporters on a conference call after the rule’s release. “And my fear is that this rule does just the opposite.”
Editor’s note: This story was also published by Vice.
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.
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