7 minute read
Gender Medicine in the Twin Cities: A Brief History
Imagine your patient has a condition with somewhere between a five and 40% mortality rate (depending on the study), and you have something that will most likely help. There is even a multinational organization that guides appropriate treatment. But most insurance policies won’t cover it because treatment is deemed to be “medically unnecessary.” So some of your patients can afford treatment, but many cannot. Those who cannot afford treatment and even some of those who can, are unable to live the lives they were meant to live, leading to increasing problems with depression, anxiety, substance abuse, PTSD and hopelessness. Because of discrimination in society, many end up turning to sex work and contracting HIV. Others succumb to the mental health dangers of being denied medically necessary care and/or the ongoing discrimination in society. How would you feel? What would you do? This is what it was like to practice what is now called “Gender Medicine” back in the early 1990s when I first started prescribing hormones and doing hysterectomies for transmen. It was hard work, both literally and emotionally. It was (and still is) a labor of love for my LGBTQ + community. It took a little while to be able to find my fellow Gender Medicine practicing colleagues in the larger community, though I was very lucky to have been led into this work by my senior partner, Mario Petrini, MD. He was a mentor to me in so many ways that it would take a whole separate article to enumerate them. In more than just this one area, he helped me understand the principles of medical practice; and the transgender and gender non-conforming patients I inherited from him as he gradually retired taught me much in those early days. I am forever grateful to them, as well, for opening my eyes to their everyday realities. What I and my fellow Gender Medicine colleagues across the city did in the beginning, and continue to do now, was to find all the resources that we could find to provide the best possible evidence-based care. There were a few books and journal articles then, as well as the Standards of Care from what was then the Harry Benjamin Society and is now the World Professional Association for Transgender Health (WPATH). Fast forward 30 years—now there is a Transgender Center of Excellence in San Francisco and Los Angeles and the Fenway Clinic in Boston to provide resources online and in written form. WPATH has continued to provide updated Standards of Care (Version 8 is due out soon). There are journals like Transgender Health. And many local healthcare organizations, including HealthPartners, are working to provide ALL clinicians and support staff of all types the kind of education they need to provide respectful, competent care. At Park Nicollet, we have founded a Gender Services Clinic through which we can provide much of the care that our patients need. Where we can’t provide that care ourselves, we work with partners to do so. To have the support of one’s partners and administration to provide care to people who need it so much is one reason I have been so grateful to practice where I do. I am also grateful to still be doing Gender Medicine when most insurance, including Medicare and Medicaid, cover transition care. This is
because Article 1557 of the Affordable Care Act has been interpreted to include sexual orientation and gender identity in the provision where discrimination is illegal based on sex. I understand the practice of Gender Medicine did not start in the Twin Cities with Mario Petrini. Dr. Petrini had run a Gender Identity Clinic while practicing in Detroit. When he moved to the Twin Cities to practice at what was then the St. Louis Park Medical Center (now Park Nicollet Clinic, part of HealthPartners), he began prescribing hormones and doing hysterectomies. The Program in Human Sexuality had been established here long before that, practicing Gender Medicine with hormones, gender affirming surgeries, and the provision of cutting edge mental health services. In fact, the staff at the Program in Human Sexuality, led admirably by Dr. Eli Coleman, have been integral to WPATH for decades, and continue to be extremely active in that organization. Dr. Coleman has been a leader in the development of several versions of the WPATH Standards of Care, including the soon to be released 8th version.
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In the intervening time, the number of Minnesota clinicians who provide mental health services, prescribe hormones, provide respectful primary care, do gender affirming surgeries, and are strong members of or allies to the transgender and gender non-conforming communities has grown exponentially. A small group of us from several clinics across the Twin Cities used to meet every other month at a local restaurant to provide each other support and co-strategize on how to get the needed care to our patients. Now, while we still have that small local group, there are huge numbers of clinicians who do provide this care across the state. Primary care and OB/ GYN residents are educated in the care of sexual and gender minority patients as a matter of course in their residencies. JustUs Health puts on the Opportunity Conference every year to bring community and care providers together. And they are about to launch a website to help community members seeking Gender Medicine care as well as clinicians looking for resources for their patients. This was unheard of in the past, but is a fabulous demonstration of how far we’ve come. For more information on the current status of care for the Trans and Gender Non-Conforming Community, please visit this website: https://www. justushealth.org/VOH for the most current Minnesota information. I wish this could just be a positive article about life being rosier now for our patients and those of us who provide their care. The reality is however, that our transgender and gender non-conforming patients continue to face discrimination in everyday life. It can be very dangerous for transwomen, especially transwomen of color, to be out in the world. At least 16 transgender people (mostly transwomen of color) have been murdered in the US so far in 2020 and reported as hate crimes based on their being transgender. Discrimination in the workplace, in housing, in education, in health care, and many other avenues of life is still too real for our patients. The recent Supreme Court Decision on June 15, 2020, stated that the 1964 Civil Rights Act protects gay, lesbian and transgender employees from discrimination in the workplace based on sex, which should help reverse some of that structural discrimination. Hopefully, that decision will also be used to reverse the recent executive ruling (effective August 1, 2020) by the Department of Health and Human Services that does allow discrimination on the basis of sexual orientation and/or gender identity, in reversal of the Obama era interpretation of article 1557 of the Affordable Care Act. I am worried that we will go back to insurance (public and/or private) not covering medically necessary treatment of Gender Dysphoria. This has been a brief overview of a short time in the history of one area of medicine in the Twin Cities. An area in which I have been grateful to be involved. I look forward to what the next 30 years will bring!
Debra Thorp, MD, has worked as an OB/ GYN at Park Nicollet for over 30 years; Gender Medicine has been a large part of that practice for most of that time. She is currently the Medical Director of the Gender Services Clinic after serving in a variety of leadership roles within the Department of OB/GYN at Park Nicollet Clinic and Methodist Hospital.
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