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The home for VPR's coverage of health and health industry issues affecting the state of Vermont.

The Evolution Of Gender-Affirming Health Care For Trans And Nonbinary Vermonters

The transgender flag behind the caduceus staff of Hermes.
Wikimedia Commons
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"Vermont Edition" talks about the state's changing rules around gender-affirming surgery for trans and nonbinary Vermonters, and the spectrum of treatments and therapies available to Vermonters.

Vermont's health care rules could soon make it easier for trans and nonbinary youth under the age of 21 to get gender-affirming surgery. But for many, surgery may only come after months or even years of other treatments and therapies. Vermont Edition talks about health care options for trans and nonbinary Vermonters and what changes to state rules could mean for those seeking surgery. 

Guests:

  • Barb Prine, staff attorney with Vermont Legal Aid's Disability Law Project, explains the state's current and pending changes to health insurance rules with regards to gender-affirming surgery.
  • Leo Kline, a certified nurse practitioner working at the Be You Clinic for LGBTQ Health Care at the Community Health Centers of Burlington, about the various treatments, therapies and services for trans and nonbinary Vermonters.
  • Aaron Young, a senior at South Burlington High School, sharing his experience growing up trans in Vermont and starting his transition at age 13.
  • Allison Line-Andrews, a therapist in private practice working with LGBTQ patients in Wells River, White River Junction and St. Johnsbury, shares her experience with patients in transition.

Changes to state rules

Transgender and nonbinary youth could soon have an easier time getting gender-affirming surgery in Vermont.

Insurance regulations have removed age restrictions for surgeries to medically transition. Vermont's Medicaid program could also open up surgeries to those under 21, as well as change how much documentation medical professionals are required to provide for coverage claims.

Attorney Barb Prine, with Vermont Legal Aid, told Vermont Edition that the state's removal of insurance age restrictions went into effect on June 12 and that the Medicaid proposal still needs to go before the Vermont Legislative Committee on Administrative Rules.

"The cost for this surgery should be like all other surgeries," Prine said. "Transgender health care should be no more, nor no less, burdensome than all the other health care we get."

Prine represents youth seeking to have their surgeries covered by Medicaid, and she said the surgeries are medically necessary due to high rates of anxiety, depression and suicidality among trans youth.

"Insurance companies are in the business of paying for care that's been determined to be medically necessary," Prine said. "And when you take one kind of care and say, ‘we're not going to provide that,’ even though multiple health care providers have told this is medically necessary, that is flat-out discrimination. And in Vermont, that's illegal."

Gender-affirming surgery still requires doctors and mental health professionals to sign off — and minors need parental consent.

Vermont's gender-affirming health care landscape

The discussion during this program covered a range of topics. Some excerpts from guests are below; you can listen to the full podcast version by playing the audio at the top of the post.

Being a care provider:

"Folks will come in seeking affirmative care and initially just hoping to have someone who can hear them and show up for them in a way that maybe parents or teachers at school or whoever it is that's theoretically their support system may not actually be able to do for them," said Leo Kline, a nurse practitioner at Community Health Centers of Burlington. "So the initial step is just listening and trying to understand what's going on for that person."

Not having support, Kline said, can lead to detrimental health effects.

"These are individuals who if they don’t have that support, they can feel incredibly isolated and that can lead to all sorts of negative sequelae, such as depression, anxiety, self-harm, using substances. We've had teens that have killed themselves for … simply not having a space to be themselves."

Patients' choices:

"Each individual has a very different path with this," Kline said. "There are some folks who come and see me, and they want no medical intervention, like at all — but they do consider themselves transgender, and they are, and they want certain pronouns used and they live their life that way and are very happy as long as people respect their wishes.

"And then you have another individual who only wants hormones, and that's perfectly fine. And yet we also have people who, their life will not be quite right until we address whatever the sexual characteristic is that can't be changed by a hormone therapy."

Care decision timelines:

"There's often this sense that people rush into treatment or there's a fear that children or youth will rush into treatment, and I think that's very rarely the case," Kline said. "Because not only are we making sure that we’re providing a really safe space to thoroughly discuss the entire topic and all of the impacts this could have on their life, but also the person themselves has typically put themselves through a lot of inner turmoil to get to the point of 'I absolutely have to talk to someone about this.'"

Aaron Young, a South Burlington High School student, shared his personal timeline for pursuing care and transition with Vermont Edition. He also highlighted the continuing discussion he's had with medical professionals that has accompanied the process.

"I first went to see a doctor for my trans health care when I was 14. I didn't start hormones until I was 15, and you know, surgery was just a couple months ago," Young said. "It's definitely an ongoing conversation. You're always talking to your doctor about 'Does this still feel right? Do you still like the plan that we have?' You know, it's definitely very methodically thought out and you are always talking about it, always trying to make sure that it's really what you want."

Leo Kline and Aaron Young stand in front of a green VPR sign
Credit Olivia White / VPR
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VPR
Nurse practitioner Leo Kline, left, and student Aaron Young joined 'Vermont Edition' in the studio for a conversation about health care options for trans and nonbinary Vermonters.

Obstacles to care access:

An inability to find a surgeon in Vermont that can offer the treatment a patient needs is something Kline has witnessed.

"It's a source of a lot of strain and stress for many of my patients," Kline said. "Locally, we have pretty good access for trans men who need a mastectomy. But when you go beyond that — trans women can also get augmentation here, although that is a little bit more difficult to get that approved. When it comes to genital surgeries, there are very few options that are doable for most people in terms of travel and expense."

Klein said one step that's been taken is setting up a contract with a surgeon in Pennsylvania and beginning to build that partnership.

“It is definitely a very big issue,” Kline said, “and all we can do is continue to advocate for these specific surgeons to do a contract with Vermont Medicaid because from my understanding Vermont Medicaid is open to the idea of doing this for patients and they understand that we don’t offer it locally. But the surgeon who is accepting the insurance has to be willing to do that extra homework and credentialing and all that.”

Therapist Allison Line-Andrews, whose practice is based in Wells River with offices in White River Junction and St. Johnsbury, discussed the travel some patients need to undertake for care. 

"I have worked with patients that come down from, like, Newport and they have to go all the way down to Dartmouth for an initial endocrinology appointment, and then from there their PCP [primary care provider] can take over the treatment … The trans clinic [at Dartmouth] is once a month, and so they will have to coordinate their appointments to go down there when they need to."

Serving gender nonbinary patients:

"We should all as providers be more comfortable using they/them pronouns, encouraging people to talk about the different ways they experience their gender identity," Kline said. "And I think if we're able to do that, it means that we’re going to have patients being more appropriately cared for and allocating services that actually address whatever that individual's needs are. So I would encourage people to think of gender nonbinary youth as needing the same level of support as somebody who very clearly identifies as transgender."

Broadcast live on Wednesday, July 17, 2019 at noon; rebroadcast at 7 p.m.

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