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• The California Transgender Advisory Council — Transgender, Gender Diverse or Intersex Workgroup (CTGI Workgroup) participants expressed several challenges accessing healthcare, including: • Lack of competent care • Absence of safe gender-affirming care • Providers not recognizing TGI identities • Patient difficulty changing names and pronouns within medical systems and EHR Confusion among providers regarding providing preventive care procedures Absence of integrated TGI care • Lack of TGI-affirming HIV care • Safety concerns and a scarcity of doctors in rural areas. Providence Patient and Family Advisory Council (PFAC) patients confirmed these same concerns. PFAC members, like the CTGI Workgroup, also highlighted that patients experience intersectional barriers to care related to race, socioeconomic status, age, disability, body size and immigration status. These identity factors compound health disparities amongst TGI individuals. Patient Experience: Barriers to Care, Disparities and Inequities The CTGI and Providence's PFAC have also highlighted that trans+ patients experience: • Difficulty with navigation to begin gender- affirming care. • The feeling from the community that many doctors just didn't "care" about them. • There is systemic discrimination and consistent misgendering of people seeking services. There were reports of doctors setting requirements before TGI individuals can receive gender affirming care that are more stringent or inconsistent with the current standards of care (i.e. requiring more letters for surgery than necessary). • There is a lack of follow-up on referrals made to fellow practitioners. • Enrollees and insureds are hesitant to seek services due to a history of high 8 denial levels. • Lack of insurance coverage of needed prescriptions and proper equipment (i.e., hormones and syringes of the correct gauge and length). • Lack of adequate and competent in-network providers for referrals to care. • The assumptions of femininity and masculinity are reflected in denials of surgical procedures (i.e., breast augmentation or facial feminization). • Insurance coverage does not include financial support for recovery from surgical procedures. Integrating pronouns into introductions, patient appointments and work environments can be simple. For example, some things you can say are: • "Hi, I'm Juan and my pronouns are he/him. What name do you go by, and what are your pronouns?" • You can also do this in meetings: "Hi everyone. I'm Allie. I'm an MA and I go by she/her." • Add them to your email signature next to your name: D. Marshall (pronouns they/them/theirs) • When checking someone in, ask someone's full legal name, pronouns, and what they like to be called (these might be different than what you assume!) For example: "Welcome. Can you please tell me your legal name as it shows up on your insurance?" (let patient respond) "Thank you. How do you like to be called, and what are your pronouns?" Provider Education Training Manual 38 |

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