Carlene MacMillan, MD, Founder and Clinic Director at Brooklyn Minds
As Pride month draws to a close, I have been reflecting on how our healthcare system impacts the lives of individuals with identities across the gender spectrum. Sometimes, when sending a prescription to a pharmacy for any given patient, we will get a phone call that the date of birth on file with insurance does not match the date of birth we have on file. Typically, this is a clerical error that is easy to fix. What is more jarring is when a patient we know identifies as female is on file with their insurance company as being male. That one letter on a chart — M instead of F — is a stark reminder of the many daily challenges faced by those who are trying to live as their affirmed gender rather than the gender they were assigned at birth.
The World Professional Association for Transgender Health (WPATH) has made recommendations that electronic medical record systems include fields for not only assigned sex at birth and legal name, but also affirmed gender pronouns used and what name a person goes by if not their legal name. The final rules issued by the Office of the National Coordinator for Health Information Technology (ONC) and the Centers for Medicare and Medicaid Services (CMS) in October 2015 require EMR software certified for meaningful use to include fields for gender identity and sexual orientation.
However, technology can move at a glacial pace in the healthcare space. For individuals who identify as trans, non-binary, or other identities along the gender spectrum, the result is that many systems we use to store healthcare data still do not conform to the WPATH or CMS recommendations.
To address this in the group mental health practice I run in Brooklyn, we have turned to a custom electronic health record designer in part to ensure we can capture these aspects of a person’s identity. Making sure the experience of receiving mental healthcare is an affirmative experience for individuals of all gender identities and sexual orientations is a priority for us. However, currently, that experience stops with us. Once medical information hits insurance companies, things get a lot more complex.
For example, when we call a prescription into a pharmacy, the pharmacy is legally obligated to use on the claim whatever gender the insurance company has on file in order for coverage to be approved by the insurance company. This means that unless the patient has changed their gender with their insurance, both we and the pharmacy are forced to use birth pronouns on materials that sometimes reach the patients themselves.
Individuals can certainly contact their insurance company to change the gender on file, but if only it were that simple. Some procedures and medications are gender-specific. For example, if someone with an “M” on their chart has a pap smear ordered, the system could encounter an error that may be time-consuming to fix. Furthermore, any time a data system changes or adds fields, it can be a programming challenge with many unintended consequences.
This may not always be the case, however. While some countries recognize non-binary gender identities on official identification documents, this is very much in flux in the United States. Oregon, California and Washington, D.C. have taken steps to allow for individuals to indicate a non-binary gender identity on their documents. In New York City, legislation was introduced earlier this month to allow people to choose “X” on their birth certificates and do so on their own without a healthcare provider providing an affidavit. Over the next several years, I think we will see further shifts toward more inclusive and affirmative healthcare, but there is much work to be done.
In the meantime, no matter what our role is in the healthcare space — from physicians to pharmacists to hospital administrators, let’s keep in mind that helping our patients live as their authentic selves is some of the best medicine we can provide.
Carlene MacMillan, M.D., is a board-certified adult and child psychiatrist. She is the founder and clinic director of Brooklyn Minds and the medical director of the NYC Ellenhorn Private Assertive Community Treatment Program.
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