A Look at Transgender Health Care in Nashville

Tennessee isn’t exactly the epicenter of the transgender vanguard. Just ask any activist fighting the state’s antiquated, discriminatory birth certificate laws, which prohibit trans people born in Tennessee from correcting the gender marked on their birth certificates.

But with Vanderbilt’s transgender services, new paths forward for individuals undergoing gender transition are being forged here in Nashville. Vanderbilt University Medical Center’s Clinic for Transgender Health opened in August 2018, shoehorned though its caseload is into overbooked Friday slots at a forlorn storefront clinic in a Bellevue strip mall. The grand plan? A one-stop shop for Nashville’s transgender needs, from hormone-replacement therapy to consultations about top surgery — the blanket nomenclature for surgeries that reconstruct a transgender person’s chest. (So-called bottom surgery is the procedure by which a person’s genitals are altered to match their gender identity.)

The initial rollout was mostly bare-bones. As news of the transgender clinic spread, grumblings about six-month wait times reached fever pitch on various Facebook transgender forums. (As of press time, the clinic has since expanded its hours, with the next available appointment slots being late January 2020.)

A smattering of offerings exist outside the Vanderbilt system for people without insurance, including Connectus Health and My House. As the Trump administration tinkered with Planned Parenthood’s funding earlier this year, questions arose about the future of the clinic’s informed-consent policy around hormone-replacement therapy. Also this year, there was a sudden surge of panic after lower-income provider and nurse practitioner Alice Sattler left town. But Rager Health’s Dr. Kristin Rager — an adolescent specialist — recently expanded her clinic to serve patients up to age 30 affected by Sattler’s departure. What’s more, Nashville Mayor John Cooper’s press secretary Chris Song confirms that his boss is interested in continuing initiatives from the Briley administration of extending coverage of gender-confirmation surgery to transgender Metro employees.

The question raised by the growing pains involved with Nashville’s nascent transgender medical industrial complex: How does a lower-income person planning for a gender transition obtain services outside of Vanderbilt’s near-monopoly and occasionally impersonal third-party answering service? “When a parent calls, they get me and only me,” Rager Health practice manager Michael Reding tells the Scene. “They’re not going to get a call center or a random employee.”

Be that as it may, transgender Nashvillians will be seeing a lot more of Vanderbilt’s Clinic for Transgender Health in the years to come. With new hire Dr. Julian Winocour’s first Vanderbilt vaginoplasty scheduled this month, Vanderbilt’s full-time LGBTQ Health program manager Del Ray Zimmerman has racked up a few successes: He’s helped overhaul Vanderbilt’s burdensome phone and technology system to cut down on flagrant misgenderings from nonplussed receptionists, and in December, Zimmerman will meet with outside consultants about ramping up the transgender clinic’s services.

A Look at Transgender Health Care in Nashville

Del Ray Zimmerman

The Scene recently spoke with Zimmerman about the future of the clinic, health care options for transgender Nashvillians and more.

In talking with transgender people for this story, there was a general concern from people without insurance utilizing some of the services.

That’s just a pretty standard Vanderbilt rule. It has nothing to do with the program. At the same time, Vanderbilt provides more uncompensated care. We have to fall in line with how the rules are and how they’re laid out. It does get difficult for uninsured and under-insured patients to access services. One of the things we help folks with is navigating other services outside of our system. If a patient calls us looking to start hormone therapy without insurance, we’ll give them the names and numbers of folks they can call to get set up with sliding-scale fees.

What about the patient who has Affordable Care Act or TennCare coverage? How are they billed differently, and what would be the key differences in how that transition would look?

Folks are picking up products associated with Cigna and Blue Cross Blue Shield through the [health insurance] exchange. It is impossible for our program to keep up with all of the insurance plans’ levels and packages. More generally, those companies are on board to be more transgender-inclusive. It depends on the kinds of products people buy. Vanderbilt doesn’t readily accept adult TennCare products. That’s another hiccup in the system. There are some ways that patients can request authorizations. It depends on the powers that be and how they judge the medical necessity around it. The inner workings in how to get those authorizations are still pretty complex. Unfortunately, our insurance system has a lot of problems that negatively affect LGBTQ patients.

Would you say the authorization codes are a common hiccup transgender patients are having with Vanderbilt? And how would you advise them on that?

With the advent of bottom surgery at Vanderbilt, we’re seeing new things for the first time. I’m seeing more complexities with patients who have resources. Unfortunately, it’s harder for me to give advice because each patient has some sort of financial relationship with their insurer. If there were errors being made in processing between our [plastic surgery] clinic and carriers, there are back-office things that clinic staff can do to mitigate problems as they submit. On the front end, there’s a contractual relationship between the patient and insurer. That makes it difficult.

Are there internal guidelines for the pricing decisions made at Vanderbilt?

On one level, it’s unethical to quote prices up front. From one patient to another, you have anatomical considerations. As people are needing to budget, I’m looking to give ballpark figures based on anecdotal information. For top surgery, you’re looking from anywhere from $4,000 to $9,000. In terms of bottom surgery, I can’t give a ballpark, because there aren’t any precedents set at this point. Once Dr. Winocour and Dr. [Salam A.] Kassis have surgeries under their belts, I will have a better understanding of what I can tell patients.

In talking to doctors, they mentioned the extensive staff training involved and how that impacts wait times for surgery. For staffers who aren’t aware of transgender patients, are longer training sessions needed? What’s some of the language used to finesse their transgender awareness?

It’s typically on an ad hoc basis. I have two emails in my inbox today looking for training. With the transgender procedures rollout, we’ve intentionally gone in and trained hundreds of staffers. We walk people through some basic LGBTQ cultural competency. We really hit the point home that sexual orientation and gender identity are not the same thing, because people often conflate them. We spend a concerted amount of time on how to talk to transgender people with respectful language, how pronouns are important, and the hiccups that exist today in our electronic health records and how that can negatively impact the transgender patient.

That’s something the transgender patients we’ve interviewed noticed. It seems like the electronic health records are now more consistent, and the misgenderings have lessened.

We’ve certainly had plenty more opportunities lately to take our training on the road. We’re kind of busting at the seams right now in turns of the opportunities that have been presented to us. If people are benefiting from that, I would hope that’s a result of our training. In our front desk positions, we have higher turnover. Staff training should be ongoing. Once we roll out new protocols in our electronic health records, we’re also going to do new training on inputting data. We’ll have a more seamless system over time. That has broader ramifications. When we make these improvements for transgender folks, everyone actually benefits. I use myself as an example. I use my first and middle name. If you just use my first name, it makes me feel like I’m 5 years old. If I have the opportunity to put that, I use “Del Ray,” and it shows up every time I call, then I benefit from the impetus we’re using to make these changes.

That brings me to my next question. People have said that receptionists at Vanderbilt’s Bill Wilkerson Voice Clinic sometimes work with patients to schedule appointments on the fly, whereas other clinics have an impersonal third-party answering service. Is there anything being done about the uniformity and management across the board?

When we launched in August 2018, we got permission to start with a half-day of service. That’s four hours of patients’ appointments. As you can imagine, the schedule filled up pretty quickly, and we had a six-month waiting list. We got permission to expand the clinical offerings to a full day of service, and that’s helpful with some of the wait times. We have a lot of transgender people trying to access the system. What we’re trying to build is a solid foundation. We started small, and we’re continuing to build out. We put ourselves on the map, and a lot of transgender people are trying to connect with service.

On one hand, that’s a really great problem to have. On the other hand, we have a logjam in the system, and we’ve got to fix it. From the beginning, we wanted that one-stop shop, and have different providers weaving into one clinic. You’d have an appointment for hormone-replacement therapy and schedule a surgeon in the same visit. We’re just not there yet. Several high-level department chairs have gotten together to shore up resources to bring down consultants from cities with more established transgender clinics. They’re going to look at Vanderbilt Transgender Health 1.0. They’re going to help us come up with recommendations about what Version 2.0 should look like. We expect to get a better design that will be patient-centered and help navigate some of the hiccups.

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