This week, AMPA submitted recommendations on the top 3 healthcare needs of LGBT military families to the Defense Health Board an independent Federal Advisory Committee to the Secretary of Defense on health policy that is tasked to examine opportunities to improve the overall provision of health care and related services in the Armed Forces. AMPA is committed to education, advocacy, and support for our nation’s modern military families, and here’s what we had to share with the committee for their upcoming meeting on Monday, June 26:

1. Standardized and Inclusive Language at Patient Intake & Provider Visits

Incorporating the “Do Ask, Do Tell” campaign into military treatment facilities encourages patients to speak openly to their health care providers about their sexual orientation and gender identity. Using inclusive language on all standardized forms used in medical facilities (e.g., transgender female, transgender male, non-binary, etc.) allows patients to disclose their gender identity, preferred name, and preferred pronouns to facility staff so that facility staff can address patients appropriately at each interaction. Additionally, by incorporating sexual orientation within the patient’s medical profile in a standardized manner, it appropriately places the responsibility of gathering pertinent objective information about the patient on the medical team while simultaneously fostering an inclusive care environment. This is also important in the pediatric setting, where patients may have same-gender parents, such that it may be inappropriate to refer to the patient’s parent as “mother” or “father” in discussion.

Unfortunately, based on feedback from focus groups of lesbian, gay, bisexual, and transgender service members and dependents, it does not appear that these are standardized approaches employed across all military treatment facilities. As a result, providers with patients who identify as LGBT are not always knowledgeable of their patients’ sexual orientation and/or gender identity. This knowledge gap has the potential to have a profound negative impact on a patient’s access to appropriate medical care and health outcomes, as specific needs of the patient based on their sexual orientation and/or gender identity may be left unaddressed (e.g., cervical cancer screening, STD screening, hormone replacement therapy, treatment with hormone blockers, HIV pre-exposure prophylaxis/PrEP, mental health needs, etc.). Furthermore, LGBT families with children have consistently experienced providers’ inappropriate use of “mom” or “dad” in front of – or even to – the pediatric patient when referring to the parent that is not present at the appointment due to the provider assuming the parents are opposite-sex. When inappropriate or non-inclusive language/terminology is used, it does not foster a welcoming or comfortable care environment. It also suggests staff are not competent in or sensitive to LGBT healthcare, thereby discouraging LGBT military families from accessing needed health care services.

We respectfully request the Defense Health Board work with the Department of Defense to ensure that discussions regarding sexual orientation and gender identity are incorporated in patient care in a standardized manner across all service lines and specialties, including but not limited to: pediatrics, family medicine, internal medicine, infectious diseases, emergency department, psychiatry/psychology, endocrinology, and others. We also recommend that all medical facility and TRICARE staff be trained and demonstrate competency regarding appropriate inclusive language/terminology, and that they be required to use such terminology during each patient interaction (i.e., preferred pronouns).

2. Clear Communication to Transgender TRICARE Beneficiaries Regarding Medical & Prescription Coverage

Information regarding medical care and prescription therapy covered by TRICARE beneficiaries, especially for transgender beneficiaries, has been a moving target and is scant at best. There are little to no resources from TRICARE or elsewhere indicating support or information for transgender dependents, including mental health therapy, pharmacotherapy, hormone replacement therapy, etc.

On February 1, 2016, the Department of Defense published a proposed rule removing the categorical exclusion on treatment of gender dysphoria. The subsequent change in policy permitted “coverage of all non-surgical medically necessary and appropriate care in the treatment of gender dysphoria,” such as psychotherapy, pharmacotherapy, and hormone replacement therapy. Despite publication nearly 17 months ago, there still continues to be unclear and inconsistent information communicated to our LGBT families in terms of exactly what is covered.

Numerous medical facilities both CONUS and OCONUS have been providing different and often conflicting information to our families, and most families are unable to find any meaningful guidance or information from TRICARE customer service representatives. For example, several families with pediatric transgender patients have been incorrectly informed by TRICARE customer service representatives as well as medical providers that hormone blockers are not covered for their transgender children. This has resulted in significant delays in patients receiving pharmacotherapy. Likewise, civilian providers who accept TRICARE have also provided incorrect information about covered medical care & pharmacotherapy to transgender beneficiaries. This communication of inaccurate information and lack of clarity in coverage is negatively affecting our LGBT military families and has contributed to delays to time-sensitive medical care – especially for pediatric patients who identify as transgender and depend on timely initiation of hormone therapies and/or hormone replacement therapy to prevent secondary sex characteristic development.

Transgender beneficiaries need help from the Defense Health Board to work to create a clear channel of communication to TRICARE beneficiaries, military providers, and civilian providers who accept TRICARE with reliable, timely and accurate information regarding covered benefits granted by the recent policy change. We recommend a specific webpage be created and maintained with up-to-date information that clearly outlines all covered benefits related to transgender health, including any coverage differences based on patient age. We also recommend that all TRICARE customer service representatives be required to receive training with respect to benefits related to transgender health and demonstrate competency of said benefits such that they are able to provide accurate information to inquiring beneficiaries. The Defense Health Board may also wish to consider creating a team specifically dedicated to transgender health coverage inquiries for more complex inquiries/cases so that beneficiaries have ready access to time-sensitive health information, thereby minimizing the current barriers impeding access to information and appropriate and quality care.

3. Training for Military Healthcare Providers on LGBT Healthcare Topics & Transgender-Specific Resources

The ability for our LGBT military families to have access to appropriate, culturally competent, and quality care varies by location, providers’ clinical training, and provider willingness to provide medical care for LGBT patients. Additionally, it does not appear that the referral process for transgender patients to receive care from providers off base is standardized. Thus, beneficiaries are often confused and unclear about what options are available for care. This has lead to delays in receiving time-sensitive care, and unnecessary changes between TRICARE Prime & Standard plans, among other issues.

Families with transgender children have approached our organization for assistance due to the child’s primary provider not addressing the child’s transgender-specific healthcare needs upon disclosing to the provider they identify as transgender. There have also been instances in which providers refused to manage transgender patients, and/or refused to place implantable pharmacotherapy in pediatric patients (e.g., hormone blockers). Unfortunately, it appears that this varies widely among CONUS facilities, and with significantly less available providers among OCONUS facilities.

One transgender child’s mother discussed her experience with a military provider upon the child disclosing their gender identity to their primary care provider. The patient’s provider told the parents “basically to wait and see, and decide what our personal beliefs were on the matter.” She continued, “we told him a second time [that our child identifies as transgender]. He put an off-post referral in and no doubt knew it wouldn’t be covered. Dr. X [an adolescent physician who treats transgender children] was in the peds clinic and no mention of him. Until she cut. Then we got referrals that would be covered. But there are not a lot of Dr. X’s on military bases. Families who speak to their physician should be able to get a consult and therapy referrals.”

Given the limited number of providers trained and/or willing to manage transgender patients, we recommend mandatory transgender-related training for all pediatric and primary care providers. This training should include guidance to providers regarding a standardized referral process for transgender patients to receive care from providers off base. We also recommend a Tri-Service/Defense Health Agency LGBT Healthcare Conference, including interactive breakout sessions for providers to learn about and discuss healthcare topics and best practices. Transgender beneficiaries would greatly benefit from a dedicated Transgender Care Case Manager from beginning-to-end to assist with referrals to mental health therapy, endocrinology, pharmacy, legal/name change, etc. Transgender Care Case Managers would also be able to assist with properly worded letters and appeals to ensure that medical care and pharmacotherapy is covered, as appropriate within the limits of the coverage policies. Lastly, we recommend an up-to-date list of transgender-related health resources — including a list of transgender-affirming providers — be created, maintained, and readily available to beneficiaries.