Assessment and Referrals Standards of Care. Randi Ettner, PhD Clinical and Forensic Psychologist

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1 Assessment and Referrals Standards of Care Randi Ettner, PhD Clinical and Forensic Psychologist

2 Continuing Medical Education Disclosure Program Faculty: Randi Ettner, PhD Current Position: Clinical and Forensic Psychologist Disclosure: No relevant financial relationships. Presentation does not include discussion of off-label products. It is the policy of The National LGBT Health Education Center, Fenway Health that all CME planning committee/faculty/authors/editors/staff disclose relationships with commercial entities upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and, if identified, they are resolved prior to confirmation of participation. Only participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in this CME activity.

3 Access to surgery Medicare exclusion removed - opened the floodgates State and private insurers follow However, many people are resource poor, with inadequate assessment and no follow-up 3

4 Prevalence Rates exponentially higher than previously reported in the literature Old rates were 1 in 30,000 assigned female; 1 in 11,000 assigned male Epidemiologists at Emory conclude the prevalence range may be as great as per 100,000 4

5 SOC 7 Criteria for hormone therapy Persistent, well-documented gender dysphoria Capacity to provide informed consent Age of majority Mental health or medical concerns must be reasonably controlled 5

6 Referral and assessment for hormones Can be done by a mental health provider or health professional who is competent to assess and prepare the patient for hormone therapy. No longer restricts referrals to mental health providers Inclusive of informed consent model used in clinics across the US 6

7 Mental health issues Hormone therapy is safe, even when there are mental health conditions Some conditions improve with hormones Are the conditions well-controlled, or being managed? Do they require referral for medication? Collaboration is necessary. 7

8 Changes to the SOC Psychotherapy is not a requirement (but highly recommended) No requirement of real life experience of social transition for hormones, chest/breast surgery, hysterectomy-oophrectomy, or orchiectomy 12 months of hormone usage recommended prior to breast augmentation Genital surgery still requires 12 months living in a congruent role, and 12 months hormones, unless medically contraindicated 8

9 Referrals for surgery One referral from a mental health professional for chest/breast surgery Two for genital surgery or removal of reproductive organs One from a psychotherapist who has followed the patient Second from a person who has evaluated the patient (some insurance companies still insist one referral letter from be from a doctoral level provider) 9

10 Referral letter is an assessment With more people seeking surgery, some professionals with insufficient experience are writing letters, but not doing assessment. Surgeons note more complications with patients who have brief, cursory letters Surgeons should be able to verify that the provider is the author of the letter, and has experience with gender incongruence. 10

11 Import of the referral letter The letter should give information to the surgeon that informs care. For example, culturally relevant information. [case of Nicole] The author should be willing and able to discuss the patient with the surgeon or other providers Each provider has deep but specific knowledge and collaboration is essential for optimal care. 11

12 Content of the letter 1. Background information Identifying characteristics: DOB, date seen, duration of the relationship btw patient and author. Place of birth, family constellation, education Information about the history of the patient s gender incongruity, onset, coping strategies, feelings about the body. Sexual relationship history, including preferred partner/usual partner. Will surgery affect sexual expression? 12

13 Content of the letter 2. History and current status Medical history, current medications, prior surgeries, height, weight, nicotine use (free nipple grafts), allergies. Mental health and history: well-oriented? history of abuse? Substance abuse? Previous treatment? Prior diagnoses (e.g. eating disorder, ADD, etc ) Suicide attempts/ideation/self-harm? Current treatment, medications, substance use. If mental health concerns, are they stable? Can patient provide informed consent? Participate in health care decisions? Present status: transition, employment, social support, family support 13

14 Content of the letter 3. Preparation for surgery Understands risks and process of surgery, and postoperative care Has realistic expectations for surgery What is the rationale for having surgery now? Why this surgery? Why this surgeon? What type of post-operative care and support are planned 14

15 Content 4. Assessment Surgery is medically necessary Results of the assessment, including any diagnoses Confirmation that the patient has met the SOC criteria Confirmation that the provider is available and willing to speak with the surgeon 15

16 The second letter of referral I want this to be a positive experience for the client An independent assessment, and an opportunity to cover areas the first evaluator may not have...e.g. fertility, post-operative care,. Will they continue therapy after surgery? An opportunity for the client to tell their story without worrying about giving the right answers to the gatekeeper. A statement that the author is available for coordination of care. Case example - Elaine 16

17 Complex Cases Many co-morbid conditions improve or remit with treatment for gender dysphoria May need to consult with a specialist or refer to a provider with specific experience e.g. dissociative disorder 17

18 Atypical Cases Requests for unusual surgeries Gender queer adolescent with OCD requesting surgery : case of Macy Request for surgery, absent gender dysphoria: case of MD 18