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Episode 3 Transcript

The Road to HRT: Informed Consent & Insurance

Erin Everett:
Welcome back everyone. You are listening to Exclusively Inclusive, an LGBTQ themed cast for members and allies alike. I’m your host, Erin Everett, and on today’s episode we’re going to be discussing the road to HRT, which is hormone replacement therapy. So while there’s a lot of information that could be covered under the road to HRT, and we’ll definitely be addressing those in future episodes, first I just wanted to touch on a few things that I get the most questions about. So the few things that we’re going to be discussing today will be informed consent, insurance coverage, and then probably the most popular question I get is will I get my hormones on the first visit?

First we’re going to be talking about informed consent. What is it? Why do some practices have it and others do not, and why do other practices require a therapy letter? Well, just to give you some background, and a reminder, I’m your host, Erin Everett, and I’m a nurse practitioner and work at Druid Hills Primary Care. Now at Druid Hills Primary Care we see a lot of different patients ranging from a traditional primary care patient, but we specialize in the LGBTQ community. We offer HIV prevention, HIV treatment, and hormone replacement therapy for transgender, queer, and non-binary folks.

What is Informed Consent HRT?

So all that to say is we offer informed consent, and we are one of the few practices in the Atlanta area doing informed consent. And there’s really no right or wrong way to do this as far as whether you require a therapy letter or informed consent. Some providers prefer a therapy letter because they feel more comfortable in knowing that the client has already gone to see a mental health care provider or the mental health care provider has officially diagnosed them with gender dysphoria, and that they’ve had several sessions and the mental health care provider believes that this person is ready for hormones.

So that’s one route you can take. But informed consent was something that when I started working with Dr. Smiddy, he had been utilizing for many years. Dr. Smiddy has been doing transgender medicine for a long time, since basically the beginning of transgender medicine. Back when we didn’t really know how to treat trans individuals, we just knew they needed hormones. And he was one of the trailblazers that helped figure out which hormones to use and what doses. Back then is when he decided to do informed consent, and he didn’t have that many patients back then. Not that many people were coming out and seeking care. So it seemed like a good, feasible way to break down a barrier and not gatekeep and allow people to get the care that they needed.

Informed Consent for HRT is a Legal Document

Informed consent is a legal document, and it can be used for multiple different things. When people go into get surgery, what they’re signing is an informed consent. So as far as it pertains to hormones, each time a new patient establishes care with me and they let me know that they’re coming in to discuss hormone replacement therapy, I immediately, before even entering the patient room, develop their personalized contract. Typically … I mean, we have to put the legal name on there, but I will also, if it’s listed on their intake paperwork, put on their preferred name as well. It doesn’t have any pronouns or anything included in it. Basically it’s today’s date, the legal name with, in parentheses, the chosen name.

Informed Consent HRT Differs for MtF and FtM

Now, depending on the way that you’re going to be utilizing hormones, whether it’s feminizing or masculinizing, you’ll be getting a different contract of course. But the contract goes ahead and outlines in a very clear and easy way to understand the risks of taking hormones, the benefits, the expected timeframe, and they expected changes, physical changes. It also covers some of the emotional changes that can occur.

So the purpose of me printing this out before our actual visit and encounter is so that when I’m in the room with the new patient, I can actually go over it and make sure we hit everything on the consent and then that allows the patient to to then stop and ask questions about what’s on the consent before they sign it.

Informed Consent Covers Risks, Benefits, & Followup

So when we go through everything, we list out the risks and benefits, also at the end of our informed consent, has the patient agreed to the schedule of followups and blood work? Because it’s really important to both Dr. Smiddy and myself that if we’re going to be prescribing new medications, and particularly hormones, that you come in for your followups. Because, like with every medication, there are side effects and there are things that we’re looking for in the blood work to make sure that your body is tolerating the medicines.

I can’t sleep at night knowing if my patients are safe and healthy. If you don’t come in, and I try to outline it, we’ll work with you, but if you cannot come in and it’s been some time, then I can’t refill your hormones because I need know that your liver is working well and your kidneys are working well and that your blood’s not getting too thick. And all of these side effects are listed in the informed consent and granted, while there is increased risk of these things, it doesn’t happen a lot. Most people tolerate the medicines very well. And we’ll go into more detail on that on another followup episode to this.

Witness Required for Signing Informed Consent HRT Contract

So basically today I just wanted to focus on this piece of it, the informed consent. After we’ve gone through everything, I leave the room and I go get a support staff member, either the nurse, the medical assistant, or the office administrator to come in and witness the patient’s signature on the consent.

Now, what’s important to note is they’re just witnessing that they’re the person that signed it, I didn’t make them sign it and they didn’t feel forced to sign it in any way. There is no way to witness a person’s level of comprehension of the consent, so I really stress that to patients. Once you’ve signed this consent, you’re stating that you understood the material and that you’re ready to move forward with hormone replacement therapy.

Minimum Age Requirement for Informed Consent HRT

So then they sign the consent and the witness will then witness their signature by just signing their name below it. It is important to know that I can only offer informed consent for clients 18 years or older. Informed consent cannot be offered to patients under the age of 18 because they do not have rights to sign their own consent, so they still need a parent or guardian.

My Practice Does Not Provide HRT for Patients Under 18

We actually don’t see clients unless they’re 18 years or older. There are other clinics in Atlanta that are seeing younger patients and so there is that access, but our clinic in specifically only sees patients 18 and up. So that’s the main gist of informed consent.

A Therapy Letter Is Not Required for Informed Consent HRT, but Seeing a Therapist is Encouraged

A lot of patients will say, or people of the community will ask me, “Well, how come you don’t require a therapy letter? Is it important that they get therapy?” My answer to that is of course it is. It’s important that everybody get therapy, aside from patients with gender dysphoria.

So during that first visit, yes, we do informed consent, but I always connect my patients with a mental health care provider. It is so important. Aside from … I feel like it’s less important actually for the diagnosis of gender dysphoria, because most of my patients who come to me have been feeling this way for many years. It’s clear that they have gender dysphoria. It’s less about diagnosing it and getting to the root problem of why they feel this way and it’s more about offering transitional support.

A lot of things can occur once a transition starts and so it’s really nice to have somebody completely objective in a safe space where the patient can contact them when they need them and go over any of their needs, concerns, and also assist them in coming out to their family, coming out at work, all types of things. So yes, we do encourage patients to have contact and develop a relationship with mental health care provider, but we do not require a letter outlining their readiness for hormones.  So if anybody has any additional questions about informed consent, please feel free to go ahead and email me at erin@exclusivelyinclusivepodcast.com. That is erin@exclusivelyinclusivepodcast.com.

Insurance Coverage for Hormone Therapy

And I’m glad we had an opportunity to talk about informed consent, but one of the other things that really plague people and they really want to know more about is does insurance cover hormone replacement therapy?

Well, that is a very variable answer. There are definitely more and more insurance companies covering the cost of both hormones and doctor’s visits, nurse practitioner visits related to hormone replacement therapy. When I first started practicing several years ago, that was really not the case, and so we really had to encourage patients to use prescription discount programs, but as things have gone on, we have found that more and more companies are paying for Testosterone Cypionate, which is used for the masculinizing process.

Now, I will say most of them are still only paying for the injectable medicine. However, I have had several clients be able to access topicals and patches through their insurance, and of course they’re going to be subject to the same tier pricing as they would if they were cisgendered or biological males. However, some people who are able to afford that do want to go ahead and move in that direction.

We’ll go into like the initiation of hormones on another day, but it’s important to note that I really rarely start off anybody in a transition with topicals. So most people who are looking at topicals have been on hormones for a long time, but again, we’re going to go into all of the masculinizing and feminizing processes in much more greater detail in another episode. So today I just really wanted to touch over these few things as an intro to HRT.

The other thing with insurance coverage is most of the time all the visits are covered, because we’re just billing a regular medical visit. Every now and then we will get a rejected claim because we’ve used the dysphoria code to claim … To code the visit, and when that happens we just use other comorbidities that are going on and try to avoid using that dysphoria code for the actual visit. But it doesn’t happen very often anymore. It definitely used to happen a lot more. So I try and remind my patients, even slow progress is progress.

GoodRx Drug Savings Card

There was a time where everything was cash pay. As far as the prescription savings programs, most of my patients we direct to GoodRX when their medications are not covered. That is goodrx.com, so all this information too will be posted underneath the podcast online, if you did not get an opportunity to write anything down. But yeah, so most of my patients are able to get their medicines pretty affordably.

Now, I can’t speak for other areas, but here in Atlanta, Georgia, and even outside of Atlanta, most of the time Publix and Walmart offer pretty deep discounts with those savings programs, to where 90-day supply should be around $30 or less. Every now and then I get patients saying that their medicines were way more than that and so I get online with them and we sit down and we find the coupon that’s most appropriate to reduce that cost.

That’s if they do not have insurance coverage or if their insurance is declining coverage for it. The most expensive one really is the Estradiol Valerate, which is the injectable estradiol, which is another reason why I kind of shy away from heavy use of that medication because the oral estrogen is so affordable and it’s so easily accessible. However, it’s not going to work that well if people will have a hard time being adherent to their medications and remembering to take pills multiple times per day, which I understand can be a true struggle, especially with fluctuating work schedules, school schedules, and everything else that everybody else has going on. However, when they can adhere to the pills, it usually results in a great, effective transition at a fraction of the cost. The other issue with the estradiol valerate, I don’t have a lot of insurance companies paying for it.

I’m not sure if there’s other providers out there that would want to email and chime in on how they’re getting that covered. I do have some people getting it covered, but then the other issue and barrier with injectable, or what us in the field called EVIM, estradiol valerate intramuscular is it often goes on back order because of the oil that they compound the medication with goes on back order and so there’ll be periods where patients are calling us my pharmacy doesn’t have it in stock, I’m not sure what to do. And so often even when patients are on the injectable, they’ll find themselves going through periods of having to be taking the oral pills just because the other was unavailable.

Other thing with insurance coverage is when people are establishing care with me at Druid Hills Primary Care here in Atlanta, most of the time patients find me through my website and so they’ll reach out via the contact form and so we’re able to email them back with full detailed explanation of what they need to be doing prior to their first visit. And that would include calling their insurance company and asking them if they pay for any services related to the ICD 10 code F64.0, that is the gender dysphoria code. And if the insurance company does pay for it, it’s then advised that the patients say, “Okay, are visits paid for? Is blood work paid for under this code? And are medications covered?” And at that that point, their insurance agent should be able to tell them exactly what the coverage looks like.

Insurance Coverage for Other Gender Affirming Procedures

Over the last few years I have more and more patients getting their gender affirming surgeries covered as well. Most of the times it includes vaginoplasty, bilateral mastectomy, or what we call top surgery, and then therapeutic orchiectomy. Unfortunately, the coverage for facial feminization surgery has still been spotty in my experience. I do have a few patients who we’ve talked through this process, they felt kind of left out when they’re saying, “Top surgery gets covered for trans men. Why aren’t they paying for facial feminization or FFS surgery for trans women?” And I kind of tell them it’s really hard because you don’t want to always have to be your own advocate, and sometimes you just want things to be fair. But it is an area that a lot of people who are developing healthcare insurance plans aren’t familiar with. They may not be aware that facial feminization surgery is a required and often desired surgery that would be medically necessary for someone undergoing a transition.

Talk to Your Human Resources Department About Coverage

So it’s not included under the benefits. So I have had conversations with my patients about going to their HR department and talking to the benefits coordinator about getting that included under their plan because, again, if they don’t know that it exists or that it’s medically necessary, then there will never be coverage for it. And I have written letters of medical necessity for those patients to be able to take to their HR benefits coordinator, and I’ve actually had really good results with that.

So unfortunately there’s a lot of people out there who are ignorant, just uninformed about the transgender life, and what surgeries are required for gender affirming surgeries and for the medical and surgical treatment of dysphoria. They just don’t know. And so sometimes it can be exhausting, but we have to advocate, and we have to educate, and we have to inform if we want insurance coverage to get better.

The other thing that insurance has been covering lately too for patients is phalloplasty. Now, phalloplasty historically’s been a less desired surgery than some of the others. Mainly because it’s such an extensive surgery, there’s not a lot of options to get it done at different places, you really have to find someone really good and who’s done a lot of cases for it, but also it’s a three stage surgery. But I have seen more coverage for that popping up. Although it’s probably the last surgery that most people get. I don’t have a lot of trans men who have gone on to get phalloplasty. But hopefully once the options change for that surgery and it becomes a little bit more accessible, then more people will be able to acquire that surgery.

Okay. So now that we’ve covered informed consent and insurance coverage, for those of you who have just started listening, I do recommend you hit the rewind and go back and listen to that really good content.

Will You Get Hormones on Your First Visit?

We’re going to move on to will I get my hormones on the first visit? When I’m reading the emails that come in from my patients, that is probably the one of the first questions that everybody asks. They’ve waited this long, so how much longer am I going to have to wait? Are they going to have to wait three visits, four visits?

The answer to that is at our clinic, Druid Hills Primary Care Dr. Smiddy and myself have always tried to really allow access, but also in a safe way. So yeah, the majority of the time people are leaving with a prescription for their hormones. The only caveat to that, and really the only reason why we would, quote, withhold the hormones is if we had some concerns about the patient’s health and really needed to wait on blood work to return before they started using their hormones.

Get Established With Your Pharmacy

Now when we’re prescribing the oral estrogen and the spiral lactone for the feminizing process, yes, those patients leave with a paper script so that they can … If their insurance is not going to pay for it, they can look on GoodRX, The prescription savings program that I mentioned earlier, that’s goodrx.com, and what they do is you just type in your hormone, the amount that it’s going to be dispensed, which I usually give a 90 day supply on that first visit, and it will pull up all the pharmacies and how much it costs near you.

So that’s the whole reason why we did the paper prescription. It allows people to get established at a pharmacy that they can afford.

Need for Testosterone Injection Training

For Testosterone Cypionate, that one is a little bit trickier because people need to know how to inject it. So there was a time where we were doing injection training on that first day and then they were leaving with their prescription and going home and a week later giving them their first shot, or their second shot rather, because they would get the first shot in the office.

But we ran into a lot of problems with that mainly because even if I’m writing a certain type of needle or syringe, the pharmacy was dispensing different types. And so there was a lot of confusion when the patient got home. Like wait a minute, this does not look like the same syringe that Erin and her nurse showed me how to use. This is confusing. So we adapted the way we do things.

And so now on that first visit, yes, people do get a prescription for it and then they get it filled, and as soon as they have their medicine, they call the office back and schedule an injection training only visit. We’ve found this to work a lot better because then people are getting used to their own equipment that they’ve been dispensed at the pharmacy, and we can educate them. And really the hardest thing I think for people is just the hand coordination of drawing up the medicine and learning how to give the shot.

For Patients Averse to Needles

I mean, there’s definitely a lot of needle-phobic patients and so either they tend to learn how to do it themselves or it’s totally okay for someone to come with them to their injection only appointments. And that will be sometimes they come in and they get trained on how to do it and then they go home, decide, “Yeah, I don’t want to do this. I think I’m going to go into the office and get my injections every week.” And that’s also another option. It just depends on the person’s situation. If they’re really needle-phobic, after several shots often they get more comfortable with it, especially if you’ve had a few successes.

Reasons You Might Not Receive Hormones

But yes, to answer the question, people will get hormones on their first visit, probably about 95 to 98% of the time. If I have serious health concerns about somebody’s liver function or kidney function or they have a list of other health concerns, then sometimes we do wait for the blood work to come back before we give the hormones, mainly because we need to make sure that you’re okay.

But however, again, that is the least likely scenario and more common than not, people do leave with their prescriptions on that first visit. And again, if you have an injectable medicine, you will come back for injection training, make sure you’re really comfortable we give you the sharps container, and then most people follow up within two months of starting hormones so I can check their blood work. So that was just a brief episode just to kind of go over the top three things that I hear the most about the road to HRT.

It’s really hard to kind of say, “Okay, well, where do we start?” When we’re talking about a transitional process. And I think those three things were really good to start with, and in later episodes we’re definitely going to talk in way more detail about the feminizing process, the masculinizing process, and then in other episodes we’ll address too surgical options and all the other things that go into having a good healthy transition. And each of those episodes will probably have their own dedicated episode just because there’s so much to cover.

Informed Consent for Non-Binary Patients

And we’ll also be talking about non-binary care and low dose hormones. Yes, it is a thing. People who are non-binary or gender fluid and gender queer, who don’t want to have a full transition, yes, there is an option for you. I have a lot of patients who I treat with this option and they’re very happy and it’s affirming and so don’t feel like just because you don’t want to have a full transition and you don’t want to have strong male or female physical sex characteristics, then it doesn’t mean that you’re not included in this. You’re totally included in this, and that’s part of the nice thing about Druid Hills Primary Care, and the services I’m able to offer folks. We are able to adapt a hormone replacement therapy treatment plan that suits you.

Get More Information on Informed Consent HRT

So if anybody else has any questions or concerns or they want to add to that or if there’s any other topics you want to hear about or hear from me about, please email me at erin@exclusivelyinclusivepodcast.com. Again, that is erin@exclusivelyinclusivepodcast.com. And just as a friendly reminder, I do monitor those emails, but I’m mostly unable to send out personalized responses.

So if someone is looking to establish care, you need to contact me through my website and send out a contact form and the staff will be in touch with you about getting all that information and getting you a new patient appointment as soon as possible. Well, thanks everybody, and I’m so excited to record another episode with you guys, and look forward to next time. Have a great day.