People who are transgender continue to face insurance barriers in accessing the health care services they need.

And those who lack access to insurance coverage for gender-affirming hormone therapy are more likely to turn to sources other than a licensed health care provider, compared to those with insurance coverage, a new Michigan Medicine led study finds.

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About 9% of transgender people, which translates to nearly 170,000 individuals, may access hormones from non-licensed sources like friends or online, according to the findings in Annals of Family Medicine.

"Transgender and nonbinary people face major barriers to insurance coverage for their needed care, with many people still lacking or being denied coverage for gender-affirming care," says lead author Daphna Stroumsa, M.D., M.P.H., an obstetrician gynecologist at Michigan Medicine Von Voigtlander Women's Hospital and researcher with the U-M Institute for Healthcare Policy and Innovation.

"Those barriers affect transgender people's ability to receive the care they need. Those who can't, may seek alternative ways to get their medications, which can increase their risks for negative health outcomes."

Not only may medications be unchecked for content, quality, formulation and dosing, but the use of non-prescription hormones likely means providers aren't as involved in monitoring hormone levels and mitigating potential harm, Stroumsa says.

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Researchers evaluated national data and found that 84% of the 27,715 respondents were interested in using hormones, while only 55% were using hormones. Overall, 3,362 (15%) of respondents were uninsured, compared with about 13% of all Americans at the time of the survey in 2015.

Among insured respondents, 21% reported that their claims for gender affirming hormones were denied.

Nonprescription hormone use was most common among respondents assigned male at birth, and differed by race. Among all who had interest in taking hormones, those who were uninsured were less likely to use hormones in general compared with insured counterparts, which experts say could negatively impact mental and emotional health.

Insurance ranks high on list of concerns for transgender population

When respondents were asked to evaluate the most pressing issues affecting transgender people in the U.S., they listed insurance coverage as one of most important (among 44% of respondents). It ranked second only to violence against people who are transgender.

Many major U.S. medical societies and associations, including the American Academy of Family Physicians, have issued statements in support of insurance coverage for gender-affirming care. Clear guidelines also support the provision of gender-affirming hormones for transgender people who seek them, which is associated with improved mental health outcomes.

But significant barriers to accessing these health services still exist, experts say.

For example, transgender people often face employment discrimination leading to un-insurance and those who are insured often encounter insurance policies with specific exclusions or barriers for coverage of gender-affirming therapy.

There are structural barriers too. These include high rates of homelessness secondary to stigma, rejection and discrimination, a lack of knowledgeable and supportive clinicians, and transphobia and direct discrimination in health care settings.

And while the Patient Protection and Affordable Care Act increased coverage for transgender people through a variety of mechanisms, regulatory and legislative changes are in constant flux, and have been threatened and eroded in the past few years under the Trump administration, authors say.

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"Transgender people face a host of structural barriers combined with barriers to insurance coverage that limit access to gender-affirming hormones," says senior author Caroline Richardson, M.D., family medicine physician at Michigan Medicine and IHPI researcher.

"These limitations may have broad implications for the health and safety of transgender people."

When people are unable to fill a prescription through a regulated process, Stroumsa notes, they are left with options that increase negative health risks.

"People who need hormones for gender affirmation may either turn to risker sources or forgo hormones altogether, which means losing the opportunity for affirmation and improvement in their mental health and well-being," Stroumsa says.

"Ensuring access to hormones can decrease the economic burden and greatly improve health and quality of life for people who are transgender."

Paper cited: "Insurance Coverage and Use of Hormones Among Transgender Respondents to a National Survey," Ann Fam Med. DOI: 10.1370/afm.2586