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Joshua Safer Part 3, Transgender Specialists in Endocrinology

In part 3 of this Exclusive Interview, Joshua Safer talks with Diabetes in Control Publisher Steve Freed about the number of transgender specialists in endocrinology that can be found, and more on the field overall as a specialty.

Joshua Safer, MD, FACP, is the Executive Director of the Mount Sinai Center for Transgender Medicine and Surgery in New York.


Transcript of this video segment:

Freed: As far as in endocrinology because you’re dealing with hormones, how many endocrinologists are really specialists in this field that you’re aware of?

Safer: The number of people who labeled themselves specialist in this field is very small. I’d say there are probably a dozen or so at this juncture. But part of my agenda and part of the reason why I’m talking here is because we all need to know this a little bit. Because wherever you are across the country, you are going to have primary care practitioners who are going to have maybe a handful of people who are going to come to them and say, “I think I’m trans,” or, “I think my kid is trans,” or whatever. And at some juncture that may be true and they may need some hormone assistance and the endocrinologist doesn’t have to be the big expert. If you’re just seeing the occasional person here or there, you don’t have to be the expert on the diagnosis or all the other pieces of it but you do need to know your hormones, that’s what you went through all your training for and that’s what everybody in the rest of your community is going to depend on you for and that’s the point of today’s talk.

Freed: So, if I wanted to get some — as a medical professional, if I wanted to get some information as to where to direct somebody, is there an association?

Safer: There is. There’s a professional association of transgender professionals called WPATH, World Professional Association for Transgender Health. There’s a US chapter which is actually a big chunk of the membership like you might expect, the US Professional Association for Transgender Health or US PATH. Those can be found on the web. And so, yeah, you can track people down. And then Endocrine Society has guidelines that came out in November, just the November revision along with AACE, the organization hosting today’s meeting which give some guidance and UpToDate, which is the online program that many physician use. It is [called] UpToDate, wouldn’t you know it’s not always up-to-date. And this subject though, it is up-to-date both with hormone therapy and with primary care therapy. So, for endocrinologists, those hormone chapters are current.

Freed: It kind of fits into the aspect of endocrinology because of the hormone aspect. Are most of these specialists endocrinologists?

Safer: Within the field of transgender medicine most of the specialists are still mental health experts and that’s because for so many decades this was considered a mental health concern. Mental health expertise is still important. These are very, very stressful situations. And part of our assessment, especially for kids, is making sure that there’s not something else going on. That it’s really just they’re transgender and not a mental health concern. So, mental health people have a big role but they’re still an out-sized fraction of the overall community from an era when we thought that’s all it was. And getting more medicine people whether they’d be primary care or endocrine specialists involved is actually an important thing. It’s an important gap in terms of being able to provide sufficient care for the people who are trans.

Freed: And most insurance companies are respectful in paying for these services?

Safer: In 2018, more and more insurance companies pay for these services. It depends on the state. I think we’re up to 18 or 19 states where insurance companies are obliged to provide transgender care. It would be considered discrimination if they did not. There are therefore a bunch of states where that’s still not the case. One thing I’ve noticed, living in two states where there is good insurance coverage for trans care, Massachusetts, where I’ve been working up until a few weeks ago, and New York where I just moved, that when that’s the situation, the insurance companies are not very worried about the cost. That is mental healthcare, primary care, endocrine care, hormones, are all relatively inexpensive interventions. The number of people who are transgender is much bigger than people realize but it’s still a relatively small fraction of the population. Even the surgeries that some transgender people have are not very expensive surgeries as surgeries go. So, the insurance companies that have come to me for assistance in their policies are pretty relaxed. It’s actually not a huge cost like some other medical concerns are. And so therefore, it’s just a matter sometimes of the states saying — it has to be and the insurance company saying, “Okay. Let’s get our wording correct, so we do the right thing.”

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