Joey Wahler (Host): It's a crucial part of healthcare for the LGBTQIA community, so we're discussing transgender and gender diverse health equity. Our guest, Jackie Levin. She's a Registered Nurse, also Patient Advocate, and Transgender Care Navigator at Jefferson HealthCare. This is To Your Health, a Jefferson HealthCare podcast.

Thanks so much for joining us. I'm Joey Wahler. Hi there, Jackie. Thanks for being with us.

Jackie Levin, MS, RN, HWNC-BC: Thanks for having me.

Host: Great to have you aboard. So first, tell us what's meant by health equity in the first place, especially in this case for the LGBTQIA community.

Jackie Levin, MS, RN, HWNC-BC: Yeah, thanks. So, equity actually is a step that we're in the process towards health justice, and I just want to talk a little bit about what that is, and in the world of looking at inequality, equality, equity and justice, sometimes we use a image of an apple tree and the apple tree, in the inequitable system is half the tree is full of apples and the other side has no apples and that's an inequitable system and that's where we started over 10 years ago in this inequality, inequitable system.

We started with a transgender patient calling our patient advocate line, describing an experience she had had in our emergency department. And she had, arrived with a clinical condition, and the nurse kept referring to her as sir. Over and over again, sir, let's do this, sir, let's do that, and the patient said, please, just use my name.

And today, we hope that would not happen with what we've done on this 10 year journey. That patient became our biggest supporter and partner in our journey towards health equity and our journey towards justice. So where we are now in terms of equity; we have trained many providers in gender affirming care, where we were then as patients were in the sense of equity, inequity, equality, and justice.

Where we were several years ago was our patients, didn't have access to providers who knew how to offer them hormone replacement therapy for our transgender patients.

 But they were giving hormone replacement therapyto people with menopause or low testosterone, so we knew how to use that medicine. We knew how to prescribe that medicine just not for this particular population. And so we made a big effort to get many of our providers trained in gender affirming care and now have many more providers our transgender patients have access to. And so I think justice would be that every provider, health primary care provider could do that.

Though I would say it's no different than, let's say somebody has diabetes, our primary care providers can diagnose diabetes. They can provide medications for uncomplicated diabetes, but if somebody had more complex needs, we would be referring them to an endocrinologist.

Host: So you're talking here about justice as you put it, equity, acceptance really, making people feel at home, welcome, as though this is where they want to be. So, in your role as patient advocate and transgender navigator, how do you and yours make that happen?

Jackie Levin, MS, RN, HWNC-BC: That's a great way of framing it, and that is exactly what we're working to do, is make our organization feel welcome, make it feel as if everyone belongs, and that we're increasingly making it feel inclusive. So what we're doing is we, as we said, we just trained many providers. We have worked with our local transgender and LGBTQIA community, in a task force.

So one of the first things we did was create a health equity task force, and now we've more specified that to the LGBTQIA task force. We had community members as well as staff members. We met, regularly, irregularly as we could, addressing issues that were being requested by our community. So the first thing that we began to do was look at our health medical record.

The electronic medical record. And that didn't have a place for people's pronouns. It didn't have a place for people's sex assigned at birth versus their current gender identity. It didn't have a way for us to make those updates. And we had a team from our clinical informatics, work with the electronic medical record host of Providence, which is Providence Health Care, that to add those fields, and that has become the norm now. Ten years later, those are in medical records. We can do that. We can put in people's sexual identity, their orientation, their sex assigned at birth, the organs that they currently have, so that we can start from that base with that. We also started to do pronouns. Our own pronouns. We wear buttons on our badges that announce our pronouns.

We are putting them on our electronic signatures, in our emails. We're adding them to our provider pages. This is a way of showing respect that we know what somebody looks like on the outside or how they present on the outside may not be how they present on the inside.

Host: Interesting, so it sounds, Jackie, as though, it sounds like you've certainly filled in a lot of gaps, if you will. So what services does Jefferson Healthcare provide for the transgender community? You mentioned hormone therapy, what else?

Jackie Levin, MS, RN, HWNC-BC: Well, I think basically we recognize that every person has you know, the same needs. So what we're working on is making sure that our, specifically our transgender patients know how to find the care that they need from providers who are knowledgeable. So again, that went back to training, but we're also, as a transgender navigator, we have a lot of new people moving into the area, which is wonderful, and they call and look for providers, so I help navigate them to our providers.

I help them also navigate resources. We are training our staff with regular education at New Employee Orientation. And we're also partnering with a local trans man, Beau, who does quarterly Lunch and Learns for us. He and I do national and state presentations to help other organizations begin this journey.

And the journey began, if I'll go back to at the same time as our first transgender patient called our office, the CEO, Mike Glenn, had noticed an award called the Health Equality Index Award, and he wanted us to go for it. So, we applied. It was, not a very rigorous application to begin with. It required just a little bit of education, but every year it's become more and more rigorous with more and more expectations. And it is a roadmap of really good equitable care, care leading to justice. And so every year we've done more and more things to help bring that about.

 We participate in our local pride event, which just happened last weekend. We have a booth. We've had a booth there for many, many years. And, answering questions about what we can do to better serve our community.

Host: And you beat me to the punch there, Jackie, because I'm, I was going to ask you about that recognition. I'll ask you a little bit more about it in just a moment or two. First, let me go back for a moment to the fact that many transgender patients, of course, do seek hormone therapy. I mentioned it a moment ago. If you could talk a little bit more about what support you provide for those patients, because that's often a big part of their journey in healthcare, right?

Jackie Levin, MS, RN, HWNC-BC: Yeah. Well, it it is for many and not for all, certainly. The providers that we have trained help people find other resources. So if we don't do, reconstructive surgery at this time, we don't have the staff resources for that, but we do hope that's on our horizon. We will be looking at that.

We're building a new surgery center. We do hope that we'll get more team members on board and that we might be able to begin offering that. We send them to our local community resources that Beau leads a lot of that in the community, so that we can help them find them outside of Jefferson Healthcare.

We don't offer electrolysis, so we help them find local people who do that. I recently had a phone call for a vocal course, coaching, vocal coaching, for a transgender patient. I don't believe we have one in our local community. So this might be something that we begin to look into to see, gosh, is there anybody who's doing vocal coaching now in our community who might be interested in getting additional training so that this can be something that we offer here and people don't have to go, over the bridge, as we say.

Host: Now, you mentioned earlier that often these patients are looking for the same health care that the rest of the community is, but of course, in addition, some health issues can be specific to transgender patients. So, what are some of those?

Jackie Levin, MS, RN, HWNC-BC: That's a great question. I don't know that I have an answer specifically. What we want to do, I'll just back up for a minute, is to make sure the environment that they're walking into feels inclusive and welcoming so that they can talk about whatever issue they would like. So several years ago I had a couple, one of the patients was a transgender patient who wanted to get pregnant. They were asking me all kinds of questions about where they could go to begin this process of going off their hormones or becoming pregnant.

And I said, well, have you talked about this with your primary care doctor yet? I'm sorry, back up. They needed something signed in order to be able to get some particular care outside of our area. And it would have been signed by a primary care provider. I said, well, have you talked to your primary care provider about this?

And they said, no, I've been seeing them for a couple of years now and I've never told them I'm trans. So I thought, Oh, well, we need to do a little work in the back end of this. So I reached out to them. I said, is it okay if I let your primary care provider know and that you'd be reaching out to them? And they said, yes.

So it's helping navigate a system more than what the healthcare needs are, that it's more of making sure that the communication pathways are open so that people can have honest and open communication about what they're looking for, for their health. And then we can find the resources that they need if we can't provide it.

Host: Gotcha. Now, as for many people in general, of course, Jackie, mental health, a big need for the transgender community. So, what does Jefferson Healthcare provide there?

Jackie Levin, MS, RN, HWNC-BC: Well, we have what we call an integrated behavioral health system where behavioral health is integrated into our primary care. And we have social workers, we have psychiatric support as well. And so if people are needing support in that way, we refer them to our mental health providers.

 Also we have a resource page with mental health providers in the community who also specialize in working with transgender children or other transgender people, adults. So we'll refer out. If we don't feel that we can, we have a resource that we will refer to.

Host: A couple other things, as you mentioned earlier, Jefferson Healthcare recently won a Healthcare Quality Index Award. First, congrats on that. What exactly was that for? What does that mean? And what's the significance of that for you and yours?

Jackie Levin, MS, RN, HWNC-BC: Yeah. Well, I think it's an organization, we are not a checkbox organization, so it's not something just to go, oh, here we have this award. It becomes, as I said, the journey that we enter. When we are going for an award like this, we're saying, what are the needs in our community and how can we better address them? How can we become more inclusive? And the Health Equality Index Award has several categories that you must meet and you must achieve 100 percent in order to receive the award. And part of that is, how are you working with the community? What are you doing for patients? And also, what are you doing for your staff? o One of the things that we're working on this year is how we are going to be better meeting the needs of our staff, especially if we have a staff who is transitioning from one gender to another in the external presentation or even internal presentation and how we can make that an easier process for them and a more respected process and a fluid process.

One of the things that we had to do is make sure that we had all gender bathrooms. Not just ones that are labeled for men or ones labeled for women. And recently we are under construction. We were at our Pride event and I had a community member come up to me and say, you know, with the reconstruction, we lost those all gender bathrooms.

 And I said, Oh my gosh, that's right. So that was like, thank you. And now I'm going back to the team to say what, is there any way we can convert something in the meantime? So the idea is that we are not perfect by any means. I think with the Health Equality Index Award, what it says is, and they're always including more and more, is to say this is a journey.

This is not something that we know we'll ever achieve in perfection, and we don't want to be perfection. We're not reaching perfection. We're reaching cultural humility and inclusion. So that would be our journey is to make sure that we hear things, we are willing to open our eyes to see them, and then make adjustments so that we do better.

Host: And so in summary, Jackie, it seems to me like what you're really saying is that the work you're doing here with this community, it's old yet new in the sense that you're taking many things that the rest of us consider run of the mill, but that these people have been lacking, haven't been offered in a healthcare setting. And so in that sense, you're turning what's been around for ages into something new for many of them. And I wonder, what part of that is most rewarding for you?

Jackie Levin, MS, RN, HWNC-BC: Yeah, it makes me a little emotional. It's, it's that healthcare in itself is not an equitable system. I mean, it's across the board, and I think what is most rewarding is that every patient has a voice. They're able to express it, that they're treated with respect, that they're part of the team, and that, we recognize that we are not always the ones with the answer and that we can look to our community and involve our community as the ones who partner with us in making healthcare more of a just place, a more welcoming place, and a place where they can feel like they can share who they are, and get the care they need.

Host: Well, Jackie, I think you've done a great job of delivering that message. And I'm sure people can feel the passion that you have for what you do. It's great to see. And folks, we trust you're now more familiar with transgender and gender diverse health equity. Jackie Levin, a pleasure. Keep up this great work and thanks so much again.

Jackie Levin, MS, RN, HWNC-BC: Thanks for having me.

Host: Absolutely. And for more information, please visit jeffersonhealthcare.org. Again, that's jeffersonhealthcare.org. If you found this podcast helpful, please share it on your social media. I'm Joey Wahler, and thanks again for being part of To Your Health, a Jefferson Healthcare podcast.