Integrated Behavioral Health Clinical Pathway Proposal: Transgender-affirming Care in the United States

Home » Integrated Behavioral Health Clinical Pathway Proposal: Transgender-affirming Care in the United States

By: Jeremy Henderson-Teelucksingh, DBH Program student at Cummings Graduate Institute for Behavioral Heath Studies, written for the course DBH 9021: Women’s Health

Transgender people experience a gender identity different from their sex assigned at birth (Baker & Restar, 2022; Valente et al., 2022). Transgender is an umbrella term that often includes additional gender identities; however, some gender-nonconforming people prefer to use more precise terminology to identify their gender (Mason et al., 2022). Herein, transgender healthcare refers to the healthcare practice and experiences of transgender people, not those who identify as non-binary, genderqueer, agender, and other gender-nonconforming identities.

Expressing gender characteristics inconsistent with one’s sex assigned at birth is common and natural (Coleman et al., 2022). According to the Williams Institute, a research group at the University of California, Los Angeles School of Law, approximately 1.6 million people in the United States identify as transgender. Of this total, 1.3 million are adults (Herman et al., 2022). Across the United States, transgender people belong to all racial and ethnic identities. However, transgender people are less likely to report a Caucasian racial identity and more likely to report a Latinx identity (Herman et al., 2022). Of the 1.3 million adults reporting a transgender identity, Herman et al. (2022) estimate that 38.5% are transgender women and 25.9% are transgender men. Additionally, these researchers indicated that younger people aged 13 to 17 are more likely to report a transgender identity than older adults (Herman et al., 2022), which may signify the cultural, legal, and healthcare advances in the United States. Baker and Restar (2022) make clear that transgender people may seek gender-affirming care, thus requiring clinical pathways to support transgender people across the lifespan. This research seeks to identify the most effective integrated behavioral health clinical pathways to deliver effective, efficient healthcare to the transgender population.

Transgender-affirming Healthcare

Inherent in transgender-affirming healthcare is the transition from gender identity associated with one’s sex assigned at birth to the gender identity of one’s experienced gender. The transition is divided into social transition and medical transition. However, a transgender person’s transition is non-prescriptive and follows no standard plan since transgender-affirming healthcare depends on the patient’s goals (Baker & Restar, 2022). The University of California, San Francisco (UCSF) is considered a leader in transgender healthcare in the United States. UCSF (n.d.) includes hormone therapy, hair removal, speech therapy, and fertility preservation in the medical transition and demonstration of gender identity in public, gender identity verbalization to others close to the patient, and legal document confirmation of gender identity in the social transition. Baker and Restar (2022) add the rejection of internalized transphobia and gender-affirming surgery, such as facial, chest, and genital surgeries, to the transgender transition process.

The World Health Association for Transgender Health publishes Standards of Care, which defines quality transgender healthcare. The Standards of Care is in its eighth version (SOC8). The SOC 8 identifies social support and stress management as crucial to the success of a transgender patient’s transition (Verbeek et al., 2022). Because transgender patients can lose the support of important people in their lives (Mezzalira et al., 2023), including social support opportunities and coping skills is crucial to the successful transition of transgender patients (Verbeek et al., 2022).

Inclusive Clinical Healthcare Settings

Healthcare clinics provide the environmental context in which transgender-affirming care is delivered. As a result, a focus on transgender-affirming healthcare training and inclusive practices is necessary (Mason et al., 2022). With first contact with any given healthcare provider or clinic, patients are often required to complete paperwork. Forms that include the patient’s legal and preferred name, pronouns, sex assigned at birth, and gender identity are considered inclusive and can help to develop a productive patient relationship starting with treatment initiation (Ingraham et al., 2022). Furthermore, once patients have disclosed their identities and expectations via inclusive forms, Mason et al. (2022) reinforce the importance of using their gender identity, preferred name, and pronouns when addressing the patient.

Reisner et al. (2016) identify two healthcare practices that have successful models for treating transgender patients; Callen-Lorde Community Health Center in New York and Fenway Health in Boston. Both pract

ices use an informed consent model, which renders transgender clinical documentation by a mental health provider an unnecessary barrier to transgender-affirming healthcare delivery. Although the Callen-Lorde Community Health Center clinical pathway was not discoverable, Fenway Health’s clinical pathway is available in Appendix D (Thompson et al., 2021).

Family planning offers patients an additional clinical setting where transgender-affirming care can be delivered. In a national study, transgender patients reported satisfaction with the transgender-affirming care they received at family planning clinics (Ingraham et al., 2022). Study participants reported surprise with the use of informed consent and the ability of clinic staff to support their healthcare needs. However, barriers to care in rural areas still exist (Ingraham et al., 2022).

Ingraham et al. (2022) described increased transgender-affirming care provided at family planning clinics over the past ten years. However, the authors cautioned about seeking care from Catholic-affiliated family planning providers because these establishments often deny care to transgender people. Ingraham et al. (2022) noted that Catholic providers are often banned from providing transgender-affirming care. This prejudicial denial of care limits access to care.

Additional Barriers to Care

Barriers to transgender-affirming care are built into the medical and insurance healthcare system, primarily based on the binary view of gender (Ingraham et al., 2022). To provide quality care to the transgender population, many clinics utilize policies and practices that circumvent barriers to transgender-affirming care (Dowshen et al., 2019). The ingenuity of the professionals who utilize mechanisms to overcome the binary system to find solutions to care delivery deferrals likely saves lives. Treatment delays are associated with worsening mental health symptoms, such as suicidality (Verbeek et al., 2022).

According to Healthcare.gov (n.d.), doctors are tasked with determining medical necessity, and insurance companies are prohibited from limiting sex-specific services because of the patient’s transgender identity. However, to access transgender-affirming care, such as those healthcare services described above, insurance companies often require clinical documentation from mental health professionals, which can serve as an additional barrier to treatment (Baker & Restar, 2022). Some insurance plans expressly exclude some or all aspects of transgender- affirming care (Healthcare.gov, n.d.). Because of variances in health insurance coverage, the National Center for Transgender Equality (n.d.) advises patients to fully understand the specific requirements of their plan to ensure the patient can receive treatment and share the policy with the appropriate providers to fulfill plan requirements.

Read the Full Paper

To read the complete paper by Jeremy Henderson-Teelucksingh, DBH program student at Cummings Graduate Institute for Behavioral Health Studies, visit: Integrated Behavioral Health Clinical Pathway Proposal: Transgender-Affirming Care in the United States.

About the Author

Jeremy Henderson-Teelucksingh, MA, MHR, LPC/MHSP, NCC, CCMHC

Jeremy Henderson-Teelucksingh, DBH Student at Cummings Graduate Institute for Behavioral Health Studies, is a counselor, leadership and management coach, and corporate and community human relations consultant. Jeremy brings passion, innovation, and creativity to his clients to enable them to live fulfilling lives. As a counselor, Jeremy works with adults, couples, and families, focusing on anxiety and anger, trauma, personality disorders, relationships, and issues related to adoption and foster care. Jeremy works with the LGBTGEQIAP+ community and is an “out” counselor with a history of diversity, equality, equity, inclusion, and belonging advocacy.

Before becoming a clinical mental health counselor, Jeremy spent nearly 20 years in the technology industry. Jeremy was frequently the first-ever employee engagement leader guiding the employee, manager, and leadership experiences at companies like Salesforce, eBay, VeriSign, and Aricent (now Capgemini). Currently, in addition to providing mental health services, Jeremy serves as Chief Operating Officer at Centro Health Solutions, a Nashville health tech start up creating a better way to healthcare by putting the patient at the center of their healthcare experiences and wrapping their providers around them.

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“As a member of the AAPI community, I’m very familiar with the barriers to mental health services and the need to break through the glass wall of cultural stigma that prevents many from receiving potentially life–saving treatment. I was the only Asian American person in my master’s cohort, the only Asian American person in many of my clinical work settings, the only Asian American person to walk into many of the professional settings that I pushed myself to show up to. In my current practice, I’m constantly reminded by my patients of how difficult it is to find an Asian American mental health provider, though this reminder constantly informs me that more needs to be done for my community. Day after day, I read stories of Asian American people who die by suicide as a consequence of our culture’s avoidance of mental health topics. As a DBH, my biggest goal is to use my expertise in whole–person care to amplify the conversation around mental health and help my community understand that mental healthcare is not a privilege that we are not entitled to, it is a crucial part of our healthcare that will manifest differently in us than what many Western psychology or psychiatry textbooks will describe, and that our unique experience of mental health issues are valid, important, and is time to be part of the larger conversation.”
Willam Chum, LMHCDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - September 16, 2022

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Brandy K. Biglow LMHC, CCTP, QSDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - February 5, 2024

“The Doctor of Behavioral Health (DBH) program has definitely transformed my understanding of behavioral health. Understanding the links between physical and mental health has taught how to make better treatment decisions. The DBH program has also given me insights that otherwise would not be possible and allows me to view individuals through a lens that I was previously ignorant of. This program has helped me grow into a more confident individual, provider, and parent.”
Cory H. Cannady, BCBA, LBADBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - March 13, 2024

“The DBH program has been a pivotal turning point in my understanding and application of behavioral health principles. Recently, the concept of ‘whole person health’ has gained widespread attention in healthcare circles, becoming somewhat of a buzzword. Like many others, I embraced this term, believing in my capacity to deliver comprehensive care.

Prior to my engagement with the program, my approach, albeit well-intentioned, lacked an appreciation for the intricate interplay between physical and mental health. More importantly, the role of unmet social needs as a catalyst for health disparities was a dimension I had not fully integrated into my practice. The DBH program illuminated these connections, offering me a robust framework to understand and address the multifaceted needs of individuals, especially within marginalized communities.

Additionally, the confidence I have gained through the DBH program extends beyond theoretical knowledge. My role as a connector and advocate for these individuals has become more pronounced, driven by a deep-seated commitment to fostering accessibility, equity, and comprehensiveness in care.”
Michelle Stroebel MA, NCC, LCMHC, NADD-CCDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - June 12, 2024

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Trina K. Ita, MA, LPCDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - July 10, 2024

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Michelle Francis, LCSW/LICSW-QSDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - September 10, 2024

“The DBH program’s mission, purpose, and objective say it all: We strive for intentional care outcome improvement practices that exemplify whole person-centered integrated healthcare advanced competency. The program of study drives insights and awareness of the ever-changing patient population and multidisciplinary practice environments to change how the world experiences healthcare. This is further reinforced by the pillars of medical literacy, integrated behavioral health intervention, and entrepreneurship skills and expertise. Development growth is needed to prepare the aspiring DBH for the future of the shifting healthcare marketplace through international networking in a growing community of disruptive innovators and an evolving movement toward systemic healthcare change. I feel that I will be positioned alongside a fellowship of like-minded professionals trying to improve the quality of healthcare service delivery value and outcome sustainability.”
Jose Mathew, LCSW, LAC, ACS, EMDR-T, CCTP-IIDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - October 8, 2024

“The DBH program has reinforced my vision of viewing behavioral health (BH) as an integrated component of the healthcare system rather than a siloed service. As a practitioner in the focused BH realm of substance use disorder (SUD) treatment, I observe on a regular basis how identifying and serving SUD patients is often missed, ignored and stigmatized in primary healthcare, despite the fact that early intervention at these check-points often has the potential to intervene earlier and lessen the negative SUD outcomes frequently seen by the time a patient reaches specialty SUD services. Reinforcement received in my DBH program has motivated me to promote integration as a leader in my workplace and is a primary factor in considering the long-term trajectory of my individual career path.”
Kenneth L. Roberts, MPS, LPCC, LADCDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - November 5, 2024

“By becoming a DBH, I have found that I am able to have different conversations with different people. Before having my doctorate degree, I was able to speak to certain items in behavioral health, but was only seen as a licensed therapist where as a doctor, I am able to speak to the changemakers and policy makers in a more collaborative manner which then allows us as a group to enhance the services we are providing. I also found that as a DBH, my confidence in the treatment room has improved immensely and cases that may have been more difficult for me before are no longer as difficult due to the training I have received in the program.”
Dr. Allison Earl, DBH, LPC-SDBH Alumna, Cummings Graduate Institute for Behavioral Health Studies - November 13, 2024

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Jason P. Sargent, B Policing, GDip Psych, MSW, JPDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - December 10, 2024

“Graduating from the DBH program has influenced and enhanced my approach to addressing behavioral health challenges and making a difference in the field by preparing me to become a serious business owner. Through the DBH program, I understand now that becoming a business owner not only assists me in reaping the financial benefits of working for myself, but the program also offers me a sense of freedom to make a difference in an individual’s life.”
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Elizabeth Nekoloff, M.Ed., LPCC-S, NCCDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - January 16, 2025

“Prior to obtaining my DBH, I practiced behavioral health within the boundaries of behavior analysis. The DBH degree has given me the ability to broaden my scope of competence allowing me to provide a higher quality of care to my clients through a person-centered approach, while still staying within my scope of practice. I was in the beginning stages of opening my business when I enrolled in the DBH program which set my trajectory towards being a stronger leader. The program equipped me with essential healthcare leadership and entrepreneurial skills, allowing me to ensure high-quality services for my clients and foster a supportive work environment for our staff. It has also given me the confidence to expand my business and pursue other healthcare ventures, reaching a broader range of patients in need.”
Dr. Pauline Tolentino Pablo, DBH, BCBA, IBADBH Alumna, Cummings Graduate Institute for Behavioral Health Studies - January 21, 2025

“Although I have worked with many patients who have mental health diagnoses, or behaviors which make managing their medical diagnoses and day to day life difficult, the DBH program at CGI is broadening that knowledge and providing a deeper understanding of behavioral health and how best to help these individuals manage their health and improve their quality of life. This will allow me to provide and advocate for more meaningful and seamless integrated care, providing new tools for my intervention toolbox, and the confidence and skills to collaborate within and lead whole person focused interdisciplinary teams. I also anticipate building upon my knowledge as a nurse case manager and long time caregiver, as well as my personal passions and professional vision, learning about processes and operations, to be in position to start up and lead my own company one day, offering the services and care I know every person should have access to.”
Hollie Wilson, MSN, RN, CCMDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - February 11, 2025

“The Doctor in Behavioral Health (DBH) program has changed my understanding of the subject and career path. Before this academic journey, my knowledge of behavioral health was primarily theoretical, including essential ideas and methods. However, the DBH curriculum combined intense academic research with practical application, helping me understand behavioral health from multiple angles. Recognizing mental health as part of total health changed my perspective. The biopsychosocial model, which showed how biological, psychological, and social variables affect mental health, was stressed in the DBH curriculum. This comprehensive approach made me realize how complex human behavior is and how important it is to address mental health issues. Effective interventions must target the individual’s surroundings, relationships, and life experiences, not just symptoms. The curriculum also gave me enhanced evidence-based practice training to execute successful solutions. Studies methods and data analysis classes improved my critical thinking and allowed me to evaluate and apply behavioral health studies. This gave me the confidence to contribute to the field’s knowledge base through practice and research.”
Dr. Rhea Hill, DBH, LPCDBH Alumna, Cummings Graduate Institute for Behavioral Health Studies - February 17, 2025

“The DBH program will open opportunities for me to contribute to healthcare system innovation, particularly through trauma-informed care and integrated behavioral health settings. I will be better positioned to advocate for and implement holistic care models that improve health outcomes for underserved populations. Ultimately, this program will help me transition into higher-level roles, such as a director or consultant in behavioral health, where I can influence broader system changes and contribute to the future of healthcare delivery.”
DeKyn Rashad Peters, MPH-CHES,BSW/BA,APCDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - March 4, 2025

“The DBH program has been integral in preparing me for leadership roles by providing a solid foundation in both the theoretical and practical aspects of leadership within the behavioral health sector. Through coursework, case studies, and hands-on experiences, I have learned to lead with empathy, data-driven decision-making, and strategic planning. The program has also honed my skills in organizational development, communication, and policy advocacy, equipping me to effectively lead teams, drive impactful change, and foster environments that promote positive behavioral health outcomes. With this training, I am confident in my ability to lead initiatives that address systemic barriers and improve care delivery.”
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