VUMC
So I wanted to share an update on what's happening at Vanderbilt, to my understanding. Disclaimer that I am not a lawyer and don't know the internal discussions at play. But I do have a background in healthcare and I am currently between stages 1 and 2 with this team. I know that people are very upset and I don't want to invalidate any of that. It's a time of severe upheaval for me as well; I can't overstate how disruptive this is for my life right now. What I do hope is that I can explain, based on my understanding, some of what's happening. I know a lot of other people here are working on this and welcome them to add or correct anything I say here.
For those who don't know, in February Vanderbilt announced they are ending their gender affirming surgery program. They are a major center in the south. It's a huge blow.
At the time, there was a lot of speculation about why the program was ending - whether Vanderbilt pulled the plug, the surgeons jumped ship, or what. It has now become much more clear: a bill was working through the Tennessee legislature that has been called the "trans tracking" bill. That bill passed earlier this month and was signed into law. To be blunt, it is intended to make it impossible to provide these surgeries. It is now clear that the program is closing because of this law and the harsh penalties it will level against doctors and facilities unless they violate fundamental patient privacy.
The law says that providers who work at "gender clinics" must report information to the TN state department of health that will be added to a registry, some of which will be made public. That data includes the age of the patient, surgery, diagnosis, previous surgeries, mental health diagnoses, and the doctor and facility's information. This is an egregious violation of patient privacy. It puts both patients and doctors in an impossible position, and is obviously intended to stop care completely. The law is also poorly written, fairly vague, and contradictory, and it's unclear if it just applies to surgeries or to all gender affirming care.
The penalty if a doctor does not provide this information to the state to be placed in the registry is 1) a 6 month license suspension and 2) a fine of $150,000 to the facility. That is an outrageous penalty. I don't think the law explicitly states this, but it would be reasonable to assume that this is a penalty per case. The goal of the massive fine is to make facilities police the doctors. For context, major healthcare laws like HIPAA and EMTALA are enforced through fines. The fine for a major HIPAA or EMTALA violation is usually in the ballpark of $20,000-60,000. As in, if a hospital turns away a patient from the emergency room and they die because of it, the hospital would be fined about $60,000. So I hope that makes it clear that $150,000 over providing data to the state is an astronomical penalty. In my limited knowledge, this kind of penalty over this kind of law seems unprecedented.
There has been a lot of attention to the privacy aspects of this law. But I want to highlight what this means for care. Very few doctors are going to willingly place their patients and themselves on a public registry intended to target them and to reveal protected health information; even with state carveouts for HIPAA, this seems legally dubious and certainly ethically dubious. On the flip side, it is not realistic to think that doctors will defy the law and provide care without reporting. Not only would they risk their license, they would be under immense pressure from their facility. Again, facilities comply with major federal laws because of fines less than a third of this size. The facility is not going to tolerate a doctor defying the law, so they would almost certainly be fired, ending care. Edit: And the facility has to be on board for a surgeon to use the operating room, inpatient care, etc. I really can't overstate how severe and disproportionate a penalty this law creates.
In this context, Vanderbilt's phalloplasty program is scrambling to finish surgeries for patients between stages before the law takes effect. They do not know how long that window is but estimate it will be by the end of this year. They use a staged approach where patients have graft creation in stage 1 and urethral lengthening in stage 2. They are trying to avoid leaving patients without care between stages 1 and 2 since that would be the most difficult time for another surgeon to take over. They are cancelling stage 1 surgeries because they do not think they will be able to complete stage 2 for patients who haven't already had surgery. It is a dire situation and the surgical team is basically working up until the last possible minute to complete as many surgeries as they can.
I am in limbo right now, basically ready to drop everything at any time for stage 2, and I really feel for everyone who has had their surgeries cancelled. It's a chaotic mess. Tennessee Republicans in the legislature are pure hate and evil. This law is cruel and pointless. At the same time, I am grateful that the team did the surgeries they did, and very sad to lose an excellent center in the south.