A trio of civil rights groups on Wednesday released a set of guidelines to help hospitals improve health-care access and outcomes for transgender people.

The guidance comes after the federal government strengthened nondiscrimination protections for transgender patients under Section 1557 of the Affordable Care Act (ACA).

The final rule to Section 1557—which builds on a history of federal civil rights laws—prohibits the “denial of health care or health coverage based on an individual’s sex, including discrimination based on pregnancy, gender identity, and sex stereotyping,” according to the Department of Health and Human Services (HHS). The rule mandates that covered health programs and activities under the ACA “treat individuals consistent with their gender identity.”

Wednesday’s publication serves as a revised update to a 2013 report coauthored by Lambda Legal, the Human Rights Campaign (HRC), and the Committee on Lesbian, Gay, Bisexual and Transgender Rights of the New York City Bar Association on best practices in transgender care. The report’s authors recommended, among other measures, that hospitals adopt nondiscrimination policies with regard to gender identity and expression, and amend their respective Patients’ Bill of Rights to provide for transgender patients, including the right to privacy, and freedom from abuse and harassment based on gender identity.

New recommendations in the updated document offer tips for appropriate collection of gender identity data—such as accurate pronouns—in electronic health records, and policy recommendations that would strengthen access to hormone therapy, which refers to the use of estrogens or androgens to induce physical or psychological characteristics consistent with a person’s gender identity.

Advocates contend that transgender people face serious barriers to quality and affordable health care: an analysis of the 2011 National Transgender Discrimination Survey of nearly 6,400 trans and gender non-conforming participants found that 19 percent of respondents reported being refused care as a result of their gender identity, while 28 percent postponed or delayed needed care due to discrimination.

Discrimination against trans patients ran the gamut from violence and harassment at the hands of medical professionals or hospital staff to verbal abuse in medical settings, according to the analysis. Respondents to the 2011 survey, which represents the most up-to-date and comprehensive data on discrimination against the trans community, reported being subjected to unnecessary and invasive physical exams, mockery, and violations of their privacy.

About 2 percent of respondents said they were physically attacked in a doctor’s office, while 28 percent said they experienced verbal harassment in a medical setting.

Survey participants reported incidents in which doctors conducted unnecessary pelvic exams, and one patient—whose gender identity was different from their sex as assigned at birth—said a doctor forcibly examined their genitals and discussed the case with other hospital workers in violation of HHS’ Health Information Privacy Act (HIPAA).

Authors of the revised guidelines say that many trans people opt to disengage themselves from the health-care system altogether, rather than endure abusive and insensitive treatment, resulting in poor health outcomes for the trans community.

“Just 21 percent of hospitals participating in the HRC Foundation’s 2016 Healthcare Equality Index (HEI) had specific policies outlining procedures and practices to eliminate bias and insensitivity toward transgender patients,” Tari Hanneman, deputy director of the organization’s Health and Aging Program, said in a press release issued Wednesday.

“This revised publication will go a long way in helping more hospitals adopt crucial policies and practices to ensure that transgender patients are welcomed and treated with appropriate care,” said Hanneman, who authored the HEI, which evaluated more than 2,000 health facilities for the 2016 index.

The revised document offers policy recommendations pertaining to patients’ access to personal items that would help with gender expression—such as makeup and gender appropriate clothing—and other items that assist with gender presentation, including material used in binding, padding, and tucking.