Inclusive Medical Practice: Caring for Transgender and Gender Diverse Patients
8-9 Minute Read
Authors: Julpohng Vilai, MD, FAAP & Judy Hanrahan, JD, MA with quotes from Maria-Vazquez-Amaral, JD, MEd parent of a transgender daughter, and MJ Vazquez-Amaral, a transgender woman.
Purpose
To prepare clinical educators to provide appropriate healthcare for transgender and gender diverse patients and reinforce the best practices for gender affirming healthcare with learners.
Learning Objectives
1 . Discuss an example of a negative and a positive patient care experience as a transgender patient.
2. Describe two ways healthcare providers could improve the healthcare experience for transgender and gender diverse patients.
3. Identify three areas for which gender identity may have clinical relevance.
I was introduced to the realities of discrimination faced by transgender and gender diverse (TGD) people when the parent of one of my patients told me that they were considering transitioning from female to male. The parent was concerned about how their transition would affect their child. I instinctively told the parent that it was important to take care of themselves and encouraged them to make choices that would enable them to live authentically because children need parents who are thriving. At the time I was a clinician in a conservative part of the country, but this parent felt comfortable talking to me because I wore a Human Rights Campaign pin on my lanyard. I was hesitant at first to wear the pin because I thought something overt like a rainbow or trans flag would be more powerful, but a colleague articulated it best, “the people who need to know that you are a safe provider will recognize the symbol, and people who don’t know will ignore it.”
Practice Tip: Signaling openness and acceptance goes a long way. Lanyard pins, pronoun badge buddies, “open to all” stickers on windows, or even advertising with local LGBTQIA+ organizations all help increase patient access by signaling safety.
Word spread quickly that people could safely discuss TDG issues with me, and I learned that transphobia, misinformation, and confusion around TGD issues came as much from within the medical community as the general population. When utilizing healthcare, TGD people encounter gender non-affirming healthcare professionals; barriers to gender-affirming medical interventions, primary and preventative care, and mental health services; inappropriate care; and healthcare refusal and mistreatment.(1,2) This results in reduced healthcare access for TGD individuals and signals a general lack of competency in transgender care; it was even evident within my own practice. I have come to believe that the biggest barrier to healthcare for transgender patients is likely clinician discomfort, especially in the areas of 1) TGD vocabulary, 2) medical management for TGD patients, and 3) the legal landscape for providers. As we discuss each area in turn, consider the value of practicing with respect, openness, and curiosity; I have found that these attitudes are key to providing appropriate care for TGD patients.
Challenge: Evolving Vocabulary
Working with TGD people requires an understanding of new and evolving vocabulary. The LGBTQIA+ Glossary of Terms for Health Care Teams provides a list of useful terms and their definitions.(3) Respect starts with using the right terminology, including calling patients by their affirmed name* and pronouns. Most medical record systems allow you to indicate a patient’s preferred name, for example “Jake” instead of “Jacob,” and this field should be used to note a patient’s affirmed name and pronouns.
Resource: The National LGBTQIA+ Health Education Center offers continuing education on various aspects of care for LGBTQIA+ patients including one on “Effective and Affirming Communication.”(4) Check out the center’s other CME offerings and resources: https://edhub.ama-assn.org/fenway-institute-edu/by-topic.
Pronouns can present a difficult adjustment when one has known a person as a particular gender for a long time. For many of us “they/them” pronouns are especially difficult due to the grammatical rules we learned in elementary school. One useful technique a transgender advocate taught me was to practice using “they/them” pronouns with pets. This practice helps to start rewiring your brain to make it easier to refer to a single entity as “they,” and, if you get it wrong, your pet’s feelings won’t be hurt. You might also come across other pronouns like xe/xem/zyr and ze/hir/hirs; these ‘neopronouns’ represent an effort to incorporate gender neutral pronouns into English.
Practice Tip: If you mistakenly use the wrong pronoun for someone, apologize and move on. Dwelling on the mistake is uncomfortable for both you and the person who was misgendered.
For clinicians uncomfortable with the idea that sex is not binary, I encourage you to listen to the podcast “X & Y” in the 2018 RadioLab series “Gonads”; it is an entertaining and helpful review of the scientific understanding around sex determination.(5) Understanding the pathways associated with sex determinations, enables one to have a more nuanced, scientifically sound understanding of sex as a non-binary category. For example, while the Sry gene on the Y chromosome was once thought to be the ‘biological switch’ that dictated female or male, researchers have since discovered that the process may be more complicated. As an example, the gene DMRT1 is expressed in the human testis and thought to actively suppress female sex. In mouse models, if this gene is excised in XY males, sperm cells begin making estrogen and become ovarian cells. Similarly, if an analogous gene is knocked out in XX females, ovarian cells try to organize into a testis. The science is complex and fascinating.
Challenge: Discomfort with Medical Management for TGD Patients
As a primary care physician, an endocrinologist, or a general surgeon, you may encounter patients who are seeking gender-affirming care, while other physicians might only see transgender patients for issues other than gender affirmation care. Openness and curiosity go a long way for both.
Patient Perspective
“I have encountered too many doctors unwilling to learn how to give me good and appropriate care. If you can’t treat a trans person because of your personal beliefs or if you are not curious enough or willing to learn, then refer them to someone who can actually help them get the care they want and need. A clinician’s job is to help people.”
Practice Tip: Transgender patients often understand that their situation might be new to a physician or unique in their particular stage of gender affirmation, and they appreciate a clinician’s openness and honesty about this. An attitude of partnership, “let’s learn this together,” and co-navigation of the recommendations, standards of care, and medical evidence can go a long way in creating a mutually beneficial experience for both the patient and clinician.
As clinicians, we are proficient in asking patients about themselves and their medical history; this is essential to appropriately care for TGD patients. Providers should include gender history questions in the comprehensive medical history. When patients establish care, it is appropriate to ask about gender identity and do an organ census in addition to obtaining the patient’s list of current medications. The organ census and use of hormone therapy should guide preventative screenings and recommendations; see the chart below. However, it is not always appropriate to ask a detailed gender history outside of the establishment of care; it may feel intrusive, disrespectful, or have little impact on health outcomes for many acute care situations, e.g., cold symptoms.
Practice Tip: Train office staff and students to understand and respond appropriately to patients who ask for seemingly incongruent medical services, for example, when a patient calls presenting as male asking for an appointment for gynecological care. This happened to a transgender friend who had difficulty establishing with a gynecologist because the front desk kept repeating that they do not provide care to men; it was a humiliating experience that made this person less inclined to get gynecological cancer screenings.
Caregiver Perspective
“We lucked out and found a physician who wanted to learn, did the work, and truly cared and listened – all too rare.”
Clinicians providing primary care and gender-affirming treatments should familiarize themselves with the Standards of Care for the Health of Transgender and Gender Diverse People Version 8 (SOC8) published by the World Professional Association for Transgender Health.(6) SOC8 is a comprehensive, evidence-based compendium on management of gender dysphoria, “which articulate a professional consensus about the psychiatric, psychological, medical, and surgical management of gender dysphoria and help professionals understand the parameters within which they may offer assistance to those with these conditions.”(6).
Patient Perspective
“Trans people largely understand the risks of our care, like what happens when we take HRT; many of us have done our research and are willing to accept those risks. When a doctor lectures us about the risks, it feels like gatekeeping from life-saving care, that they don’t actually care, and we lose trust and are less likely to see another doctor. It becomes an issue of safety: we have to be vulnerable when we seek care; the least someone can do is create a safe space for us.”
Practice Tip: While a clinician has a responsibility to provide patients with the risks and benefits of a particular course or treatment, they need not do so in a condescending way or over-emphasize the risks. One way to facilitate this discussion is to ask the patient what benefits and risks they are expecting, this provides an opportunity for the clinician to affirm those benefits and risks that the patient understood, correct those that aren’t accurate, and supplement with the risks and benefits the patient missed. The tone of this coversation should be more “a team of experts reviewed all the literature up till X, and here’s how they interpreted what’s out there” rather than “I’m telling you this.”
Legal Landscape for Clinicians
Over the past several years there are more than 500 bills introduced in state legislatures targeting TGD people,(7) including bathroom bans, limits on participation in youth sports, restrictions on discussion of sexuality, gender, and identity in public education, removal of TGD youth from affirming families, and bans on provision of gender-affirming care for teens.(2)
Caregiver Perspective
“In most ways, things are worse now than they were then regarding medical care available and the national climate.”
Bans on gender affirming care are popping up all over the United States—approximately 38% of transgender youth live in states that have passed bans on gender affirming care.(8) While some states have considered bans on gender affirming care for individuals up to 26,(8) currently only physicians who treat pediatric patients need to worry about navigating the legality of providing gender affirming care. Some bans have been enjoined and are not in effect while their legality is litigated. Given the shifting legal landscape, physicians who treat pediatric populations should keep up to date on local conditions through the Human Rights Campaign or their local specialty group, and they should work with the local chapter of the American Academy of Pediatrics, their malpractice insurance carrier, and local legal counsel to guide practice.
Caregiver Perspective
“Get educated. Stay current. ‘First do no harm’ means actually treating these folks as humans who are NOT broken. If someone needs insulin for diabetes, we do not refuse to treat them because it does not align with the doctor’s religious beliefs. Family and especially parents are worried and deeply afraid for our loved ones as our country has become more and more hostile toward trans folks. Adding the burden of fear regarding their medical care is unconscionable.”
Conclusions
While clinicians may struggle with knowledge gaps, misconceptions, and personal biases around the care of transgender and gender diverse people, evidence and first-person experience attest that TGD patients endure healthcare inequity. Learning about TGD health and available resources or making appropriate referrals can provide a literal lifeline for those with gender incongruence. In this way, the medical community can support those with gender dysphoria to live as their authentic selves.■
References
(1) National LGBTQIA+ Health Education Center. LGBTQIA+ Glossary of Terms for Health Care Teams. 2024. Available at: https://www.lgbtqiahealtheducation.org/glossary/.
(2) Branigin A, Kirkpatrick N. “Anti-trans laws are on the rise. Here’s a look at where — and what kind.” Washington Post. 2022. Available at: https://www.washingtonpost.com/lifestyle/2022/10/14/anti-trans-bills/.
(3) National LGBTQIA+ Health Education Center. LGBTQIA+ Glossary of Terms for Health Care Teams. 2024. Available at: https://www.lgbtqiahealtheducation.org/glossary/.
(4) National LGBTQIA+ Health Education Center. Effective and Affirming Communication (AESGM 2023). March 2024.
(5) RadioLab. Reporter Webster, M. Producer Kielty, M. Gonads: X, Y. 2018.
(6) Coleman E, Radix AE, Bouman WP, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgend Health. 2022;23(Suppl 1):S1-S259. Published 2022 Sep 6. doi:10.1080/26895269.2022.2100644
(7) Erin in the Morning. Anti-Trans Legislative Risk Map. 2023.
(8) Human Rights Campaign. Map: Attacks on Gender Affirming Care by State. Accessed May 22, 2024. https://www.hrc.org/resources/attacks-on-gender-affirming-care-by-state-map