Overcoming care barriers for transgender patients

Transgender patients' biggest barrier to care may be the care experience itself. In the U.S. Transgender Survey, conducted in 2015, one-third of respondents said they had at least one negative experience with a clinician in the last year related to being transgender, including verbal harassment or refusal of care. Nearly a quarter of respondents reported that they avoided needed care out of fear of being mistreated.

These types of experiences lead patients to delay care, causing them to present with late-stage or uncontrolled conditions, from diabetes to advanced cancer, said Mitchell R. Lunn, MD, MAS, FACP, an assistant professor of medicine and of epidemiology and population health at Stanford University School of Medicine in California.

“What we see is that patients' negative experiences are actually the largest access-to-care issue,” said Dr. Lunn, who is also co-director of The Population Research in Identity and Disparities for Equality (PRIDE) Study, the first large-scale, long-term U.S. health study of people who identify as LGBTQ or another sexual or gender minority. “That's why it is really important for health care systems and for providers to be educated about gender-affirming care and to share broadly that they are gender-affirming providers.”

Gender-affirming care

Gender-affirming care can include hormone therapy or surgical procedures, but it also encompasses general support for an individual's gender identity.

For primary care physicians, the process of creating a welcoming office environment means thinking about the entire patient encounter, beginning from when patients start searching for a physician and when they check in at the reception desk. Start by making sure the office or clinic is identified online as a place that provides gender-affirming care, said Carl G. Streed Jr., MD, MPH, FACP, an assistant professor at Boston University School of Medicine and the research lead for the Center for Transgender Medicine and Surgery at Boston Medical Center.

Once the patient comes through the door, the office space should reflect the community in some way, Dr. Streed said. This might mean displaying a sticker with a pride flag or ensuring that the posters and pamphlets don't depict only straight, cisgender couples. The entire clinic staff, from the medical assistants to the custodial staff, also needs training on how to speak with patients in a respectful way, such as being familiar with correct terminology and pronoun use, he said.

Update intake forms to collect information on the name the patient uses, their legal name, or the name that is on their insurance card; their pronouns; sex assigned at birth; gender identity; and sexual orientation, advised Dr. Streed, who is also the president- elect of the U.S. Professional Association for Transgender Health. These same intake questions should be used for all patients, he said. “These questions shouldn't be treated as separate from other demographic questions. That is how they end up getting stigmatized in a way.”

Once in the exam room, Dr. Lunn said he introduces himself and shares his pronouns. He begins the visit by asking the patient what is important to them, rather than jumping into questions about gender identity. But once that subject comes up, sometimes after a few visits, he uses open-ended questions and mirrors the language of the patient. “Some people don't identify with the transgender label, so instead of saying ‘I'm a transgender woman’ they will say, ‘I'm a woman.’ It is always important to use the language the patient uses, rather than the language that you want to use,” he said.

Preventive care

In “Care of the Transgender Patient,” an In the Clinic article published in Annals of Internal Medicine in 2019, experts advised that clinicians should pay attention to all tissues and organs present, regardless of the gender identity of the patient. In practice, that means that a patient who has a cervix would undergo cervical cancer screening and a patient who has retained or developed breast tissue would undergo age-appropriate breast screening, which could include a mammogram, said Cynthia Herrick, MD, FACP, an endocrinologist and co-director of the Washington University Adult Transgender Center in St. Louis.

Dr. Lunn said he finds it helpful to conduct an “organ inventory” to find out which organs patients have, what they were born with, what has been removed, and what has been created or developed through surgery or hormone therapy. But keep in mind that patients are all on different paths and timelines in affirming their gender, so not all transgender men will have undergone surgery to remove their breast tissue, for example.

“I have patients who have not changed their names or their pronouns but have had an orchiectomy to remove their testicles. People can have surgery first, they can do hormones first. There is no defined path for transgender people,” he said.

Cancer screening for transgender patients can follow the guidelines for the general population, depending on type and duration of hormone use, surgical intervention, or both, according to the most recent standards of care from the World Professional Association for Transgender Health, which were published Sept. 6 by the International Journal of Transgender Health. For example, the standards of care recommend following breast cancer screening guidelines developed for cisgender women in the care of transgender and gender-diverse individuals with breasts from natal puberty who have not had gender-affirming chest surgery.

The standards also recommend against routine oophorectomy or hysterectomy to prevent ovarian or uterine cancer for transgender and gender-diverse individuals undergoing testosterone treatment who otherwise have an average risk of malignancy.

Hormone therapy may affect cardiovascular risk for transgender patients, Dr. Streed said, and guidelines differ on whether patients should be treated based on their gender identity, their sex assigned at birth, or a combination of both factors. Long-term risk can be difficult to estimate due to lack of evidence, but physicians can best monitor patients by keeping an eye on lipids and blood pressure and tailoring care accordingly. “In primary care, we're measuring those already and we're intervening on those anyway,” Dr. Streed said.

Physicians should also be mindful of updating vaccinations for transgender patients, including human papillomavirus or hepatitis A when needed. Dr. Lunn uses a comprehensive questionnaire to find out more about patients' sexual behaviors and the genders of their sexual partners, which can help inform screening for sexually transmitted infections.

A discussion about contraception is also critical, Dr. Lunn said. “You can imagine if you're a transgender man who still has a uterus and ovaries and fallopian tubes, getting pregnant may be very dysphoria inducing,” he said. “It's important to have a discussion about that because there are some myths going around that testosterone is really an effective form of contraception, which it is not.”

The key to providing gender-affirming care, and any comprehensive care, is understanding your patient, Dr. Herrick stressed. “Gender-affirming care at its core is really meeting the patient where they are and establishing rapport and making sure that people feel comfortable in your office,” she said. “That's something that we all can do and that we all need to strive to do in medicine.”