Points on providing gender-affirming care

There are simple things that physicians can do, regardless of their practice setting, to communicate to patients that they are safe in the clinical space.

I'm a primary care clinician, and I care for a large panel of transgender and gender-diverse patients for whom I prescribe gender-affirming hormones. One of the things that I've learned in several years of caring for this population is the importance of listening to my patients and respecting their own knowledge about their bodies, while also helping facilitate each person's individual gender expression and gender goals.

It is important to start with a foundation of trust. The transgender community has valid reasons to mistrust the medical community, but there are simple things that each clinician can do, regardless of their practice setting, to communicate to trans patients that they are safe and able to be authentic in the clinical space. First is to ensure that intake forms are inclusive. These should allow patients to designate the name that they prefer to be called, also known as their chosen name, in the event that name does not align with their legal name. There should be options to describe one's gender identity, which may be different from one's sex assigned at birth, and from one's current legal sex. Intake forms need to reflect the complexity that can be relevant for trans patients.

Dr. Hedian explains in an interview how to create a more accessible environment for gender-affirming care. (Duration 2:10)

Second, have visible signs which communicate a welcoming environment, like a Progress Pride Flag (a more inclusive variation on the traditional rainbow pride flag), and inclusive reading materials in the waiting room that are representative of diverse identities. Third, have a gender-neutral bathroom available so that all patients have a safe place to go. If there is a single-stall restroom, rather than label it for "men" or "women," it can simply have a sign which says "restroom." Each of these are small, simple things in the physical environment that can help patients feel more comfortable and define the clinic experience even before a patient enters the exam room.

Once we are in the room with patients, one thing that we can do to help them feel comfortable is to address patients by their chosen name and pronouns, and if we're not clear on what those are, we should ask. As an example, when I meet patients for the first time, I introduce myself first. I say, "My name is Dr. Hedian and my pronouns are she/her. What name do you go by? And what pronouns do you use?" I don't assume that they use their legal name. I don't automatically use a gendered title like Mr. or Mrs.; I simply ask how patients want to be addressed. Asking a patient for their pronouns communicates that this is a place of safety—this is a place where trans and nonbinary patients can feel able to express and talk about the things that they need in health care.

I let patients take the lead on when it's time to talk about gender. Some patients, when they come in the door, immediately want to talk about their experience with gender. If that's what the patient is communicating to me, then that's where we'll start. Other patients may want to talk about gender, but they have other concerns they want addressed first. In that case, I ask about their current concerns. I take a routine history and physical—I ask about past medical and surgical history, family history, social history, current medications and allergies. As a primary care physician, these are all things that I need to know regardless of a patient's gender identity or goals.

Once I have collected that information, when it's time to talk about gender, I usually start with an open-ended question: "Tell me about your experience with gender." It's helpful for me to know how people identify and their gender embodiment goals to determine what care they need. Some people approach medical transition or hormones with a desire to see changes as quickly as possible—as quickly as is medically safe. Other people take a more gradual approach, hoping to see some small changes first, then reassessing and deciding what the next steps will be. But starting with that single open-ended question gives me a wealth of information which helps me understand not only what my patient is looking for in terms of their hormonal journey, but it also helps me get to know them better as a person. I can respond to patients and offer better care when I know them as an individual.

I ask patients whether they're interested in surgery for gender affirmation. It doesn't have to be now. It might be something they're interested in down the road, but knowing what their goals are helps us to make plans for the future. I ask what their fertility goals are. That's something that should at least be addressed prior to starting hormone therapy. If patients desire fertility preservation, a referral for that can be initiated, though unfortunately insurance coverage is often a barrier. And the flip side of fertility is contraception, recognizing that gender-affirming hormone therapy is not birth control. Hormones make it harder to conceive but not impossible, and taking hormones while pregnant can be detrimental to a developing fetus. If patients are having sex in a way that can lead to pregnancy but don't wish to conceive, I talk about birth control and other ways to prevent pregnancy.

Finally, is there any interest or need for other nonmedical, nonsurgical treatments? For example, are patients interested in hair removal as part of their gender journey, or do they have a need for speech therapy? If so, these are services I can refer them for to help them along the way.

This process may sound complex, but truthfully, gender-affirming care, and in particular hormone therapy, is one of the easiest things that I do in primary care. There are three primary medications that we use for this: estradiol, spironolactone, and testosterone. Yes, we need to do baseline labs and monitoring labs throughout this process, but we know what the effects of hormones are. We know what side effects to watch for and what complications to be mindful of. Medically speaking, it's more straightforward than other care that we routinely offer as primary care clinicians. With diabetes, for example, there are many different medications from several different classes that we prescribe, monitor, and titrate. We might refer a complex case to endocrinology, but we are certainly capable of managing straightforward cases. The reason clinicians feel more comfortable offering diabetes care than gender-affirming care boils down to differences within medical education. We aren't currently doing a good job of equipping clinicians to offer gender-affirming care, so it seems much more intimidating than it actually is. One good resource for primary care clinicians from Johns Hopkins is available online.

It's a wonderful feeling to be able to prescribe a medication and see patients become increasingly more comfortable in their bodies. I have seen many people come out of their shells and thrive as a result of being able to access transition-related medical care. I've seen people attend graduate school and engage in meaningful and loving relationships in a way that they couldn't before transition. I've seen people's mental health dramatically improve as a result of accessing this medically necessary care. Gender-affirming hormone therapy is not hard to prescribe. It is safe, and we know a lot about it. It's incredibly medically rewarding, and you can do it too.