Commentaries by Joshua D. Safer, MD, FACP; Dylan Thomas, MD; and, Timothy Cavanaugh, MD
People who are transgender suffer a higher incidence of high-risk behavior, including smoking and using hormones without a prescription, and are at increased risk for anxiety, depression, and suicidality, according to the study background.
“The biggest physician-related barrier to receiving appropriate and effective medical care reported by transgender individuals is a lack of knowledgeable physicians,” said co-author Joshua D. Safer, MD, FACP, Director, Endocrinology Fellowship Training and Endocrinology Education, Boston University Medical Center, and Associate Professor of Medicine and Molecular Medicine, Boston University School of Medicine. “That barrier is reported to be greater than lack of sympathetic physicians and reported issues with forms and office staff—all of which are also barriers,” Dr. Safer said.
“This straightforward evidence-based approach to teaching transgender medicine resonated well with physician-trainees and resulted in enormous impact in the trainees' comfort with the topic,” said Dr. Safer, who collaborated on the study with Dylan Thomas, MD, also of Boston University School of Medicine.
A lecture and brief interactive session on gender identity and hormone treatment regimens were presented to both internal medicine and family medicine residents as part of the curriculum in 2014. Residents were surveyed both before and after the lecture about their willingness to assist patients who are transgender with hormone therapy, their knowledge about the permanent nature of gender identity, and their knowledge of the routine healthcare maintenance for these patients.
Improvements in Knowledge Found
Of the 46 residents who attended the lecture, 20 residents completed a pre-lecture survey, and 21 completed a post-lecture survey. The percentage of residents who felt sufficiently knowledgeable to assist with hormonal therapy for a female-to-male patient increased from 5% to 76% after the lecture (P<0.001) and from 5% to 71% for male-to-female patients. In addition, the percentage of residents who responded that they “agree” or “strongly agree” that they felt sufficiently knowledgeable to assist with hormonal therapy for hypogonadal male patients increased significantly from 40% to 71% (P<0.001) and with hypogonadal female patients from 33% to 86% (P=0.002).
“Providing physicians and medical students with the tools and training necessary to appropriately administer transgender hormone therapy and to understand the unique sensitivities and health issues of transgender individuals is vital to this growing patient population,” Dr. Safer said. “A key subtext of the study is that only a modest investment is required by medical school and post-graduate training programs to substantially improve teaching,” Dr. Safer added.
“This study represents the first ever demonstration that transgender medicine can be taught in the conventional evidence-based framework that we use for most medical teaching,” Dr. Safer concluded. In addition, he said that the novel approach used to teach transgender medicine at Boston University may be used as a model for teaching at other institutions.
Timothy Cavanaugh, MD
Physician and Medical Director of the Transgender Health Program
Fenway Health, Boston, MA
I am very grateful to Dr. Thomas and Dr. Safer for all the work that they are doing on trying to improve training on transgender health issues within the Boston Medical Center residency program. Education at an early stage of medical training is the key to improving access to medical care for trans-identified patients, and their work is reassuring and inspiring.
It is truly encouraging to see how providing even just this brief introduction can peak the interest in and promote an openness to the issues of gender variant identity and how this is supported, affirmed, and managed in patients.
It does strike me that the training is quite brief (only 1 hour) and that a great deal of information is incorporated into that one session. I feel quite certain that their supposition is correct, that the increased comfort with providing hormone treatment to trans-identified patients means that these residents would be more comfortable and liable to REFER a patient to an endocrinologist rather than provide hormone therapy themselves. In my experience at Fenway Health, where we provide a detailed introduction to transgender health care to all our new primary care physicians, providers continue to need intensive support and reassurance as they begin to see transgender patients on their own. The basics of hormone therapy are not difficult, as Dr. Thomas and Dr. Safer point out, but overcoming that discomfort with topics and areas that providers feel inadequately trained for, and developing a nuanced and truly affirming approach to care takes time and support.
To that end, I think that to successfully prepare students and residents to provide care to trans-identified and gender non-conforming patients, the issues involved and examples of transgender patients must be incorporated into the curriculum in the context of multiple areas of expertise. Certainly, it makes sense to address this topic within endocrinology curricula, but the issues involved also may be illustrated in the context of childhood development and pediatric care, adolescent care, cardiovascular disease, preventive care, gynecologic care, surgery, behavioral health/psychiatry, and any field treating patients. Our best estimates based on recent studies are that somewhere around 1 in 300 to 1 in 1000 people identify as transgender or non-binary. So medical students and residents need to understand that, whether they realize it or not, they can and will see transgender patients presenting for care in many settings and with many issues that may or may not directly impact their trans-specific care.
October 5, 2015
Thomas DD, Safer JD. A simple intervention raised resident-physician willingness to assist transgender patients seeking hormone therapy. Endocr Pract. 2015 Jul 7. [Epub ahead of print]