Clinical Competence for Transgender Care Needs Improvement

Lack of training for gender-affirming patients identifid; medical interventions, while not complex, require more than simply giving estrogen or testosterone.

Written by Adam Marcus

With commentary by Caroline Davidge-Pitts, MBChB and Joshua D. Safer, MD 

Endocrinologists often treat transgender patients, but they feel ill-prepared to manage the needs of this population — a gap that should be addressed in medical school and early in training,1 a new study suggests.

The study, published in the Journal of Clinical Endocrinology & Metabolism, paints a mixed picture of the state of transgender care among practicing endocrinologists. The researchers surveyed 6,992 US-based members of the Endocrine Society of whom 411 (5%) responded.1 Of those, 80% said they had treated a transgender patient, yet never received formal training to care for such patients.

Still, roughly 65% of clinicians said they felt very or somewhat confident in their ability to prescribe hormones to transgender patients, and 77% said they felt the same about their knowledge of definitions surrounding transgender medicine.1

Training Needed to Improve Delivery of Transgender Care  

At issue is that fewer than half of practicing endocrinologists expressed similar confidence in their knowledge of related medical issues, including gender confirmation surgery (30.8%), organ-specific screening guidelines (42.4%) and psychological or legal issues (35.5%), according to the researchers.

Among directors of 104 endocrinology fellowship programs, 52% responded to the questions.1 Of those, 72% said they offered some instruction on transgender medicine during their training but some reported a lack of interest or experience among the faculty to teach about this subject. The overwhelming majority of respondents (94%) endorsed the need for endocrine fellows to receive training in transgender medicine.

“Providers and trainees in endocrinology need to become competent in transgender healthcare,” said Caroline Davidge-Pitts, MBChB, of the Division of Endocrinology, Diabetes, Metabolism and Nutrition at Mayo Clinic, in Rochester, MN, who led the study. “Our research suggests an education deficit in both fellowship programs and physicians in practice, particularly in nonhormonal topics,” she told EndocrineWeb.

Specifically, Dr. Davidge-Pitts said, endocrinology fellows should not only receive in-depth training about the prescribing of hormones and sensitivity issues, “they should understand the referral process for surgery and have an understanding of which patients might benefit from a mental health evaluation. Resources for legal referral should also be provided.”

Transgender health issues are becoming increasingly relevant for physicians in this country as the number of Americans who identify as transgender has risen dramatically over the past 5 years.2 A 2016 report from the Williams Institute at the UCLA School of Law found that 1.4 million American adults identify as transgender, up from about 700,000 in 2011. 

Cultural Sensitivity is Key to Diminishing Discrimination  

Discrimination, real or perceived, is a significant problem for this patient population. The 2015 U.S. Transgender Survey,3 published last month, found that 33% of respondents who saw a physician or other health care provider in the year leading up to the survey reported having at least one unpleasant experience related to their gender, including being verbally harassed or being refused care because of their transgender status. Nearly one-quarter of respondents (23%) said they opted not to seek care out of concern that they would be discriminated against, the survey found. 

Endocrine practices can do several things to make transgender patients feel more welcome.  "An example of this would be to ensure use of correct names and pronouns; the practice should have intake forms that include options other than male and female; gender neutral bathrooms should be available," Dr. Davidge-Pitts said.

“Staff interacting with transgender patients should be culturally competent,” she added, "and endocrinology fellows should not only receive in-depth training about the prescribing of hormones and sensitivity issues, they should understand the referral process for surgery and have an understanding of which patients might benefit from a mental health evaluation. Resources for legal referral should also be provided.”

Transgender health issues are becoming increasingly relevant for physicians in this country as the number of Americans who identify as transgender has risen dramatically over the past 5 years.2 A 2016 report from the Williams Institute at the UCLA School of Law found that 1.4 million American adults identify as transgender, up from about 700,000 in 2011. 

Knowledge Deficit Requires Immediate Attention

Joshua D. Safer, MD, FACP, Medical Director of the Center for Transgender Medicine and Surgery at Boston Medical Center, said the JCEM study offered some “good news, in that substantial numbers of participants in the survey were interested in caring for transgender individuals; he was not involved in any of the studies cited.”

“At the same time the study highlighted an important gap: providers, even interested providers, feel that they don’t have sufficient knowledge to provide the needed care,” said Dr. Safer.

Although the medical care of transgender patients is not necessarily complex, neither is it simple.

“Physicians providing medical interventions for transgender individuals do need to know the strategy and goals for hormone therapy—such as blood levels to follow to determine if medication doses have been titrated correctly—and monitoring requirements for the medications used to achieve those goals,” Dr. Safer said.

“For example, many think that it’s simply a matter of giving testosterone to trans men and estrogen to trans women but the actual strategy relates to changing the patient’s testosterone levels in a safe way by using certain medications and hormone regimens.”

The authors of the new study noted that the low response rate to the survey among clinicians in practice was low — perhaps indicating a lack of interest in transgender medicine or discomfort with the subject. “Physicians who responded to the survey may have had more experience in transgender health than those who did not respond,” Dr. Davidge-Pitts said. “Therefore, the education deficit may, in fact, be larger than what our results showed.”

The Endocrine Society is updating its 2009 practice guidelines on the treatment of transgender patients. In the meantime, an excellent resource for clinicians, Guidelines for the Primary and Gender-affirming Care of Transgender and Gender Nonbinary People, is available from the University of Southern California Center for Excellent for Transgender Health; click HERE to review.  

 

Sources

  1. Davidge-Pitts C, Nippoldt TB, Danoff A, Radziejewski L, Natt N. Transgender Health in Endocrinology: Current Status of Endocrinology Fellowship Programs and Practicing Clinicians. J Clin Endocrinology Metab. Published online ahead of print. Assessed on January 12, 2017. Available at: https://academic.oup.com/jcem/article-lookup/doi/10.1210/jc.2016-3007.
  2. Flores AR, Herman JL, Gates GJ, Brown TNT. How many adults identify as transgender in the United States. July 2016. Los Angeles, CA: The Williams Institute at the University of California School of Law.
  3. James S E, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. 2016. Executive Summary of the Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality.

 

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