The Clinician's Guide to Transgender Care
Key strategies necessary to provide comprehensive, sensitively delivered care

Quality Clinical Care for Trans Patients: Identifying Barriers, Offering Solutions

Chapter 2: Recognizing obstacles to care of trans* individuals in private practice, and recommending solutions to assure quality care for this patient population utilizing a medical model for trans medicine..

In general, an insufficient sensitivity to and a lack of knowledge about the concerns and medical needs of the trans community persists among the vast majority of endocrinologists and primary care providers.1 Despite an evolving acceptance of trans individuals by both medical care providers and mental health specialists, significant barriers to clinical care remain.

Demonstrating acceptance and quality care begins with a gender neutral bathroom.When trans individuals go the doctor, there should be a bathroom that doesn't require a gendered choice.

Lack of Training and Knowledge of Trans-Specific Medical Needs

Patients in the lesbian, gay, bisexual, transgender, and intersex (LGBTI) community face known disparities in their medical care.1 For trans individuals, in particular, this insufficient care stems from a lack of knowledge and sensitivity from their providers.2

At present, across the years of medical education in the United States—including medical school, internship and residency, and fellowship training—there is no structured or standardized curriculum addressing trans healthcare. Reports from a series of studies have confirmed the inadequacy of medical education and need for intervention.3-9

Starting with a survey of medical students at Boston University, the students in three out of four of the classes reported a deficiency in their understanding of transgender health, less so than for LGB patients.3

In a study that evaluated the medical school curricula for transgender content across Canadian institutions, significant differences were found.Factors such as time spent on transgender education ranged from zero to two hours in some programs whereas other schools offered more than eight hours.

Only about 7% of medical students in Canada reported feeling knowledgeable enough to address the concerns of a transgender person in a primary care setting;4 yet, 24% of them indicated that the topic was adequately taught in medical school. Gaps in knowledge were evident in student responses such that 25% reported a lack of competence in the proper care of patients transitioning from male-to-female (MtF) patients who were taking hormones but did not undergo sex reassignment surgery.4

These students remained uncertain as to a need for these patients to have mammograms. In addition, nearly half of first-year students incorrectly answered that the prostate gland is removed in sex reassignment surgery.4

Davidge-Pitts et al queried endocrinology fellowship program directors.5 Of the 35 out of 54 respondents, these directors said they offered dedicated teaching on trans health topics. Yet, they also indicated that a lack of faculty interest or experience was proving the biggest hurdle to doing more during the fellows’ clinical experience.

These program leaders (n=411) found that a dearth of clinical understands among medical students extended to practicing endocrinologists.5 Among those who responded to the survey, four of five physicians who specialized in treating hormone-related health conditions said they had not received formal training in caring for trans individuals.5

On the upside, nearly 80% of the endocrine specialists indicated having treated a trans patient at some point. However, while they reported being comfortable taking a history or prescribing hormones, they were less confident about discussing surgery and other non-hormonal options to address these trans patients' clinical needs.5

Until sufficient familiarity with management of transgender patients is achieved, it may require referral to surgeons or other healthcare providers.1,2

Any and All Forms of Intervention Will Enhance Transgender Care

Early and comprehensive exposure to content, clinical training, online medical education, medical meetings sessions will assure that trans patients receive satisfactory care.2

A team of second-and fourth-year medical students at Case Western Reserve University School of Medicine in Cleveland recently designed a mandatory session (encompassing a lecture, patient panel, and small group discussion) as an introduction to LGBT health for the 167 first-years.After attending the program these medical students at Case Western reported feeling better prepared and more confidence in their ability to provide care to this population.

Results of a pilot study at the Mayo Clinic in Rochester, Minnesota,7 were presented as a poster presentation at ENDO 2018; the results offered support for the benefits of a multifaceted and integrative curriculum as the most effective approach to improving trans care, particularly in urban settings.

The Mayo approach is a modified version of a curriculum trialed at Boston University (BU). In a poster also presented at ENDO 2018, by Jason Park, MD, a BU medical student, (and co-authored with Joshua Safer, MD), which earned the Presidential Award, this pilot featured the greatest impact on care was achieved after direct clinical interaction with transgender patients.8
 

 

Introducing experiential learning improved students preparedness beyond cultural competency curriculum and didactic teaching alone. Growing evidence supports the value of incorporating clinical experience with the trans community during medical school to improve delivery of care. In a pilot study of Boston University medical students (n = 20),8 the impact of an elective in which they had real-life encounters with transgender patients was assessed. Dr. Park reported  an increased comfort among participating students, rising from 45% to 80%, and their familiarity with clinical care increased to 85% from a baseline of zero.

During a postgraduate program, residents (n=acceptance of a biological underpinning for gender identify increased, the appropriateness of offering hormone and surgical options, and they gained sufficient knowledge regarding the appropriate hormone therapy of female to male-to-female patients after a single lecture, rising from 5% to 76% (P < 0.001).9

Three overriding barriers to care have been identified

Lack of Health Insurance Coverage
A disproportionate number of trans individual do not have insurance at all and 19% have been denied care by healthcare providers,9 according to Lambda Legal, a non-profit advocating for LGBT rights. This advocacy organization cites a 2011 survey of more than 6,000 transgender Americans, which found that 28% had postponed necessary healthcare and 33% had delayed or not sought preventive care due to healthcare discrimination based on their transgender status.9

The status of care for transgender patients is improving,10 according to the Human Rights Campaign. While care may be evolving, coverage may be stalling or worse as the ACA is dismantled. However, physicians can refer their patients to a variety of sources regarding healthcare coverage. For instance, many private sector (employer-based) plans have removed exclusions on transgender healthcare. On its site, the Human Rights Campaign offers a list of employers who provide coverage and other information, such as state laws regulating coverage of trans-specific healthcare.11

Yet, the approach to coverage is very heterogeneous for patients on Medicare, differ state to state for Medicaid programs. Just as for private health plans, it is always best to contact the respective state programs for patient coverage and reimbursement. 

  • Too Little Long-Term Research

Research on lasting outcomes of treatments specific to trans individuals is sparse. One of the only large studies, presented at the 2014 Endocrine Society meeting, followed more than 2,000 transgender people cared for in six US and nine European centers for at least a year after transgender hormone treatment was initiated.12

Very few side effects were reported, with one main serious concern being venous thromboembolism in 1% of the treated group, which was related to estrogen use. However, the researchers acknowledged bias, as some patients were lost to follow up.12

  • Lack of Awareness about Treating Trans Adolescents

By introducing biological evidence for the durability of gender identity to first-year medical students, an immediate and near-universal change in response was seen,13 according to Eriksson et al. 

Since the period of pubertal development is finite, the opportunity for clinical intervention is also of limited duration. Therefore, providing a timely and accurate evaluation of a prepubescent adolescent with gender incongruence is essential. This assessment will require the contributions from a multidisciplinary team, including specialists in mental health, pediatric endocrinology, and primary care.1

Youth who express gender incongruence (the term for a medical diagnosis whereas gender dysphoria is evolving as a mental health diagnostic term) that intensifies at the onset of puberty are most likely to be trans adults.1 An important advance in the care of teens who express themselves as identifying as trans is to present the teen and family with the medical option of employing a gonadotropin-releasing hormone (GnRH) agonist at early puberty (Tanner II).

This treatment approach initiates a ''pause'' on pubertal changes and is reversible, allowing these young individuals and their families the time to live with the physical and emotional reality of such a decision. Later, trans-specific hormone therapy may be initiated so phenotypic transition can match the individual’s experienced gender.[See Chapter 3 for a more more encompassing discussion of treatment modalities.]

Regarding a more indirect aspect of care, when the practitioner’s office does not provide a gender-neutral bathroom, trans patients may take that as a sign of disregard, and/or may feel conflicted about the anticipated care to be received. It’s important that the care begins with an office that presents as inclusive and sensitive to patient’s basic needs as much as possible.

  • Overcoming Barriers and Optimizing Transgender Medical Care

One overriding solution to the noted barriers to clinical care is to implement a ''medical model" that leverages the new acceptance of trans patients’. This approach is one that employs all the resources that make up the healthcare system in a way that acknowledges the trans patient’s needs.1

Addressing clinical needs of the transgender population should be informed by this model of medical care.Joshua Safer Introduces Model of Care for Trans* Patients

A key component of this model necessitates the involvement of providers who are both evidence-based and patient-centered in their approach.1 Providers also must be prepared to focus on encouraging patient choice among the medically appropriate treatment options.

To address the needs of trans individuals, providers should plan to utilize the resources of the multidisciplinary team so as to have access to both mental health and endocrine expertise. This access can be internal to the private practice or external within the community. While access is vital, its origin can vary.

In this medical model,1 ongoing interaction between the patient, PCP, endocrinologist, mental health therapist, surgeon, and other specialists, as needed, is crucial to ensure the long-term health of transgender individuals.9

Providing transgender-specific hormone therapy and/or surgery improves both self- and public acceptance of trans individuals. Once acceptance of gender identity is achieved, the appropriate and necessary treatment is straightforward.1,2

The recommendations for treatment and monitoring are addressed in the next chapter.

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Transgender Hormone Therapy to Match Gender Identity
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