Cultivating More Inclusive Medical Care for Transgender Patients

Need to infuse more sensitivity in meeting the medical needs of transgender patients while assuring comfort in the delivery of necessary medical care.

With Joshua D. Safer, MD 

Approximately 1.3 million adults (approximately 0.6%) of the United States identified as transgender the last time an estimate was sought by the Williams Institute in 2016,1 and just a year later the GLAAD Media Institute estimated that 3% of the US population indicated they were transgender.2

This suggests that “most primary care providers and endocrinologists are likely already seeing patients who identify as transgender, whether or not they are aware of it,” says Joshua D. Safer, MD, executive director of the Mount Sinai Center for Transgender Medicine and Surgery and Senior Faculty in Medicine (Endocrinology, Diabetes, and Bone Disease) at the Icahn School of Medicine at Mount Sinai, in New York City.

Transgender patients need greater clinical sensitivity when seeking medical care.

Need to Adopt Greater Sensitivity in Managing Transgender Patients 

Towards that end, Dr. Safer and Vin Tangpricha, MD, PhD, an endocrinologist with the Emory Clinic and Emory School of Medicine in Atlanta, Georgia, developed a comprehensive review that addresses current practice recommendations for the medical care of transgender patients: “In the Clinic: Care of the Transgender Patient.”3 This is a continueing medical education

There has been ongoing reports acknowledging that many clinicians have not received adequate training in the care of the transgender patient.4

Under the guidance of Dr. Safer, EndocrineWeb responded to an acknowledged lack of preparation in managing the particular and usual needs of this patient population by producing, The Clinician’s Guide to Transgender Care, created more than two years ago.  

“The need for better access to care is not new. What is notable is the decision by the journal of the American College of Physicians to publish a review and guide targeting their membership representing primary care practitioners,” he says. “Improving health care access for transgender individuals by educating providers has been an interest of mine for years, including EndocrineWeb Clinician's Guide, published in 2016, and the article in the Annals of Internal Medicine, appearing now."3

Clinical Care is a Matter of Attention, Not Skills

“It is not that difficult to manage transgender patients; this is very much within practitioners’ current skill set.” In fact, Dr. Safer says, “it won’t take much education for most practitioners to get to a place where they can feel comfortable and be helpful.”

The recommendations range from terminology and how to address transgender patients politely and accurately, to providing evidence-based medical care reflecting the state of our knowledge.3

“Many clinicians feel uninformed and may fear making clinical mistakes,” he says, whether from undertreatment or inappropriate treatment. In truth, “clinicians need knowledge regarding the status of the patient’s current hormonal treatments and anatomical body parts–what they currently have and what organs/body parts, if any, have been removed–and the medical implications of these changes on current treatment and monitoring.”

In this clinical perspective,3 the authors address how to determine transgender identity (ie, establish that the patient has persistent [multiyear] gender incongruence), noting that while the Endocrine Society guidelines prefer that a mental health professional be involved in the diagnostic assessment of all patients, any sufficiently knowledgeable provider can make the determination in adults.5

However, it is still advisable that determinations and treatment of children and adolescents be guided by a team of clinicians that includes mental health professionals since the impact of puberty adds a level of consideration to usual care.

It's Important for Primary Care Setting to Feel Safe and Inviting

Dr. Safer acknowledges that not all transgender individuals seek medical intervention. For some, they are healthy and have no urgent needs while young. But others have been put off by bad experiences and clinical rejection.

He also emphasizes that with sufficient knowledge, primary care clinicians (in consultation with an endocrinologist, as needed) need not hesitate to initiate and manage transgender medical interventions, specifically hormonal therapies.

Just in case, the hormone regimens used in treatment of both transfeminine (male-to-female) and transmasculine (female-to-male) transgender patients, is presented along with guidance on appropriate monitoring recommendations.

As with all patients, clinicians are instructed to review the risks and potential adverse effects of hormone therapy and surgical interventions with patients before initiating any treatment, including the potential consequences to fertility.

Attending to Medical Concerns of Transgender Patients  

Cancer surveillance and strategies for chronic disease prevention refer to established guidelines that take into consider the individual’s present body parts and tissues, regardless of gender identity, Dr. Safer tells EndocrineWeb.

In other words, all adult individuals with a cervix will require pap smears, adults with breasts will require mammography, and anyone with a prostate gland will (eventually) require PSA monitoring as per national preventive screening guidelines. Monitor to the parts that are there; treat to the person sitting with you.

An estimated 50% of medically-treated transgender individuals will seek transgender-specific surgeries, optimally after at least one year of hormonal therapy. Clinicians should be aware of the available surgical options and associated implications in order to counsel patients regarding gender-affirming procedures.

Providers need information about potential preoperative alterations to current medications, insurance considerations, and anticipated postoperative alterations to medications and hormonal regimens. Drs. Safer and Tangpricha clearly delineate all of this information to assist providers in these tasks.

In addition to offering guidance regarding medical considerations for transgender patients, this clinical overview addresses the medicolegal and societal issues that arise in the care for transgender patients. For example, they emphasize that “discriminating against transgender patients is a straightforward violation of standard professional practice.” 

Establishing Charting Procedures that Reflect Clinical Sensitivity 

The authors highlight the importance of clearly documenting the transgender patient’s identity in medical records and prominently on the chart. In addition, they explore the importance of instituting clear policies and practices regarding these sensitive issues.

In particular, the current electronic medical record (EMR) represents a potential barrier to documentation for transgender patients, as it may not have the ability to record the pronouns used by the patient, or their gender identity or organs/tissues present.3

Therefore, clinicians are urged to consistently collect and record the following:

  • The patient’s legal name
  • Used (announced) name when different or if changed
  • Legal sex
  • Sex recorded on the birth certificate
  • Gender identity
  • Preferred pronoun

In addition, there should be a clear record of organs and tissues that are and have ever been present, recognizing that some of this information may change over time so records should be updated at least annually.3

Finally, there are recommendations proffered in a section on how to develop a successful care environment for transgender patients. Here, the authors stress the importance of staff training so every member of the team is trained to be cognizant of issues specific to transgender patients, from ensuring use of appropriate pronouns when speaking with the patient, to having inclusive restrooms suitable to all gender identities.

Since the lack of training regarding transgender concerns is a consistently acknowledged need cited by most healthcare professionals, Dr. Safer shares possible training opportunities to plan for your staff.

“Ultimately, we want to reassure clinicians that they are able to provide evidence-based care to their transgender patients even with their current skills, and possibly with a little more knowledge,” says Dr. Safer.

In effect, optimizing treatment to transgender patients requires, there are three overall recommendations that should be considered by every practice: 

  • Becoming comfortable with transgender terminology and language.
  • Improving one’s knowledge of current evidence-based medical care as relates to trans men and trans women.
  • Providing appropriate staff training to assure consistency in interactions, recordkeeping, and ongoing care.

The fundamentals are pretty basic, says Dr. Safer, essentially the clinical care is similar to those of cisgender patients; however, there will be times when it is appropriate and okay to call for specialist support.

That “the American College of Physicians, which is the largest medical organization which represents most primary care physicians, is including a paper like this in their medical journal to assist their members to do the right thing” demonstrates how far we have come in the provision of care to transgender patients, Dr. Safer says.

The authors have no financial conflicts to disclose regarding the preparation of this article.

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