Taking the Time to Learn About Transgender Health Care

Rebecca Bak, MD, MPH

A few weeks after I met a young transgender woman in our urgent care and had offered to become her primary care doctor, she sent me an email with a link to a small study in which only 41% of endocrinologists felt competent to provide transgender care. In her email, she thanked me for being the first doctor to ask about her chosen gender pronouns and for taking the time to learn about transgender health care.

I am a family doctor working in rural New Mexico, 2 years out of residency. I still often feel like I am working just outside my comfort zone—when I’m reducing a dislocated shoulder, managing a retained placenta, or caring for a young patient who had ingested a liquid poison. I’ve learned to rely on my colleagues, consult specialists when needed, and read—a lot. At the end of residency, I still didn’t feel comfortable with interpreting complicated EKGs, so I set up a rotation with a cardiologist and went through page after page of EKGs. I still don’t feel completely comfortable providing rheumatologic medications to patients (and my patient population has a large number with rheumatoid arthritis), so I read up and call the specialists.

Family doctors, whether working rurally or urban, are often expected to work just outside their comfort zone. I did my residency in Rhode Island and, though the nearest city with the preeminent hospital was 15 minutes away, many patients with complicated illnesses chose to continue care with us because they felt more comfortable with their family doctors, they couldn’t afford bus fare, or they were caregivers to others and wanted to stay close to home.

We, family doctors, should be at the forefront of providing medical care, including hormone therapy, to our transgender patients. We are present for our patients from birth to death, during severe medical illnesses, at moments of depression and anxiety, and also during moments of joy. It is a statement of acceptance to continue caring for our patients who are making the momentous decision to transition to a body that feels right to them.

According to a 2010 study by Lambda Legal, a national organization aimed at achieving civil rights for LGBT and HIV positive individuals, 70% of transgender individuals had experienced discrimination from health care professionals. This includes health care professionals and facilities refusing to care for them or even subjecting patients to verbally or physically aggressive or abusive behavior. The National Gay and Lesbian Task Force with the National Center for Transgender Equality noted that in their 2011 survey of transgender patients, 28% of patients delayed medical care when they were acutely ill due to fear of discrimination. Additionally, only 28% of patients are out to all their medical providers about being transgender. When patients do talk about being transgender, 50% find they have to teach their own doctors about their health needs. Largely as a result of discrimination both inside and outside the health care system, transgender individuals are at greater risk of physical and sexual violence, contracting HIV, tobacco and drug use, and attempting suicide.

My patients with hypertension or coronary artery disease do not expect to need to teach me about their medical issues. Just as I have now learned more about rheumatoid arthritis so I can be a better physician, I need to learn about the health care needs of transgender patients.

Seven Steps to Improve Your Education About Transgender Health Care

These are the steps I have taken to improve my education about transgender health care needs, including (but not limited to!) provision of hormone therapy. I hope others comment on classes, books, webinars, and other methods that have worked for them:

1. During residency, I sought out a doctor who provided hormone therapy to transgender patients and asked to do a short rotation with her.
2. I attended the Annual Philadelphia Trans-Health Conference. It’s a really fun conference with lots of transgender individuals and their family members and supporters gathering in one place for celebration and learning and teaching each other. They also have a professional track where I delved into the ins and outs of providing hormone therapy.
3. The National LGBT Health Education Center (through the Fenway Institute) has various webinars ranging from the basic (what IS transgender, anyway?) to the more advanced (how do I provide gender affirming hormone therapy?)
4. The Primary Care Protocol for Transgender Health Care through the Center for Excellence for Transgender Health (UCSF) is my go-to for basic questions.
5. WPATH (World Professional Association for Transgender Health) also has extensive guidelines. They now endorse, along with other organizations providing standards of care for hormone therapy, a harm reduction approach. This means that patients are capable of making an informed decision to start hormone therapy; while some patients presenting for care may need psychiatric services for concomitant mental illness, a year of care and evaluation by a psychiatrist is not required.
6. I’ve sought out mentors—one 40 miles away, another 2,000 miles away. Some I’ve met at conferences, others through word of mouth.
7. The Transgender Medical Consultation Service, staffed by medical providers expert in trans health, has aided me with complex patient situations.

I also advertise myself to the LGBT community through local and national LGBT physician directories. Both online and in meeting new patients, I am upfront about my limited (so far!) knowledge base. I promise that I will be open and honest when I don’t know something and that I will look into the answer. In my experience, patients are okay with this and relieved that they can find a family doctor motivated to providing comprehensive medical care.

I view my transgender patients as whole human beings, with hopes and dreams and challenges.  Transgender health is not just about whether or not to provide hormone therapy; some want this, while others simply want an open-minded provider. It’s also about focusing on all the other family medicine type issues—like quitting smoking and managing their diabetes and talking about reproductive health care and helping them cope with depression and anxiety.

I continue to learn so much from and with my transgender patients, and I feel I’m a better doctor—and person—because of these relationships.

References

1. Grant J, et al. Injustice at every turn: a report of the national transgender discrimination survey. Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.
2. Seaman A. A third of endocrinologists are unwilling to care for transgender patients.  Huffington Post 2016;March 10. Link: http://www.huffingtonpost.com/entry/a-third-of-endocrinologists-are-unwilling-to-care-for-transgender-patients_us_56e1a432e4b065e2e3d50366.  Accessed June 15, 2016.
3. When health care isn’t caring: Lambda Legal’s survey of discrimination against LGBT people and people with HIV. New York: Lambda Legal, 2010. Available at lambdalegal.org/health-care-report. Accessed June 15, 2016.