How to improve primary care for trans patients

This year, I stood on the curb at the 2017 Halifax Pride Parade and watched high-energy floats pass by. Leading the parade was the indigenous float. The vibrant trans youth float warmed my heart. The prime minister waved and called out “Happy Pride!” to the spectators. It was a stream of enthusiastic faces, song, dance, and brightly colored banners.

I love pride. It’s is a special time for a lot of people. The celebration I witnessed is a sign that we, as a society, are moving in the right direction. But we still have a long way to go, especially when it comes to providing health care to transgender patients.

When Caitlin Jenner came out as a trans woman, she helped bring more awareness to the general public about what it means to be transgender. However, it is only in recent years that the government began to fund gender-affirming surgeries, finally considering it medically necessary. Procedures such as electrolysis and laser hair removal continue to be at the patient’s expense.

To be transgender means that one’s gender identity does not align with the biological sex they were assigned at birth. Research shows that trans people have poorer health outcomes when compared with people who are non-transgender (i.e., cisgender). They have higher rates of many medical conditions, including type 2 diabetes. In the trans community, there is more poverty, depression and even suicide. Although health care is a right in Canada, many members of the quickly growing transgender community are fearful in its pursuit. This needs to change.

I became interested in providing health care for transgender patients upon realizing the difficulties many have faced when encountering the medical system. Some have told me that they bought hormones (or what they presumed to be hormones) on the street or from Kijiji (free classified ads in Canada) because they were too afraid of being judged by their health care providers. A 2013 study conducted in Ontario found that over one-fourth of transgender individuals taking hormones have done so without supervision (i.e., obtained them on the black market or from a non-medical source).

What we know about transgender health care from research

In a recent study, graduate student Ella Vermeir of Dalhousie University investigated the experiences of transgender patients with health care.² She conducted individual interviews with the participants in the study to gain an understanding of the barriers trans individuals face when accessing primary and emergency care.

One barrier identified was that health care professionals lacked knowledge about trans-specific issues. Some doctors weren’t even familiar with what it meant to be trans. Another problem is that transgender people are frequently misgendered by health care professionals (i.e., calling someone a pronoun that does not reflect the gender they identify with). Though this may seem like an inconsequential error to some, it can have important implications. It may result in “outing” a trans individual against their wishes. Misgendering can be a damaging mistake that we, as medical professionals, should work to avoid. To be honest, I have made the mistake of misgendering my trans friends and patients a few times. Thankfully, these folks were forgiving and understanding. However, the more trans people you know, the easier it becomes to avoid misgendering.

Some of the trans research participants in Vermeir’s study felt that health care practitioners seemed to ask questions out of curiosity rather than out of medical necessity. If I’m seeing a patient for an ear infection at a walk-in clinic, teasing out the details of their gynecological surgeries is likely not relevant.

Lack of training about transgender health care

I’m a recent graduate, so education in this field was included in my medical school and residency training, albeit minimal. In medical school, we had a series of lectures one morning devoted to LGBTQ health. A similar session took place during residency. These lectures were more focused on the provision of culturally appropriate care, which is great, but we didn’t learn about how to properly manage hormones. Nor did we cover the details of gender-affirming surgeries. It was necessary for me to pursue continuing education on transgender health. Since the training I received in my formal education was limited, I imagine that generations of physicians before me received little to no teaching in the field.

What can we do? Vermeir’s study pointed to a few simple suggestions offered by her trans research participants, and I think they would make a big difference. Having a pride flag or pink triangle sticker in your office — indicating it’s an LGBTQ friendly place — or hanging posters or brochures about LGBTQ health in the office are two simple ways to make people feel more at ease. Vermeir’s participants suggested doctors ask their patients the terms they prefer to use to describe their body parts and also to provide accommodations when appropriate, like if someone is uncomfortable waiting in an open waiting room, allowing them to wait in an empty office.

Making the extra effort to avoid misgendering is important. In addition, genital examinations warrant extra sensitivity. It may be helpful for the patient to have a support person present if they desire. In some cases, sedation may be appropriate. Medical clinics can seek out cultural competency training in the field. Finally, health care practitioners like myself, with an interest in providing trans health care, should take responsibility to train medical students and residents in this field.

The Sherbourne Health Centre is a medical facility in Toronto, Ontario that has a focus on LGBTQ health. They have published a helpful document entitled “Guidelines and Protocols for Hormone Therapy and Primary Health Care for Trans Clients.” It serves as a great starting point for medical professionals interested in caring for trans patients. The World Professional Association for Transgender Health is a non-profit organization centered on trans health. They are an excellent place to get educational materials, and they host an annual conference. The Canadian Professional Association for Transgender Health (CPATH) also hosts an annual forum and is another informative resource.

A key concept in family medicine is that of providing patient-centered care. Taking a patient-centered approach to our trans patients is no exception.

Sarah Fraser is a general practitioner who blogs at Sinus Rhythm.

Image credit: Shutterstock.com 

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