This past spring, I sat in a lecture hall at the Warren Alpert Medical School at the third annual Transgender Conference. A graduate of the Brown family medicine program, Alexis Drutchas, MD was the co-founder. I remember interviewing for residency and asking her what she was working on; she casually mentioned that she was creating a conference for the transgender community and medical community in the Blackstone Valley.
Three years later, I sat there as a resident eager to learn everything about caring for transgender patients. The conference gave me a lot to think and feel inspired about. So much of the time in medicine we think of patient’s needs and histories in terms of a possible diagnosis; we work on labels, billing codes, and treatment plans. Gender has been thought of under this same paradigm, and it had left me wondering: what if I make the wrong diagnosis? And is this the paradigm I should be working under in the first place?
At the conference, guest speaker AndreAs Neumann-Mascis, PhD argued that a provider’s biggest fear when taking care of transgender patients often lies in “the diagnosis.” The provider might question themselves, “Am I making the right diagnosis?” Becoming an expert diagnostician is drilled into our heads from an early stage in medical school. We are conditioned to think about people in a disease model. When we diagnose a disease, we are determined to treat it.
The World Professional Association for Transgender Health (WPATH) guidelines issued a statement in May 2010 which supported depathologizing people who identify as transgender. The same statement also reminded providers that this concept is separate from gender dysphoria. They argue that there is a need for the diagnosis of gender dysphoria which is the discomfort or distress caused by a discrepancy in one’s gender identity and their sex assigned at birth. WPATH suggests that by labeling this as a disorder means that there is the possibility for treatment and this may improve access to health care.
An article from the Lancet, titled, “Serving Transgender People,” supports this idea that being transgender is not pathological. In fact, it was taken out of the DSM-5. However, it too acknowledges that people can experience distress related to living in the “wrong body” which is often called dysphoria. The severe distress that comes from this disconnect and dysphoria does need to be treated. There are many different ways to “treat” gender dysphoria and the Netherlands have been doing this for decades. For some, that means transitioning medically, socially and or legally; for some, it includes all of these paths.
When taking care of transgender patients, I would challenge us to stop thinking of this in terms of our traditional reductionist disease model. Instead, AndreAs suggested at the 2017 Rhode Island Trans Health Conference that, “Our job is to mitigate pain. Our job is to help people live the full version of themselves. Our job is to support people in feeling whole and being seen.”
As primary care providers, we should not be “gender police,” or create further barriers to a patient’s care. We should be facilitators and affirm people wherever they are on their journey. In the words of activist and educator Jaymie Campbell, MEd, remember this pearl, “Someone is trans the minute they tell you they are trans.”
This same article from the Lancet argues that a mental health provider’s job is to improve overall health by mitigating negative effects of stigma and prejudice, “by helping clients to find their most comfortable and fulfilling gender expression, and, if applicable, by facilitating gender role changes and coming out.” This role should be extended to primary care providers as well. In primary care, we too strive to mitigate stress, stigma, and prejudice with our patients. Research shows that supporting patients in their gender affirmation through hormone therapy and gender-affirming surgery correlates directly with improved quality of life. As my mentor, Dr. Michelle Forcier frequently reminds her residents and families, “It is more dangerous to withhold care than to treat.”
Next time you care for a transgender patient, I would urge you not to think about this care in terms of making the “right or wrong diagnosis.” Gender is innate to all of us; it comes from one’s innermost self. Our job as clinicians is to listen and understand our patient’s stories and journeys. Our patients are their own experts on their gender. So let’s continue talking about gender in primary care. Include the discussion in new patient visits, annual wellness exams and well child checks. Instead of trying to rush towards a diagnosis, sit quietly, listen, and learn. Let your patients guide you.
Chelsea Graham is a family medicine resident.
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