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Create affirming environment when caring for transgender patients
NEW ORLEANS — When treating transgender patients, primary care physicians must foster an affirming environment and shift their focus from gender-based care to anatomy-based care, according to a presentation at the ACP Internal Medicine Meeting.
“Many providers may feel daunted by the prospect of taking care of transgender patients,” Richard E. Greene, MD, director of health disparities education at New York University School of Medicine, told Healio Internal Medicine in an interview. “There has historically been little education in medical school on the topic. However, treating patients who are transgender requires only the desire to provide affirming care and the drive to become educated on the topic.”
During his presentation, Greene said that physicians may falter over using the correct terminology very early in the care of transgender individuals. He suggested that if a physician stammers over the correct words, they should apologize and acknowledge it because that shows that they care to say the right thing. He recommended that physicians say transgender, transwoman or transman instead of “transgendered,” “tranny” or “transsexual.”
“I hear a lot of people say things like ‘There aren’t that many trans people, why are we having these conversations? — They can go to special doctors,’” Greene said. “Here’s the problem: there are 25 million transgender people in the world and 1.4 million transgender people in United States by recent estimates... which is about the same number of people who have type 1 diabetes in this country. We know how to take care of type 1 diabetes, but most of us walk into the room with a trans patient and don’t know what to do next.”
Transgender health disparities data indicate that 19% of transgender patients are refused medical care because physicians don’t have an appropriate referral, 28% postponed medical care due to discrimination, 48% are unable to afford care and they are more likely to have depression, experience loneliness or have experienced violence, according to Greene.
Treating transgender patients carriers a new quantum of information, which is why a lot of providers may have resistance to caring for this population, he said. Many clinicians do not have a lot of exposure to transgender patients, he said. There is no true “transgender specialist” and endocrinologists are not necessarily well-versed, he noted.
Additionally, hormone therapy is “off-label” which may make a physician feel like they shouldn’t be doing it, he said.
Creating an affirming environment for trans patients is critical for their well-being, he said.
“First, think about forums, what your system is and what information is in your medical record,” he said.
Greene listed several important questions to ask trans patients, including:
- How do you identify your gender?
- Tell me about your transition/gender?
- Do you use hormones?
- Have you had gender affirming surgeries?
- Do you want to use hormones or have surgery?
- Have you used nonmedically prescribed treatments during your transition?
Greene also noted that physicians should ask about preferred names for body parts and recommended that physicians ask before touching during a physical exam.
The big paradigm shift in caring for trans patients is switching focus from gender-based care to anatomy-based care, he said.
“In many ways, beginning hormone therapy in transgender patients is similar to an adolescent going through puberty and once stable on these hormones, their risks of cancer and metabolic disorders likely become similar to cisgender patients with some exceptions,” Greene said in the interview.
He added, “Screening for prostate and testicular cancer in trans women are rarely needed without symptoms, but they may have this anatomy. Similarly for trans men, endometrial and ovarian cancers are possible, but not generally screened for without symptoms or other clues.”
HIV is highly prevalent in transgender patients; therefore, screening for HIV is of paramount importance in this population, he said.
To begin gender-affirming hormones, patients should have persistent and well-documented gender dysphoria or gender incongruence and the capacity to give informed consent, he said. Additionally, patients must be of the age of majority or have family consent if they are an adolescent, he said. Mental health visits are also important to document gender dysphoria, he said.
“The most important statement that I can make is that trans people are able to decide what is best for themselves and their bodies and when... We don’t have to give hormones, but withholding hormones can create real health risks for our transgender patients,” Greene said. “Therapy is an option, not a requirement, for accessing gender-confirming health care.”
During the initial visit with a trans patient, physicians should discuss goals and health history, perform a physical examination, risk assessment and relevant laboratory tests, he said. Additionally, physicians should discuss reproductive options before starting hormone therapy because some effects of hormones are irreversible, he noted. Physicians should also discuss expected effects of feminizing or masculinizing medications and possible adverse health effects, he said.
Prior to initiating estrogen hormone therapy in trans women, physicians should address issues of thromboembolic disease, macroprolactinoma, breast cancer, coronary artery disease, CVD, severe hypertension or unstable liver, Greene said. Similarly, any breast cancer, coronary artery disease, hypertension, active pregnancy or uterine, endometrial or ovarian cancers in trans men should be addressed before beginning testosterone hormone therapy, he said.
During follow-up care, physicians should assess patient comfort with transition, assess social impact of transition and social support, ask about legal name and/or gender changes, discuss family issues, monitor mood cycles and counsel regarding sexual activity, according to Greene.
“Patients of transgender experience deserve culturally affirming care from us,” Greene said. “We can actually save their lives just by giving it to them. Everyone’s transition will be different. Don’t make assumptions about what hormones or surgeries people want... Experience and interest will go a long way when taking care of transgender patients. Don’t let your discomfort get the best of you. Partner with your patients, tell them it’s okay, that you might make some mistakes but that you want them in your practice and want to take the best care of them that you can.”
He told Healio Internal Medicine that “there are excellent resources for providers who are new to working with transgender patients, including the UCSF Center of Excellence for Transgender Care, the World Professional Association of Transgender Health Standards of Care and the Callen-Lorde Hormone Protocols.” – by Alaina Tedesco
Reference:
Greene RE. Transgender health. Presented at: ACP Internal Medicine Annual Meeting; April 19-21, 2018; New Orleans.
Disclosure: Greene reports no relevant financial disclosures.