Jose Delfin Castillo III, PhD, MSNA, CRNA, APRN

Both of these articles are very pertinent for primary care physicians and health care providers as a whole. Admittedly, the sample size was small and the geographic location used for Shires and colleagues’ study was not nationwide. But I do think, as a researcher and presenter on the topic of transgender care, that the results on the willingness to provide routine care to patients who are transgender would have been similar had the survey been conducted with a national reach throughout the United States. Nevertheless, it is important to note that the high numbers would not likely be duplicated on a national level when it comes to understanding how to treat our transgender patients.

The case scenario essay by Goldhammer et al provided me with new and useful information about the software systems that incorporate preferred name vs. legal name and biological sex vs. preferred sex that will greatly assist nurse anesthetists and other health care providers. Having a tool such as this will allow a holistic approach to our patients in the manner that they desire to be recognized. From my personal experience as a member of the LGBTQ community, Goldhammer and colleagues are on the right track in suggesting that all medical office personnel, not just individuals with a medical degree, learn how to treat patients who are transgender in an appropriate manner. Education and training should be extended from the registration staff member, the security guard (if any), the billing staff, and any person within the facility or office that has any point of contact with the patient. There is a lack of formal policies at the practice level on treating such patients, even on matters as seemingly simple as utilizing which pronoun to use as appropriate when entering information in our patients’ electronic health records. Overall, these best practices, if incorporated in our day-to-day routine, can make a difference in our patients’ health care experiences and play a role in seeking health care in the future.

Finally, clinicians should continually educate themselves as much as possible, by attending conferences that offer current best practices on the subject of transgender patients. Our understanding of our patients grows greater with the passage of time, and these educational opportunities can further a healthcare professional’s willingness and understanding of how to treat our transgender patients. Ideally, this will in turn lead to increased collaboration and presentation at conferences, in research, and professional practice as a whole, which will result in the desired outcomes.

Morissa Ladinsky, MD

Behind an explosive increase in media attention and visibility are more than 1.3 million Americans whose gender identities and expressions challenge conventional understanding. Openly transgender and gender nonconforming people now occupy seats in classrooms, chatrooms, board rooms and our exam rooms. Yet their journeys often incorporate shame, guilt and marginalization. These factors, not their transgender identity, underlie their high rates of depression, anxiety, substance use, self-harm and suicidality. Medicine today recognizes adverse childhood events and social determinants as key drivers of adult health outcomes and societal well-being. As transgender and gender nonconforming individuals and their families increasingly present to physicians for care, advocacy and understanding, providers can meet their needs with humility and affirmation.

Shires et al, provide a limited needs assessment of one institution’s medical providers. While intent on providing affirming care for transgender and gender nonconforming patients, they feel ill equipped to do so. Though this survey is limited in size, scope and specialty, its findings are echoed nationally. Large gaps exist in provider knowledge of and experience in caring for transgender and gender nonconforming people.

Goldsmith et al, beautifully address this gap to enhance providers’ understanding of gender identity (one’s internal sense of gender) and identity beyond the gender binary. These authors succinctly articulate language and pronoun usage inclusive of key gender identities and their use to enhance patient’s longitudinal health and wellness.

In our work with transgender and gender nonconforming youth and young adults, several concepts have emerged:

• Gender identity is an inherent trait. It is not chosen. It does not result from past trauma or “hormonal imbalances.”
• View “transgender” as an adjective, never a noun.
• Many transgender and gender nonconforming people experience intense dysphoria. This internal incongruence between their assigned sex and gender identity underlies their high prevalence of mental and physical health challenges.
• Transgender and gender nonconforming patients may have experienced painfully stigmatizing medical encounters. Fear of another transphobic event often impedes transgender and gender nonconforming people from seeking health care. Be aware their medical concerns may carry a higher acuity when they do arrive.
• A transgender and gender nonconforming identity is unrelated to sexual orientation.
• Transgender and gender nonconforming people youth can be aware of their identity as early as 3 to 5 years of age. Others become aware later as puberty looms. While their adult identity is not secure, affirming and nurturing their expression is proven to enhance health.
• Transgender and gender nonconforming patients appreciate proactive discussion of the physical exam: when, where, and why we will examine each section of their body.
• Each transgender and gender nonconforming person is unique. While some affirm their identity and mitigate dysphoria through gender expression, hormonal therapies and gender affirming surgeries, others choose not to. Awareness of these medical modalities, and regional sources for referral, are important. So too are competent and affirming local mental health resources.
• Transgender identities and diverse gender expressions do not constitute a mental disorder. As such, attempts to alter them via conversion therapy or behavioral regimens to reverse them, are not endorsed by any medical body. Severe and irreparable harm are often the outcome.

Stephanie Tran, MD

Shires and colleagues’ findings highlight the large discrepancy that exists in some aspects of treating patients who are transgender, particularly the quality of care and the attitudes and comfort level that primary care physicians have towards treating these patients. Since every study has its limitations, future studies should strive to sample larger groups of physicians to include multiple geographical areas which would contribute to the data that already exist on this topic. That said, it was wonderful that so many resident physicians responded positively to the questions Shires et al asked, since many of these clinicians will represent the primary care physicians of the future. It’s my hope that medical schools will observe these findings and incorporate more LGBTQ-friendly training into their curriculums, and as well as national accreditation institutions to offer more LGBTQ focused CME training into their course requirements.

In the second report, Goldhammer et al displayed an excellent grasp of the best ways that primary care physicians and their support staffs, such as those who deal with appointing and direct patient care, treat and address these patients in a respectful, culturally competent way. I would add that I have seen many patients who are transgender are often subject to discrimination, violence and safety issues, a higher severity of intimate partner violence, substance abuse and mental health discrepancies in comparison to that seen in the general population. Therefore, providers should have this on their radar and equip their practices with the appropriate screening tools and resources to best address these psychosocial issues that often serve as barriers to care and to diagnosing and treating patients in a comprehensive manner.

Treating patients who are transgender is a dynamic, ever evolving topic, and PCPs should not assume that Goldhammer and colleagues’ findings and my observations will always hold true. Literature and websites provided by, but not limited to, the World Professional Association for Transgender Health (WPATH), University of California at San Francisco, Endocrine Society Clinical Guidelines, and the Fenway Guide to LGBT Health can help update and expand a PCP’s knowledge and provide a sense of relief among patients that their medical provider is appropriately versed on this critically important topic, from seemingly minor, but often overlooked details, such as a patient’s chosen name and pronoun on intake forms and designations in electronic medical records, to larger particulars that embody cultural competencies, such as transgender-appropriate preventative screening guidelines, harm reduction, and awareness of the fluidity of gender when addressing and serving our gender nonbinary patients.

Joshua D. Safer, MD, FACP

The Shires study was useful and represents an important advance for developing hypotheses that might explain barriers to clinicians providing care for transgender patients. Data have previously been primarily from the patients themselves, so knowing what physicians self-report is helpful. Of course, the survey focused on only one health system. The actual statistics elsewhere would need to be measured with future studies in other locations or with larger studies.

In 2018, individuals with nonbinary gender identities seem to be a small segment of individuals with gender identity that does not align with sex recorded at birth. Further, there is some variation in terms and definitions among transgender and gender nonbinary individuals. The chance that clinicians will make errors in referencing such individuals is high.

Therefore, important points of the Goldhammer manuscript are: 1) be open with regard to the labels a given individual might use, including pronouns, names, and other elements of gender expression; and 2) be respectful of the patient. Exposure to such circumstances will make the nuance easier for clinicians over time. Record-keeping systems that are inclusive of transgender and gender nonbinary expression will help keep physicians organized on the topic and will help maintain a respectful environment.

John A. Schneider, MD, MPH

I highly doubt that 86% of clinicians in the Midwest would be willing or competent to provide comprehensive primary care to transgender patients. Looking at the survey as representation of the entire U.S., the sampling methodology, while OK, was not systematic to deliver a representative sample. That being said, I do believe that 86% of clinicians want to become competent at caring for transgender patients, which I think is encouraging.

During the past 5 to 10 years, there has been an increase in training in medical school to raise awareness of issues that transgender patients experience. There are several great resources for providing competent care to these patients including the University of California, San Francisco’s Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people or WPATH. These resources describe the importance of listening and following the cues of transgender and gender nonconforming patients as well as more medical information around hormone therapy and laboratory monitoring.

Clinicians should not hesitate to ask a clinician who is well-versed in these guidelines to serve as a mentor. Conversely, those very familiar with these guidelines should offer, if schedules allow, to mentor someone interested in learning more about treating these patients.