Q&A: How providers can better care for transgender patients

Individualized health care can be a positive first step “that goes a long way” for primary care physicians looking to create a safe, respectful environment for transgender patients, according to Olivia T. Van Gerwen, MD.

However, the health care system could do much more to support both these patients and providers, said Van Gerwen, an assistant professor in the division of infectious diseases at the University of Alabama at Birmingham.

Van Gerwen, who is currently working to develop curriculum to better support medical students’ understanding of gender-affirming care, explained that some PCPs who see transgender patients feel unprepared to address all their needs.

As “people who are trans have an ingrained mistrust of authority and the medical establishment, specifically,” misconceptions and harmful legislation aimed at transgender youth can make it difficult for even for the most well-meaning practitioner to create a positive environment, Van Gerwen said.

Healio spoke with Van Gerwen to learn more about gender-affirming care, resources and misconceptions about transgender health care, and how PCPs can best care for transgender patients.

Healio: In general, how much training do medical students receive on transgender health care? Should there be more, and should it be mandatory?

Van Gerwen: It really depends on what medical school you're talking about. Some schools have a lot more robust curricula than others do. And that's especially true, I would say, in parts of the country where there are a lot of resources for trans health and for trans individuals in general. The medical schools associated with those places tend to have more options for students to learn about trans care, but, in general, the boards that govern the curriculum that must be taught in medical schools nationwide do not have a whole lot that they require regarding transgender care.

I'll use my institution as an example. So, at UAB at the Heersink School of Medicine, where I am a faculty member, they in their standard medical curriculum have fairly limited exposure to trans care. They learned a little bit about it during their endocrine module, and they learn some basics about how to talk to people about pronouns and gender identity in their clinical skills courses. Outside of that, for the whole population of medical students in each class, that's about what they get in terms of standardized curriculum. At UAB we do have lots of elective options and extracurricular opportunities where students can learn about trans care and LGBTQ+ health care, but those are things that students elect to do.

It really depends on the school, and then it depends on your interest as a student. But I will say as a blanket statement, it’s pretty limited. I think there should definitely be more. I think one misconception that medical students have is that they’re not going to take care of these patients if they’re in a field that’s not directly related to gender care, but that is absolutely untrue. Trans people need knee replacements, trans people need skin care from dermatologists, trans people need cataract surgery. In all of these specialties, you will interface with patients from the LGBTQ community. Learning some of the basic needs that this community has and some of the challenges they face is important for every single person who’s going to be a doctor or health care provider. With that, I think training in these topics should be more robust and I do think it should be mandatory. I don't think every single medical student needs to know the ins and outs of prescribing hormones and what the different types of gender-affirming surgeries look like in terms of the details that surgeons need to know to perform the operations, but I think a working knowledge of the community and the issues they face is important for all physicians.

Healio: Can you further discuss your efforts to develop curriculum for transgender healthcare at your institution, and what do you plan on including in that curriculum?

Van Gerwen: Currently, a lot of our efforts have been going towards some of these more elective-style outlets. We have a Health Equity Scholars Program at UAB, which I've been a speaker for. I'm not directly involved in the leadership of that program, but it is a program for about 10 students per year. It's composed of medical students from first to fourth year who have interest in health equity — including in terms of gender identity, sexual orientation, race, socioeconomic status, all of those things — and they go through various seminars and trainings and activities throughout their time in medical school to get skills and learn how to achieve health equity for all those populations. We're working on integrating some trans-specific topics into that program, which has been really exciting.

We also are working to have some more robust representation of trans issues outside of just the endocrine module and the second year of the preclinical coursework for students. I think that the focus on the hormonal impacts of gender-affirming therapy is very important for people to learn, but I think there are other places where we can emphasize the needs of trans patients throughout the curriculum, so we're working on trying to expose students to trans issues in their clinical skills courses. We have a course called “Introduction to Clinical Medicine,” and then in conjunction with that, they do standardized patient interviews. We have a set of standardized patients who are trans individuals living in the community, and those are people who the learners will come and interview and examine and talk with. It may be about something related to their gender identity, and it may not, but it helps people get comfortable with using pronouns and using terminology and basic respect with patients who are not necessarily people they may be used to interacting with. This also gives them an opportunity to put a face to the name, I think, especially in a place like Alabama. There are people who come to medical school, and they've never really been exposed to anyone outside of perhaps their small town or the town they went to college in, and so they may not realize how many trans people they will interact with in the world throughout their life and their career. Meeting people who have lived trans experience can be a really important experience, even if they're not learning anything specific about trans care. So, exposure and representation are things that we're trying to integrate into the curriculum.

A more long-term goal is to build more experiences into their clinical rotations in the third and fourth years. Currently, medical students do their first 2 years in the classroom where they learn about the different organ systems and biochemistry and pharmacology and all that good stuff, and then in their third and fourth year, they go on to the wards in the hospital and in the clinics and they learn how to take care of patients. So, finding ways to integrate trans care into the standardized curriculum for all medical students going through, say, their internal medicine or family medicine rotation is something we're exploring.

All of that is what's in the works, but I think in general here at UAB, we're trying to just build a culture that we are an open, accepting and respectful institution. We try to teach that to our students from the first day they come on campus. We also have a lot of great resources in terms of research that students can get involved in, and also clinical experiences that they can get as part of their electives during their clinical years. I do research about sexual health in transgender populations. I have several students who do research with me, and I think that is a really important way to expose students to those issues.

We have a lot going on, but we have a long way to go.

Healio: What resources are currently available to physicians who did not receive adequate training during medical school and residency?

Van Gerwen: There are several institutions that have great websites. I would definitely refer people to the WPATH website and the UCSF Transgender Center of Excellence website. They are fantastic resources. They have really easy-to-use guidelines on gender-affirming care. If people want to learn how to prescribe hormones to patients, you can learn a lot from just reading through the website and the guidance on those websites. That's actually how I learned how to prescribe hormones: I had a mentor who kind of took me as an apprentice when I was a resident and taught me the basics of prescribing hormones, and then I used those guidance documents on a daily basis to learn how to prescribe hormones. In addition to those hormone references within those websites, they also have a lot of great information about general primary care for trans people and issues that they face in terms of age-appropriate cancer screening, things that you should consider when you're thinking about long-term side effects of hormones. So, things that maybe people who aren't prescribing hormones wouldn’t need to know, but things that general internists and primary care doctors would need to be familiar with when they're taking care of trans patients who have either just started hormones or have been on them for a long time, and also who may have had gender-affirming surgery.

The other reference I will mention is The Fenway Institute in Boston. They are an excellent LGBTQ health care center, and they do a lot of incredible research and community partnership. They have in-person trainings, which are typically over 1 or 2 days, where they teach the basics of transgender care. It’s an intensive way to learn the different guidelines and approaches to caring for this population. So, there are a lot of people doing great work to teach these things to physicians who have already completed their training.

Healio: What are some misconceptions about transgender health care among physicians?

Van Gerwen: I think where I see a lot of misconceptions — and I cannot speak to this as much as someone who may practice, say, in a pediatric setting — but I think a lot of the misconceptions come around how we care for adolescents and young people who are gender diverse. This is amongst physicians, but also among the lay public. I think that all of the legislation that we've seen, especially in Alabama, has really focused on gender-affirming therapy and puberty-blocking medications for youth and adolescents.

The discourse you hear, even amongst physicians, is that surgeries are being done on children without the consent of their parents. There are misconceptions that these are irreversible treatments, that these are things that are happening with limited data to support the good outcomes that gender-affirming therapy provides for young people, and all of those things are just not true. There are really good data that, for youth, going to a doctor to figure out how to best affirm your gender at an early age has much better outcomes in terms of the transition for the patient and also in terms of mental health for the patient.

Also, the hormone discussion for youth is very different than we hear in the public discourse. A lot of times, what we're doing for these young people is blocking puberty with puberty blockers — which, there are definitely consequences to doing that, particularly in terms of bone health and other sequelae of delaying the onset of puberty. However, the benefits often outweigh the risks, and I think that the important thing is that this type of treatment is happening in the setting of a patient, a physician and parents all having a risk-benefit discussion that is balanced and focused on making the right decision for that patient. So, that being said, puberty blockers for that age group are also reversible so that they do not have feminizing or masculinizing effects that are permanent. We sometimes do start youth on hormones before they turn 18, and that is a decision, again, that's made between the doctor, the patient, the parent, the care team, based on the results that the patient is looking for and how everything is going in terms of their mental health and their physical transition. These are also things that are not permanent. They can stop hormones and be reversed if something happens and the person does not feel that they would like to continue to pursue gender transition.

I think some other misconceptions that people have in the medical field about trans care is that it's really hard to do gender-affirming hormone therapy. It is actually very simple. If you get appropriate training and know when to ask questions to people who know more than you do about the subject when you're first learning, it's actually a pretty easy thing to do for patients. I think, more and more, I would love to see primary care doctors taking this on as something that they can offer for their patients to make one less barrier for them. Having to find a gender clinic is not necessarily something that all patients are able to do, so having options in their own town is something that we all aspire to in this field.

I also think that the transgender health care is more than just medicine. It's a lot about the approach. You can do so much by just being a nice person, being a respectful person, hiring a staff that is going to respect your patients, and creating an environment where patients feel safe. That is half, if not more than half, of providing good affirming trans care. The medicine you can learn and it's fairly simple, but the harder part I think for a lot of people is creating that environment and being a place where people feel safe, even though it probably shouldn't be hard.

Healio: What further should primary care physicians know about gender-affirming care?

Van Gerwen: I think, if you're not going to be prescribing it, the most important things for people to know are the typical side effects that people can have with long-term use of hormones and then the risk profile of these medications. In general, the medications are very safe, but as with all medicines, there are risks with taking some of these gender-affirming medications. For example, feminizing hormone therapy like estradiol, which adds exogenous estrogen to someone to feminize their appearance, is generally very safe but does have some cardiovascular risks. So, for people who are on estradiol long term and perhaps have a history of blood clots or smoke or have a family history of any of those issues, you may want to take care in how you prescribe those hormones and how you monitor those patients. You certainly want to counsel them on smoking cessation, and you certainly want to take a lot of care in dosing their estrogen if they have a personal or family history of blood clots. So, side effects are really important because you're going to see patients on these medicines. It's just like any other medicine.

I would also say, I think primary care physicians should not be scared to take care of the patients. I think for all the reasons we've already talked about, a lot of people in primary care feel that they're not equipped to handle all the needs of these patients when in fact their needs are just like any other patient’s. If you have a patient who's a 65-year-old man with diabetes, hypertension, who smokes and who has mental health comorbidities, that patient may be more complex than most of our trans patients.

It can be intimidating because it's an unknown, but I think educating ourselves on the fact that this is a patient population just like any other population that deserves respect and care is important. I think the most important thing that primary care physicians should know is you can do so much for your patients even if you don't prescribe their hormones or refer them to a surgeon. If you just provide a place where they feel safe getting their health care and they feel affirmed in who they are and whether their doctor uses their name that they want to be called and their pronouns (it’s essential that you also have a staff that does the same) that is moving mountains for these patients. So, I think if primary care physicians can do that, that is a great place to start, but we can also do a lot more in terms of learning how to take care of their specific needs.

Healio: Can you discuss the importance of individualizing health care for all patients, including those who are trans?

Van Gerwen: I think it's important for all patients, but I think, in general, people who are trans have an ingrained mistrust of authority and the medical establishment specifically. So, not only is individualized health care important because you are able to do what your specific patient needs, but also it is an act of showing your patient that you care about them and that you are going to listen to them. It also shows that you are not going to betray them or harass them or discriminate against them, which is what many trans patients have experienced when they interface with the medical establishment. Just the act of providing individualized health care is a sign of respect that goes a long way with a disenfranchised, underrepresented population that has not had the best experience with the medical system.

I think more and more people have embraced that there are many, many, many ways to identify in terms of gender and sexuality, and so there are a lot of people who are not necessarily transgender but may be nonbinary, maybe have a sexual identity that is not in the trans/nonbinary realm, that is not the cisgender heteronormative stereotype that I think the world kind of wants everyone to be. So, providing individualized health care for people who may not fit within the binaries that we've created for them, it means a lot to patients, and it can go a long way for you as a provider in having them open up to you, and you can take the very best care of them that is possible by doing that.

Healio: Is there anything else you’d like to add?

Van Gerwen: Despite the fact that much more needs to be done about enhancing education around trans care in medical education, I really do think that we have come so far, even from when I was a medical student from 2010 to 2014. I think the fact that culture as a whole has shifted in a way that is, in general, more accepting of LGBTQ+ people is a very meaningful thing. I think the medical students who I see today are more open to learning about trans care and very much more interested in taking care of these patients than some of the colleagues who I had in medical school just very recently. I think embracing that and running with this momentum that we have with the way students are interested is going to be so important to build the next generation of doctors so that I don't have to say something like “you should be a respectful provider.” I hope that in 10 years’ time, maybe some of those barriers are broken down and those are things that we don't need to focus on anymore.