Letters to the Editor
Health Care and Insurance Issues for Transgender Persons
TO THE EDITOR: In reading the article, "Testosterone Treatments: Why, When, and How?," in the May 1, 2006, issue of American Family Physician, I was surprised that it did not mention the use of this treatment in transgender men.1 As an openly gay and transgender physician, I am saddened by this omission. This population often experiences discrimination, violence, and poor access to medical care. More than 70 percent of transgender men in the United States report that they delayed seeking care because of fear of discrimination from health care professionals.2 Thirty to 40 percent of transgender persons in the United States lack a primary care physician; a survey showed that almost one half of those who have a primary care physician have not informed their insurance provider of their transgender status.3 Because of these disparities, it is crucial to ensure that these patients receive culturally and clinically competent care.
Transgender patients also experience disproportionate poverty and lack of health insurance. Assessments of transgender populations in the United States report that up to 60 percent of these persons live below the poverty level, with more than 40 percent being uninsured.4,5 Even when insured, most health insurance policies in the United States specifically exclude transgender-related care.
Because the American Academy of Family Physicians has recently reaffirmed that it "opposes all discrimination in any form, including but not limited to, that on the basis of actual or perceived race, color, religion, gender, sexual orientation, gender identity, ethnic affiliation, health, age, disability, economic status, body habitus or national origin,"6 I strongly urge you to include information about transgender patients in review articles that are germane to their care. Educating primary care physicians about transgender medicine is critical to ensuring that this population receives the knowledgeable and sensitive care that all of our patients deserve.
REFERENCES
1. Margo K, Winn R. Testosterone treatments: why, when, and how? Am Fam Physician 2006;73:1591-8.
2. Newfield E, Hart S, Dibble S, Kohler L. Female-to-male transgender quality of life. Qual Life Res 2006. Epub ahead of print.
3. Feldman J, Bockting W. Transgender health. Minnesota Medicine. 2003. Accessed September 1, 2006, at: http://www.mmaonline.net/publications/MNMed2003/July/Feldman.html.
4. Xavier J. The Washington, D.C. transgender needs assessment survey: final report for phase two. Washington, D.C.: Gender Education and Advocacy; 2000. Accessed September 1, 2006, at: http://www.gender.org/resources/dge/gea01011.pdf.
5. Transgender Law Center. Accessed September 1, 2006, at: http://www.transgenderlawcenter.org/tranny/pdfs/Trans%20Realities%20Final%20Final.pdf and http://www.transgenderlawcenter.org/pdf/Good%20Jobs%20NOW%20report.pdf.
6. American Academy of Family Physicians. Discrimination: Family Practice Residency Guidelines. Accessed July 31, 2006, at: http://www.aafp.org/online/en/home/policy/policies/d/discrimination.html.
in reply: We appreciate Dr. Gorton's response to our article. We are both very familiar with the use of testosterone for transgender men and are in full agreement with his concerns. Unfortunately, the scientific literature on this topic is limited. A few studies have looked at the effects of testosterone for transgender men and have found some benefit in quality of life with little in the way of adverse effects,1,2 although we are unaware of any randomized controlled studies on the subject. Dr. Winn has treated many transgender men who have used testosterone successfully and feel that they have derived tremendous benefit from it with minimal side effects. Dr. Margo has found Dr. Gorton's online book, "Medical Therapy and Health Maintenance for Transgender Men: A Guide for Health Care Providers,"3 to be most helpful in caring for this group of patients.
REFERENCES
1 Newfield E, Hart S, Dibble S, Kohler L. Female-to-male transgender quality of life. Qual Life Res 2006. Epub ahead of print.
2. van Kesteren PJM, Asscheman H, Megens JAJ, Gooren LJG. Mortality and morbidity in transsexual subjects treated with cross-sex hormones. Clin Endo 1997;47:337-42.
3. Gorton RN, Buth J, Spade D. Medical Therapy and Health Maintenance for Transgender Men: A Guide for Health Care Providers. Accessed September 14, 2006, at: http://www.nickgorton.org.
The article "The Challenge of Pelvic Inflammatory Disease" (March 1, 2006, page 859) contained an error in the first paragraph of the "Treatment" section on page 861. The first sentence of this paragraph incorrectly referred to a low index of suspicion for pelvic inflammatory disease (PID), rather than a high index of suspicion. The sentence should have read as follows: "Physicians should have a high index of suspicion for PID and should initiate therapy in all women who are at risk of PID and uterine, adnexal, or cervical motion tenderness on bimanual examination with no apparent cause." The online version of this article has been corrected.
The article "Behavior Disorders of Dementia: Recognition and Treatment" (February 15, 2006, page 647) contained a misspelling of the third author's name in the byline on page 647 and on the table of contents on page 563. This author's name should have appeared as Ben Schoenbachler, M.D. The online version of this article has been corrected.
Send letters to Kenny Lin, M.D., Assistant Editor, American Family Physician, e-mail: afplet@aafp.org. Letters submitted via regular mail should be sent to: 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-6272.
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