• Being an FP Means Always Stretching Your Scope, Knowledge

    When I told my neonatologist-turned-pediatric-anesthesiologist dad that I wanted to be a doctor, he was confused.

    physician and patient talking near window

    “You’ll be so bored,” he said.

    My dad is a quiet man and creature of habit. He is excellent at his job, his co-workers love him and the once poor Egyptian immigrant has found a path to prosperity in the United States. Unlike me, he likes repetition. He knows me well, and I don’t thrive when staying in the same environment. I thrive on constant challenge, a bit of chaos, using my brain in diverse ways and a good dose of human contact.

    So when I decided on family medicine, he had to do some research. At first, he considered it similar to an unspecialized generalist physician in other countries where he had lived. But after talking to U.S. colleagues and looking at the training, he said, “That will be good for you. You won’t be bored.”

    And he was right.

    In December 2019, our federally qualified health center just south of Boston made a commitment to expand our five-site FQHC to provide comprehensive primary care for LGBTQ+ patients. Our clinic already had an infectious disease program, including HIV and hepatitis care, as well as robust family planning and teen programs. As director of women’s health, I sat with our urgent care director and CMO, and we created a team to start additional training on gender-affirming care.

    We discussed the biases that exist, even within our own health care teams, and prioritized finding staff that wanted to provide gender-affirming care. One study showed that although 85.7% of primary care clinicians were willing to provide primary care for transgender patients, only 69% felt capable of doing so. Another study showed that only 50% of primary care physicians were willing to continue prescribed gender-affirming hormone therapy in transgender patients. The AAFP has endorsed a recommended resident curriculum in LGBTQ+ care, including hormone therapy for gender-affirming care, but there is a broad spectrum of how such training is implemented.

    I found appropriate CME and trainings for staff, including our phone receptionists, medical assistants, front desk staff, nurses and physicians. The trainings were aimed at two goals: making all staff more aware of bias and developing comfort providing LGBTQ+ care, and specifically training teams to directly provide that care. We used grant money to get training and created a website. We were revving and ready to go.

    And then came the pandemic. Our FQHC became one of the primary partners with our county’s public health department for south shore testing and triage. Two of the three leads providing gender-affirming care were redeployed to provide almost 100% COVID-19 care. I got pulled into full-time inpatient medicine and obstetrics care. Our urgent care director became focused on COVID-19 testing and triage care. The outside trainings were canceled (though we continued to provide Lunch-and-Learn lectures on LGBTQ+ topics), and our expansion of services to include gender-affirming care were put on hold.

    Regardless of how the priorities of the clinicians involved shifted, the new website was launched, and shortly, patients started seeking care.

    And that’s how I met Liberty. I was working a day of clinic every two weeks. She sent a message through our patient portal that included a paragraph about how she’d been searching for a nearby clinic to provide gender-affirming care. She was specifically looking to start estrogen therapy and testosterone-blocking therapy. Her note covered her anxiety and history of depression, and mentioned that she didn’t have means to make the commute into the city for transgender care. She wrote that she realized that in-person visits were few and far between, but she really wanted to see me. Someone forwarded me the message, doubtful I could book her in because my schedule was always stacked with in-person procedures and high-risk obstetrics patients. I said of course we would fit her in.

    In Boston, we are fortunate to have Fenway Health — a provider of fabulous, free CME and protocols, and always happy to answer questions. I reviewed their protocols and did some CME on my COVID night shifts.

    And then I met Liberty. She was in tears, she’d known she was ready to transition for years, but just couldn’t get into Boston and couldn’t figure out how to find a doctor. From our suburb on the south shore, our health care center is a 20-minute drive without traffic, over an hour by public transportation. The only parent who supported her decision was her step-mother, who didn’t have a car. Our suburban clinic was less than a 10-minute subway ride for her. A majority of our patients are on public insurance, and for their specialist appointments many require transport through MassHealth, our state Medicaid program (a program called PT-1). Although it might seem like access to Boston is easy, for many of our patients the distance is a barrier.

    Liberty and I went through the protocols together, and we discussed the options. During the next few weeks, she started the appropriate medications (estrogen and spironolactone). What I realized in my learning is that there aren’t any medications in gender-affirming care that are novel to me. I prescribe hormonal medications frequently. I prescribe spironolactone for certain types of acne, in cirrhosis, etc. I frequently check hormone levels for other indications. Expanding into gender-affirming care was simply learning a different indication for medications, different goals, and a new way to achieve patient well-being and health.

    As for Liberty, she was almost giddy when she started medication. She loved the first change she noted — her softer skin. She credits finding our website as “life-saving.” It’s been seven months. She’s doing great and feeling confident. We’ve moved to telehealth visits. She’s applied and gotten into design school.

    Was it a stretch for me to learn a new scope of practice on the fly?

    Yes.

    Am I as a family medicine doctor dedicated and passionate about finding healthy, evidence-based answers to any of my patients’ health needs?

    Yes.

    I see providing gender-affirming care as any other medical condition that may come my way. I am always here to advocate for and affirm my patients’ health needs.

    These patients don’t just live in city centers with clinics like Fenway and University of California San Francisco. They live in rural communities, suburbs, every community. Every patient we encounter has a gender, has a sexuality. Gender diversity is part of human diversity. Assessing each patient includes gender and sexual health; it should not be seen as specialty care. Our patient-centered medical homes should include all the diversity of patients.

    I don’t take gender-affirming care lightly. Many of these patients have experienced trauma — physically, psychologically, systemically — and having adequate training and access to mental health and subspecialists is important. My background at the UCSF School of Medicine and Santa Rosa Family Medicine Residency, including its embedded HIV track, gave me a background and a network from which to draw from. Our residency included a gender-affirming clinic and we had regular didactics on LGBTQ+ health. That said, being five years out and never having practiced gender-affirming care without a preceptor, I appropriately sought out updated information and CME.

    Several organizations, such as Fenway and UCSF, have compiled comprehensive websites to assist the uninitiated in caring for this population. Programs like Fenway’s Project ECHO and other intensive training programs run by Fenway, UCSF and many academic centers across the country are available for those wanting a deeper dive into making their organization fully LGBTQ+ competent.

    An outsider would’ve asked, simply, why can’t Liberty just go to Fenway Health Center? Indeed, a map makes it look easy. For a young adult or adolescent who is isolated, without a parent willing to drive them, dependent on public transportation and uncomfortable navigating a city environment, it’s not. However, being able to take the subway, or even walk, to the nearest community health care center is a huge relief to them, or as Liberty said, “life-saving.” By expanding our medical homes to include these services, we are doing exactly what primary care is built for: providing evidence-based medicine for any of our patients’ medical needs.

    MaryAnn Dakkak, M.D., M.S.P.H., practices full-scope family medicine and is a clinical assistant professor at Boston University Medical Center. She is Women’s Health Director at Manet Community Health Centers. Her views do not represent those of the organizations with which she is affiliated.

    Additional Resources
    Fenway Health LGBT Health On-Going Training Series 2020-2021
    (Up to 116 AAFP Prescribed Credits)

    National LGBTQIA+ Health Education Center

    UCSF Transgender Care Guidelines

    Transgender Health Echo



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