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Tuesday Apr 11, 2017

FPs Can Lead in Treating Transgender Patients With Dignity

Do you remember throwing pennies into a fountain when you were younger? Do you remember making a wish before tossing a coin over your shoulder? I recently talked to a patient who'd had only one wish as a child. That wish was to wake up in a different body, the right body.

Caring for transgender patients is an honor. The trust they give you in that first meeting is intense when, after having only just met you, they discuss when they came to understand gender and feel that the body they were in was wrong. Helping patients who identify as transgender and gender-nonconforming access gender-affirming hormones is a privilege. Health care and bodily autonomy are rights of all our patients.

Patients who identify as transgender often share stories of discrimination by close friends and family, as well as by co-workers, bosses and medical professionals. These experiences coincide with increased incidence of mental illnesses such as anxiety and depression. They also lead to distrust of health professionals and reduced access to health care.

Discrimination against transgender people can be as blatant as a refusal to provide care or as passive as refusing to call a patient by the correct name. The former may seem like an unreal example, but it is not. In December, a federal district judge in Texas blocked efforts to prevent insurers, hospital systems and doctors from discriminating against transgender persons(www.latimes.com).  

Most patients are already protected from discrimination from insurers and health care providers. Extending that right to include transgender patients was part of the Patient Protection and Affordable Care Act, but that protection was blocked by the December court ruling.

The judge's ruling is alarming. As family doctors, we know the importance of recognizing our patients' diverse backgrounds and experiences. Caring for transgender patients is no different. We must strive to protect the right of all our patients to have insurance coverage and thus access to health care -- free of discrimination. It is our responsibility.

I cannot think of one patient who received gender-affirming therapy who did not benefit from the care. Every such patient I know has. Every single one. Even if physicians choose not to provide gender-affirming therapy, it's a simple matter to offer patient-centered care to all patients.

Joe, for example, was referred to my continuity clinic to get his nexplanon removed. He'd had it for two years and struggled with side effects the whole time. Our electronic health record system allowed for entry of the name a patient wanted to be called by, and I easily knew to call him Joe rather than Jenny, his legal name. Before I entered the room I took a look at the chart, noted Joe's pronoun, the reason for his visit, and recorded gender(s) of his partner(s). I asked my medical technical assistant to set up the tray for nexplanon removal and she gave me a sideways look, but said nothing.

During his appointment, Joe and I talked about whether or not he would need contraception once the nexplanon was out. We talked about how being on testosterone wasn't protective against pregnancy. We went through the consent for removal, and then we chatted about weekend plans while I took the nexplanon out.

On his discharge paperwork, I wrote the name he should be called by at the top and circled it, explaining to him that the computer didn't transfer that information to the paperwork yet. When Joe left the clinic, my team and I talked about how we likely will be seeing more transgender male patients with contraception needs. We also talked about where to find the proper name to use when referring to these patients if it was different from their legal name, as well as how to talk with and about patients without knowing their pronouns.

If these details seem small -- using the correct name and pronoun, being informed about Joe's contraceptive needs as a trans male, and helping to educate staff -- it's because they are. They are clearly the least we can do for our patients: Use the right name and pronoun, be educated on their care, and help educate others. When we realize that their right to receive medical care from us is not currently protected, we should embrace our responsibility as primary care physicians to go a step further than the least we can do.

As family physicians, we have opportunities to influence AAFP policy on a variety of topics, including patient care and transgender issues. During last year's National Conference of Constituency Leaders (NCCL), delegates adopted three measures that sought to safeguard the rights of transgender and gender-nonconforming people. 

For the uninitiated, NCCL is the AAFP's leadership and policy development event for underrepresented constituencies: women; minorities; new physicians; international medical graduates; and lesbian, gay, bisexual and transgender physicians or physician allies. This year's event is April 27-29 in Kansas City, Mo., and coincides with the Academy's Annual Chapter Leadership Forum.  

If you are interested in standing up for the rights of your patients and their diverse needs, contact your state chapter about being an NCCL delegate. If you are unable to join your chapter delegation, you can still attend NCCL as a general registrant and have your voice heard.

Natalie Hinchcliffe, D.O., loves teaching residents, advocating for her patients and addressing stigmas in medicine. She is passionate about providing care for lesbian, gay, bisexual, transgender and queer patients, HIV primary care, and reproductive health and family planning services where access to such care is limited. She currently practices in Ohio.

Posted at 08:00AM Apr 11, 2017 by Natalie Hinchcliffe, D.O.

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