Although overall global attitudes toward transgender individuals have shifted in a positive direction in recent years,(www.slideshare.net) many transgender patients still encounter discrimination in various settings and situations, including experiencing difficulty accessing the health care they need.
In 2016, the National Center for Transgender Equality published the 2015 U.S. Transgender Survey,(www.ustranssurvey.org) which reported on the experiences of more than 27,000 transgender people in the United States. The survey found that one-third of all transgender individuals who had seen a health care professional in the past year had been harassed or denied care, and one-quarter experienced a problem with insurance related to being transgender. In addition, 23 percent of respondents said they avoided seeing a physician when needed because they feared they would be mistreated.
Less is known about transgender care from the physician's perspective. Although the AAFP's LGBT Curriculum Guideline(19 page PDF) recommends that family medicine residents receive training in this area, few studies have reported on how the average physician feels about caring for transgender patients.
Now, results of a small survey(www.annfammed.org) published in the November/December issue of Annals of Family Medicine shed new light on this issue. The survey examined whether primary care clinicians felt capable and willing to provide routine care and administer Pap tests to transgender patients, along with factors that could affect their ability and willingness to care for these patients.
In short, the survey found that surprising numbers of clinicians did not feel they were capable of providing transgender care, and that smaller (but still concerning) numbers would not be willing to care for transgender patients in need.
Survey Methods and Results
The survey population consisted of 140 primary care clinicians (97 in general internal medicine and 43 in family medicine). The clinicians provided demographic information and reported clinical and personal exposure to transgender individuals. In addition, they answered a series of questions about barriers to care and willingness to provide care, as well as questions designed to measure their levels of empathy and transphobia.
- A small survey published in Annals of Family Medicine examined the willingness of primary care clinicians to care for transgender patients.
- Results showed that a considerable number of clinicians did not feel capable of providing or were not willing to provide routine care to these patients.
- The authors emphasized the importance of including best practices for transgender care into medical education to help resolve this issue.
Eighty-two clinicians, or 58.6 of the survey population, were female. More than half of those surveyed (52.1 percent) were residents; the rest were attending physicians or advanced practitioners. More respondents reported having political views that were liberal (47.1 percent) or moderate (36.4 percent) than conservative (16.4 percent).
More than 75 percent of the clinicians surveyed said they had ever met a transgender person, and 53.6 percent reported treating a transgender patient in the past five years. The average empathy and transphobia scores were 5.4 (out of 7) and 3.2 (out of 7), respectively, with higher scores indicating greater empathy or transphobia.
Overall, 85.7 percent of clinicians were willing to provide routine care to transgender patients and 78.6 percent were willing to provide Pap tests for transgender men. Although a higher percentage of male clinicians were willing to provide routine care than females (89.7 percent vs. 82.9 percent), more female clinicians were willing to provide Pap tests than males (80.5 percent vs. 75.0 percent).
Determining what made some clinicians more willing than others to care for transgender patients was more difficult.
A multivariate analysis showed that several factors were associated with an increased willingness to provide routine care or to provide Pap tests to transgender men, including
- specializing in family medicine,
- having met a transgender person,
- having cared for a transgender patient in the past five years,
- showing empathy for transgender individuals and
- feeling capable of providing routine care.
Notably, family physicians were about five times more likely than internists to be willing to provide Pap tests for transgender men, although the authors noted that many internists routinely refer all patients for these tests. In addition, clinicians who had met a transgender person were roughly four times more likely than those who hadn't to be willing to provide these tests.
Factors associated with a decreased willingness to provide care for transgender patients included
- older age,
- having higher levels of transphobia,
- lack of exposure to transgender patients and
- lack of knowledge among staff.
Reported barriers to providing transgender care included
- lack of training on transgender health,
- lack of exposure to transgender patients,
- lack of knowledge about transgender care among staff and
- lack of familiarity with transition care guidelines.
So, whereas nearly 86 percent of clinicians were willing to provide routine care to transgender patients, only about 69 percent of clinicians reported feeling capable of doing so.
"While most clinicians were willing to provide routine care and Pap tests to transgender patients, support was not universal," the study authors wrote, adding that their findings "point to the importance of integrating not only clinical but also personal exposure to transgender individuals into medical education."
Improved Communication a Key Factor
In a related commentary,(www.annfammed.org) the authors discussed the importance of language in talking with patients who do not identify solely as a man or woman.
"The terminology for nonbinary identities varies from person to person; over time, new terms also emerge while others become outdated," they wrote. As such, they included in the article a table of terms that nonbinary individuals may use to describe themselves, along with a table of nonbinary pronouns and sample sentences that could be used in the clinic or as part of a training exercise. Using these terms, the authors suggest, could provide affirmation to the patient while helping to establish a relationship and build rapport with the physician.
"Best practices for all health care staff include avoiding assumptions about patients' gender identities, asking for information about name and pronouns in order to adopt these consistently throughout the clinical setting, and describing anatomy and related terms with gender-inclusive language," they wrote. "Through these communication approaches, health care clinicians can remain responsive to rapidly expanding concepts and terminology for gender identification and expression within our society, and can offer more patient-centered care that moves beyond binary gender concepts."
Family Physician Experts Offer Perspective, Advice
Natalie Hinchcliffe, D.O., of Cleveland, is well-versed in providing care for transgender patients and is a frequent contributor to AAFP News' Fresh Perspectives blog on this and related topics. She works at two clinics dedicated to serving the needs of LGBT patients and told AAFP News that 90 percent of her patients are transgender or gender-diverse.
"Caring for transgender patients can be truly lifesaving," said Hinchcliffe. "It is some of the most rewarding work a family doctor can do."
Marty Player, M.D., an associate professor in the Department of Family Medicine at the Medical University of South Carolina in Charleston and a member constituency alternate delegate to the AAFP Congress of Delegates, also provides care for transgender patients in his practice.
"Generally, people come to me because I am listed in a local directory of LGBTQI-affirming (lesbian, gay, bisexual, transgender, questioning/queer, intersex-affirming) physicians and practices or they are referred to me by their colleagues," he told AAFP News. "These patients are specifically seeking a primary care physician and practice open to their needs, and we are in tune with that."
Hinchcliffe and Player say family physicians should be open to treating transgender patients.
"Transgender patients are no different from other patients," Hinchcliffe said. "They have a variety of health concerns, and refusal to treat them is unethical, just as it is clearly unethical to refuse treatment to someone based on their race or religion."
"The vast majority of what a family physician treats in transgender and gender-nonconforming individuals is the same as what we encounter with cisgender individuals: upper respiratory infections, back pain, depression, hypertension, etc.," Player added.
That said, Player noted that transgender patients may have specific needs such as those that relate to use of gender-affirming hormones. He told AAFP News that although some family physicians may not feel comfortable providing these therapies, they are obligated to ensure patients receive the best care possible, whether it's from them or by referral to another clinician. "Our job is to know where to send our patients to get those services if we cannot fulfill them," he said.
Hinchcliffe said that in her practice, she treats encounters with transgender patients the same as those with anyone else and recommends that other FPs do the same. "Ask patients about themselves and break the ice before asking about their specific health concerns," she said. "Get to know them. 'Where are you from? How was your weekend? What do you do?'" Asking general questions at the outset helps to establish confidence and trust, she said, and lays the foundation for a good relationship going forward.
If a physician is unsure about how to address a transgender patient, Hinchcliffe's advice is simple. "Just ask," she said. "Ask the patient … 'What's the best name to call you? What pronouns do you use?'" If indicated, the physician should update the patient's electronic health record (EHR) to reflect the correct name and add a note regarding which pronouns to use during future visits.
Player uses a similar technique in his practice. "I ask transgender patients their preferred name and keep that in a prominent area of the chart so I and staff can refer to it easily," he said. "I think knowing someone's name, what they want to be called, goes a long way to building and maintaining rapport."
Player noted that his institution currently is undertaking an initiative that aims to incorporate standardized information on a patient's sexual orientation and gender identity into the EHR to help build rapport right from the start. And as part of a pilot program to provide pre-exposure prophylaxis therapy for HIV prevention via telemedicine, physicians ask patients specific questions about the sex they were assigned at birth, their gender identity and which pronouns they prefer to use.
"These three questions cover much of the information needed," Player said. "Patients can answer them however they choose."
Hinchcliffe recommends that family physicians and staff members be trained to ask transgender patients the same questions. She also recommends they undergo training intended to uncover any unconscious bias they may harbor and to increase their knowledge of LGBT-related terms and definitions, as well as words that may be offensive or should be avoided.
Inevitably, mistakes are bound to occur. When that happens, Hinchcliffe recommends that family physicians acknowledge it, but not dwell on it. "It's OK to make mistakes. Apologize and move on," she said.
"Transgender and gender-nonconforming patients often feel isolated, disconnected from society at large, maybe even angry or depressed," said Player. "It's my job as a family physician to acknowledge that suffering and to at least not make it worse. I can do that by educating myself, being aware of the language I use, admitting mistakes when they happen, and asking for help when needed."
Related AAFP News Coverage
Fresh Perspectives blog: Protect Transgender and Intersex Patients