Am Fam Physician. 2018;98(11):635
Related article: Caring for Transgender and Gender-Diverse Persons
Author disclosure: No relevant financial affiliations.
As family physicians committed to continuity of care, patient advocacy, and treating patients regardless of their age, biologic sex, or gender identity, we are in a unique position to provide inclusive care to diverse populations. However, as described by Dr. Klein and colleagues in this issue of American Family Physician,1 transgender persons face many barriers to accessing care, and about one-third do not receive preventive health services.2
A 2018 study found that gender identity disparities in cancer screenings still exist, even after controlling for social and health care factors.3 Transgender persons are less likely to be up-to-date on colorectal cancer screening, to ever have had a Papanicolaou test, or to have discussed the risks and benefits of prostate-specific antigen testing with a clinician. They also experience differences in life-time rates of colorectal cancer screening, but these differences are partially mitigated by other social and health care factors.3 Similarly, a 2016 systematic review found gender identity disparities in colorectal cancer screening, mammography, cholesterol and blood pressure screening, tobacco use and smoking cessation, cervical cancer screening, human immunodeficiency virus testing, and influenza vaccination.4
Some community clinics have made great strides in reducing health disparities experienced by vulnerable communities. Callen-Lorde, a community health center where I rotated during medical school that specifically serves the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community, employs LGBTQ medical and administrative staff. The center has pamphlets and educational materials showing same-sex couples and transgender persons, and it is active in advocacy, policy, and education related to transgender health. As important as this clinic's resources are, more needs to be done.
To promote health equity, all primary care offices must be open to and accepting of transgender persons. Clinicians can facilitate this by training staff, displaying transgender-affirming materials and brochures, and having intake forms that feature inclusive language rather than the gender-binary “male or female.” Physicians with little training in transgender health care may want to be up-front with patients about their lack of expertise, while also stating their intention to learn more and their commitment to creating a safe and inclusive clinical space. Tables of transgender-friendly primary care concepts and key resources can be found in the article by Dr. Klein and colleagues.1 There are numerous national organizations that offer training in the care of transgender persons. For example, the National LGBT Health Education Center has online modules, articles, and continuing medical education opportunities on including gender identity in the electronic medical record, management of diabetes mellitus in LGBTQ patients, and strategies for eliminating health disparities.5 For clinicians seeking more detailed standards of care, the World Professional Association for Transgender Health provides guidelines on caring for transgender persons.6
Family physicians must understand that transgender health care encompasses more than a person's sexual and reproductive health. The longitudinal aspects of transgender care, which family physicians are poised to holistically address, include evaluating a patient's mental health and social support systems. Although most physicians are not experts in hormone therapy, they are responsibe for knowing how it affects laboratory test interpretation7 and preventive health needs and for screening patients appropriately while considering their anatomy and mental health.
To mitigate the persistent health disparities experienced by transgender persons, family physicians must use the resources available to us to take the lead in meeting the medical and social needs of these patients.