Best estimates indicate that approximately 1.4 million people self-identify as transgender in the United States, which is double the initial estimate made by the Williams Institute in 2011.1 According to a review by Stuart R. Chipkin, MD, and Fred Kim, MD,2 this sudden increase suggests a greater willingness for people to identify as transgender rather than an increase in the actual numbers, which are likely to be even greater than we know about now.
The bigger problem, they wrote, is that by guarding their gender identity, many individuals are excluded from obtaining healthcare that is appropriate for their needs. Data from 2010 showed that ≤48% of people who transitioned to male and ≤25% of people who transitioned to female admitted to delaying or avoiding medical care.3 The reasons are many and complex, involving discomfort by patients and providers alike to openly discuss necessary issues, coupled with a genuine lack of knowledge on both sides of the special needs of transgender individuals.
Barriers to Care
The cultural perceptions (and often misperceptions) of the roots of transgender issues continue to drive many of the obstacles to appropriate care for this population, including variations in the current healthcare insurance environment from state to state on coverage of many transgender-related health issues, making access challenging2; lack of sensitivity or verbal harassment in healthcare settings toward transgender patients seeking care4; and a general lack of training in transgender-related health issues for physicians and other providers.
In a study published in the July-August issue of the Journal of Pediatric Health Care4 G. Nic Rider, PhD, and colleagues reviewed questionnaires completed by 8 nurses and 6 physicians to examine the training received by healthcare providers and their attitudes toward treating adolescent transgender patients. The study identified 5 major gaps that negatively affect the treatment of transgender youths. First, most of the participants reported receiving no specific training in medical or nursing school related to transgender health issues.4 In addition,
there was a lack of conformity among providers who did discuss gender, and the providers expressed discomfort with discussions of transgender topics, did not often ask questions regarding gender preferences, and were generally unaware of resources to help improve their own comfort with these discussions.4
Gaining Patient Confidence
As a result of these many issues, the physician-patient relationship is often guided by physician “transphobia,” Daphna Stroumsa, MD, and colleagues reported, which represented a more global social barrier that was not substantially modified by specific provider education on transgender care.5 In another study by the same group, the investigators found that although 85.7% of 308 primary care physicians surveyed were willing to provide routine care to transgender individuals, attitudes became more negative with increasing age of the physician.6
A number of recent studies of provider attitudes found they were especially concerned with being perceived as offensive or not having an appropriate understanding of the most recent modifications to gender-related terminology.4,5,7
In a study of transgender patient care in dermatology, Patrick Sullivan, MD, and colleagues reported that, “Making assumptions regarding gender identity, choice of pronoun, or sexual orientation can damage rapport between a practitioner and a transgender patient.”7
Patients also seem to feel they cannot get quality healthcare advice from providers. Deirdre A. Shires, PhD, MSW, MPH, and colleagues found that one-third of transgender patients reported having to educate their providers about transgender healthcare issues, severely undermining their confidence in the provider and the treatment.6 This concern was echoed by physicians, who frequently expressed a lack of knowledge of relevant resources to offer their patients.7
Many physicians are exposed to transgender patients in practice, but not all practitioners recognize their special needs. In a 2019 study published in Neurology, Nicole Rosendale, MD, and colleagues found that although more than half of neurologists surveyed believed that gender identity was a primary factor in general health, a third would not consider it in their therapeutic strategy for neurologic disorders.8
Dermatologists, in particular, are often consulted during the transitional process to help with desired changes to facial skin and removal of body hair. They may provide noninvasive options to facilitate feminization through the use of cosmetic fillers, neurotoxin injections, and laser hair removal, and they often perform procedures to reduce scarring and skin complications resulting from surgical transition procedures. Although the need for transgender dermatology is growing, guidelines for many aspects of treatment have yet to be established. The Sullivan review pointed to the need to better identify the hormonal and reproductive status of individual patients for the purposes of clinical trials and making clinical treatment decisions, and to continue to investigate the consequences of gender transition treatments.7
Multispecialty Approach to Transgender Care
The transgender process takes place over many years, during which time the individual may experience a range of health issues that may be related to the transition, as well as other health issues that are not related but may be affected. Continued health issues need to be addressed over the transition period and are affected by hormonal treatments and psychological stress from many sources. Dr Chipkin and Dr Kim2 recommended a team approach to treatment that allows for interaction between endocrinologists and surgeons initiating changes and the dermatologists, neurologists, reproductive health specialists, urologists, mental health providers, and primary care providers who often treat downstream effects that may or may not be anticipated.
Editor’s note: This article has been updated as of 7/25/2019 to reflect changes in language.
1. Flores AR, Herman JL, Gates GJ, Brown TNT. How many adults identify as transgender in the United States? Los Angeles, CA: Williams Institute; 2016.
2. Chipkin SR, Kim F. Ten most important things to know about caring for transgender patients. Am J Med. 2017;130(11):1238-1245.
3. Grant GM, Mottet LA, Tanis J, et al. National transgender discrimination survey report on health and health care. Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force; 2010.
4. Rider GN, McMorris BJ, Gower AL, et al. Perspectives from nurses and physicians on training needs and comfort working with transgender and gender-diverse youth. J Pediatr Health Care. 2019;33(4):379-385.
5. Stroumsa D, Shires DA, Richardson CR, Jaffee KD, Woodford MA. Transphobia rather than education predicts provider knowledge of transgender health care. Med Educ. 2019;53(4):398-407.
6. Shires DA, Stroumsa D, Jaffee KD, Woodford MR. Primary care clinicians’ willingness to care for transgender patients. Ann Fam Med 2018;16(6):555-558.
7. Sullivan P, Trinidad J, Hamann D. Issues in transgender dermatology: a systematic review of the literature [published online March 15, 2019]. J Am Acad Dermatol. doi:10.1016/j.jaad.2019.03.023
8. Rosendale N, Ostendorf T, Evans DA, et al. American Academy of Neurology members’ preparedness to treat sexual and gender minorities [published online June 14, 2019]. Neurology. doi:10.1212/WNL.0000000000007829
This article originally appeared on Medical Bag