Considering the Healthcare Experiences of Transgender Individuals

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Considering the Healthcare Experiences of Transgender Individuals

Written by Sylvia Sontheimer (MS4)

Edited by Lauren Walter, MD

It is estimated that 1.4 million individuals in the United States identify as transgender or gender non-conforming (TGGNC), making up 0.5% of the U.S. population (1). TGGNC individuals are disproportionately impacted by social risk and need including homelessness (2), poverty, and unemployment (3). This population is also excessively impacted by significant mental health disparities, with one survey demonstrating 44.1% of TGGNC individuals reporting depression, and 33.2% reporting anxiety, much higher than current national averages of 6.6% and 8.2%, respectively (4,5). Furthermore, a staggering 41% of TGGNC people reported having attempted suicide at some point during their life, compared to 1.6% of the general population (6).


These disparities are undoubtedly related to discrimination TGGNC individuals face on a regular basis from society, and in multiple spheres of life. Harassment in school (reported by 78% of TGGNC individuals in K-12) and at the workplace (reported by 90% of TGGNC individuals), as well as discrimination in obtaining housing (reported by 19%) or access to a homeless shelter (55%), have been widely reported (6). 


Unfortunately, health care settings are also often sites where TGGNC people experience harassment and discrimination. A study by Chisolm-Straker et al. investigated the experiences of TGGNC individuals in the emergency department (ED) and found that many individuals were misgendered by health care professionals even after the person shared their preferred pronouns (the patient shared, “Referred to as a woman even after I explained to the doctor that I was a trans-male; they ignored my statement and proceeded to call me she”) (7). Another individual reported that their provider had a change of attitude towards them after disclosing their transgender status and threatened to call security on the patient when they tried to use the women’s restroom. The patient said, “I would die before I went back [to that ED] again” (7). After hearing these traumatic experiences, it is unsurprising and understandable that TGGNC individuals would delay healthcare or avoid healthcare settings altogether. Furthermore, it highlights the imminent need for widespread provider sensitivity training and formal education as it pertains to transgender medical care.


A study by the National Center for Transgender Equity found that 50% of transgender individuals have had to teach their healthcare provider about transgender care (6). This theme is mirrored in Chisolm-Straker et al., where multiple people reported providers were unsure of how hormone use may impact their health (7). Providers may argue that transgender care was not emphasized or even taught in their medical school or residency training, which may be true. However, in the practice of modern medicine, this is not a plausible excuse for lack of knowledge about transgender health. If we expect providers to stay up to date regarding other standard-of-care practices in their field and emphasize medicine as a career of lifelong learning, why are we not demanding that all providers be educated on health care needs specific to transgender patients? 

In Chisolm-Straker et al., 55% of TGGNC individuals recommended that providers should ask all patients for their preferred pronouns and name and use these throughout care (7). This is a simple step that could be easily included in the intake process, put in the EMR, and relayed to all members of the care team so the patient is not constantly having to correct people or experiencing fear of being misgendered. 

Many also wanted providers to stop asking questions about their gender identity or experience (such as gender-affirming surgeries) when it was not relevant to their chief complaint, as many felt their providers were asking unnecessary questions (like one patient, who was repeatedly asked about their sex life when coming in for pneumonia) (7). Alternatively, however, a patient may feel it is unnecessary or invasive to be asking about hormone replacement therapy use when they are coming in for shortness of breath; in these instances, it may be helpful for the provider to say something like, “some hormones may increase the risk for blood clots, which can be one of many causes of shortness of breath. Are you currently taking any hormones?” This way, the patient understands why the question is being asked, versus thinking it may be a nosy and unnecessary question in the context of their complaint. 


Furthermore, systemic change is needed to educate medical students, residents, and current physicians and health care providers regarding TGGNC medical care, including awareness of health disparities and discrimination faced by these individuals. A meta-analysis conducted in 2018 found that much of the medical student training on transgender health was lumped in with LGBTQ health as a whole, versus seen as a separate entity (8). A recent scoping review by Nolan et al. identified only 10 novel transgender-specific health professions educational interventions published in the evidence-based literature. Curricula ranged from didactic lectures, to case-based learning, to Objective Structured Clinical Examinations (OSCE), and varied from a one-time intervention lasting a few hours to a longitudinal curriculum over the duration of a medical student’s education (9). There were interventions reported at multiple levels of training, including undergraduate medical education, graduate medical education for Internal Medicine residents and Endocrinology fellows, interdisciplinary interventions for students in a variety of healthcare professions, and web-based continuing medical education (CME) modules.


Nolan et al. acknowledged that they identified a growing amount of literature on the topic of transgender healthcare education within the last five years, which suggests that perhaps more institutions are incorporating this topic into their curricula. Furthermore, the studies included in the scoping review largely reported positive outcomes after the educational interventions, with students and practitioners having a self-reported increase in comfort in caring for and meeting the needs of transgender patients (9). However, it is unclear if this increased self-efficacy correlates with changing practice patterns long-term, exposing another knowledge gap in the current literature. And, notably, there is still no consensus regarding the type and length of educational intervention that is best suited to teach about TGGNC healthcare. More research on intervention outcomes and additional curricular input from experts in the field, as well as TGGNC individuals themselves, is needed. 


Despite a lack of educational intervention consensus at present, there are a number of things that can be done now, at a personal, departmental, and institutional level, to improve the experiences of TGGNC people in the healthcare setting. Institutions can encourage or even consider requiring providers in all fields to complete a portion of their annual continuing education in topics related to transgender healthcare. Even simpler, as providers, we can purposefully elect to universally adopt the use of preferred pronouns and names for ALL patients (to include providing space on intake forms to record these preferences). In addition, we can be conscientious about only asking medically relevant questions during history-taking and, when needed, explaining why questions about hormone replacement therapy, etc. are being asked. This is especially vital in the emergency department setting. The emergency department is viewed as the healthcare safety net for the community, but it can only act as such if people feel safe going there. If our spaces are not welcoming for TGGNC people, we may cause individuals to delay or forgo care altogether, resulting in poor health outcomes and increased healthcare disparities. Let’s do our part as individuals and as advocates within our own institutions to push for changes to make our spaces safe for everyone.



Sources:

  1. Flores AR, Herman JL, Gates GJ, Brown TNT. How many adults identify as transgender in the United States? 2016. Available at: http://williamsinstitute.law.ucla.edu/wp-content/uploads/How-Many-Adults-Identify-as-Transgender-in-the-United-States.pdf. 

  2. National Center for Transgender Equality. 2020. Issues: Housing and Homelessness. Available at: https://transequality.org/issues/housing-homelessness

  3. Movement Advancement Project, National Center for Transgender Equality, Human Rights Campaign, and Center for American Progress. September 2013. A Broken Bargain for Transgender Workers. Available at:  https://www.lgbtmap.org/transgender-workers

  4. Lombardi E. Transgender health: A review and guidance for future research—Proceedings from the Summer Institute at the Center for Research on Health and Sexual Orientation, University of Pittsburgh. International Journal of Transgenderism. 2010 Mar 2;12(4):211-29.

  5. CDC National Center for Health Statistics. Anxiety and Depression: Household Pulse Survey. National Center for Health Statistics. Available at: https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm 

  6. Grant JM, Mottet L, Tanis JE, Harrison J, Herman J, Keisling M. Injustice at every turn: A report of the national transgender discrimination survey. National Center for Transgender Equality; 2011. Available at: https://www.transequality.org/sites/default/files/docs/resources/NTDS_Report.pdf 

  7. Chisolm-Straker M, Jardine L, Bennouna C, Morency-Brassard N, Coy L, Egemba MO, Shearer PL. Transgender and gender nonconforming in emergency departments: a qualitative report of patient experiences. Transgender Health. 2017 Feb 1;2(1):8-16.

  8. Dubin SN, Nolan IT, Streed Jr CG, Greene RE, Radix AE, Morrison SD. Transgender health care: improving medical students’ and residents’ training and awareness. Advances in medical education and practice. 2018;9:377.

  9. Nolan IT, Blasdel G, Dubin SN, Goetz TG, Greene RE, Morrison SD. Current state of transgender medical education in the United States and Canada: Update to a scoping review. Journal of Medical Education and Curricular Development. 2020 Jun;7:1-13

  10. Park JA, Safer JD. Clinical exposure to transgender medicine improves students' preparedness above levels seen with didactic teaching alone: a key addition to the Boston University model for teaching transgender healthcare. Transgender Health. 2018 Jan 1;3(1):10-6.

John Purakal