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Trans Care Call to Action
Call to Action and Reflection: Inclusive, Compassionate, and High-Quality Healthcare for Transgender Individuals

Released: June 28, 2022

Nelson F. Sanchez
Nelson F. Sanchez, MD
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In the United States, there are approximately 1-2 million transgender individuals, and healthcare professionals (HCPs) must consider their unique healthcare needs to provide them with optimal care. In this commentary, Nelson F. Sanchez, MD, the director of our comprehensive educational program “Multidisciplinary Approach to Ensure Inclusive, Compassionate, and High-Quality Healthcare for Transgender Individuals,” calls for inclusive healthcare, shares key insights on best practices in the care of transgender patients, and advocates for ongoing education to prepare HCPs to provide equitable and compassionate care to their transgender patients.

Who are transgender individuals? 
Transgender is an umbrella term for individuals whose gender identity, gender expression, or behavior does not conform to that typically associated with the sex to which they were assigned at birth. Although there are no specific US Census data for transgender individuals to self-identify, reports from the Williams Institute and various peer-reviewed scientific publications indicate that transgender representation in the United States ranges from 0.4% to 0.6%. This translates to approximately 1-2 million Americans living across the country—in every state and every community, including big cities, suburban communities, and rural areas and across all ages, races, and ethnicities. 

Why is providing inclusive, compassionate healthcare to transgender individuals important?
To achieve health equity in our country, we need to identify and understand historical gaps in access to healthcare for transgender individuals and address these problems. For example, a 2020 Center for American Progress study found that nearly one half of transgender adults report having had negative or discriminatory experiences with a healthcare professional, and nearly 1 of 2 transgender adults has had insurers deny them coverage for gender-affirming care. These experiences may affect whether transgender individuals seek healthcare. In fact, research has shown that transgender adults are significantly less likely than cisgender adults to have flu shots and routine doctor visits.

According to a 2019 Behavioral Risk Factor Surveillance System study, 3 of 5 transgender respondents reported experiencing poor mental health at least 1 day in the past month, which is approximately 23 percentage points higher than that of cisgender respondents. Transgender respondents also were 4 times more likely to report making at least 1 suicide attempt in their life. Furthermore, 54% of transgender individuals reported poor physical health at least 1 day in the past month, which is approximately 18 percentage points higher than that of cisgender respondents. These statistics highlight the disparities that exist within the community and the work that needs to be done to achieve health equity in our country. 

Who needs to be trained about the healthcare needs of transgender individuals? 
Anyone in the healthcare community who interacts with patients needs to be trained in the unique healthcare needs of transgender individuals. This includes senior physicians, physician associates/physician assistants, nurses, pharmacists, medical assistants, lab and imaging technicians, frontline staff such as those at registration desks and in transport, and all of our students. Ideally transgender healthcare curricula will be provided at all levels of training (medical, physician associate/physician assistant, nursing, allied health, pharmacy), but even after traditional training has been completed, or for those who never received it, best practices for transgender care and communication can be conveyed through on-the-job training, continuing medical education activities, conferences, or local events. Ongoing education is essential to best meet transgender patients’ needs and optimize health equity.

What skills do HCPs need to learn to provide optimal care to transgender individuals?
Communication skills, both verbal and nonverbal, are critical for HCPs to learn for the optimal care of transgender patients. A key example of effective nonverbal communication is to maintain eye contact with your patients during conversations. HCPs also should take care in using appropriate language to unveil a patient’s gender identity and related information such as surgical history and hormone therapies that they may be using.

Here are a few questions about gender identity that may help you get to know transgender patients during a hospital or clinic visit:

  • How do you self-identify? Do you identify as a man, a woman, a transgender woman, a transgender man, gender nonconforming, or something else?
  • What pronouns do you use? He/him/his, she/her/hers, they/them/their, or something else?

Furthermore, it is important to approach a patient in a private space and not ask private questions about gender identity or sexual behavior in a crowded or public arena, such as an emergency room hallway. Not only is this considerate, but it also can be a matter of safety.

What special considerations are there for performing physical exams of a transgender patient?
One best practice is to invite a support person into the room for the exam. HCPs also should explain what body parts need to be examined and why, and they should examine only those parts related to why the patient is there for the visit and what is medically necessary—don’t be a medical voyeur.

It is also good practice to ask the patient how they refer to their “top” and “bottom” anatomical parts—their chest or breast and pelvic regions, respectively—as the patient may have renamed their body parts. Not only may a patient be uncomfortable having a conversation about their anatomical regions depending on the verbiage their HCP uses but referring to body parts with language that makes the patient uncomfortable may cause trauma.

Finally, based on a patient’s reported anatomy, you will need to provide appropriate counseling in terms of health maintenance and care. For example, if a transgender man retains their natal cervix, you will want to offer a cervical cancer screening. However, this procedure may be uncomfortable, even traumatizing, so some patients may prefer to come during specific office hours, or you may want to offer them a home testing kit if available. 

What do HCPs need to know about the specific clinical care needs of transgender individuals related to their transition? 
Two key considerations related to a patient’s transition are whether they use or have used masculinizing or feminizing hormone therapies and whether they have pursued gender-affirming surgery.

It is important to know a patient’s history with hormone use. If a transgender patient is using hormones, how is the patient accessing the hormones? Is the patient accessing hormones safely via prescription or obtaining them from friends or off the black market? Are they using injectables, oral formulations, or patches? If the patient is using injectables, are they obtaining safe and clean needles? HCPs also should inquire whether the patient is using the appropriate dosage. Some patients use higher hormone doses than is normally recommended because they want to achieve faster and more immediate effects. Other patients may not be satisfied with their current regimen and may need an increase in dosage or a change in formulation. Laboratory tests are also necessary for monitoring patients before and while they are receiving hormone therapies. For example, hemoglobin levels should be tested at baseline and during testosterone treatment for transgender men.  

With regard to surgery, HCPs should remember that not all transgender patients pursue gender-affirming surgery. It is available if they so choose, but many choose not to pursue it. HCPs should be aware of the common procedures for top and bottom gender-affirming surgery and associated postsurgical complications such as fistulas, urethral stenosis, and poor wound healing. Furthermore, many transgender patients worry about facial appearance, so often they pursue procedures to optimize gender affirmation via their facial appearance (eg, tracheal shave or a facial feminization surgery in a transgender woman).

Patients also need adequate mental health support before, during, and after transitioning.

How can we address barriers to care in the transgender community?
In addition to discussing gender identity and transition-related care, it is important to obtain an overview of the patient’s current health status, including taking a thorough sexual history and inquiring about safe housing, reliable employment, and access to adequate health insurance.

Transgender patients also should have optimal access to routine cancer screenings and screening for sexually transmitted infections. For a transgender man, you want to think about access to cervical cancer screening and mammograms; for a transgender woman, consider access to prostate cancer surveillance. In addition, similar to the general population, all of your transgender patients should have access to lung cancer, colon cancer, and skin cancer screening. HIV screening is also important for all your transgender patients, particularly for transgender women, who have been shown to be at higher risk for HIV infection.

Another thing to think about is the availability of support groups within the community for different aspects of transgender patient health, such as whether they are trying to quit smoking or alcohol, if they are a victim of domestic violence, or if they have received a cancer diagnosis. Although some patients are fine going to any support group composed of patients from the general population, for some patients, it is important that they are referred to a safe space for support, such as a transgender-specific or LGBTQ-specific group.

Finally, we should keep in mind the subpopulations within the transgender community. Older transgender patients may need referrals for inclusive, transgender-friendly end-of-life, palliative, and pastoral care. For transgender children and adolescents, HCPs also need to ensure that they have a safe home and a safe neighborhood and that their parents are well supported and informed. This includes making sure that their school is well informed and can be another support system. Also, HCPs need to make sure that children and adolescents receive appropriate gender-affirming care with regard to mental health, hormone care, and gender-affirming surgeries, if those are so desired.

What other topics are important to consider in providing optimal clinical care to transgender individuals?
Creating a welcoming and inclusive setting is important to providing optimal clinical care to transgender individuals. For example, images in clinics and hospitals should be inclusive of transgender communities and patients, and gender-neutral bathrooms should be available at hospitals or clinic sites. Registration forms should be inclusive of all gender identities, as this is a cue to a patient that the staff and HCPs are aware and open to all gender identities. As I mentioned previously, staff at registration desks in waiting rooms and those involved in transport services should be educated on best practices in communication with transgender patients. One thing to avoid is having patients being called by the incorrect name or the incorrect pronoun while they are in the waiting room or in transport to be taken somewhere. 

Considering the challenge of identifying underrepresented racial and ethnic minorities, what can we do to support the inclusion of transgender individuals in clinical trials? 
There are many barriers to the inclusion of transgender individuals in clinical trials, which has led to overall poor participation. Some things we can do to mitigate these barriers include educating our researchers and their staff on best practices in recruitment, enrolling, and studying transgender patients, including being cognizant of transgender identities and ensuring that trial enrollment forms and advertising materials are inclusive of transgender identities or are gender neutral when appropriate. If a clinical trial involves gender-specific research, we need to make sure that the research activity includes transgender people. For example, transgender men who have retained their natal cervix should be included in cervical cancer research, and promotional materials should be inclusive of transgender men. Another thing to think about is hiring trans-identified researchers and staff to recruit, enroll, and study transgender patients, so that when transgender patients are approached or involved in a research project or a clinical trial, they can see concordant researchers and staff who are invested in the health of their community.

How can we support our transgender-identified HCPs in the workplace?
There are many ways we can support transgender-identified HCPs in the workplace. One thing we can do is ensure that transgender staff are provided adequate health insurance that includes gender-affirming care. Transgender staff and faculty should be included throughout all the inner workings of the hospital and clinic, including being on institutional committees, such as quality assurance committees or Institutional Review Board committees, as well as being provided robust opportunities for promotion and advancement. It is also a good idea to sponsor regular networking events at your hospital and clinic that are inclusive and celebratory of transgender identities.

Conclusions
There are many important considerations in caring for transgender patients. As healthcare professionals become more aware of the concerns of transgender individuals and continue to be educated on transgender care, we will begin to see disparities in this community diminish. Stay tuned for additional education from CCO on this topic!

An unabridged version of this conversation is also available as a podcast here.

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