Transgender is a term used to describe people whose gender identity differs from their assigned sex at birth. (See Figure 1.) The estimated number of transgender and gender diverse (TGD) individuals ranges between 0.1% and 2% of the population.1
Most studies on TGD people assessed those seeking care or were referred for care at gender-affirming healthcare centers2, yet the available data most likely underestimate the number of TGD people as many are reluctant to seek help.
TGD people may or may not seek gender-affirming interventions, including gender-affirming hormone therapy (GAHT), surgery, interventions for the modification of speech and communication, and behavioral adaptations such as genital tucking or packing, or chest binding. Gender-affirming medical care is a critical and life-saving step for many TGD individuals, and all of these procedures are defined as medically necessary by the World Professional Association for Transgender Health (WPATH). Not everyone undergoes all components, but each patient does what best reflects their gender as defined by them.
It is important to remember that TGD people have existed long before surgical interventions and GAHT were made available, and as such, an individual’s gender should not be judged by their choice to pursue or not pursue those options.
The social and economic marginalization of TGD individuals is widespread, which results in healthcare inequities and poorer health outcomes for this population.3 They tend to have more chronic medical conditions than their cisgender peers, including human immunodeficiency virus, diabetes mellitus and obesity.4 TGD people are also more than twice as likely to be diagnosed with depression and to experience mental health distress.4
TGD people face many barriers to healthcare. More than 27,000 individuals participated in the 2015 U.S. Transgender Survey, which reported that 55% of participants were denied coverage for transition-related surgery, 25% were denied coverage for gender-affirming hormone therapy and 33% that saw a healthcare provider reported at least one negative experience, including being refused treatment, verbal harassment, physical or sexual assault, and having to teach a healthcare provider in order to get appropriate care. 23% did not see a healthcare provider for fear of being mistreated and 33% because of cost. 40% have attempted suicide in their lifetime.5
Another common barrier TGD people face when attempting to access healthcare is inadequately trained medical providers6, and often report having to teach medical providers about TGD health.7 This occurs across all different specialties, including primary care, surgical care, obstetrics and gynecology, and endocrinology.8
Creating a safe and affirming healthcare environment for transgender and gender diverse people is essential. This can begin right when the patient enters the waiting room. Gender neutral artwork can be hung on the wall. All bathrooms in the office should also be gender neutral. A non-discrimination policy can be placed at the front desk where people check in for their appointment to let patients know that everyone is welcome and will be treated fairly.
The front desk staff are often the first interaction a TGD patient has with the office. They are likely to encounter situations in which a transgender patient’s registration forms, records, insurance and/or identity documents have different names and genders/sexes listed.9 The staff should ask for their name and pronouns and should avoid using gendered words like ma’am or sir when addressing patients.
These questions should preferably be asked in a private setting. If that is not possible, ask the patients to write down their names or have a sign in at the front desk. Healthcare providers and staff should also have pronouns on their name badges.
It is also important to have inclusive intake forms that don’t force people to choose a box to fit into that may not represent them. Forms should ask for a patient’s birth sex and gender identity – anytime birth sex is asked, it should be coupled with asking about gender identity. Consider allowing written responses for gender identity and sexual orientation. Patients should be able to write in their name and their pronouns. It is important to ensure that intake forms don’t make assumptions.
Electronic health records should be updated with the patient’s name and pronouns. Make sure that there is a way to document the patient’s name if it differs from their legal name for future visits.
If staff or healthcare providers make a mistake about a name or pronoun, apologize to the patient and move on. Minimize focusing on the mistake as this often prolongs an uncomfortable situation for the patient.
Trainings to educate staff and healthcare providers can help to increase both their knowledge and comfort level when providing care for transgender and gender diverse patients. Training should be mandatory for all new staff, and ongoing training should be provided throughout their employment.
During the hiring process, screening for transgender competency should also occur. Continuing education should also be provided so staff and healthcare providers can stay up to date with TGD health.
Many TGD people avoid exams due to fear, which often results from personal or collective trauma in healthcare settings. Nearly one-quarter of transgender and nonbinary individuals report avoiding seeking healthcare due to fear of being mistreated due to their gender.5
During the physician exam, the patient’s gender should be affirmed throughout the entire visit. It is important to be sensitive and respectful during the visit as it can be traumatic for patients.
Always provide care for anatomy present, regardless of the patient’s identification or presenting gender. An exam should only be performed on body parts relevant to the reason for the visit. Consider doing an exam at a separate visit unless the complaint is urgent.
Allow the patient to suggest measures that will make them more comfortable with the exam. Permit a support person in the exam room if preferred. If a breast/chest or pelvic exam is needed, inquire about the terminology they prefer to use or copy the language they are using.
Explain why the exam should be performed and ensure all questions and concerns are addressed prior to starting. Ask if any form of distraction during the exam would be helpful, such as music, talking or permitting the use of their phone. Also inquire about whether it would be helpful to talk through the steps of the exam.
Perform a speculum exam only if necessary. The patients can also collect their own specimens to allow for greater control over the process. If a speculum is needed, they can help to place it or inquire about the use of a mirror so they can watch the exam. Lastly, consider prescribing anti-anxiety medication if necessary.
It is essential that healthcare practitioners recognize the prevalence and effect of trauma on TGD patients and incorporate trauma-informed approaches to delivery of care.10 A trauma-informed perspective should be taken with each TGD patient.
It is important to realize the widespread impact of trauma as well as its signs and symptoms. Shared decision-making should be implemented when determining if diagnostics and exams are performed. Limiting access to certain types of care due to incomplete evaluations in other areas (such as not providing gender-affirming hormone therapy if a pap smear has not been performed) is not acceptable. Healthcare providers need to meet the patient where they are at when it comes to providing care.
Healthcare professionals can help to start to break down these barriers for TGD people by providing sensitive and respectful care. From more inclusive healthcare forms to clinical training for providers, there are numerous ways we can transform our clinics into safer, more welcoming places for trans patients.
Although this article provides some tips, there is a lot of work to be done. Training needs to begin in medical and nursing school. Policies need to shift on all different levels to ensure that TGD individuals have access to quality care. As healthcare providers, we can and should do better.
Figure 1
Definitions
Sex Assigned at Birth: The assignment and classification of people as male, female, intersex or another sex assigned at birth, often based on physical anatomy and/or karyotyping.
Gender Identity: One’s internal sense of being male, female, neither of these, both or other gender(s).
Cisgender: Identifies as their sex assigned at birth. Cisgender does not indicate biology, gender expression or sexuality/sexual orientation.
Transgender: An umbrella term for people whose gender identity differs from the sex they were assigned at birth.
Non-binary: An umbrella term for all genders other than female/male or woman/man. Not all nonbinary people identify as trans, and not all trans people identify as nonbinary.
Gender Diverse: An umbrella term to describe an ever-evolving array of labels people may apply their gender identity, expression or even perception does not conform to the norms and stereotypes others expect.
Transistion: A person’s process of developing and assuming a gender expression to match their gender identity. Transition can include: coming out to one’s family, friends and/or co-workers; changing one’s name and/or sex on legal documents; hormone therapy; and possibly (though not always) some form of surgery.
Sexual Orientation: A person’s physical, romantic, emotional, aesthetic and/or other form of attraction to others.
References
- Goodman, M. et al.Size and distribution of transgender and gender nonconforming populations: A narrative review. Metab. Clin. N. Am. 2019:48, 303–321.
- Kuyper, L. & Wijsen, C. Gender identities and gender dysphoria in the Netherlands. Sex. Behav.2014:43, 377–385.
- Health Care for Transgender and Gender Diverse Individuals: ACOG Committee Opinion Summary, Number 823. Obstet Gynecol. 2021 Mar 1;137(3):554-555. doi: 10.1097/AOG.0000000000004296. PMID: 33595249.
- Downing JM, Przedworski JM. Health of transgender adults in the U.S., 2014-2016. Am J Preven Med. 2018;55(3):336–344
- James SE , Herman JL , Rankin S , Keisling M , Mottet L , Anafi M . The report of the 2015 U.S. transgender survey. Washington, DC : National Center for Transgender Equality ; 2016
- Obedin-Maliver J., Goldsmith E.S., Stewart L., White W., Tran E., Brenman S., Wells M., Fetterman D.M., Garcia G., Lunn M.R. Lesbian, gay, bisexual, and transgender–related content in undergraduate medical education. 2011;306:971–977
- Xavier J., Bradford J., Hendricks M., Safford L., McKee R., Martin E., Honnold J.A. Transgender health care access in Virginia: A qualitative study. J. Transgend. 2013;14:3–17
- Unger C.A. Care of the transgender patient: A survey of gynecologists’ current knowledge and practice. Women’s Health. 2015;24:114–118.
- https://www.cdc.gov/hiv/clinicians/transforming-health/health-care-providers/affirmative-care.html
- Caring for Patients Who Have Experienced Trauma: ACOG Committee Opinion Summary, Number 825. Obstet Gynecol. 2021 Apr 1;137(4):757-758. doi: 10.1097/AOG.0000000000004328. PMID: 33759829.
- https://transstudent.org/about/definitions/
Resources
WPATH: wpath.org
UCSF Transgender Guidelines: transcare.ucsf.edu/guidelines
Fenway Institute: fenwayhealth.org
Lauren Abern, MD
Dr. Abern (she/hers) is an assistant professor of obstetrics and gynecology at Emory University. Dr. Abern completed her medical degree at the University of Miami and residency at Abington Memorial Hospital. She specializes in LGBTQIA health including gender affirming hormone therapy and GYN care for transgender and nonbinary individuals. Her research interests include family planning, cancer screening, reproductive advocacy, and breast/chestfeeding for LGBTQIA individuals.
Jake Cook
Jake Cook is a trans guy in Philadelphia, where he works in the fields of reproductive health and HIV at PhillyFIGHT.
