What does medical care include for transgender people?

What Does Medical Care Look Like When You're Transgender?

The number of transgender people in the United States is estimated to be around 1.4 million. Despite the fact that this is a large number, many of these people have trouble locating doctors who are suited to them and their needs.

Many people have terrible stories about their interactions with medical professionals, even during regular physicals. Some service providers make degrading remarks or refuse to recognise a person’s gender identification. Others interrogate them inappropriately or refuse to treat them.

Those who care for transgender people, on the other hand, have a message for them: don’t give up on receiving medical help.

Christy Olezeski, Ph.D., a psychologist and director of the Yale Medicine Pediatric Gender Program, which treats children, teenagers, and young people up to the age of 25, says, “The doctor’s office should be one location where everyone feels secure and cared for.”

However, she claims that patients have real concerns regarding how to continue medical care once they leave the program. They’ve said things like, “I’m not sure if it’s even worth it for me to transition—even though this is who I am—because I’m frightened of what will happen in the doctor’s office for the rest of my life,” Olezeski adds. “Will they have providers who are aware of and supportive of their identities and who will not interrogate them?”

She expresses concern that some people choose not to seek medical help, even when they need to go to the ER, because they are terrified of what may happen.

Why do transgender people have trouble getting medical help?

One major issue, according to Olezeski, is that many individuals, even health-care experts, are unsure what the term “transgender” implies. Some people believe it has anything to do with their sexual orientation (whether they are sexually attracted to men, women, neither, or both), but this is not the case.

Transgender people, on the other hand, have a gender identity and/or expression that differs from the male or female gender assigned to them at birth.

Every transgender person takes a different approach to this. Olezeski states, “Everyone’s gender path is unique to that individual.” “Not everyone opts for the same procedures to better align their body and presentation with their gender identification.”

The fears of transgender people about having their choices respected are well-founded. A third of transgender people say they’ve had bad experiences with medical professionals.

They include the need for them to educate providers about transgender health, provider rejection to treat them, verbal harassment, and even physical or sexual assault, according to a poll conducted by the National Center for Transgender Equality.23 percent of those who responded to the study said they were afraid of being mistreated if they sought help.

They also face the issue of being excluded from “conventional” medical classifications. Clair Kronk, Ph.D., a postdoctoral fellow in medical informatics at Yale and a transgender woman, recounts enrolling for a COVID-19 vaccination clinical study only to be denied because she didn’t fit into the right category.

“I have mixed feelings about it,” she says, “since these were some of the most important clinical trials in American history.” “I was trying to do my part because there were lives on the line.”

In the doctor’s office, there may be mistreatment.

Kronk visited an optometrist regarding her astigmatism, which is a common issue affecting the curve of the eye.

The doctor informed her the condition was “probably related to taking hormones,” a theory her endocrinologist later refuted, in part because her astigmatism had been diagnosed two decades before she started hormones, according to Kronk.

Some of the young adults with whom Olezeski has worked are concerned about something that many of us have never considered: how they feel when waiting in medical offices. Although transgender males may require gynecological care, they may be hesitant to wait in a room full of cisgender women.

(The term “cisgender” refers to those who identify with the gender they were given at birth.) Similar worries arise while visiting a urologist. According to Jaime Cavallo, MD, MPHS, a Yale Medicine urologist, there is a persistent misconception that urologists only treat men, despite the fact that patients of all genders seek care for urologic disorders.

According to Dr. Cavallo, some transgender patients are afraid of physical examinations, particularly when the doctor is a gynecologist or urologist performing genital exams. Individuals may have gone through a difficult life journey. According to Dr. Cavallo, “some transgender patients experience depression, anxiety, or post-traumatic stress disorder [PTSD], and an examination can elicit their melancholy, worry, or dread.”

There have also been stories of clinicians unfamiliar with transgender care not knowing how to appropriately care for patients who have had non-genital gender-affirming (also known as “top”) or genital gender-affirming (commonly known as “bottom”) surgery, which can feel alienating to the patient, she says. Sometimes, patients feel more at ease if they bring a loved one with them to the exam, Dr. Cavallo explains.

The transgender community needs regular medical care more than anyone else.

According to Olezeski, some transgender people do not seek medical attention at all, which may be one of the reasons they face dangerous health risks:According to a Dutch study released in 2021 based on five decades of data on adult transgender people getting hormone treatment, their risk of death for a variety of reasons is twice as high as those who are not transgender.

Olezeski also attributes the increased health risks to the accumulated stress caused by prejudice, which includes assassination attempts, physical and sexual assault, and threats from family members, claiming that transgender people are more likely to be rejected and even homeless.

Harassment, rejection, and microaggressions can mount up quickly. The stress response and the subsequent cascading effect on mental and physical health can be devastating, “she explains. And if you’re not getting preventive care and getting things treated at an earlier stage, tiny health issues may definitely increase.

That is why, according to Olezeski, a transgender person must have a primary care physician. In their adult lives, they should expect to be treated with respect by medical specialists, just like everyone else.
The following are some examples of a short list:

1. Urological follow-up care after a medical or surgical procedure.

“The urologic history and examination should be personalized for the patient based on the types and duration of hormone therapy they’ve received, the patient’s age when hormone therapy was started, and any procedures they’ve had,” Dr. Cavallo says.

She advises that anyone who has undergone genital gender-affirming surgery see a urologist at least once a year to be checked for strictures and fistulas, which can cause urinary problems and sexual function disorders.

Transgender women who have preserved their testicles or penis should be checked for benign and malignant illnesses. Similarly, she says, transsexual women who have preserved their prostates should be checked for benign prostatic disorders as well as prostate cancer.

For transgender people, hormone therapy and genital operations can help in the identification and treatment of malignancies of the reproductive organs. “At this moment, we are unable to appropriately quantify transgender individuals’ risks due to a lack of high-quality data in the medical literature on urologic cancer incidence, stage at diagnosis, and outcomes,” says Dr. Cavallo. “Transgender patients must be included in well-designed studies.”

2. Visits to a gynecologist on a yearly basis

The American College of Gynecologists has specific rules on transgender care, including this statement of the doctor’s role: “Any physical structure present that warrants screening should be tested, regardless of gender identification, to guide preventive medical care.”

Cervical cancer tests for those assigned female at birth, breast cancer screenings for those designated female at birth and transgender women, and HIV and other sexually transmitted disease screenings for all transgender people are among the services provided.

“Screening for HIV as part of routine medical treatment is part of our message,” says Yale Medicine infectious diseases specialist Michael Virata, MD. According to the United States Transgender Survey, the number of transgender people living with HIV (1.4 percent) is approximately five times that of the general population (0.3 percent) and is particularly high among transgender women of color.

According to Kronk, the figures could be substantially higher than those published. “Providers rarely know about HIV/AIDS medications like PReP [pre-exposure prophylaxis], and PReP can be pricey if you don’t have insurance,” she says. “If you have insurance, it’s usually free, but many trans people don’t have it.”

It’s also worth noting that a number of trans people are driven into sex work simply to survive and make ends meet, she says. “The data, when presented without context, may infer that being trans entails being hypersexual, which is not often the case,” she explains.

A gynecologist should continue to provide birth control counseling to transgender males or nonbinary individuals (those whose gender identity falls outside of the traditional gender binary structure of girl/woman and boy/man) who still have their reproductive organs.

According to Amanda Kallen, MD, a Yale Medicine gynecologist and reproductive expert, most menstrual bleeding can be stopped with testosterone supplements; those who continue to experience menstruation can be treated with hormonal therapy or surgery.

3. Consult a reproductive specialist if you want to start a family.

Dr. Kallen believes that everyone who wants to have a child should be able to use their own eggs or sperm regardless of their gender identity.

The Yale Fertility Center offers treatments for storing sperm for later use by a female partner or surrogate, as well as freezing eggs and embryos, which can be costly (and may not be covered by insurance).

“The good news is that fertility clinics are now marketing themselves as transgender-friendly,” adds Dr. Kallen. “In the last five years, the number of patients we’ve seen in consultation for transgender fertility preservation has increased by 900 percent at the Yale Fertility Center,” she says.

Should you inform your doctor about your gender identity?

Susan Boulware, MD, a pediatric endocrinologist who works with patients in the Pediatric Gender Program, says, “It can be a difficult topic.” Unfortunately, it is the patient’s responsibility to be as well-informed as possible, Dr. Boulware explains. “We discuss with patients what types of things a new doctor should know—and how open to being in particular situations.”

Dr. Boulware says that one young transgender patient needed to go to an urgent care facility with a sprained ankle and wanted to know if they had to inform the doctor that they were on testosterone.

“We talked about how the patient has to be honest when answering inquiries about prescriptions; if asked, they may explain that testosterone is being used for “hormone replacement treatment.” She argues that explaining that they are transgender may not be essential in that case.

In other circumstances, she says, it’s crucial to be honest, particularly when it comes to hormone therapy. Transgender people should always inform their general or specialty care doctors if they are taking estrogen therapy so that potential side effects can be monitored.

“Puberty blocker” medicines, according to Dr. Boulware, can affect bone density, and estrogen raises the risk of blood clots. Similarly, testosterone-based therapy may increase the risk of cardiovascular problems in transgender males or nonbinary people.

According to Yale Medicine’s David Mulligan, MD, both doctors and surgeons require a thorough medical history in order to correctly give therapies. He says we must always be vigilant in monitoring the effects of hormone therapy on the development of other hormonal illnesses, such as diabetes.

Even so, patients may find it challenging to make the decision to reveal the source. According to Kronk, a thorough medical history might be very important—even life-saving—but this isn’t always the case.

“Patient privacy is vital, and considering that many jurisdictions have the ability to withhold care from LGBTQ+ people, it’s natural why people would not reveal such information,” she says. It is the responsibility of providers to provide a secure and trustworthy environment for their patients. It is not the obligation of the patient to presume that every environment is safe and reliable. ”

Efforts are being made to improve transgender treatment.

Despite the greatest efforts of demographers to make precise estimates, it’s difficult to tell exactly how many transgender people there are. Kronk led a team of Yale academics in an endeavor that could help shed some light on the issue while also clearing the way for additional research into the transgender community.

She collaborated on recommendations for modernizing the way transgender patient information is documented with other transgender researchers in the United States and Canada.
Until 2015, most electronic medical records (EMRs) had gender fields that were confined to categories for men and women, “male,” “female,” and “neutral,” respectively.

Many didn’t even offer the choice of “other.” According to Kronk, it would simply be left blank and reported as “unknown.”

In a study published in the Journal of the American Medical Informatics Association in 2021, Kronk and her colleagues recommended a two-step self-identification strategy. People would be able to declare their gender identity—”female,” “male,” “non-binary,” “questioning,” “not listed,” “prefer not to disclose”—as well as their given gender at birth or the gender on their birth certificate.

Implementing ideas like this will necessitate “several levels of advocacy,” according to Kronk. “In order for it to operate, you need a broad range of clinicians to sign on, not just gender clinics.”

But, as Kronk points out, EMRs are important. They notify providers when a medicine is less effective or has a detrimental influence on specific interventions, among other things. However, when it comes to gender, they are dependent on what the patient tells the doctor—or, in some cases, what the doctor assumes based on the patient’s appearance, which can lead to problems.

“You can miss information that could lead to serious effects if you base all your decisions on “gender identity” or “assigned gender at birth,” she explains.

Patients who are transgender should seek out doctors who will be supportive of them.

Experts believe that as more doctors get trained in transgender treatment, the situation will improve. For the time being, transgender people will have to be diligent in finding doctors who are sympathetic to their needs.

For many practitioners, this is typically an unfamiliar area, says Dr. Boulware, who adds that most doctors will lack specialized training. “As a result, it is frequently on the shoulders of patients to educate themselves.”

Dr. Kallen continues, “This is the most difficult phase. Preventive screening, on the other hand, is an important aspect of total health care. ”

A local organization that is sensitive to LGBTQIA+ problems may be able to recommend a provider for transgender people, according to Dr. Kallen. “It can also wind up being a lot of word of mouth,” she says, “asking around about providers who might be receptive.”

Meanwhile, Olezeski claims that any provider can make easy, common-sense improvements. “Think about what medical questions you’d ask anyone about—or anyone who had these organs,” she says. “Alternatively, you can explain to a patient why you need to do a certain test or exam and give them the opportunity to opt out if they have had previous trauma.”

And, if a doctor still isn’t confident in their abilities, they can send the patient to a doctor who specializes in transgender care.

However, it’s crucial to keep in mind that delegating this to specialists may result in longer wait times; the solution here is increased training and knowledge across the board, Kronk argues.

Olezeski concurs. “Being alert is extremely crucial. Even a bad encounter at the receptionist’s desk can leave an impression on people. We must treat all of our patients with kindness and respect, “she explains.