How PCPs can meet needs of transgender patients
There are 1.5 million people in the U.S. who identify as part of the transgender population, and this number is expected to increase in the future, according to the American Journal of Public Health and The Williams Institute, a think tank that specializes in issues of sexual health.
Medical schools are now trying to catch up by offering courses and training to treat the specific needs of transgender patients, but many clinicians who have been in practice for decades face a potential disadvantage when it comes to treating these patients, an expert in transgender health told Healio Primary Care Today.
“So many primary care physicians, pediatricians and family medicine doctors on the front line of patient care like me are in their mid-50s. We were never taught how to communicate with these patients and what these patients are at higher risk for,” Morissa Ladinsky, MD, a member of the AAP Section on LGBTQ Health and Wellness, told Healio Primary Care Today.
Stephanie Tran, MD, a HIV/transgender medicine and family medicine physician at Cedars-Sinai Medical Group in Los Angeles agreed, saying a PCP’s limited training can be in congruent to their good intentions.
“Many PCPs have the desire to provide transgender-specific care, but they are often unsure of how to initiate this process,” she said in an interview.
Ladinsky and Tran’s concerns are being borne out in practice.
A 2018 survey in Annals of Family Medicine found only 31.4% of 140 PCPs felt capable of providing routine care to transgender patients.
To help PCPs meet the needs of their transgender patients, Healio Primary Care Today asked Ladinsky, Tran and other experts in transgender health to discuss creating an office environment that encourages transgender patients to be active participants in their well-being and provide insight into some of the common health conditions this population group faces.
Creating a welcoming environment
A study in Annals of Family Medicine cites that “a small but growing body of research” suggests transgender patients often encounter discrimination.
Many of the experts consulted for this story agreed that this discrimination makes transgender patients less likely to want to receive health care.
Therefore, word choice — both spoken and written — is critical to making the transgender patient feel comfortable, A.C. Demidont, DO, chief medical officer of LGBQT care at the Anchor Health Initiative in Stamford, Connecticut, told Healio Primary Care Today.
“A PCP can be up-to-date on ways to screen, diagnose and treat patients for whatever condition brought the patient into the office in the first place, but if he or she does not make their patient feel welcome, it is all for naught.”
Demidont said PCPs and all of their colleagues should ask patients their preferred name and preferred pronouns at every visit. Intake forms should also be updated to reflect these questions.
PCPs should also offer all-gender bathrooms, provide areas where transgender patients can talk without shame, use gender neutral terms, and listen for patient cues on what other terminology is appropriate, according to “Providing affirmative care for patients with non-binary gender identities,” a publication published by the National LGBT Health Education Center.
Tran provided an example of how PCPs can address common medical procedures with their transgender patients.
“When you perform any physical exam maneuver, such as listening to a patient’s heart or lungs, explain why you are doing so and share your observations with them in real time. By explaining your rationale, and engaging them in step-by-step care, you put your patient’s worries at ease and gain their confidence and trust,” she said.
Studies also suggest using photos, videos or other visual representations to promote gender and bodily diversity and language that is respectful of the person's privacy, researchers wrote in the International Journal of Transgenderism.
“Training on these changes needs to start from the person at the top of your employee organization chart and work its way all the way down,” Demidont said. “Making these changes can be the difference between a patient returning for follow-up care and the person never coming back to the office again.”
Ladinsky and Tran said grasping the verbal, administrative and procedural changes that create a welcoming environment is critical to ensuring a long-standing, positive patient-physician relationship.
“If you have asked about the pronouns, made the changes to your forms, and correctly perform the exam, you have unlocked a massive door to letting your patients know you are there for them,” Ladinsky said.
“So long as the PCP provides genuine care and the willingness to apologize in instances of misunderstandings that can inevitable arise from time to time, regardless of practice, a transgender patient is often understanding ,and at times grateful for this acknowledgment, given the interpersonal nature of medicine, not necessarily limited to trans health,” Tran added.
The shame and confusion transgender patients often have about their bodies and the lack of support many of these patients have among family members, friends, classmates and colleagues can take a physical and mental toll, the experts told Healio Primary Care Today.
This puts transgender patients at higher risk for several mental health conditions and potentially dangerous unhealthy behaviors, they added.
“Transgender youth often have internalized shame and confusion, are frequently bullied, and are sometimes kicked out of their homes — it’s no wonder these persons are more susceptible to mental health conditions like anxiety, eating disorders, obesity, depression and suicide,” Ladinsky, who is also an associate professor of pediatrics at the University of Alabama at Birmingham School of Medicine, said in the interview.
CMAJ reports depression, dysthymia or symptoms of depression affect from 12% to 64% of transgender teenagers with gender dysphoria, while the CDC reports 4.9% of all children aged 6 to 17 years have been diagnosed with depression.
Research suggests many of these conditions in transgender patients stem from gender dysphoria. Though research on treating teenagers with this condition is limited, Joseph S. Bonifacio, MD, MPH, of the department of pediatrics at the Saint Michael’s Hospital in Toronto and colleagues suggested PCPs take what they called the affirming approach.
“The goals ... are to destigmatize gender variance, promote self-worth, allow for opportunities to access peer support, and enable parents and other community members to create safer spaces in schools and other social environments, rather than to pathologize the adolescent’s behavior or identity,” they wrote, adding PCPs should also provide “guidance on the timing of social transitioning, reviewing and overseeing the potential use of medical management, and connecting them with local community resources and supports.”
Data suggest older transgender patients are also susceptible to depression, with estimates ranging from 44% to 62% in this population group vs. 1% to 8% in the general population, according to a report in the American Journal of Community Psychology.
Data indicate the prevalence of HIV is higher among the U.S. transgender population than the general population (2.2% vs. 0.5%). A review of several articles on this topic suggest differing opinions on why this might be so.
Researchers reported in the Journal of Homosexuality that potential reasons for the increased risk included unprotected anal/vaginal sex, multiple sex partners, drinking alcohol and/or doing drugs.
“Our study suggests that gender nonconformity, despite its accompanying social marginalization, income loss, and risk of violence, does not in and of itself result in markedly higher HIV risk compared to other socially disadvantaged groups,” Jamie Feldman, MD, PhD, of the department of family medicine and community health at the University of Minnesota and colleagues wrote.
“Rather, sex with nontransgender men emerged as the strongest independent predictor of unprotected intercourse and high-risk behavior for both [male-to-female] and [female-to-male] participants; the meanings enacted through these relationships appear a driving force in sexual risk taking for both transgender men and women. However, male-to-female and female-to-male persons represent distinct groups, arriving at increased risk of unsafe sex through different trajectories of identity and experience, including types of gender identity, age, and use of hormones and gender related surgery,” they added.
Other researchers suggested other possible reasons for the increase in HIV cases among the transgender population.
“Transgender persons experience more social stressors than cisgender persons. Social and structural factors creating stress among transgender persons include unemployment, stigma and discrimination, and homelessness,” Mary Spink Neumann, PhD, of the National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention within the CDC and colleagues, wrote in the American Journal of Public Health.
“Stressors are compounded by discrimination on the basis of one’s social identity (e.g., race, class, gender expression, immigration status,” they added.
These researchers suggested interventions specifically aimed at the social determinants of health, clinical and educational components could potentially reduce the rates of HIV infection among this population group, including GED classes, job-training and housing programs; physically safe social venues and activities; health insurance that covers biologic sex–related care (eg, Pap smears for transgender men), increased availability of gender-affirming, knowledgeable, and transgender-specific and -sensitive medical care; as well as receiving hormone replacement therapy or PrEP from the same provider to encourage HIV care and prevention.
Hormone replacement therapy
Many transgender men and women seek hormone replacement therapy as part of the transition process to suppress the characteristics that make them uncomfortable and accentuate the traits the patient desires, according to an article in Translational Andrology and Urology.
Though the exact number of transgender patients undergoing hormone replacement therapy remains unclear, it is a “very common reason” these patients will visit their primary care physician, according to Ronica Mukerjee, DNP, clinical director and family nurse practitioner at Tree of Life Primary Care and Recovery in New Haven, Connecticut.
“Historically, the majority of patients receiving hormonal care have gotten their hormonal care in primary care settings because primary care hormone replacement therapy is easy and safe,” she said in an interview.
No medications have been specifically approved by the FDA for the purpose of aligning a patient’s secondary sexual characteristics with their gender identity.
“The medications for hormone replacement therapy are often estrogen and progestin — the same medications PCPs give their patients who are post-menopausal and experience low estrogen levels or non-transgender men who are experiencing fatigue or erectile dysfunction as a result of hormone deficiency,” Mukerjee explained.
Transgender men usually receive an increasing dose of testosterone intramuscularly in doses of 50 mg to 200 mg until the patient reaches testosterone levels of 300 ng/dL to 1000 ng/dL, Sarah Houssayni, MD, and Kari Nilsen, PhD, department of family and community medicine at the University of Kansas School of Medicine wrote in Kansas Journal of Medicine.
Patients taking these medications who are younger than 40 years of age should be seen every 3 months for the first year to check for viralizing, loss of menstrual cycle and increases in body and facial hair. These patients will also see an increase in muscle mass with redistribution of body fat to represent males, acne, and libido. Houssayni and Nilsen advised that a deepening of the voice, a larger clitoris (clitoromegaly), and male pattern hair loss occurs to varying extent in these patients.
Transgender women require a blockage of testosterone until levels reach 30 ng/dL to 100 ng/dL and an increase in estrogen to 200 ng/dL, according to Houssayni and Nilsen. They added this is often accomplished through a daily oral dose of spironolactone of 100 mg to 200 mg and a daily dose of estrogen, either 2.5 mg or 7.5 mg of estrogen or 17-beta estradiol at 2 to 6 mg orally, or estradiol valerate 2 mg to 10 mg once a week or 5 mg to 20 mg every 2 weeks) intramuscularly. These patients will frequently see less body hair, oily skin and spontaneous erections, as well as a decrease in muscle mass with redistribution of body fat to represent females. Libido and breast development typically increase within 3 to 6 months.
Mukerjee said there is evidence to suggest these medications increase the risk for CVD and the ability to have children in all transgender patients and increase the risk for osteoporosis in transgender women. Though these risks should be discussed with the patient, Mukerjee said this should not be done in a way that overwhelms the patient or that could be viewed as discouraging the procedure.
Researchers also recommend measuring BP, electrolytes, estrogen, full blood count, HbA1C, liver function, lipids, prolactin, testosterone and thyroid function to prevent “peaks and troughs” of hormone concentrations.
Research and experts indicate smoking often serves as a coping mechanism for the transgender patient. This may be why some studies have shown many kinds of tobacco use are more prevalent in the transgender population than other population groups.
A study in the American Journal of Preventive Medicine found 39.7% of transgender adults reported higher past 30–day use of any cigarette/cigar/e-cigarette product vs. 25.1% in the cisgender population. Current use of cigarettes, cigars and e-cigarettes was also higher in the transgender population.
Tran and Ladinsky said there is a link between the higher prevalence of mental health conditions and smoking among transgender patients.
“Within the transgender population, there is a higher comorbidity associated with behavioral health issues. This population often faces tremendous psychosocial stressors with additional barriers to accessing health education and preventative health care services. This can often trigger and fuel unhealthy habits. For instance, smoking tobacco starts as a transient socialization construct that frequently leads to habituation with high potential for addiction over time,” Tran said.
“Put yourself in a transgender patient’s shoes,” Ladinsky added. “Time and again, this person has likely been told they shouldn’t be who they know they are, and that some of their thought processes are not aligned with mainstream normalcy. For some transgender patients, tobacco or drug use serves to mitigate this internal pain.”
Despite the reasons why the smoking started, research suggests traditional smoking cessation techniques can be effective.
Eric S. Grady, PhD, of the department of psychiatry at the University of California at San Francisco and colleagues studied 777 patients — 17% who identified themselves as members of the LGBT community — who smoked at least 10 cigarettes a day and received counseling, nicotine replacement, and bupropion for 12 weeks. These patients were then randomly assigned to either extend or cease the treatment. Researchers found the LGBT participants were just as likely to quit as the cisgender participants.
For more information
Additional resources on transgender health concerns are available on the websites of the AAP, World Professional Association for Transgender Health, University of California at San Francisco, Endocrine Society Clinical Guidelines, and the Fenway Guide to LGBT Health. – by Janel Miller
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Disclosures: Neither Demidont, Ladinsky, Mukerjee nor Tran reports any relevant financial disclosures. Please see the studies for those authors’ relevant financial disclosures.