This post continues our series on LGBTQ+ populations and the health concerns and disparities that affect these communities, in alignment with one of our newest workgroups here at the Bree, LGBTQ+ Health Care. We invite interested members of the public to join upcoming meetings by phone or in-person.
By Emily Wittenhagen
Program Assistant, Bree Collaborative
In our LGBTQ+ workgroup, the desire to build recommendations that meet the needs of transgender patients is a big topic. It’s clear that there is much work to be done to build a health care system that is transgender-affirming and also, as is best practice with all patients, uses a whole-person approach. After all, all patients are individuals with unique needs that deserve to be considered with respectful, wholistic care.
GETTING THROUGH THE DOOR
Unfortunately, seeking care as a transgender person can prove to be a challenge right out of the gate. At times patients have to call several practices before finding one willing to provide care and can feel dismissed by those who would not take them on. The reason, providers say, is a lack of training in this particular specialty and therefore a hesitancy to take on a patient whose needs they may not feel equipped to meet. This points out a great need for increased provider training. Some patients report driving hours to seek care, being unable to find providers in their own area able or willing to work with them. This barrier to access is echoed by many across the healthcare spectrum and highlights the crucial necessity for medical institutions, including universities training the next generation of providers, to recognize this gap and accelerate education to close what is undeniably an inequity placing people at risk. As Unger (2015) notes, “Medical school and residency curricula are lacking in content on the care of the transgender patient.” In other words, it seems understood that a universal stepping up to the plate is in order.
“Transgender individuals remain one of the most underserved groups in healthcare”
CONFRONTING HESITATION WITH EDUCATION
There are of course priorities for transgender patients that go beyond the realm of primary care — and for this, specialists like endocrinologists, behavioral health providers, and reproductive specialists play an integral role. However, even in these realms, there are clear barriers to address. As Dr. Veronica Hackethal noted in a March 2016 article in Medscape, “Transgender individuals remain one of the most underserved groups in healthcare, as evidenced by a new survey that indicates that most endocrinologists do not offer care for transgender patients and feel neither comfortable nor competent to do so.” While 63% of those surveyed said they were willing to provide transgender care, the majority of providers had no experience with it and only 20% described themselves as “very comfortable in discussing gender identity and/or sexual orientation.” Among OBGYNs in the US, only 35.3% and 29% of those surveyed by Unger (2015) were comfortable caring for male-to-female and female-to-male transgender patients, respectively.
In many cases, it seems provider hesitancy may be based in fear of doing the wrong thing. As Keren Landman cited for the Atlantic, a Canadian study in 2016 revealed that many physicians were “fretful, scared they would offend patients by using the wrong language, or fail to catch side effects of hormones.”, To dissipate this fear among providers is a clear priority to achieving care equity. It is this kind of fear and hesitancy, Landman notes, that “has the effect of keeping trans people away from the doctor’s office,” going on to cite a 2011 survey showing that nearly 90% of transgender people queried felt there weren’t enough medical providers adequately trained to care for them, and another that cited this lack of provider knowledge as the most common barrier to care.
Additionally, there are centers devoted specifically to treating transgender or LGBTQ+ patients. These include the community-based Seattle Counseling Service, which has been “dedicated to promoting health and wellness within the LGBTQ community for 45 years” (making it the oldest LGBTQ-focused community mental health agency in the world!), and the Transgender Services Program at Kaiser Permanente. These dedicated facilities also tend to be centered in urban areas, so while being an excellent service for those able to visit, the same barriers to access mentioned above can exist for those in rural health settings and can also risk overextending the existing facilities.
“The use of A preferred name for transgender patients is important for inclusion”
CALL ME BY MY NAME
This brings us to a subject we’ll close on before sharing some helpful articles and resources on this topic — the lag in many systems to adequately address people by their preferred names and pronouns. Often, a patient’s preferred gender pronouns and name differ from their birth gender and legal name. Unfortunately in a lot of cases this gap is a technological hurdle as this information is not easily able to be stored and found in EMR systems, resulting in misidentification that requires a patient to correct the provider, or quietly accept being called by the wrong name or pronouns. To be misreferred by a person one is trying to entrust with medical needs can threaten to make a person not only feel less ‘seen,’ but also compromise the trust that’s so important to build between a patient and their provider. As noted by Imborek et al (2017), “The use of preferred name for transgender patients has been identified as important in providing inclusion toward a class of patients that have historically been disenfranchised from the health-care system.” In this case, for the issue to be reliably addressed, it must be fixed at the source with changes implemented within EMR systems.
We will be looking at this and other key focus areas in the ongoing work of our LGBTQ Health Care workgroup. Stay tuned for more explorations in this series, and see below for further resources.
The Atlantic | Making Primary Care Trans-Friendly
The National LGBT Health Education Center, Fenway Health | Meeting the Health Care Needs of Transgender People + Optimizing Transgender Health: A Core Course for Healthcare Providers
Medscape Medical News | Better Provider Access, Training Needed, in Transgender Care
The National Center for Transgender Equality + The National Gay and Lesbian Task Force | Injustice at Every Turn: A Report of the National Transgender Discrimination Survey
Transgender Law Center | 10 Tips for Working with Transgender Patients
Canada Medical Education Journal | Addressing gaps in physician knowledge regarding transgender health and healthcare through medical education