As a medical professional, I’ve experienced firsthand how increased advocacy and visibility of transgender people in recent years has made an impact—more trans patients are coming in for routine primary care, and doctors are helping to achieve more positive health outcomes.
Unfortunately, despite this progress, many transgender patients are still traumatized by our health care system.
In a 2011 survey by the National Center for Transgender Equality, of more than 6,000 transgender people surveyed in all 50 states, 28% of respondents reported delaying care due to past discrimination—and 19% were denied care outright.
Like many issues facing the LGBTQ+ community, health care for transgender Americans is highly politicized. Access to care is further complicated by the fact that state policies vary widely. The Affordable Care Act (ACA) makes it illegal for health care workers to discriminate against transgender people, but the provision is ill-defined and inconsistently enforced. And many trans people have little recourse if their employer or insurance plan does violate the ACA, because taking legal action could potentially cost someone them their job or their personal safety.
As I mentioned, there have been positive developments, such as when the American College of Physicians issued its first guidelines on care for transgender patients in July. But far too often I’m disappointed by the inadequate care that most trans people receive in the doctor’s office.
As an LGBTQ+ primary care provider, I’ve had the pleasure of working with many trans patients from a variety of backgrounds, from a 60-year-old trans woman coming out for the first time to a trans service member navigating their identity within US military culture. Each person’s journey is unique, and each day I am moved by their stories and their bravery.
It shows how far we have to go when taking care of trans patients is considered a specialty in the first place. These days, there is a growing number of primary care providers like myself who specialize in transgender care. But it shows how far we have to go when taking care of trans patients is considered a specialty in the first place, rather than just part of normal daily practice.
Transgender patients deserve more than a welcoming and accepting health care environment. They deserve providers with training in LGBTQ+-specific needs who can offer health services unique to their community. That includes training in hormone therapy, but also aspects of mental health, sexual health, gynecologic care, and comprehensive health services. Patients should not have to guard against hostile providers or navigate the health care system on tiptoe. We need to create spaces that empower trans patients to engage in shared decision-making and take full control of their health.
This is easier said than done. For the trans patients that I see every single day, their relationship with the health care industry is emotionally and financially taxing. Trans patients face an immense number of obstacles, from insurance to pharmacy to legal and social services.
Many patients must lean on their families and pay large out-of-pocket sums just to receive treatment. And sometimes accessing this support is contingent on the person remaining in the closet about their gender identity. The barriers to providing high quality care can feel overwhelming, but there are ways providers and practices can improve the situation for patients right now.
Ongoing training is essential, for both clinical and administrative staff. On the clinical side, it means making it standard to equip primary care providers with the tools to master competencies like hormone replacement therapy and gender-specific cancer screenings.
Administratively, it means constantly staying on top of the intricacies of the insurance industry, even as they change in different states and jurisdictions, and becoming better advocates to help patients navigate the overall system. Every time a trans patient enters the waiting room, they should know they are going to be treated with respect by the entire team.
Trans-inclusive intake forms, for example, signify that the practice is actively thinking about taking trans patients and is equipped to offer care. A form that allows patients to specify their assigned sex at birth and their gender identity rather than having to check “male” or “female,” for example, is both more inclusive to the patient and informative for the provider. This piece of paper alone can have a profound impact on a patient’s overall experience and quality of care.
Lastly, providers need to change the way that we get to know our patients. This means asking the right questions about gender identity, sexual history, and pronouns, as well as using inclusive language. We should learn to let trans patients tell their stories, rather than forcing them into a narrative that we construct. It is also crucial to ensure we ask trans patients about their mental health. The population has a higher prevalence of mental health conditions and suicide, and as primary care providers, we have a touchpoint with patients that many health providers don’t have.
In order to achieve safe, equitable health care for all, providers must constantly evolve, educate, protect, and defend. That means recognizing that patients need our expertise not just to deliver health care, but also to guide policy makers, educate the public, and drive community engagement. We should advocate for our patients not just in the office but in our schools, workplaces, communities of faith, and civic organizations. Transgender care doesn’t begin with a diagnosis and end with a prescription—like all good health care, it is continuous, human-focused, and driven by human relationships.
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