I know I’m a proud parent, but my teenaged sons’ respect for and acceptance of their friends’ preferred pronouns, dress, and names, as well as their understanding of cis- and transgender identity, is striking – and honestly humbling. I recently asked my older son to pose a question to his TGNB friends: “If you could communicate one thing to doctors, what would it be?†The answer was clear and powerful: “Make the health-care setting not seem hostile.†Until we address this fundamental perception, health-care inequities for the TGNB population will persist, as will their understandable reluctance to seek medical care.
One of his friends, a transgender girl named Sara,* shared her experience in the emergency room (ER) after a fall in which she fractured her arm. As she recounted, the ER doctor “spent twice as long asking questions about my gender and hormone therapy and trying to dissuade me from continuing to take my hormone therapy as they did evaluating my arm.†Sadly, Sara’s experience is quite common among TGNB people, and although data suggest that hormone therapy increases the risk to some extent for thrombotic events, many patients are willing to accept the risks of continued hormone use after a first VTE and take concomitant anticoagulation therapy.
The need for appropriate care for the TGNB population is apparent. Approximately 1.4 million Americans (roughly 0.6%) identify as transgender.1 Other recent surveys reveal that 12% of Millennials identify as TGNB.2
Identifying Barriers to Care
In a recent Lancet Hematology article, Jean Marie Connors, MD, outlined several essential aspects of caring for transgender patients, including respect for the patient’s gender identity and knowledge of the requirements for treatment to maintain it.3 Without that understanding, Dr. Connors explained, “Patients might not disclose hormone use, particularly if obtained without a prescription, making diagnosis and management of other health problems difficult. … We still hear from patients and colleagues that the necessity for hormone use is questioned, particularly after patients have had an adverse vascular outcome.†Many transgender patients do, in fact, report that their clinicians have an overaggressive reflex to discontinue gender-affirming therapy, even when the patient is being seen for unrelated medical concerns.
A report by the Center for American Progress (CAP) found that nearly 50% of transgender people in the U.S. have experienced mistreatment by a medical provider, ranging from refusal of care to verbal or physical abuse.4 The number was higher among transgender people of color, at 68%. One in five patients has been denied treatment because of their TGNB status and half have had to teach their clinicians about the care they need.5 A survey by the National Cancer Institute revealed that only 19.5% of oncologists expressed confidence in their knowledge of transgender patients’ health-care needs.6
My son’s friend Sara added her own observation that transgender men and women experience the health-care system differently when they seek medical care. “Trans women are often treated as if they are actively malicious and something to be feared, while trans men are often treated as if they are confused and simply lesbians in denial,†she said. “The experiences may feel more confrontational for trans women and more condescending or patronizing for trans men.â€
Education and Action
Despite a global call to action to provide universal access to high-quality and affordable health care, education for future and current physicians on transgender issues, including gender-affirming therapies, remains rare.
The governing associations of the Liaison Committee on Medical Education and the Accreditation Council for Graduate Medical Education have yet to include a single required competency specific to the care of transgender patients.
Ideally, medical education programming for students, residents, and trainees should address the following:
- cultural humility and anti-oppression training to gain greater understanding of health-care inequities
- development of transgender health programming longitudinally within the curriculum both for routine care of transgender patients and issues specific to the transgender population
- engagement of the TGNB community in the development and evaluation of educational initiatives
- practice-focused, case-based, and didactic learning that simulates patient consultations
- faculty development to include training in TGNB health, including modules for continuous professional development
- recruitment of TGNB candidates into undergraduate and graduate medical education and
- faculty positions to ensure that clinicians reflect the population they are serving7
While the Association of American Medical Colleges has developed extensive curricular materials to inform medical school training, a recent study of TGNB medical students and resident physicians found that trainees received less than three hours of TGNB health education throughout their entire training program.8
Cross-sex hormone therapy is an important psychosocial need of transgender patients, but, as evidenced by Sara’s story, it is often overlooked or ignored by health-care providers. To provide comprehensive care for TGNB patients, hospitals should include hematologists on multidisciplinary teams to assess thrombotic risk associated with gender-affirming therapies or planned surgical interventions, and to advise on the compounding effect of underlying hematologic disorders. Proper risk assessment of erythrocytosis and knowledge of the expected complete blood count parameters, and of the relative risks of VTE associated with the different formulations and delivery systems of hormone therapies, are vital.
Education about culturally sensitive care is also essential, and something that 70.4% of oncologists expressed a desire for in a survey.6 In the clinic, providers can practice culturally sensitive care by asking about and using patients’ pronouns and avoiding assumptions that are based on traditional gender norms, such as inferring relationship roles during medical evaluations. Adding gender identification to our email signature and Zoom calls are other examples of steps we can all take. Institutions should also adopt interventions to create welcoming, inclusive clinical and hospital environments. That includes training for each person who interacts with the patient – from the hospital staff cleaning the rooms to the physician making treatment decisions.
Hematologists have a commitment to provide unbiased, culturally sensitive, comprehensive care and engage in shared decision-making with all our patients. We need to check our biases at the door and engage in dialogue with our TGNB patients to establish a trusting and mutually respectful therapeutic alliance.
Alexandra Wolanskyj-Spinner, MD
Associate Editor
*The name has been changed to protect the person’s privacy.
References
- UCLA School of Law Williams Institute. How Many Adults Identify as Transgender in the United States? June 2016. Accessed September 8, 2021. https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/.
- GLAAD. Accelerating Acceptance 2017. Accessed September 8, 2021. https://www.glaad.org/publications/accelerating-acceptance-2017.
- Connors JM, Middeldorp S. Transgender health and haematology–a matter of respect. Lancet Haematol. 2020 May;7(5):e367.
- Center for American Progress. Protecting and Advancing Health Care for Transgender Adult Communities. August 18, 2021. Accessed September 8, 2021. https://www.americanprogress.org/issues/lgbtq-rights/reports/2021/08/18/502181/protecting-advancing-health-care-transgender-adult-communities/.
- National Center for Transgender Equality. National Transgender Discrimination Survey: Full Report. September 11, 2012. Accessed September 8, 2021. https://transequality.org/issues/resources/national-transgender-discrimination-survey-full-report.
- Schabath MB, Blackburn CA, Sutter ME, et al. National survey of oncologists at National Cancer Institute-designated Comprehensive Cancer Centers: attitudes, knowledge, and practice behaviors about LGBTQ patients with cancer. J Clin Oncol. 2019;37(7):547-558.
- Hana T, Butler K, Young LT, Zamora G, Lam JSH. Transgender health in medical education. Bull World Health Organ. 2021;99:296-303.
- Dimant OE, Cook TE, Greene RE, Radix AE. Experiences of transgender and gender nonbinary medical students and physicians. Transgend Health. 2019;4(1):209-216.