A. What and When?

On July 2, 2019, the American College of Physicians (“ACP”) published an article entitled “Care of the Transgender Patient” in ACP’s Annals of Internal Medicine. [1] In the article, the authors provide an updated set of guidelines reflecting the growing significance and better understanding of issues pertaining to transgender patient care.  The guidelines set forth recommendations relative to the provision of care to transgender patients by internal medicine and family medicine doctors.

B. Unique Challenges of Transgender Patient Care

The transgender population, which is estimated to be around 1.4 million adults in the United States, according to the studies cited by the authors, faces unique access to care challenges.  The authors explain that the most significant access to care issue is that there exist a limited number of primary care and specialty physicians with sufficient knowledge of transgender medicine and an insufficient number of facilities throughout the nation providing quality transgender care.  Historically, such care was limited to select facilities.  The authors argue that improving access to quality care for transgender patients is an initiative requiring qualified primary care physicians outside of those select facilities.

The authors describe that another challenge related to transgender patient care is that many institutions’ electronic medical record (“EMR”) systems inadequately document the condition and medical history of transgender patients.  The authors explain that EMR systems “should have the capacity to record appropriate pronouns used by patients in addition to their used name, their gender identity, and the organs and tissues present.”  The authors further explain that the medical record may need to be updated over time given that a patient’s name, pronoun used, gender identity, and organs and tissues present may change over time.

Additionally, another challenge related to transgender patient care described by the authors is insufficient coverage for transgender care and procedures.  Approximately 20 states require insurance for transgender care, with coverage for a wide array of procedures.  Fortunately, the Patient Protection and Affordable Care Act included the obligation to provide transgender care nationwide.

The consequences of inadequate transgender care are dire.  The authors cite studies that demonstrate that transgender persons have “increased rates of certain types of cancer, substance abuse, mental health conditions, infections, and chronic diseases.”  For example, according to a study published by the American Academy of Pediatrics, 50.8% of transgender male teens and 29.9% of transgender female teens who participated in the survey had attempted suicide.  [2] These rates are in contrast to the overall rate of suicide attempts by teens who participated in the survey, which was 14%.  Moreover, as summarized in a Committee Opinion of The American College of Obstetricians and Gynecologists, “More than 50% of persons identified as transgender have used injected hormones that were obtained illegally or used outside of conventional medical settings.  Additionally, such individuals frequently resort to the illegal and dangerous use of self-administered silicone injections to spur masculine or feminine physiologic changes.” [3]

C. Best Practices for Successful Transgender Care Environments

The authors explain that successful care environments for transgender patients require (1) transgender-specific staff training, with annual refreshers, (2) transgender-specific provider training as required, (3) transgender-friendly environment (e.g., inclusive bathroom use policies), and (4) use of an EMR system that is able to appropriate collect and update legal names, used names, sex on birth certificate, gender identify, and pronouns used. The authors further explain the importance of training staff in addition to training providers with respect to care of transgender patients. For example, staff should be trained with respect to and comfortable with “changes in names, pronouns, and physical appearance among transgender patients” and identifying changes in identifiers from older records and insurance information.  Staff should also be trained in how to maintain a respectful, helpful environment for transgender patients.

The authors provide other recommendations regarding care of transgender patients, including providing criteria that may be used to establish that a patient is transgender, explaining how providers should manage transgender patients considering medical intervention, describing the role of hormone therapy and how providers should monitor patients receiving hormone therapy, distinguishing treatment approaches for prepubescent children and older individuals, explaining the role of psychologists and psychiatrists in the care, and providing information regarding transgender-specific surgeries.  The authors also recommend that specific attention be given to address avoiding confidentiality breaches for patients who have relatives present during meetings with a provider or treatment as the relatives may be unaware of specific medical details with respect to the transgender patient. For example, a parent of a transgender teenager may be unaware of the child’s gender identity. Ultimately, the importance of increased training and greater awareness of relevant issues must remain a near term goal to improve access to quality care for transgender patients.

Footnotes:
[1] Safer JD, Tangpricha V. Care of the Transgender Patient. Annals of Internal Medicine 2019; 171 (1): ITC 1-ITC 16. doi: 10.7326/AITC201907020.
[2] Toomey, R., Syvertsen, A., & Shramko, M., (2018). Transgender Adolescent Suicide Behavior. Pediatrics, 142(4) e20174218; DOI: 10.1542/peds.2017-4218.
[3] Healthcare for Transgender Individuals. Committee Opinion No. 512. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011; 118: 1454-8.