Better Provider Access, Training Needed, in Transgender Care

Veronica Hackethal, MD

March 11, 2016

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.

Eighty attendees at an annual conference sponsored by the American Association of Clinical Endocrinologists in College Park, Maryland, in September 2014 were interviewed, and the results were recently published online in Endocrine Practice.

One explanation for the findings is that transgender medicine remains a new area for many endocrinologists, according to the survey author, Michael Irwig, MD, director of the andrology center at George Washington University, Washington, DC.

"Access has always been a problem, and it continues to be a problem," he told Medscape Medical News. "Some doctors feel uncomfortable with the transgender topic. Others probably feel that they don't have enough training or experience with transgender patients. They may feel they can't provide high-quality care, so they'd rather refer the patient to somebody who has higher volume."

Another group of doctors is tackling this issue by providing training in this field.

Corina Lelutiu-Weinberger, PhD, of Hunter College of the City University of New York, and colleagues report the results of a new pilot training program in transgender health at their institution — the first evidence-based testing of such a program — and show that just 6 hours of training can have a positive impact; the results are published in the January issue of the new journal Transgender Health .

However, Dr Lelutiu-Weinburger stresses that "a one-time training is going to make a small dent. We are advocating that this program be incorporated into regular training within clinics and provided on a recurrent basis."

Survey Indicates Much Work to be Done, but Hope for Future

Most transgender individuals have legitimate concerns about discrimination and affordability of care, which results in delays in them seeking treatment, potentially affecting their overall health.

There are a number of issues when considering care of these individuals.

Dr Irwig explained that under the stipulation regarding preexisting conditions, the Affordable Care Act and Medicare have stated that transgender care should be covered, but this may vary between states, and insurances may not always cover routine medical visits or lab work,

But doctors can usually get around this issue by billing for a specific symptom or code rather than using the transgender code, he noted.

Actual hormone therapy is fairly inexpensive, and insurance often covers it. Some Planned Parenthood clinics also provide affordable, safe, hormone therapy for transgender patients who might struggle to obtain it due to insurance or provider access issues.

On the other hand, the costs of gender-reassignment surgery can be prohibitive. Few surgeons are qualified to do such operations, and many of them may not be covered by insurance. Out-of-pocket gender reassignment surgery can cost upward of $20,000, according to Dr Irwig.

In his survey, which covered 80 healthcare professionals including 61 adult endocrinologists, 13 endocrinology fellows, two pediatric endocrinologists, and four nurse practitioners/physician assistants, the majority of the 80% who responded did not currently treat any transgender patients, and they rated their competence to care for such patients as low.

Less than one-third of respondents had seen five or more transgender patients during their careers, and only 16% currently cared for five or more transgender patients.

More than 30% indicated that they do not provide hormonal therapy to transgender patients. And just 20% said that they would like to see more transgender patients in their practices.

Equally, only 20% reported being "very" comfortable discussing gender identity and/or sexual orientation. The majority rated themselves as "not at all" or "a little" competent in talking about these issues.

And while Dr Irwig acknowledges that much work remains to be done, "we are making strides," he observed.

The younger generation, in particular, seems to be more receptive to transgender care. The results indicated that often younger doctors had had a lecture on transgender care during fellowship, and 70% of those under the age of 40 had read the 2009 Endocrine Society Clinical Guidelines on transgender care, he noted.

As awareness improves and more providers start gaining real-world, hands-on experience with transgender patients, access to care will likely progress, Dr Irwig believes.

Pilot Clinic Could Be Model for Others to Follow

Meanwhile, Dr Lelutiu-Weinberger and colleagues describe the voluntary training program on transgender care that they ran between March and July 2015, at an outpatient clinic in New York City that primarily serves people of color and those of low socioeconomic status. All levels of staff were invited to participate, and 35 took part.

The program consisted of three 2-hour training sessions, given mostly as lectures with sample scenarios and group dialogue. The first session included all types of staff and provided an overview of transgender identity, stigma, and health disparities. The second included healthcare providers only and covered specialized transgender care, like current guidelines, transitioning, transgender-specific screenings, hormone therapy, and long-term monitoring.

The third session covered specific topics related to each staff member's role, including creating transgender-affirmative environments and issues surrounding medical forms and billing issues.

It's important that all levels of staff receive transgender training, according to Dr Lelutiu-Weinberger, because discrimination can occur among front-line staff — such as the security guard at the door or in the waiting room during registration — before the transgender patient even sees a healthcare provider.

And many other specialists — psychologists, psychiatrists, surgeons, social workers — are involved in the care of transgender patients and may also benefit from training, she noted.

After the program, staff showed a significant reduction in negative attitudes toward transgender individuals (P < .05) and a significant improvement in transgender-related clinical skills (P < .01).

Awareness of actions that can cause transgender stigma and their readiness to care for transgender individuals were also better among the staff who underwent the training, although not significantly.

But lecture training is not enough, Dr Lelutiu-Weinberger emphasized.

Practicing with role play and shadowing a provider with experience treating transgender individuals are both important for improving communication and clinical skills.

Staff should also get "brief boosters" to help sustain the knowledge gained, she said, emphasizing the importance of institutions buying into this type of training program.

Likewise, whether or not such training programs can extend to other hospitals and clinics also depends on institutional buy-in, she pointed out.

"We're going to test the program in two more sites…hoping that it will be a model for other clinics to follow. We can share curriculum that will be available, and we're working on some online modules."

The authors of both studies report no relevant financial relationships.

Endocrine Practice. Published online February 29, 2016. Abstract

Transgender Health. 2016;1:45-53. Article


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