Most, Not All, PCPs Willing to See Transgender Patients

Norra MacReady

November 12, 2018

Older age and lack of personal experience with transgender individuals may correlate inversely with a clinician's willingness to care for transgender patients, results of a new survey suggest.

Most of the physicians surveyed said they would provide routine care to transgender patients, but the likelihood that they would do so declined with age, Deirdre A. Shires, PhD, MSW, MPH, and colleagues write in an article published in the November/December issue of Annals of Family Medicine.

When asked about offering Pap tests to female-to-male patients, the odds of an affirmative response were higher among family physicians compared with internal medicine physicians and were higher among clinicians who had met a transgender person compared with those who had not. The odds decreased among those who scored higher on a measurement of transphobia.

The results emphasize "the importance of integrating not only clinical but also personal exposure to transgender individuals into medical education," Shires, of the School of Social Work, Michigan State University, East Lansing, and colleagues explain. They add that "ideally, every clinician should be willing to provide routine care — within the general scope of their practice — to all patients, regardless of their gender identity or expression."

In an accompanying commentary, lead Hilary Goldhammer, SM, of the National LGBT Health Education Center at the Fenway Institute, Fenway, Health, Boston, and colleagues write that transgender people often report feeling stigmatized or misunderstood by healthcare providers. They use a hypothetical case scenario to show how physicians and their office staff can communicate with transgender patients in sensitive and respectful ways.

Primary Care Physicians Surveyed

For their study, Shires and colleagues mailed surveys to general internal medicine and family medicine physicians working in a large midwestern integrated health system. The survey included questions about demographic characteristics and personal experience with transgender individuals, as well as an item designed to measure empathy, eight questions regarding transphobia, and four items on possible barriers to care. The authors described the barriers as "lack of familiarity with transition care guidelines, lack of training in transgender-specific care, lack of exposure to transgender patients, and lack of knowledge about transgender patients among office staff, medical assistants, and/or nursing staff."

Of the 308 physicians to whom surveys were sent, 163 (53%) responded, including 23 whose answers were excluded owing to missing data. The respondents included 97 internal medicine physicians (69.3%) and 43 family medicine physicians (30.7%).

Overall, 85.7% of respondents said they would be willing to provide routine care for transgender patients, and 104 (78.6%) said they would be willing to perform Pap tests on transgender men.

On multivariate analysis, willingness to provide routine care decreased with age (adjusted odds ratio [aOR] = .89; P = .019). Willingness to provide Pap tests was higher among family medicine than internal medicine physicians (aOR = 5.08; P = .016) and among physicians who had met a transgender person compared with those who had not (aOR = 4.11; P = .032). The adjusted odds of being willing to provide Pap tests were lower among clinicians scoring higher on the transphobia measurement, compared with the entire group (aOR = .54; P = .020).

These findings are not unusual, said Ada Stewart, MD, a family medicine physician in private practice in Columbia, South Carolina. "I am a provider of transgender care, and many of my patients have told me they've had poor experiences in the past. I see the trend changing with younger physicians, so it did not surprise me that they were more apt to feel comfortable providing transgender care. Unfortunately, older physicians have had very little education in working with this patient population."

Nevertheless, physicians should realize that they may encounter a transgender patient at some point in their careers, Stewart told Medscape Medical News. "More than 1.4 million adults in the United States currently identify as transgender," she explained. "This means that most physicians will come into contact with a transgender person, whether they know it or not."

A negative experience with a healthcare provider may have serious consequences for the patient's mental health, Stewart adds. "Many of these people have already been stigmatized or rejected by their families, by society, or by their employers, and if they try to seek help from a healthcare professional, and they feel that once again they're being rejected, that makes them suffer more."

Sensitive Communication Important

In their commentary, Goldhammer and colleagues write that one way healthcare providers can demonstrate their willingness to understand transgender people is to learn the nuances of communicating with them effectively.

For example, many trans people prefer not to be addressed with gender-specific identifiers such as "ma'am" or "sir." Forms asking about "name and gender on insurance," "name on identification documents," and the "name you wish to be called during the office visit" tacitly acknowledge that the gender the patient was assigned at birth may not be the gender they consider themselves to be now.

As the understanding of gender evolves, healthcare providers and their office staff should learn "to support patients' self-definition of their gender identities" by avoiding assumptions about them, by asking about preferred names and pronouns, and by using gender-inclusive language, they add.

Clinicians should "recognize that there are individuals of trans experience out there who need care, and we should not discriminate against them," Stewart said. She agreed with the recommendation to teach office staff empathetic ways of communicating with transgender patients, saying, "remember: the first person they see when they walk in the door is the individual at the front desk. And if they or your office staff do not appear to be trans-friendly, that patient will not come back."

The authors and Dr Stewart have disclosed no relevant financial relationships.

Ann Fam Med. 2018;16:555-558; 559-562. Full text, Commentary

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