Confronting Transphobia in Healthcare

George W. Citroner

Disclosures

March 08, 2019

Transgender Bias in Healthcare

Patients are often anxious when seeking medical care. Could my symptoms be serious? Do I need a second opinion? How much is this going to cost?

Compounding these worries, transgender and gender-diverse patients experience a unique type of anxiety: the fear of gender-related discrimination. These patients can be misgendered or unintentionally "outed," or they may find themselves having to educate their providers about their healthcare needs.

Underpinning their trepidation is the question of bias on the part of healthcare providers—conscious or unconscious—which can influence patient management and contribute to healthcare disparities among sexual-minority patients.

In fact, in a survey of transgender patients, one third of respondents reported that they had had at least one negative healthcare experience (including denial of care) in the past year, and 23% avoided seeking care altogether because they feared mistreatment.

Are these concerns founded? How do clinicians feel about caring for transgender patients? In a recent survey of primary care providers, most (86%) were willing to provide routine care to transgender patients, and 79% would do Pap smears on trans men. Providers who were not willing to care for transgender patients scored higher on a measure of transphobia (the fear, hatred, disbelief, or mistrust of people who are transgender or whose gender expression doesn't conform to traditional gender roles[1]).

Transphobia Versus Education

The conventional panacea for bias of any type is "more education" for healthcare providers.[2] But is this an effective solution? Does more knowledge influence a provider's competence, attitudes, and behavior toward a specific minority population?

Not always. A new study[3] found that the degree of transphobia, rather than amount of education, best predicted just how much a provider knew about transgender health. Thus, transphobia may represent a barrier to competence in transgender health.

Not only was there no correlation between education and knowledge, there was a very significant...reverse correlation between transphobia levels and transgender knowledge.

One of the study's authors, Daphna Stroumsa, MD, MPH , admitted that the study's findings were unexpected. "We were all surprised, because previous studies had shown that there was a correlation between learners who received education on transhealth and their competence," she said, adding, "A lot of our efforts have focused on implementing new programs to educate clinicians about transhealth. When we saw our results, we realized: Hang on, we have to stop and think about what we're doing."

Stroumsa and team surveyed 389 practitioners and residents from the departments of internal medicine, family medicine, and obstetrics and gynecology in a large urban health system.

"We surveyed attending physicians as well as advanced practice providers, including physician assistants, nurse practitioners, and nurse midwives. Our hypothesis was that increased hours of education about transgender health would lead to increased knowledge," explained Stroumsa.

She continued, "Not only was there no correlation between hours of education and transgender knowledge score, there was a very significant, clinically and statistically, strong reverse correlation between transphobia levels (negative attitudes towards transgender people) and transgender knowledge scores."

Clinicians with higher transphobia scores on a previously validated scale received lower scores on a scale that assessed knowledge about transgender health. People who were more transphobic knew less, no matter how much education they had received on this topic.

Education as Remedy for Transgender Bias?

Rita Lee, MD, internist and primary care physician at UCHealth University of Colorado Hospital, shared some anecdotes that suggest a lack of understanding about transgender health among some medical providers, particularly in primary care. According to Lee, when encountering a transgender patient, providers have said such things as "I don't have enough training on this topic" or "I'm not comfortable with this, so I'll stop your hormones," not recognizing the severe physiologic and psychologic distress that may result from this action.

Such episodes may explain why, despite the finding that education doesn't correlate with clinical competence and lower levels of transphobia, the main focus of efforts to eliminate transgender bias in healthcare is still clinician education.

Kecia Gaither, MD, MPH, director of perinatal services at NYC Health + Hospitals/Lincoln, said "I can't speak for all providers, but in my training days, there was certainly no education concerning the care of transgender individuals. At that time, the progress that has been made to improve the gender transition process—the operative, medical, and psychological advances—hadn't yet occurred."

Ada Stewart, MD, a family physician and member of the board of directors of the American Academy of Family Physicians (AAFP) said, "I think the training is still in its infancy. When I went through residency many years ago, the training wasn't there. But now, the AAFP is actively endorsing inclusiveness guidelines."

Stewart was impressed by a recent article[4] in American Family Physician about transgender and gender-diverse patients, telling family physicians what they need to know. Important recommendations made in that article[4] include:

  • The history and physical examination should be sensitive and tailored to the reason for each visit.

  • Clinicians should identify and treat mental health conditions but avoid the assumption that such conditions are related to gender identity.

  • Preventive services should be based on the patient's current anatomy, medication use, and behaviors.

  • Adolescents experiencing puberty should be evaluated for reversible puberty suppression, which may make future affirmation easier and safer.

Stewart added, "Articles like this also educate more experienced family physicians who may not have the training that new residents receive, bringing up everyone's education level. The AAFP is determined to do their best in educating family physicians on this issue."

There are signs that medical education is getting on board, as well. The Association of American Medical Colleges has issued a report offering curricular guidance for medical schools to increase education for family medicine residents about LGBT healthcare needs.

Stroumsa recently developed and produced training modules that prepare obstetrician/gynecologists and other providers to better care for transgender and gender-diverse people and reduce transgender bias. This training was developed in collaboration with physicians and transgender health activists, and the Council on Resident Education in Obstetrics and Gynecology.

Increased expertise in caring for transgender patients is another positive development. "Denver Health has created a transgender program, and clinical centers across the United States have been either recently formed or expanded to try to meet the needs of transgender patients," noted Lee.

Taking the Patient's Point of View

Nancy Dodson, MD, assistant professor in adolescent medicine, Montefiore Health System and Albert Einstein College of Medicine, speculated about the reason some physicians have difficulty interacting with transgender patients. "Many pediatricians have been caring for patients since they were newborns. Just as parents struggle to do so, it may be difficult for them to see their patients in a new gender."

"Even well-meaning primary care providers may misgender or misname patients out of habit," she continued. "For others, bias may stem from a belief that transgenderism is a fad or that it shouldn't be encouraged by medical professionals. Although we should never encourage a particular gender identity, we should affirm a child's gender identity and support them thoughtfully and safely."

Dodson described an experiment she has used to help people better understand transgender bias. "I ask a volunteer to describe a woman in the third person, using the male gender pronoun. So the woman might be described by saying, 'He has a red shirt on. He is a nice person,' or 'I've known him for many years.' The woman being described then reflects on the experience of being misgendered. She usually says it feels weird or irritating."

Dodson explained that "this simple, short experiment heightens people's sympathies to the feelings of transgender people who are routinely misgendered."

Transgender-Friendly Settings of Care

Much work remains to be done to make transgender patients universally comfortable in healthcare settings, from emergency departments to primary care medical offices.

"We've heard some unfortunate stories about front desk staff or medical assistants, out of fear of offending, simply not knowing what to do, or becoming paralyzed with fear, which creates an awkward situation," said Lee.

She described a common scenario. "Transmen, especially, may be very uncomfortable sitting in a waiting room filled with women. We need to train staff not to be surprised when they present to a women's health clinic."

Besides recognizing these situations, Lee said that her facility has been working with their mammogram department to create waiting rooms that are friendly to transmen and transwomen who are getting mammograms.

"Maybe the gowns don't have to be pink. There are a lot of the structural pieces that really need to be addressed in women's health clinics that serve transgender individuals," she explained.

A series of videos created by the University of Michigan's Halley Crissman, MD, MPH, can help train front-line staff, including clerks, registration staff, nurses, medical assistants, and others, to serve transgender patients with greater sensitivity and respect.

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