In a move that reflects a growing acceptance of transgender individuals in the U.S., the American College of Physicians on Monday issued its first guidelines on caring for transgender patients.

This isn’t the first set of such guidelines. They go back at least 10 years, initially aimed at endocrinologists, the medical specialty to which transgender individuals were often referred. What is newsworthy about the new guidelines is the audience, “your critical mass of general internal medicine people who are primary care providers and also people who are family medicine doctors,” said Dr. Joshua Safer, professor of endocrinology and executive director of the Mount Sinai Center for Transgender Medicine and Surgery in New York City.

According to the new guidelines, transgender medical care has been historically siloed to endocrinologists. “The biggest barrier to care reported by transgender people is lack of knowledgeable providers,” said Safer. Internal medicine and family physicians can provide this care, and it is in the scope of their practices, he added.

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An estimated 1.4 million adults in the U.S. identify as transgender.

“If you’re seeing 5,000 patients in a year, knowingly or unknowingly you’re going to see a couple dozen gender diverse people,” said Dr. Frederic Ettner, a family medicine physician in Lincolnwood, Ill., who has been seeing transgender patients for more than a decade. “You may be up to speed in rare cancers that you may not see but once in five years. You’re seeing gender diverse people all the time,” he said.

Gillian Branstetter, spokesperson for the National Center for Transgender Equality, an advocacy group, applauded the new guidelines for emphasizing the importance of education for primary care providers. “Over half of all transgender people have had to teach their provider about their health care,” she said.

Other experts agree that more types of physicians should be involved in caring for transgender individuals. “About a quarter of trans folks don’t seek medical care at all because they’re concerned about discrimination from health care providers,” said Dr. Juno Obedin-Maliver, an assistant professor of obstetrics and gynecology at Stanford University and co-director of The PRIDE Study, the first national long-term health study of people who identify as LGBTQ.

The American College of Physicians’ guidelines include sections on terminology, evaluation, medical management, transgender-specific surgeries, medicolegal and societal issues, suggestions for practice improvement, a handout for patients, and additional resources.

“They did a great job of hitting all the high points for this topic,” said Dr. Caroline Davidge-Pitts, an endocrinologist who is the education director of the Mayo Clinic’s Transgender and Intersex Specialty Care Clinic.

The value of having internists participate in medical care for transgender individuals is their often long-term relationships with their patients. An internist might be the first health care provider with whom a patient discusses their gender identity and can begin conversations about their goals of care.

One murky area of transgender care involves screening for cancer risks. How should providers screen a transgender male with a cervix for cervical cancer or a transgender female with a prostate for prostate cancer? For now, the American College of Physicians recommends that “providers should perform cancer surveillance based on the organs that are present rather than gender identity.”

The guidelines also suggested improving clinical environments, such as providing gender inclusive bathrooms and properly training staff members. “You can have a really wonderfully trained physician, but if the desk staff, billing staff, nurses, and medical assistants that get the patient in the door and set up for their visit are not [gender-affirming], that patient may not make it in to see their physician,” said Obedin-Maliver.

The Mayo Clinic’s Transgender and Intersex Specialty Clinic has instituted a gender-affirming atmosphere, said Davidge-Pitts. All providers see transgender patients on one floor. Desk staff and other providers are trained to use correct pronouns and preferred names. Subspecialists involved in multidisciplinary teams come to the clinic, so patients don’t have to visit specialty clinics. For example, a gynecologist comes to the clinic to provide pelvic health services for transgender men. “In that way,” Davidge-Pitts said, “our transgender men don’t have to sit in the general gynecology waiting room.”

The new guidelines also suggest addressing the shortcomings of electronic medical records for transgender patients. The system Ettner uses, for example, “still has male, female, and undifferentiated for gender labels,” he said.

Reflecting on the increasing acceptance of transgender health care needs in the U.S., Ettner said, “In a better world, would this be a medical condition? No. it’s a social condition. But we’ve pathologized it.”

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  • I am a transgender woman. I am also a research scientist. Nice article. Pity. They are all wrong. Not just a simple “wrong” – “ignorant wrong” as in not knowing ignorance. It is not “a social condition”….that implies “choice” and is nebulous. There is (sigh) enough – exhaustingly enough – research out there to clearly show that we are intersex…a different presentation of intersex but intersex nonetheless. Intersex is when physically a person demonstrates natal and pre-nata development that is other than “standard xx – xy”, and the criteria is…physical differences. Transgender women (I speak for myself) have a BSTc that is “physically different”, 40 genomes that are “physically different”, and it goes on from there….. I for one am really tired of the ignorance. Transgender people are not struggling with a social condition, we are struggling with the overbearing presence of testosterone and the lack of professional transgender medical personnel – researchers – who themselves are transgender and have that “research insight” that is necessary. I am NOT LGBTTTQ2S…. and the rest of it. I am a transgender woman. I am intersex. Figure it out and stop erasing me, stop marginalizing me and stop with the “professional testosterone opinions”

  • I simply do not understand the desire to want to be of the opposite gender, and to go through surgeries, lifetime hormonal therapies and loads of social complications. You are born the way you are, so live accordingly. I will not judge, but I am also 100% entitled to my very own opinion.
    If bathrooms are a problem: men / men-like shape up your urination habits. If the world supports transgenderism : have another set of separate bathrooms.

    • @Mary F , your choice of wording appears to be an indicator of your level of ignorance on this topic. My intent is not to be rude but to remind you that we are all subject to the ‘arrogance of ignorance’ when we try to enter a conversation on a topic we have little understanding of. When you say “don’t understand the desire to want to be the opposite gender”, (and you’re not transgender or GNC) using your own words, you’re saying the same thing as “I don’t understand a migraine sufferers desire to have pain free days”. Or, an epileptic’s desire to be seizure-free. Your lack of empathy of any topic does not reduce the importance of a particular topic.

      Secondly, to be more accurate, you are only ‘entitled’ to an opinion that has a chance of being true and accurate within the realm of validated evidence. Without that, your uninformed and unsupported ‘opinion’ is subject to being ripped to shreds to make room for solidly supported thoughts.

      Lastly, as far as additional separate bathrooms go, the supreme court has already ruled on the idea of separate but equal. As public as these comments are, why would you not try to be better at having your thoughts more well supported when you comment on a topic?

    • Mary F. Right …you have an “opinion” but you are not two things. You are not transgender and you are not of the medical nor scientific community. I am all three. I was never “male” despite the fact that I was born with a penis. Please, for your own education read my previous comment and do some googling on “intersex” and you will discover from the intersex society that 1 in 100 people deviate from the standard (NOT the “norm”) but the standard xx – xy. That term is just a convenience. OR…you could remain narrow minded and ignorant. That is not an insult but an observation. A transgender person is physically so. I knew at age 18 months – 2 years – that I was a girl. “Mommy when will my penis fall of so I look like my sister?” How painful. So …I married ….and divorced…and married….and divorced…perhaps if I join the military and learn to kill – that’s what REAL MEN do…isn’t it? Perhaps that will make me a man…. and finally after a profession of science, research, psychology, living and working and being in 13 different countries I have here beside me some 80 pounds of research, 9000 pages of documents and medical papers and such that say “Mary is mistaken”…. do a bit of looking please

  • I’m glad to see the American College of Physicians tackling these important guidelines and appreciate the author and STAT presenting the piece. I am, however, shocked and dismayed by some of the thoughtless and — dare I say — ignorant comments. Trans and intersex individuals are part of our society, including family, friends, coworkers, etc., and as such should receive the same kind of professional, compassionate and appropriate healthcare that we all expect. It is another cultural competency that should be integrated into the profession.

    I will say that I am a bit confused about the following: “For now, the American College of Physicians recommends that “providers should perform cancer surveillance based on the organs that are present rather than gender identity.” Medicine is not either-or. If we are trying to work toward a holistic approach to care, they should not be treating the person or the parts, but the person AND the parts. We should be well beyond 1999, when Robert Eads died from metastasized ovarian cancer because no doctor would care for him, choosing their perceived reputation over their oath.

    • As identified by scientific inquiry, bypass surgery is not the recommended treatment for anorexia. Transition and hormone therapy is recommended for transgender patients.

    • TheBerean. I have had “corrective surgery”…not to change my gender. I have always been female…before …during ….and after birth. My outward appearance was male simply because I had a penis. I also had a vagina, and internal genomes and other things you would not understand that dictated that I was female. There are approximately 200 variations of “xx – xy” . Now the only thing I have seen here is “God does not make mistakes” True. but one other thing is also very transparently clear is that you are not on God’s level and have no clue as to how He runs things.

  • I try to be supportive, but I honestly don’t understand the conflicting messages coming from the transgender community. How can these all be true:
    1. Not a medical condition
    2. Requires surgery and lifelong medication
    3. Will result in death (suicide) if treatment is not given

    What is it, then?

    • I’m not sure anyone is suggesting that it isn’t a medical condition. If anything, the suggestion is that it isn’t psychological. It’s a medical condition can result in psychological problems if left untreated however.

    • The last line of the article says, “In a better world, would this be a medical condition? No. it’s a social condition. But we’ve pathologized it.”

    • That is a rhetorical statement. The biggest problem facing transgender people are the social issues, though in the end, it is first a medical issue.

    • None of us who are informed say it is not a medical condition. It is not a psychiatric condition. W.H.O. has confirmed this. Being transgender is no longer classified under mental health but under sexual health. SOME of us require life long HRT (hormone replacement therapy) some do not. It does not necessarily end in suicide, however our suicide rate is extremely high and that is difficult to explain in this short space. We are marginalized, erased, and made invisible. We are not able to get the medical treatment that we need and thus no jobs, no relationships, often the sex trade if we want to eat, our incarceration rate is high because of emotion pain we suffer because of isolation, we turn to drugs and alcohol to assuage that, often the drug trade to support that which we do not need but must have, and it is a vicious downward spiral. Like you, very few have insight and knowledge of us. Our biggest persecutors often is the medical profession we turn to for help. It is not a choice. We are born this way and there are physical differences that are pre-natal that simply are that… my insides are female (NOT just how I think or feel but “structural stuff too”) and my outwards appearance is male. There are many variations of that. You are a rarity in asking “what are you then?” and thank you for asking. Most just want us dead. I have more university than the average two doctors – worked in nuclear physics and chemistry – and research – lost my career because of being transgender – not because I was less than or not capable – but because of prejudice and ignorance.

  • It is an epidemic pathological condition that is sterilizing young people without any possibility of truly informed consent. Yes they will be uncomfortable in many life situations, like sitting in a gyn office looking like a man. A “woman” like Caitlyn Jenner cannot play in the average suburban ladies golf club. Women are pushing back.
    They should have had extended counseling to help them consider all of the future ramifications of pretending to be the opposite sex. Hardly anyone passes like they thought they would. The average clinician is going to deadname and misgender, it goes with the territory.
    Gender neutral bathrooms are also a problem in large city clinics, why? The men urinate all over the floor, rim, seats, so women are forced to clean up after strange men. Been there done that, repeatedly.
    Not on board.

    • Claire, thank you for providing the most uninformed comment in the thread. Your representation of the community of ignorance is being heard loud and clear and is a testament to all your people who chose a rejection of knowledge over learning.

    • Almost everything you’ve just said is untrue. It isn’t an “epidemic.” Current procedures don’t improperly sterilize anyone. If sterilization occurs (during confirmation surgery), its done with informed consent. Most people “pass” well enough (especially if they’re treated early), though “passing” is not necessarily a requirement. It might make YOU more comfortable, but it isn’t necessary in a civilized society. The vast majority of people who encounter an obviously gender variant person are smart enough to simply treat that person with dignity and respect. Ignorance is only a problem if it is left unchecked.

  • . It does get just a bit disconcerting when faced with a staff and doctor who don’t have a clue. Misgendering and dead naming is common because of outdated forms that do not account for gender diverse patients. All to often it is the patient who has to educate the doctor

  • “For now, the American College of Physicians recommends that “providers should perform cancer surveillance based on the organs that are present rather than gender identity.”

    That “For now” is terrifying. We’re fast approaching a point where patients are threatening to sue care providers for not performing unnecessary opposite sex screenings. Wasting time and clogging up the system.

    “Reflecting on the increasing acceptance of transgender health care needs in the U.S., Ettner said, “In a better world, would this be a medical condition? No. it’s a social condition. But we’ve pathologized it.”

    Blantantly and dangerously incorrect. Amputation of healthy body parts and radical plastic surgery. Cross-sex hormones which massively increase the chance of heart attack/stroke, various cancers, and have horrible effects on the prostate and uterus. These are absolutely medical conditions and pretending they aren’t takes First Do No Harm and deposits it in the trash.

    • I am sure you feel the same about all other kinds of body modification. Breast reduction? Sorry it’s a healthy body part. Nose job? Sorry once again. And as for increased cancer risk the rates are lower than for many other prescription drugs on the market. I mean have you actually listened to the warnings on advertised Medications. Even some OTC’s have side effects that can be life threatening.

    • @Lee Anne Leland since I can’t reply to you directly for some reason.

      Nice try at gaslighting and putting words in my mouth instead of actually refuting my point that Trans is a medical issue and not social.

      Breast reductions often serve an important medical function. I’ve known two women who’ve struggled with severe back problems due to oversized breasts but were rejected because “they weren’t big enough” yet the same province now covers breast modification for transwomen. Because having big boobs is a key part of being a woman apparently.

      Rhinoplasty and radical SRS aren’t even remotely similar procedures and don’t carry anywhere near the same risks. False equivalence.

      Saying there are other terrible medications in no way reduces how terribly unhealthy medications like Lupron (puberty blockers that are known to permanently decrease cognitive functions and cause dangerous loss in bone density) and cross-sex hormones are for people, especially children. In fact, it furthers the point of how dangerous the pushing of these treatments are since the people who make/perform them have a vested interest in creating as many patients as possible to profit from them.

  • Such an insightful piece! Proud of the American College of Physicians. Medical schools need to train their students on caring for sexual and gender minorities

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