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.
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.”