Doctors needed

The Journal of the American Medical Association's online Medical column for October is Laura Buchholz' Transgender Care Moves Into the Mainstream

Despite the name of the article, Ms Buchholz highlights the difficulty transgender people have in obtaining competent medical care.

Trans people have been excluded from medical care, and their issues have been deemed not medical and not important.

--Joseph Freund, MD, a primary care physician at Franklin Family Practice in Des Moines, Iowa

Dr Freund recounted his struggles with insurance companies over reimbursement for transgender care, yet another barrier that transgender patients encounter.

I think [physicians] use the fact that they don’t know as an excuse because they’re uncomfortable.

I think that there are a lot more primary care physicians [who] realize they do have trans patients in their practices, that it’s inevitable, and they need to catch up.

--Jamison Green, PhD, president of the World Professional Association for Transgender Health (WPATH)

Part of catching up involves physicians understanding the research on transgender health. In 2011, the Institute of Medicine, now known as the National Academy of Medicine, issued the report The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. However, while the intent of the report was to identify gaps in lesbian, gay, bisexual, and transgender (LGBT) health research, the report found the research base so thin that the word “gap” wasn’t applicable.

All aspects of the evidence base for transgender-specific health care need to be expanded.

--the authors

The report proposed a research agenda aimed at assessing the effects of masculinizing and feminizing hormones, including the effects of long-term hormone use, and puberty-delaying hormones. Some such studies have since begun to make their way into the literature. For example, 1 study found that hormone therapy over 6 months resulted in decreased median blood pressure for transgender women (from 130.5 mm Hg to 120.5 mm Hg) and elevated body mass index for transgender men, from a median of 29.1 to a median of 30.0 (Deutsche MB et al. Obstet Gynecol. 2015;125[3]:605-610)

--Buchholz

The Bigotry Industry would have you believe that a large percentage of transgender pople regret transitioning.

Randomized, double-blind, controlled studies on the psychological outcomes of gender transition are similarly lacking, in part because of feasibility and ethics issues.

But a 2012 American Psychiatric Association report found that treatment for gender identity disorder alleviated the mental anguish associated with the diagnosis. The report measured transgender patients’ self-reported levels of improvement and satisfaction vs regret after receiving treatment in the form of psychotherapy, hormones, or surgery. Although postsurgical regret wasn’t completely absent, the report found that regrets tended to correlate with disappointing surgical results, coexisting psychiatric issues like alcohol dependency or psychosis, lack of family support, or surgery on individuals diagnosed later in life with gender identity disorder—now called “gender dysphoria” to emphasize distress over disease (Byne W et al. Arch Sex Behav. 2012;41[4]:759-779)

Research also suggests that transgender patients’ decisions to undergo gender affirmation surgery are well considered and reflect the same reasoning that nontrans people use when deciding whether to undergo surgical treatment for cancer that may affect gender identity.

Dr. Seth Pardo, lead evaluator in the research and evaluation department at th San Francisco Department of Public Health "has found that trans men contemplating gender affirmation surgery and women contemplating lumpectomy vs mastectomy for breast cancer made similar decisions in favor of the gender-preserving option (lumpectomy for women, mastectomy for transgender men) when weighing the risks of surgery. The reasoning used by all groups reflected a desire not just to live, but also to live authentically."

Trans people make [medical] decisions just like everyone else and use the same cognitive processes just like everyone else.

What? We don't just transition on a whim? Well, I'll be.

Despite the lack of research there are significant resources available to doctors for consultation.

Guidelines are not based on long-term prospective randomized trials. What has been published is consensus. It’s expert opinion.

--Dr. Madeline Deutsch, director of clinical services and assistant clinical professor at the University of California, San Francisco, Center of Excellence for Transgender Care

WPATH publishes the Standards of Care for the Health of Transgender and Gender Non-Conforming People.

The latest edition (seventh edition, 2012) includes for the first time an appendix, specifically for primary care physicians, which includes an overview of hormone therapy risks, as well as criteria that must be fulfilled before initiating hormone therapy or surgery. For example, according to the SOC, a physician should have evidence that the patient is not a minor, has been diagnosed with gender dysphoria, is capable of giving consent, and has no other medical or psychological issues that would complicate treatment before initiating hormone therapy. The same criteria apply for patients seeking breast/chest or genital surgeries. However, in the case of breast augmentation, the guidelines recommend a year of hormone treatment before surgery; for genital surgery, the guidelines recommend that the patient live as their preferred gender and undergo continuous hormone treatment for a year before surgery.

The UCSF CoE publishes the online Primary Care Protocol for Transgender Patient Care. The American College of Physicians publishes Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health.

In 2014 The American Association of Medical Colleges produced a report intended to guide medical schools in integrating education about transgender health issues.

The University of Louisville School of Medicine will launch a pilot transgender program, based in part on the AAMC guidelines. One defining element of the curriculum is that it will be integrated seamlessly into existing coursework. Amy Holthouser, MD, associate dean of medical education at Louisville, explained that isolating transgender health instruction apart from other aspects of medical education brings with it the risk of casting transgender people as “other.”

It’s easier to put aside a certain amount of time. [But] it’s also marginalizing [and] kind of demeaning.

Dr. Holthouser

[Cultural Competency] is insufficient,” said Joshua D. Safer, MD, associate professor of medicine and molecular medicine in the section of endocrinology, diabetes, and nutrition at Boston University School of Medicine. Safer believes that for physicians to understand the necessity of hormonal treatment and surgery, curricula must emphasize the biological basis of gender identity (Saraswat A et al. Endocr Pract. 2015;21[2]:199-204).

"The point isn’t even if you’re polite or not," he said, emphasizing that even physicians who use the wrong pronouns should have an appreciation for the biological underpinnings of gender identity that support transgender care.

There’s a lot of well-meaning, well-motivated providers out there who really want to do the right thing, but how many of them are actually following good practices? Because there is not really a clear standard, no clear [medical] certification that is evidence-based… anyone is allowed to say 'I’ve seen 5 patients, I’m an expert.'

--Deutsch

If anyone might be considered a true specialist in transgender care, it’s the surgeons who perform gender reassignments. “Up to this point, there have been only a handful of surgeons who perform these surgeries, and it has been a bit of a niche specialty, with only a few patients being able to afford the cost,” Cavanaugh wrote in an email. Because gender reassignment surgeries in the past were typically paid for out-of-pocket, there are not yet good data on how many people have these surgeries each year. Hormone therapy is certainly cheaper and therefore a far more accessible therapy for transgender patients, whether that therapy is managed by an endocrinologist or a primary care physician. However, as insurance coverage for gender reassignment surgery expands, Cavanaugh noted that surgical departments could start leaning on the surgeries as a moneymaker. “I think a lot of surgeons and physicians who work in this area worry about the challenge in maintaining the quality and integrity of the work that’s done,” he wrote.

Marci Bowers has been performing reassignment surgeries for 12 years. She is concerned about the lack of surgical training available.

I’m seeing worse outcomes here in the US than I did five or ten years ago. [It’s] because of poor training … people observing the surgery and then going back home and doing [it].

--Bowers

She is also concerned about PCP's who lack the training to perform post-operative care.

Urinary function, sexual function, defecation, they’re all right there, [and] they can all be impacted by a surgery that’s not executed well. It’s a major responsibility,

--Bowers

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