Primary Care Providers and Transgender Health
Importance of Transgender Health
The field of lesbian, gay, bisexual, transgender and queer (LGBTQ) health has become a countrywide priority in recent decades. Transgender individuals have unique health care concerns. They can be described as persons who identify with a gender different from the sex assigned to them at birth (N Dubin, Nolan, Streed, Greene, Radix, Marrison, 2018). The term has diverse expressions and identities such as gender minority, transgender woman, transgender man and transsexuals. The various identities can either be categorized as gender nonconforming or gender binary as they do not conform to conventional binary gender categories. To achieve the physical features that are in line with their preferred gender orientations, transgender individuals may go through medical interventions such as hormone therapy, i.e. testosterone and estrogen. An estimated 1 million Americans identify as transgender according to data from national surveys.
Transgender individuals undergo mental illness, anxiety, depression and suicide compared to the rest of the population. Also, they experience victimization, violence, non-suicidal self-harm and are at a higher risk of using and abusing drugs. Research has shown that transgender individuals, especially transgender women, are at a higher risk of contracting human immunodeficiency virus (Shires et al., 2018). When compared with cisgender people, i.e., persons whose gender orientation is in line with the sex given to them at birth, the poor health outcomes of transgender individuals are worsened by socioeconomic unfairness like harassment, poverty, legal discrimination and higher unemployment rates.
The lack of knowledge and negative attitudes towards transgender individuals by primary care providers has resulted in transgender individuals being discriminated, physically and verbally abused and denied healthcare in healthcare settings (Carabez et al., 2016). Also, the lack of insurance as a result of unemployment and poverty has affected access to health care. Most insurance companies deny coverage based on a categorization of procedures that are medically necessary such as experimental, cosmetics and sex-specific. Even though the patient protection affordable care act made an effort to improve access to health care for transgender persons, they did not do so entirely since lack of knowledge and training of physicians in transgender health has still not been addressed. One way of addressing the inequities present in transgender health is the integration of transgender health in medical education. Doing so will improve physicians awareness and attitudes towards transgender people, develop skills needed to provide efficient care and provide the knowledge necessary to address unique transgender health concerns.
Lack of Knowledge on Transgender Health
Even though several studies on nurses’ attitudes and knowledge about LGBTQ are being carried out, none is focusing exclusively on their knowledge of transgender issues. According to research by Carabez et al., (2016), it was found that only two hours are devoted to the teachings on LGBTQ health across the entire nursing curriculum. Another study found out that a majority of nurses were not aware if their institutions had forms that were gender inclusive, i.e. if the questions identified transgender patients. Historically, nursing journals and literature have few articles on LGBTQ health issues and fewer on transgender health particularly. The lack of adequate information has limited the evidence base that is essential for nursing education and practice about transgender health. Health care providers are thus uninformed, uncomfortable and at times hostile towards transgender people who go to healthcare settings to seek help.
Health care environments are not properly trained and are far from completely accepting to work with transgender patients. Most nurses confuse the term transgender and sexual orientation and further admit to not knowing what the former is. Even though some nurses have adequate knowledge of and are compassionate towards transgender patients, a greater number lack satisfactory understanding and knowledge to efficiently provide sufficient care (shires et al., 2018). Most nurses assume that mental health issues, hormones and surgery needs of transgender patients are inherent to being a transgender individual rather than the consequences of societal forces that stigmatize against them. Nurses are insecure, confused and have several misconceptions about transgender patients, their healthcare needs and lived experiences. Only a few of them are familiar with the health discrepancies experienced by transgender people.
Even though most nurses acknowledge health risks associated with transgender individuals such as suicide ideation, poor mental health and HIV/AIDS, only a few know social conditions that heighten health risks for transgender individuals (Reisner, 2012). These social conditions include stigma and discrimination that are responsible for creating barriers to healthcare, employment, social support, housing and food security. Most nurses recognize the stigmatizing environment faced by transgender individuals in health care settings. They do not, however, know the effect that stigma has on the practice and health of transgender patients. In a study by Carabez et al., (2016) indicates that to measure nurses’ understanding about transgender care, most nurses did not recognize the effect that ridiculing and stigmatizing may have on the patients. They commented on jokes and gossip about transgender patients without explaining how such behaviours compromised care. Lack of knowledge and discomfort with transgender individuals is an explanation as to why most transgender patients experience hostility, discrimination, invisibility and discomfort in health care environments.
Primary Care Provider Roles in Transgender Health
Primary care providers have a role in creating a transgender-inclusive and welcoming environment in the health care setting. Healthcare personnel should be trained to not make assumptions on an individual’s gender identity based on gender markers, patients name and identity or their insurance documents (Reisner, 2012). They should instead use forms of address that are gender neutral until they have requested the patients’ pronoun and self-identified name. The name that patients identifies themselves with should be incorporated in electronic medical records and if possible printed on their safety identifiers like wristbands. The four important areas of transgender interaction in healthcare include patient intake forms, tracking of healthcare outcomes, clinical interaction and patient satisfaction questionnaire (Bruessow & Poteat, 2018). Primary care providers should be culturally appropriate and sensitive when taking the history of transgender patients. Primary care providers should ask their transgender patients’ terms they prefer to describe their body parts, especially when talking about their anatomy. Maintenance of open communication, a respectful language and understanding and use of correct terminology when addressing transgender patients build rapport, puts the patient at ease and helps in obtaining information health risk assessments.
Primary care providers have a role in reframing their thinking about the psychosocial and physiological aspects of the sexual health of transgender patients. There should be a modification of the five ps of sexual history taking, i.e. partners, history, prevention of pregnancy, practices and protection from STIs. A sixth p that represents pleasure should be added to address sexual history taking of a preferred sexual function, interest and consent. Instead of using close-ended questions like ‘do you have sex with women, men or both?’ open-ended questions like ‘tell me about your sex partner’s gender’ are more welcome and are likely to elicit a meaningful and accurate response.
Primary care providers have a role in the management of sexually transmitted infections among transgender patients. Prevention, diagnosis, vaccination, counselling and management of STIs and HIV among transgender patients should be done based on appropriate discussion in context of the patients’ current anatomy (Bruessow & Poteat, 2018). Transgender patients living with HIV/AIDS should be given antiretroviral drugs while those at risk of contracting HIV should be given pre-exposure prophylaxis.
Hormone therapy has been found to improve psychological functioning in transgender individuals according to a recent study by Bruessow and Poteat (2018). In preventing cardiovascular diseases, reducing cardiovascular factors such as tobacco use, hypertension and diabetes have been established as a critical strategy. Hormone therapy for both estrogen and testosterone have been shown to worsen cardiovascular risk factors (Bruessow & Poteat, 2018). Testosterone increases lipid disorders, insulin resistance and increases blood pressure. Estrogen increases the risk of thromboembolic disease. Primary care providers must therefore closely follow transgender individuals who are on testosterone and estrogen regardless of when they started hormonal therapy or the duration they have been undergoing therapy.
Finally, primary care providers have a role in depression management among transgender patients. Social affirmation, just like gender affirmation via surgical procedures and hormones improves patients’ psychological wellbeing and prevents depression. In a recent research study carried out in 2016, it was identified that suicidal ideation rates among transgender individuals was 82% and suicide attempts 40% in the United States (Bruessow & Poteat, 2018). In another study measuring depression rates between transgender and cisgender individuals, it was found that transgender persons who were affirmed and accepted in their social circles were indistinguishable from cisgender individuals based on depression measures. It is therefore important that primary care providers ask transgender patients about family affirmation, acceptance and support when taking their psychosocial history.
References
Bruessow, D., & Poteat, T. (2018). Primary care providersʼ role in transgender healthcare. Journal of the American Academy of Physician Assistants, 31(2), 8–11.doi:10.1097/01.jaa.0000529780.62188.c0
Carabez, R. M., Eliason, M. J., & Martinson, M. (2016). Nursesʼ Knowledge About Transgender Patient Care. Advances in Nursing Science, 39(3), 257–271.doi:10.1097/ans.0000000000000128
Dubin, S. N., Nolan, I. T., Streed Jr, C. G., Greene, R. E., Radix, A. E., & Morrison, S. D. (2018). Transgender health care: improving medical students’ and residents’ training and awareness. Advances in Medical Education and Practice, Volume 9, 377–391.doi:10.2147/amep.s147183
Reisner, S. (2012). Meeting the healthcare needs of transgender people.
Shires, D. A., Stroumsa, D., Jaffee, K. D., & Woodford, M. R. (2018). Primary Care Clinicians’ Willingness to Care for Transgender Patients. The Annals of Family Medicine, 16(6), 555-558.
