Podcast: Transgender-inclusive health care
Transcript
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Kirsten Patrick: People who are transgender face many unique barriers and challenges in the construct of our current society and health system. Because of this, they may feel that receiving proper care from a healthcare provider might be challenging as well. But all patients deserve the same high level of respect and care and it is up to us as health care providers to ensure that they receive the care to which they're entitled. I'm Dr. Kirsten Patrick, deputy editor for the Canadian Medical Association Journal. Today I'm speaking with two authors of a practice article published in CMAJ, entitled Five Things to know about Transgender Inclusive Care. Professor Alex Abramovich is an independent scientist at the Institute for Mental Health Policy Research at the Center for Addiction and Mental Health, and an assistant professor at the Dalla Lana School of Public Health at the University of Toronto. Dr. June Lam is a fifth year psychiatry resident physician and also pursuing his master's degree in clinical epidemiology and healthcare research at the University of Toronto. They are joining me today to discuss transgender inclusive care. Welcome to both of you.
Alex Abramovich: Thank you.
Kirsten Patrick: Alex, what exactly does the word transgender refer to?
Alex Abramovich: So transgender or trans is a term used to describe people whose gender identity does not align with the sex that they were assigned at birth. So for example, someone who was assigned female at birth who identifies as a man would be a trans man. Whereas someone who was assigned male at birth, who identifies as a woman is a trans woman. And because there are so many different ways that people can identify and express their gender, the term gender expansive is also an important term. And this term refers to gender identities and expressions that are not strictly masculine or feminine. So this would include non binary, gender queer and gender fluid.
Kirsten Patrick: So let's say a new transgender patient comes into a doctor's office. What's the most respectful way for a physician to ask about the patient's gender and preferences.
June Lam I think that when we register a patient to the clinic, it would be helpful to have diverse gender identity options on the registration forms. For example, including trans man, trans woman, gender, non binary and two spirit, and the option to write out the name that they go by, which may not be the same as their legal name or the name on their health card. And then when you first meet the patient in the waiting room, rather than addressing them as Mr. or Mrs. so and so you could use their identifiers, first name on the registration form. And once they're in your office, you can then verify their full name and ask what pronouns they go by. I actually would suggest making a note in the chart of the patient's name and pronouns to flag it for other providers. As we mentioned, the legal name and the sex on a person's health insurance card can often be wrong, so it's best not to go by those indicators. It also would be helpful to label any individual single style washrooms as all gender washrooms to make the clinic more trans inclusive. Now to make these changes to the clinics, culture and practices, I think it would be important to have discussions with and seek out education for the clinic team around trans health. I know we'll have some questions later on in the podcast about the available resources. So we'll definitely talk about some of those resources that are available for the purpose of educating healthcare providers on trans inclusive care.
Kirsten Patrick: Alex, do all trans patients wish to transition to the sex that they identify with.
Alex Abramovich: So no, not every trans person medically transitions, which refers to hormones and gender affirming surgery. So some trans people will only socially transition which refers to changing their name, their pronouns, and their gender expression or the way that they dress and express their gender to the world. A common question that trans people tend to get asked is whether or not they have had the surgery or if the surgery was painful, which is why I think it's really important to note that there are many different types of gender affirming surgeries. But a trans person doesn't necessarily need to medically transition in order for their identity to be valid. So for example, if a person tells you that they identify as a man or a woman, they do not need to have surgery or be on hormones for this to be real or valid. Some trans patients will want to medically transition either through surgeries or through hormone therapy or both. And this would be in...for their body to be more consistent with their gender identity. I'd also like to note that there are many different ways that people identify and express their gender. So for example, you may have patients who identify with both masculinity and femininity. You may have patients who identify as male, but were assigned female at birth, and they've decided to not undergo any gender affirming surgeries. I think it's really important and helpful to be knowledgeable about the range of gender identities, while also being open minded about gender identities and gender expressions that might be new to you.
Kirsten Patrick: How can primary care physicians deliver proper affirming health care and guidance?
June Lam I think that's a great question. I think the first important point that I want to stress is that the majority of general health care needs for trans people can be attended to in the primary care setting. The Lancet published a series of articles on Transgender Health in two thousand sixteen. Some of which discussed trans inclusive clinical care, and how trans patients health care needs can be met in the primary care setting. These can be helpful articles for primary care physicians to refer to. There are some indications for referral to a specialist such as to a surgeon for gender affirming surgery, but most other health care services can be provided by the primary care team. The trans post study which investigated the health and well being of trans individuals living in Ontario, through surveys administered to 433 trans participants, found that approximately half of the respondents reported feelings of discomfort discussing trans health needs with their physician. They experienced discriminatory behaviour from a family doctor at least once, including refusal of care, or refusal to examine specific body parts being ridiculed, and the use of demeaning language. Negative experiences with a healthcare provider like these examples, obviously impact the trans patients likelihood of seeking medical care. So keeping this in mind, we will recommend seeking out educational opportunities for the entire healthcare team to learn more about trans inclusive care so that competent and comprehensive care can be provided. These types of educational opportunities and trainings can often be arranged through local LGBTQ's organizations, or provincial organizations like Rainbow Health Ontario, which offers comprehensive trans inclusion training to health care providers across Ontario, with expert support as needed. I think that primary care physicians can absolutely provide comprehensive care for their trans patients, including prescribing hormone therapy for those who choose to have it.
Kirsten Patrick: Can you expand a little bit on the guidelines and resources that are available to generalist physicians?
Alex Abramovich: Yeah, so there are numerous guidelines and resources that are available, many of which are available online. So June had mentioned the Lancet, which had published a series specifically on trans health in 2016. And this provided clinical care guidelines. Then we have the World Professional Association for Transgender Health, which is also known as WPATH which are an international guidelines on providing trans inclusive care. And they offer standard of care guidelines that are freely available online as well. Dr. Amy Bourns from Sherbourne Health in Toronto, has written an extensive clinical guidelines and protocols document specifically for hormone therapy and primary health care for trans clients. This is freely available through the Sherbourne Health website. There are also local mentorship programs that physicians and other providers can call into, to seek out guidance on specific questions or cases regarding providing trans care. So for example, in Ontario, there's a weekly trans health mentorship call. And this is through RHO, Rainbow Health Ontario. In BC and the Yukon there's a resource referred to as the RACE line for family physicians, to consult specialists, including specialists in trans medicine. And then the articles that are listed in the reference section of our CMAJ practice article includes several clinical and research resources for trans health, including specific articles on cancer screening, fertility, as well as long term hormonal treatment for trans people as well.
Kirsten Patrick: Okay, well, that's a great body of work out there that generalist physicians can consult. When it comes to routine testing, such as a pap test, what are some things to keep in mind?
June Lam Well, we found and referenced in our article, a comprehensive literature review by Gatos looking at cervical cancer screening in trans men. We definitely recommend family doctors take a look at that paper when they have a chance. In one study, 74% of trans gender women had up to date pap testing compared to only 64 of trans men. In addition, trans men had eight times more inadequate pap testing, which can be related to testosterone-induced physical changes, and also exam discomfort for the provider and patient. Based on the articles reviewed and summarized by Gatos, we would recommend keeping trans men on the recall list for regular cervical screening and training your clinic providers in trans inclusive pap testing. This trans inclusive pap testing can include baseline pap testing before the patient starts testosterone, short term topical estrogen prior to pap testing, topical lidocaine use of a pediatric or long, narrow speculum and making sure trends men know that test results may be inadequate, of course, communication with the patient that prioritizes their autonomy and dignity is crucial in this process.
Kirsten Patrick: So you mentioned in your article, June that it's important for physicians to discuss fertility preservation before starting gender affirming hormone therapy. Can you tell us about that, and what does that involve?
June Lam Well, I want to emphasize that we're not fertility experts, but the articles we've reviewed highlight how hormone therapy has gonadal effects that reduce fertility, even though the effects are likely partially reversible. So we think that patients will need to know this prior to taking hormone therapy as part of informed consent. In one study by Chen et al, which we referenced in our practice article, only 12% of trans adolescents were seen in consultation for fertility preservation. Prior to starting hormone therapy, we recommend discussions around fertility preservation with trans individuals, before they start hormone therapy that way. If they want, they can be referred to a fertility specialists for gamete storage and other fertility options prior to starting their hormone therapy.
Kirsten Patrick: We're actually publishing a cluster of articles on trans health at the same time, and one of the articles that I've been handling is a review on treating adolescents with gender dysphoria, who or who identify as trans. One of the issues that they talk about there is the issue of fertility preservation. And the sense that they get from the limited evidence that's available is that this isn't being routinely offered to adolescents who wish to transition. Is that just that we just don't have enough evidence? Or is it something that we're not thinking about enough currently?
June Lam I think that it makes sense to offer fertility preservation options for adolescents who choose to start hormone therapy, I think there is some evidence to support this. And there can be more evidence. I think it's also common, it makes common sense that we offer that for our patients. I think the issue may be that it's not necessarily top of mind for family physicians or other physicians who are treating trans and gender expansive clients. And I think that might be the reason that it's not offered routinely. I think the important thing is that there are fertility preservation clinics that are available, at least in Toronto, and I would imagine in other parts of the country as well. And so I think, hopefully, with our article, part of the purpose of this article is to be able to provide some education for family physicians in different parts of the country that may not be so aware of the importance of discussing fertility preservation. So that when they are taking care of a trans and gender expansive clients, that they think about this and then offer that to them.
Kirsten Patrick: It's good that you've highlighted this. I imagine that it's not necessarily top of mind for adolescents themselves, when they're, when they're thinking about whether to transition or not, or how they want to transition at quite a young age. So I was talking in my previous question, I talked about this review on adolescence with gender dysphoria. And now what is gender dysphoria?
Alex Abramovich: That's a very important question. So gender dysphoria refers to strong feelings of incongruence between one's gender identity and the sex that they were assigned at birth. Individuals experiencing gender dysphoria will often feel like they're like the gender that they identify with does not match with their body or their birth name, or the pronouns that people refer to them by. The distress and functional difficulties that can result from this incongruence is referred to as gender dysphoria. So depending on the province or territory a person lives in, the health insurance coverage for gender affirming surgery may require that a health provider diagnose the patient with gender dysphoria. Physicians often refer to specialists in trans health or psychiatrist to provide a diagnosis of gender dysphoria, but in fact, any physician can diagnose gender dysphoria with some education and support, including through some of the resources that I mentioned earlier. Physicians being able to diagnose gender dysphoria, prescribe hormone therapy refer patients who want surgery and provide comprehensive primary care to trans patients is important. Because there are limited specialists available in many parts of the country. So we can't really rely on on specialists for all of these reasons. And the long waitlist to get appropriate treatment that trans people need and deserve, contributes to the high rates of mental illness and the suicide burden experienced by the trans population.
Kirsten Patrick: In my reading around this topic, and I'm by no means an expert, I, I find the word dysphoria, a little bit challenging to get my head around, because I imagine that for some people, there is a substantial amount of distress in the disconnect between the gender that you identify with, and the sex that you were assigned at birth, but for others, perhaps there's not so much distress, perhaps you're just really happy identifying with a different gender or with no gender. So this may be a very silly question, but is gender dysphoria something that resolves the distress that a person feels is resolved through transitioning or coming to terms with the the gender identity that they've chosen?
Alex Abramovich: So I don't think it's a silly question, first of all, and so I'm not sure if I'm going to be answering this correctly. But so basically, you know, not every trans person obviously experiences gender dysphoria, like you said, there are going to be people who identify as trans, who feel absolutely fine in their body, they perhaps feel that they don't have any sort of dysphoria based on their body or their name or the pronouns that they go by. But oftentimes, people I would say more so do experience some sort of gender dysphoria when it comes to either their body, or having somebody called them by the wrong name, so by their birth name, or by the wrong pronouns. So you know, being misgendered each day could result in this type of gender dysphoria. And, yeah, I mean, one of the ways to treat gender dysphoria, one of the main ways would be through helping a person so that so that their gender identity will align with their, with their body, perhaps. And so that could be either through medically transitioning either through perhaps being on hormones or going through gender affirming surgeries, that would help things line up. Uhm yeah.
Kirsten Patrick: Yeah, that that's a great answer, actually, I mean, just for me, I sort of see the idea of dysphoria as existing in part because of non acceptance or stigma. I understand that gender dysphoria is being changed from a mental health diagnosis to a sexual health diagnosis, which I see as a really positive thing, just normalizing the experience rather than pathologizing it.
Alex Abramovich: Yeah, it's such a complicated thing. Because I mean, perhaps that is one way to, for us to move away from this type of pathologize-ation, however, I feel that there's, you know, there's still so many issues around trans people feeling pathologized based on their identity, the fact that it's even in the DSM at all, you know, or the fact that you have to have this diagnosis. So, yeah, it's really complicated. But then on the other hand, feeling like you need to have the diagnosis in order to have your treatment covered by overhead, or by you know, your health insurance.
Kirsten Patrick: Yeah. Should physicians be on the lookout for mental illness and suicidality? More so among transgender patients?
June Lam I think this is a really important question and a question I particularly am passionate about and care about, as a psychiatry resident and mental health researcher. So gender identity based stigma and discrimination, which we just talked a bit about, negatively impact the mental health of trans people, leading to high rates of mental health issues, including depression, anxiety and suicidality. One of the Lancet articles on Transgender Health by Winter et al describes the mental health burden for trans people internationally. An Australian study found that 56% of trans people were diagnosed with depression and 38% with anxiety. A US study found 41% of trans participants in that study had attempted suicide, compared to 1.6% in the general population. A Swedish study found that trans people had increased rates of death by suicide. This is very consistent with findings from the trans post study in Ontario, which found that over 60% of participants had active depressive symptoms cross sectionally and 43% had attempted suicide. This is compared to the 11% lifetime prevalence of major depressive disorder, and 3.5% lifetime prevalence of suicide attempts in the general Canadian population. The Winter et al Lancet article describes how this psychiatric burden is due to discrimination, violence and abuse, and transphobia that trans people face on a daily basis. In the clinic office. I think that you can apply this knowledge by checking in with your trans and gender expansive patients about their mental health and assessing for suicidality. You can validate that trans and gender expansive people face tremendous oppression, discrimination and transphobia, which can often lead to mental illness and suicidality. And so you want to take the time as their physician to check in with how they're doing and see if there's anything you can do to support their mental health. I think this approach can normalize the importance of assessing for mental illness and suicidality, while also acknowledging that there are very often symptoms of experiencing the significant discrimination, violence, and transphobia that trans and gender expansive people experience every day.
Kirsten Patrick: So Alex, what is the take home message that you would like physicians to have from your article and from this podcast?
Alex Abramovich: So our main key message to physicians is that you might not think that you need to offer trans inclusive care, because maybe you don't think that you have any trans patients. However, you're likely already treating trans people and you'd likely have trans patients. The questions that are asked on intake and registration forms and surveys, they truly matter. Not only can these questions help us collect important data, and understand the population that we're serving, but they can also help people feel welcome and safe. The majority of healthcare needs for trans patients can be comprehensively addressed through primary health care. Trans inclusive care saves lives because trans people get the care they need sooner rather than later. And we really hope that our article can help physicians feel more confident and feel empowered to seek out further knowledge and provide trans inclusive care for your patients.
Kirsten Patrick: Thank you. It's been so great talking to you both today. I've learned a lot.
June Lam Thank you so much.
Alex Abramovich: Thank you very much.
Kirsten Patrick: I've been speaking with Prof. Alex Abramovich, scientist at the Center for Addiction and Mental Health in Toronto, and an assistant professor at the University of Toronto and Dr. June Lam fifth year psychiatry resident and master's student at the University of Toronto. To read the Practice article they co-authored, visit cmaj.ca. If you've enjoyed listening to this podcast, we encourage you to subscribe to CMAJ Podcasts on Apple podcasts or your favorite app. While you're there, you can browse and listen to our many past episodes, and you can leave us a rating. I'm Dr. Kirsten Patrick, deputy editor for CMAJ. Thank you for listening.