Addressing the challenges of transgender health care

The social awareness and acceptance of transgender individuals has increased dramatically in the past several years. Todd B. Nippoldt, M.D., a consultant in Endocrinology, Diabetes, Metabolism and Nutrition, at Mayo Clinic in Rochester, Minnesota, says: "The transgender population continues to face major challenges in accessing and obtaining appropriate health care. A disproportionate number of transgender people are uninsured, and 19 percent have been denied care by health care providers. Most health care providers have had little or no formal training in addressing the needs of these patients, which can contribute to the minority stress that members of the transgender community may develop through stigmatization, avoidance, discrimination and prejudice.

"In addition, Lambda Legal reports that 70 percent of transgender individuals have suffered some form of maltreatment at the hands of medical providers, including harassment and violence. Suicide attempts among transgender individuals are extraordinarily high at approximately 25 to 43 percent. The prevalence increases in those who have had a negative experience with a health care professional."

Transgender and Intersex Specialty Care Clinic

The Mayo Clinic Transgender and Intersex Specialty Care Clinic (TISCC) was developed to provide for the mental health, hormonal and surgical needs of transgender patients and those with differences of sexual development (DSD), or intersex. DSD may include discrepancies among sex chromosomes, genitalia, reproductive duct development and gonadal development. DSD may also be referred to as intersex. A variety of underlying conditions can cause DSD, including congenital adrenal hyperplasia, androgen resistance syndrome and many others.

Caroline J. Davidge-Pitts, M.B., Ch.B., Endocrinology, Diabetes, Metabolism and Nutrition at Mayo Clinic in Rochester, Minnesota, explains: "Gender identity can be defined as one's internal sense of being male, female, neither or both. A transgender or gender-nonconforming person has a gender identity that does not conform to sex (chromosomal or anatomical) assigned at birth. Gender identity is quite different from sexual orientation, which includes the gender(s) a person is emotionally or physically attracted to, or both. Being transgender indicates diversity and not pathology.

"The clinical distress that may accompany being transgender (gender dysphoria) is what needs to be evaluated and treated by health professionals. Gender dysphoria may arise as a result of internal conflict associated with incongruence between gender identity and sex assigned at birth. Other contributors include work, school, home and social environments (including issues related to discrimination, relationship abuse and minority stress), and social support from family, peers and friends. The interventions to relieve gender dysphoria are unique for every person. For some, dressing in congruence with their gender identities is enough. For others, hormonal treatment and gender confirmation surgery is necessary."

Patients seen in the Mayo Clinic TISCC are initially evaluated by an endocrinologist and a mental health provider.

Mental health evaluation

All patients with suspected gender dysphoria will require evaluation by a trained mental health professional to establish the diagnosis, assess comorbid psychiatric diagnoses and evaluate social support structures.

The evaluation may include a psychologist, psychiatrist or licensed independent clinical social worker. Patients with gender dysphoria may have coexisting mental health conditions, such as autism spectrum disorder, body dysmorphic disorder or eating disorders, which should be treated with standard psychological therapy and other appropriate interventions.

Dr. Nippoldt outlines: "The individual's needs and desires are identified during initial visits and a plan is formulated. Depending on the patient's needs, referral to surgical or other specialties can occur, specifically including voice therapy; preventive gynecology care for transgender men; mental health counseling for patients, their families or both; and assistance with school, social and legal issues.

"In addition to the care provided in the TISCC, we are striving to provide competent and sensitive care for transgender and intersex patients at all Mayo Clinic campuses. Efforts include sensitivity training for staff, finding an electronic record and intake form solution for gender declaration, and providing a safe and welcoming environment, such as unisex restroom options, in all areas at Mayo Clinic.

"To date, we are caring for over 100 unique patients. Fifty-seven percent are local to Olmsted County, 22 percent are regional, 20 percent are national, and 1 percent is international. Forty-nine percent of patients are under age 30, and 8 percent are over age 60."

Dr. Davidge-Pitts notes: "Despite the multiple difficulties these patients face, each individual shows great determination, resilience and resourcefulness. At Mayo Clinic, we continue to promote advocacy for transgender patients and provide a safe, competent environment for their care."

Top 10 tips to become a transgender-friendly and competent provider

  1. If you have a question about your patient's gender nonconformity, do not be afraid to ask.
  2. Ask patients their preferred names and pronouns and use them during the encounter. If you make a mistake, apologize and continue.
  3. The preferred name and pronoun will often differ from what is in the medical record as many transgender people have not changed their names and genders legally. Ask the patient if you can use this preferred name and pronoun in the medical record. Remember that many patients may have access to their medical records, and therefore your sensitivity should be reflected in the notes.
  4. If possible, intake forms should include an option to disclose transgender status.
  5. Sensitivity training should be required for all staff members who interact with the patient. The Center of Excellence for Transgender Health at the University of California, San Francisco, has published a helpful online course called Acknowledging Gender and Sex. The course is available at http://transhealth.ucsf.edu/video/story.html.
  6. Public restrooms should include a unisex option.
  7. Have local transgender resources, such as local transgender support groups, available to help guide the patient if needed.
  8. Include transgender health topics as part of your medical school and training programs to increase the competence of future leaders in transgender health care.
  9. Provide faculty development in transgender health. Many national and international meetings now include transgender health topics, and more online resources are becoming more available.
  10. Phone a friend: Be aware of qualified providers in your area that you can contact about transgender-related questions.