Gender-affirming primary care

ABSTRACT: Transgender, gender-diverse, and Two-Spirit people report barriers to accessing health care, and lower rates of health screening, which results in unaddressed health needs. Barriers to care include the knowledge level and attitudes of care providers (actual or perceived), and a lack of culturally appropriate health information. Health care providers can take a number of steps toward improving health care and care experiences for gender-diverse people, including children and youth, by accessing educational resources on gender diversity; creating a safe clinic environment; using respectful and inclusive language, especially when taking a medical history; providing gender-affirming physical exams; learning from mistakes, which are inevitable; assessing readiness for gender-affirming hormone therapy and initiating treatment; and facilitating access to gender-affirming surgeries.


By accessing various educational resources and support from Trans Care BC, primary care providers can develop the knowledge and skills needed to create a safe, respectful clinic environment and better health care experiences for transgender, gender-diverse, and Two-Spirit people.


Transgender, gender-diverse, and Two-Spirit people who access gender-affirming care have elevated rates of a number of health conditions, including depression, HIV, and substance use.[1-4] They are also disproportionately affected by poverty, unemployment, homelessness, harassment, and violence.[2,4] Gender-diverse people report barriers to accessing health care, and lower rates of health screening, which results in unaddressed health needs.[4-8] Barriers to care include the knowledge level and attitudes of care providers, actual or perceived, and a lack of culturally appropriate health information. Accessing gender-affirming care has profound benefits in the lives of patients, including improved social and occupational function. Health care providers can reduce barriers to care and make positive contributions to the health and well-being of gender-diverse people.

Improving access to care

Accessibility to and quality of gender-affirming primary care can be improved by establishing a safe, welcoming, respectful environment and using affirming and inclusive language. Having or knowing where to access information regarding medical and surgical interventions is also very helpful. Guidelines regarding physical exams and general health screening are available and include special considerations for caring for children and youth.

Creating a safe, affirming clinic environment

Simple actions can be taken to make clinics feel safe and respectful to patients who seek gender-affirming care. Training all patient-facing staff to interact respectfully with gender-diverse patients is a good start. This can easily be achieved by supporting staff to take online courses that teach foundational concepts about gender diversity and describe effective strategies for creating more accessible and gender-affirming services [Box 1]. Small but significant changes can be made to the clinic’s physical space to create a welcoming and affirming environment. This can include displaying signs, such as a sticker of a pride flag, and inclusive health promotional material, and taking steps to ensure that patients can access the washroom without anxiety or the risk of harassment. For example, signs can be posted at single-stall washrooms to indicate they are gender neutral, and signs posted at multistall washrooms can indicate that gender-diverse people are welcome [Box 2]. Intake forms and electronic medical records can also be used to create safe clinical encounters. For instance, adding fields for “Name Used” and “Pronoun” on intake forms signals to patients that the clinic is knowledgeable about gender diversity, and it may contribute toward building patient-provider rapport. Additionally, each clinic can display the patient’s correct name and pronouns in the electronic medical record to help front-desk staff and clinicians provide safe and affirming care.

Using respectful, affirming language

Interactions with patients can be made more affirming by using language that clearly signals respect for diverse identities, bodies, and relationships [Box 3]. This is especially important when taking a medical history. For example, questions can be framed in ways that make no assumptions about gender, gender expression, or gender-related goals. Patients can be asked if there is anything about their gender or sexual health that they would like to discuss. It can be helpful to ask what steps have been taken to affirm their gender and related future goals. When discussing care needs and illness prevention, consider the patient’s anatomy, although there is no need to focus on gender if it is not relevant to the presenting concern.

Learning from mistakes

Mistakes are inevitable. Learn from them and incorporate that learning into future practice to improve care. To learn more about what you can do if you make a mistake in your choice of words, names, or pronouns, visit Trans Care BC’s resource “Making Mistakes and Correcting Them” [Box 3].

Providing gender-affirming physical exams

Many patients report significant body dysphoria, physical and emotional discomfort during physical examination, inadequate screening, and low service expectations. Physicians can address these health inequities by using a gender-affirming approach to reduce discomfort and increase the chances of a positive experience. This includes developing rapport before examining sensitive areas, whenever possible, providing a rationale for why you recommend a particular exam, using affirming or neutral terms for body parts or asking what terms the person prefers, and examining only those areas that are relevant to the situation. For concrete examples on how to provide a gender-affirming physical exam, visit www.transcarebc.ca.

Prescribing gender-affirming hormones

Because primary care providers often have in-depth understanding of their patients’ medical and mental health background and the greater context of their lives and support networks, they are well positioned to assess a patient’s readiness for gender-affirming hormone therapy and initiate treatment. Providers can explore the experience and effects of gender incongruence with their patients and discuss affirmation goals and treatment options. These discussions enable providers to comprehensively assess a patient’s capacity to consent to treatment. For patients with more complex care needs—for example, patients with endocrine conditions or who request medications or dosing that is outside of existing guidelines—referral or consultation with an endocrinologist can be useful.

Guidelines and clinical resources on how to initiate, titrate, and monitor gender-affirming hormone therapy are available. For example, Trans Care BC’s Primary Care Toolkit (https://bit.ly/3gKp7Fi) is an excellent resource for clinicians who are new to this area; it outlines the process of hormone initiation, provides a checklist for readiness assessment, and gives suggestions for starting doses, titration, lab monitoring, and follow up.

Accessing gender-affirming surgeries

Some gender-diverse people benefit from gender-affirming surgery. Primary care providers play an important role in helping patients access surgery in a timely way. This includes connecting patients with a qualified assessor who conducts surgical readiness assessments, and linking patients to resources and peer support to help with the logistical and emotional aspects of preparing for surgery. Providers can work with patients to stabilize any physical or mental health conditions to ensure they do not pose barriers to accessing surgery, and may help provide postoperative care and liaise with surgeons as needed. To learn more about gender-affirming surgeries in BC, including how to become a qualified assessor, visit www.transcarebc.ca.

Applying health screening guidelines

Health screening guidelines apply to gender-diverse patients, but additional considerations may be necessary depending on a patient’s hormone therapy or surgical history. Some programs, such as BC Cancer Breast Screening, have updated their guidelines to be inclusive of patients who have had gender-affirming medical or surgical interventions. A summary of health screening recommendations, including for sexual health, is provided in Trans Care BC’s Primary Care Toolkit (https://bit.ly/3gKp7Fi).

Providing care to gender-diverse children and youth

Providing gender-affirming care to children and youth includes addressing a range of health needs. While only a portion of gender-diverse children and youth will pursue gender-affirming interventions, all young people and their families will benefit from working with a gender-affirming primary care provider who can be an important source of information, support, and advocacy. Receiving gender-affirming care can have significant health benefits for gender-diverse youth.[4] Depending on the situation, providers may take an active role in treatment and monitoring, or they may work collaboratively with pediatricians, pediatric endocrinologists, and adolescent psychiatrists. In all cases, providers can deliver care that is affirming and supportive, and they can help nurture and sustain relationships between youth and their families.

Summary

With access to ongoing support from Trans Care BC and other clinical resources [Box 4], primary care providers can easily develop the knowledge, skills, and experience needed to provide better health care experiences for gender-diverse people.

Competing interests

Dr Townsend is medical director of Trans Care BC.


This article has been peer reviewed.

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References

1.    Witcomb GL, Bouman WP, Claes L, et al. Levels of depression in transgender people and its predictors: Results of a large matched control study with transgender people accessing clinical services. J Affect Disord 2018;235:308-315.

2.    World Health Organization. Policy brief: Transgender people and HIV. 2015. Accessed 22 August 2021. http://apps.who.int/iris/bitstream/handle/10665/179517/WHO_HIV_2015.17_eng.pdf.

3.    Scheim AI, Bauer GR, Shokoohi M. Drug use among transgender people in Ontario, Canada: Disparities and associations with social exclusion. Addict Behav 2017;72:151-158.

4.    Taylor AB, Chan A, Hall SL, et al. Being safe, being me 2019: Results of the Canadian Trans and Non-binary Youth Health Survey. Vancouver, BC: University of British Columbia, Stigma and Resilience among Vulnerable Youth Centre, 2020. Accessed 4 September 2020. https://apsc-saravyc.sites.olt.ubc.ca/files/2020/03/Being-Safe-Being-Me-2019_SARAVYC_ENG.pdf.

5.    Giblon R, Bauer GR. Health care availability, quality, and unmet need: A comparison of transgender and cisgender residents of Ontario, Canada. BMC Health Serv Res 2017; 283.

6.    Scheim AI, Zong X, Giblon R, Bauer GR. Disparities in access to family physicians among transgender people in Ontario, Canada. Int J Transgend 2017;18:343-352.

7.    Bauer GR, Zong X, Scheim AI, et al. Factors impacting transgender patients’ discomfort with their family physicians: A respondent-driven sampling study. PLoS One 2015;10:e0145046.

8.    Scheim A, Bauer G. Breast and cervical cancer screening among trans Ontarians: A report prepared for the Screening Saves Lives Program of the Canadian Cancer Society. Trans PULSE Project. 4 November 2013. www.transpulseproject.ca/research/breast-and-cervical-cancer-screening-among-trans-ontarians.


Dr Cosio is a family physician in Prince George, physician lead at the Northern Gender Clinic, and clinical instructor in the Department of Family Medicine, University of British Columbia. Ms Goldman is a nurse educator at Trans Care BC and an instructor in the Perinatal Specialty Nursing Program at the British Columbia Institute of Technology, and provides gender-affirming nursing care in a family practice clinic in Vancouver. Dr Mackenzie is a family physician in Chilliwack, physician lead of the Chilliwack Gender Care Clinic, and clinical instructor in the Department of Family Medicine, UBC. Dr Townsend is a family physician in Vancouver, medical director of Trans Care BC, and clinical assistant professor in the Department of Family Medicine, UBC.

Ingrid Cosio, MD, CCFP, Lauren Goldman, BScN, RNC, Megan MacKenzie, MD, CCFP, Marria Townsend, MD, CCFP. Gender-affirming primary care. BCMJ, Vol. 64, No. 1, January, February, 2022, Page(s) - Clinical Articles.



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