Transgender People's Perceptions of Medical Treatment: Implications for Providers and Loved Ones

Introduction

Over the past year, transgender rights have increasingly come under fire, with 2021 being a “record year” for anti-trans legislation (Ronan, 2021). There are currently over 100 bills targeting transgender individuals across 33 states (Krishnakumar, 2021). Many of these bills seek to restrict access to transition care for transgender individuals under the age of 21. In light of this zeitgeist, research on transgender health is particularly relevant. Even in the best circumstances, unless providers have been specifically trained or immersed with transgender patients, it is easy to microaggression without intention. The goal of our study is to highlight some of the concerns expressed by transgender populations, in their words. To do so, in this study we examine qualitative data from transgender participants who share what they wish health care providers knew about treating transgender patients.

Transgender is an umbrella term referring to individuals whose current gender does not align with the gender they were assigned at birth. Gender assignment refers to the process of assigning a child a gender, typically based on the appearance of their external genitalia. This is usually determined at birth by doctors/midwives/birthing assistants. Throughout this paper, the terms “assigned female at birth” (AFAB) and “assigned male at birth” (AMAB) will be used. Currently, there are estimated to be about 1.4 million transgender adults in the United States—or 0.6% of the population (Flores et al., 2016).

Transgender patients have a long history of being mistreated, including not receiving treatment, by health care providers. One of the most infamous examples is Tyra Hunter, a Black transgender woman who died shortly after surviving a car accident in 1995. Upon cutting her clothing and discovering Ms. Hunter was transgender, emergency medical technicians berated her and withdrew care. Had Ms. Hunter been given a blood transfusion and taken to a surgeon, she would have had an 86% chance of surviving (Frothingham, 2015). Instead, Ms. Hunter died and her family won a civil suit where the hospital was held accountable for medical malpractice. Unfortunately, health inequities for transgender people continue to this day (National Institute on Minority Health and Health Disparities, 2016). One-third of participants in the United States Transgender Survey reported having at least one negative experience related to their transgender status when vising health providers in the past year (James et al., 2017). For transgender people of color, these rates are even higher (Kattari et al., 2015).

In the United Kingdom, 166 medical students were surveyed regarding lesbian, gay, bisexual, transgender, queer+ (LGBTQ+) health (Parameshwaran et al., 2017). Although most medical students reported positive attitudes toward the LGBTQ+ community, 84.9% reported a lack of confidence and formal education regarding LGBTQ+ health. Most students stated they would not clarify patient's pronouns or discuss patient LGBTQ+ identity in mental health and/or reproductive settings. Having a positive attitude toward an underserved group is important. However, it does not necessarily translate into the provision of adequate care.

Providers benefit from understanding how transgender patients are uniquely impacted by the health care system. Mental and physical health are often interrelated. Thus, receiving inadequate care may lead to increased distress and health symptoms. Transgender individuals are negatively impacted in a number of ways. There is a lack of insurance coverage for gender affirmation procedures (Khan, 2013) and according to 33% of reviewed insurers, routine reproductive care screening is “gender-specific” (e.g., lack of coverage for pap smears for transgender men; Dowshen et al., 2019). The risk for human immunodeficiency virus is higher, particularly for transgender people of color AMAB (Klein et al., 2020). There is a lower likelihood of preventative cancer screening, particularly for transgender individuals AFAB (Dhillon et al., 2020). There is also a general lack of transgender education among all providers (James et al., 2017). As a result of these disparities, nearly a quarter of transgender individuals avoided seeking health care due to fear of mistreatment (James et al., 2017). Among transgender individuals, a high level of family support is positively correlated with reports of “excellent” or “good” health (James et al., 2017). Thus, mental health providers will benefit from understanding the various health care barriers their transgender patients face, from mental health and other realms, to better support their patients. Mental health providers also have an important role in helping bolster support from loved ones. Knowledge of health care systems is particularly important for mental health providers conducting medical readiness evaluations and/or supporting transgender patients through medical transition.

Materials and Methods

Results

We identified themes that emerged for our three domains of providers (e.g., doctor, mental health provider, other providers). First, 53 of 73 participants responded to the question, “What do you wish your doctor knew about working with transgender patients?” Second, 43 of 73 participants responded to question, “What do you wish your mental health provider knew about working with transgender patients?” Third, 28 out of 73 participants answered, “What do you wish your other provider/s knew about working with transgender patients?”

Examining our data as a whole, we identified four main themes across all three domains of providers. First, participants indicated that they wanted health care providers to have more education on transgender-specific terminology, identities, and experiences. Specifically, one participant noted, “anxiety about being dead named or misgendered in front of a room full of people can prevent trans people from getting routine care.” Another stated, “it took me a long time to find [a gynecologist] that wouldn't say, “your breasts” when I would clearly call it my chest and ask them to do the same. I just want to be respected.”

Second, participants said that they wanted health care providers to not blame their medical transition (most commonly hormone replacement therapy or HRT) for unrelated health concerns. This is also known as “trans broken arm syndrome,” referencing requesting treatment for a broken arm, being asked intrusive questions, and being told that medical transition is the underlying cause. One participant stated, “Overall, I wish doctors knew that I’m just like anyone else. It's OK to touch me. It's OK to talk to me. Most health concerns aren't due to my sex/gender. Just treat me with respect and not like a strange specimen.”

Third, participants said that they wanted health care providers to avoid probing transgender patients about their transitions. A study participant stated, “I just wish they’d ignore my trans status unless it's particularly relevant to their specialty or treatment. They sometimes probe for information relating to my transition that's obviously irrelevant.” Another participant noted, “I wish trans broken arm syndrome wasn't still a thing—too often my unrelated doctor visits had a doctor suggest I stop HRT and see if things fix themselves.”

Fourth, participants said they wanted health care providers to treat transgender patients as individuals instead of a monolith. A participant noted, “Just because you have worked with one trans patient prior does not mean that you know exactly how to treat every trans person. Listen to your patient when they explain that something is off.” Another participant indicated, “Trans people aren't all binary. All trans people's paths are different, even among binary trans people. Not all trans people aim to ‘pass’.”

Discussion

The data collected in our qualitative study reveals four main themes that align with data gathered by the 2015 United States Transgender Survey (James et al., 2017). We discuss each theme in turn. Additionally, we identify recommendations for mental health providers.

In our first theme, participants reported that they wanted providers to receive more education about transgender-specific terminology, identities, and experiences. For providers, this suggests that transgender patients have concerns about the training that providers receive about transgender populations. Education is a critical mechanism to address transgender health inequities. Dubin et al. (2018) conducted an extensive literature review to assess the current state of medical education to identify best practices for transgender health education. They found that 131 papers addressed medical education and transgender health. They concluded that transgender health is a nascent topic in medical schools and that it is primarily comprised of single time point attitude and awareness trainings (Dubin et al., 2018). Kellett and Fitton (2017) indicate that general nursing programs, if they provide transgender training at all, provide approximately 2 h of information about transgender issues. Although the majority of pharmacological programs indicate that it is important to educate students about transgender-related health care, only 41.2% include transgender care in their core curriculum (Eckstein et al., 2019). Thus, the concerns raised by our participants are consistent with the limited training that health professionals currently receive.

Our first theme has specific implications for mental health providers working with transgender individuals and their loved ones. Nontransgender loved ones may be unaware of the general stigma transgender people face as well as common barriers to care. According to Minority Stress Theory, there are three processes by which transgender individuals are impacted by minority stress: discriminatory environmental and external events, expectation of future discrimination, and internalization of prejudice (Hendricks & Testa, 2012). The latter two experiences are not always observable by others. Mental health providers can intervene in this domain by providing psychoeducation to loved ones and connecting with medical providers to advocate for transgender patients. For transgender patients who have recently come out, it may also be beneficial for loved ones to receive separate individual therapy to process their reactions to the news (Bockting et al., 2006). For transgender individuals, it can be stressful to come to terms with their own gender identity and simultaneously believe that they have to support their loved ones. Loved ones may also not be honest about their feelings if they solely share a therapy space with their transgender friend/partner/relative (Zamboni, 2006). For this reason, there are groups and seminars developed for the purpose of educating loved ones and providing them a space to process (Zamboni, 2006).

Knowledge does not always translate into clinical competency. Attitude and skill are also important (Hollenbach et al., 2014) as indicated by our three remaining themes.

In our second theme, our participants indicated that they wanted health care providers to not blame their medical transitions (especially HRT) for unrelated health concerns. This is another area that may be improved with provider education about transgender individuals as well as hormonal functions. Although the majority of medical professionals receive some training on the endocrine system, endocrinology is a medical specialty and requires several years of additional training. Coupled with a general lack of transgender education, it is not surprising that health care providers may blame HRT or medical transitioning for other health concerns. A greater understanding of medical transitioning procedures and their impacts on physical and mental health among providers would benefit their transgender patients.

For mental health providers, it is important to similarly obtain training about the impacts of medical transitioning and HRT. If working in a couple or family, it may be necessary for mental health providers to provide psychoeducation to loved ones. This is a domain in which family dynamics may mirror provider/patient relationships. It is common for nontransgender loved ones to be uninformed about hormones and the benefits of hormone replacement. An uninformed loved one may be more easily swayed by a provider's assessment that medical transition is the underlying cause of illness. This can be particularly impactful for transgender youth and adults who are utilizing family insurance plans or receiving financial assistance for their medical transitions from loved ones. To address this, it is necessary to educate nontransgender loved ones about the effects of medical transition and potentially involve them in the process. Additionally, it may also be helpful for mental health providers to advocate for their transgender patients in medical settings by connecting interprofessionally with their doctors.

In the third theme, participants shared that they wanted health care providers to refrain from probing transgender patients about their transitions. The fact that providers are asking questions is, in and of itself, a good sign. This may be an indication that providers are curious and wish to understand transgender patients. As providers would like to know more about medical transitioning, we recommend that curious providers advocate for transgender training as part of their graduate or professional training or that they pursue it as part of continuing education or as an extracurricular activity.

This is also an important domain for mental health providers to be aware of. In many cases, a letter from a mental health provider is required to access medical transition. This places mental health providers in the challenging role of providing mental health support and simultaneously functioning as “gatekeepers” for transgender patients (Bockting et al., 2006). Although conducting medical readiness evaluations, it is critical that mental health providers are transparent about why they are asking certain questions and that they are mindful not to probe further than necessary. During assessments, mental health providers have a great capacity to inflict harm, particularly when assessing for comorbid mental health conditions and making final decisions. It is crucial for mental health providers to be aware of their biases in this area. Comorbid mental health conditions are not immediate disqualifiers must be carefully assessed in context (Bockting et al., 2006). The primary concern for medical readiness evaluations is whether there is enough (relative) stability in a patient's life to safely begin medical transition, as opposed to whether their transgender identity is “caused by” another mental health concern. It is additionally recommended that therapy and medical readiness evaluations be performed by separate mental health providers to reduce the risk of negative transference (Bockting et al., 2006).

In our fourth theme, participants wanted health care providers to treat them as individuals instead of a monolith. Transgender patients are not all alike and have different health care needs (Sallans, 2016). To address this concern, increased exposure to transgender individuals may improve provider's ability to provide sensitive care to transgender patients. In this instance, education about transgender individuals may not be enough. Although identity-specific education can provide a wonderful foundation, identity-specific education does not necessarily emphasize intragroup differences. Exposure to a variety of transgender patients within a clinical setting (such as during a clinical practicum) may best address this concern.

For mental health providers, emphasizing patient individuality is key. When providing therapy to any patient, it is necessary to understand their unique perspective and their needs to build rapport and better contextualize treatment. This similarly applies to transgender patients, either individually or in a couple/family. Some transgender patients may want their gender identity to be the focus of therapy, others may desire to primarily focus on other concerns and will hardly mention their identity. Similarly, ample supervision and exposure to a variety of transgender patients during clinical training may be the best way to rectify this.

The concerns expressed by our participants are consistent with the training health professionals currently receive. It is imperative to bolster training on transgender-related health care in health care programs. Doing so may help alleviate pressure for transgender patients to educate their providers.

Dubin et al. (2018) raised a few concerns about the existing medical transgender health trainings: (1) transgender health is often combined with sexual orientation minority health (e.g., larger lesbian, gay, and bisexual umbrella), (2) assessments are short term with less research on long-term outcomes, (3) measurement is subject to priming or selection bias because this content is usually an elective rather than part of core curriculum, and (4) patient outcomes are not assessed.

Dubin et al. (2018) make a number of recommendations for medical education that would benefit other health professions. First, they indicate that entities such as accreditation boards and higher education administrators should specifically identify transgender health as a mandatory domain of training and identify specific clinical competencies. It is important to clearly operationalize what this training is so that curricular changes can be tracked and to ensure trainings incorporate best practices. Second, transgender health content should be separated from training under the larger LGBTQ+ umbrella because gender identity is distinct from sexual orientation. They also suggest that the transgender population should be further parsed so that gender-based health inequities (e.g., trans men, trans women, nonbinary people) can be understood more fully. Third, pedagogical interventions should address attitudes and awareness of transgender health inequities to ensure clinical comfort and competency. These interventions must include metrics that assess clinical competencies with transgender populations. Fourth, pedagogical interventions should include information about the social and legal barriers that exist for transgender people without pathologizing transgender identities. It also should highlight, as indicated in our second theme, that not all transgender people are seeking gender-related care.

Our study has limitations that may impact generalizability. A majority of our participants are White transgender men and nonbinary individuals. Transgender women were underrepresented in our sample and these responses may not adequately capture concerns of transgender woman and/or transgender people of color. Transgender People of Color are doubly impacted by their transgender status and their race (Kattari et al., 2015). In the Howard et al. (2019) study, they found that all of their participants reported experiences where their health care providers responded negatively to their race, ethnicity, and/or gender identity and believed that they would have received better care if they were cisgender or White. Thus, transgender people of color likely have additional concerns about provider care and have experiences with discrimination and stigma not reflected in our study. Our sample was also limited to adults living in the United States. Because transgender youth are being targeted by current legislation, their health care experiences may vary from that of transgender adults.

The results of our qualitative research indicate that transgender people continue to be affected by lack of provider training, health care providers blaming medical transition for unrelated health concerns, intrusive questions, and stereotyping. Our paper highlights ways in which mental health providers may help address these concerns for transgender clients. A domain that we highlight as important is familial support because increasing familial support and understanding may be a crucial preventative measure for transgender individuals. Educating loved ones on barriers to care and adverse medical experiences may increase sympathy and support toward transgender loved ones. This may, in turn, improve transgender peoples’ health and willingness to access care.