New Study, Guidance Affirm Transgender Patients’ Care Needs

Electronic Records Can Be Barrier to or Prompt for Greater Sensitivity

July 24, 2019 05:48 pm News Staff – A recently published study and updated clinical guidance remind physicians that providing primary care to transgender patients is not markedly different from caring for the rest of the population. For one thing, every person in the exam room has a preferred name.

"Many transgender patients identify with a name or gender identity that is different from that assigned at birth," says the study "Primary Care in Transgender Persons," which was published in the June issue of Endocrinology and Metabolism Clinics. A medical practice that adapts its recordkeeping to remind physicians of a patient's correct name and pronoun, the study notes, is moving toward providing essential, competent care for a particularly vulnerable patient population.

"Making electronic health records compliant with a patient's appropriate identifiers ensures improved communication and accurate health documentation for transgender patients and can prevent recurrent errors in identification that may deter patients from seeking care," the study continues.

Kevin Wang, M.D., a Seattle family physician, agrees. In fact, he tells AAFP News, updating a practice's EHR system, or working around a limited one, presents an opportunity to elevate cultural competency while creating a new best practice in the exam room.

Symbol of transgender from tree on wooden table

Wang uses a system that allows input of detailed sexual orientation and gender identity data, and he adds that information to all of his records. "I do it regardless of LGBTQI+ identity," he says. "I do it for all patients regardless of their gender identity and sexual orientation. And I review the information when I prepare for my clinic day."

To gather this information, Wang adds, he sets the rhetorical tone himself.

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"What I often try to do is open the door whenever I can. I'll say, 'Hi, I'm Kevin Wang. I use he/him pronouns. What can I do for you today?' People who are cisgender, they may not pay attention to it. But to someone who is LGBTQI+ and may be afraid to come out, or those who may be questioning their gender identity, it's a hint this person may know what they're talking about."

To determine what sexual orientation and/or gender identity information should be recorded, Wang says he asks open-ended questions such as, "Who are you physically intimate with?" and "What parts of your body do you use for sex?"

"As we build rapport with our patients," Wang says, "it's our responsibility to open the door for them."

That careful conversational approach reflects another key point of the study: establishing the physician's office as a confidential haven from judgment.

"Transgender people often are subject to prejudice within all levels of the health care system, and thus the first step in delivery of trans-competent care is to establish a practice as a safe space from the first point of contact with transgender patients," the study authors note. "Education of all health care and frontline staff on standards of respect toward transgender people is highly recommended, and discourse in the practice should reflect this training continuously."

Physicians and their staff should safeguard patient privacy and "not assume that partners, employers or family members are informed of a patient's gender identity," the study adds, because these factors are about more than just sensitivity.

"Barriers to the alignment of legal documentation with gender identity stand in opposition to the physical and mental health of transgender individuals by restricting freedom of gender expression and increasing potential for harassment," the authors say. "Health care providers are often given the role of gatekeeper for patients seeking changes to their legal identity documents, and thus it is imperative physicians stay abreast of current regulatory matters to provide the best care and guidance for their transgender patients."

And earlier this month, new clinical guidance on caring for transgender patients was published in Annals of Internal Medicine, a tacit acknowledgment that endocrinologists are not the only medical specialists seeing transgender people.

Joshua Safer, M.D., an author of the new guidance and executive director of the Mount Sinai Center for Transgender Medicine and Surgery in New York, N.Y., told STAT July 1 the guidance was written for "your critical mass of general internal medicine people who are primary care providers and also people who are family medicine doctors."

Like the Endocrinology and Metabolism Clinics study, the guidance addresses broad matters of terminology and patient care and offers more detailed context regarding transgender-specific surgeries and associated referrals. Both, says Wang, lend depth to family medicine's treatment of a population estimated to be 1.4 million U.S. adults.

"I think they have good background information, including hormonal and surgical options to help people in their transitions," he says. "And it's important for the transgender community to know we are all working to help people achieve their goals to lead the healthiest lives possible -- even if each health care professional uses a different protocol."

Wang adds that these latest publications further bolster the information in the Academy's LGBT toolkit. He was among the physicians who reviewed the toolkit ahead of its release.

Across these resources, he says, it's important for physicians to remember that transgender patients' health needs must be grounded in strong primary care.

"Yes, there are some very specific health care needs among transgender patients, but diabetes, high blood pressure, flu shots -- you manage those the same as you do for anyone else," Wang says. "If we can make sure to include everybody in our practice, we can provide patient-centered, high-quality care."

"I am grateful the AAFP sees these as important health care and social justice issues. We have physicians and health care providers who are trans- and LGBTQI+-identified, and I am proud our Academy serves to represent our LGBTQI+ family physicians and vulnerable patient populations."

Fresh Perspectives: Protect Transgender and Intersex Patients
(11/20/2018)