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Massachusetts is drafting rules that will define the transgender services insurers will be required to cover. The Association of American Medical Colleges (AAMC) has just released guidance on training doctors to treat lesbian, gay, transgender and gender nonconforming patients. And Boston University Medical School has what Dr. Joshua Safer, a professor there, says is the nation's first transgender medicine curriculum focused on the biology of gender identity.
Like I said: brand new stuff. But what do all these new rules mean for the doctor or nurse, in an examination room, who meets their first transgender or gender-fluid patient?
Here's some advice from Dr. Safer, associate professor of medicine at Boston University Medical School, and Dr. Jennifer Potter, associate professor of medicine at Harvard Medical School. (Dr. Potter is a co-author of the AAMC guidelines.)
1) When greeting a new patient, or one you haven't seen for some time, you cannot assume anything about their gender identity based on the masculinity or femininity of their appearance or the timbre of their voice. To avoid making mistakes, ask each new patient how they identify, what name they prefer to be called and what pronouns they want you to use. Note: Pronouns may be male (he), female (she), they or another gender-neutral option.
2) Consider collecting information about gender identity when you register patients, when they call to book an appointment and when they check in for a visit. This will help you identify patients and let them know they are welcome before you meet. Be sure to train office staff to demonstrate openness and respect. You can review sample registration questions here.
3) Apologize promptly if you make a mistake that causes offense to a patient. Many of us will use the wrong pronoun, for example. Or your office staff may call George into the examination room, even though George is now Georgina and presents as a woman. Transmen still need pap smears but may feel out of place in an OB/GYN office waiting room.
If your patient is offended, your apology can be a healing experience for a person who has predominantly encountered insensitive providers in the past.
4) Having such conversations and treating transgender patients or patients who do not identify as male or female may be uncomfortable for you. That is a common reaction. We all feel uncomfortable when venturing into unfamiliar territory for the first time. Use each encounter as an opportunity for personal and professional growth.
5) Always screen for gender dysphoria, but be aware that many people on the transgender spectrum have a positive self-identity and do not seek or need psychological support. However, the experience of discrimination, which unfortunately remains all too common, especially for individuals who transition after puberty and do not easily “pass," can lead to gender dysphoria in some cases. You might suggest that your patient look for a counselor through the World Professional Association for Transgender Health (WPATH) or through the Gay and Lesbian Medical Association.
6) Some of you may wonder if you should recommend counseling instead of helping your patient change their body to fit their gender. A growing body of research says no. Your patient's gender identity is rooted in biology. It is not a psychological choice. We don't understand why there is a disconnect between gender identity and your patient's body parts, but more and more research shows improvements in the mental well being of transgender individuals who change their external appearance to match their feelings inside.
7) You may also have questions about whether transgender identification is just a phase. Again, the latest research, while limited, says no, except in the case of prepubescent children. Consensus among doctors who treat transgender patients is that gender identity is established and does not change after puberty. If a child who was identified at birth as a boy switches genders during or after puberty, the new gender identity is generally fixed. This is true for adults as well.
The challenge, for children, is when to begin hormone blockers that will buy the child and their family some time before they must decide which gender to proceed with in puberty. You may want to refer a transgender or gender nonconforming child to a clinic that specializes in this care.
8) Be aware that some people on the transgender spectrum do not choose to alter their physical presentation to match their gender identity. Others may use or be interested in non-medical changes (e.g., breast binding, genital tucking, silicone injections), medical (cross-sex hormones) or surgical interventions. Be sure to evaluate each patient as an individual, by asking what they have done so far and/or what they are interested in doing in the future.
9) Your role in initiating cross-hormone therapy for adults can be pretty straightforward. A number of resources are available to guide such care and offer recommendations regarding clinical monitoring for patients on hormones.
10) Refrain from voyeuristic and intrusive genital examinations if not relevant to the patient’s presenting concerns. When such an exam is necessary, be sensitive to the fact that some people on the transgender spectrum may be uncomfortable having parts of their body examined that do not match their gender identity. Ask what words they prefer to reference body parts (e.g., gender-neutral terms such as pelvic opening as opposed to vagina) and be sure to explain what the exam entails, why you want to do it, and to obtain permission before proceeding.
11) Don’t forget about important prevention and health promotion. Patients on the transgender spectrum should have screening done as appropriate to the anatomy that is present (e.g., a transgender man with a cervix should have Pap tests). Vaccinations should be done as recommended by the ACIP. Just like anybody else, transgender individuals may have any sexual orientation and engage in diverse sexual behaviors that may change over time. Always ask and provide screening for sexually transmitted infections and contraception as needed.
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