By Ravi Iyengar, MD
Transgender and gender-diverse individuals are not a novel concept, and the idea of existing beyond the binary of female or male is centuries old. However, this population has notoriously faced discrimination, verbal and physical abuse, some of which still continues in the health care community.
A 2015 national survey of almost 28,000 transgender and gender-diverse individuals demonstrated that a third had a negative experience with a health care provider and a quarter of patients have had to educate their own providers about care.
When we look at the complexly layered barriers to care, we have to ask ourselves — would these numbers suffice for any other population seeking care? Encouragingly, there have been great strides within the past decade driving greater advocacy for and research surrounding gender-affirming care.
More societal organizations have recognized the need for better access and a more organized approach to care, as patients continue to struggle navigating systems that were not built for nor are friendly to them.
Appropriate assessment of risk
Many people will ask what gender affirmation is, and why do we treat it. Gender identity is unique to the individual, and feeling rooted in that space can happen on various levels. For some, outward gender expression and use of pronouns can be enough. For others, development of secondary sex characteristics of the identified gender through hormone therapy and/or surgery is needed.
There is no “correct” way to identify, and often, when transitioning patients are still expected to identify within the binary of male and female — this should not be held as a standard. What we do know is that when one’s deep, inherent identity differs from the sex assigned at birth, significant distress can develop.
Recently, survey results published in Pediatrics demonstrated the significantly higher suicidal behavior in transgender, nonbinary and queer adolescents compared to their cisgender counterparts. When providers are concerned about the dangers of gender-affirming therapies, an important question to ask is what is the danger of not treating?
Concerns regarding adverse effects of hormone therapy have mostly been extrapolated from cisgender data, and, combined with lack of education, have understandably caused a degree of hesitancy and willingness to treat.
The bottom line is that hormone therapy appears safe and effective when administered and used appropriately. Certainly risk does exist and can be complicated by any predisposing medical history, but observational data suggest it is less than previously thought. Further, long-term studies are needed to truly determine how much risk is involved.
Care training helps
The vast majority of health care professionals have never received training on gender-affirming care. Fortunately, this is increasingly being recognized as a deficit, with medical trainees now seeking out and requesting appropriate training.
Through the efforts of Hale Thompson, PhD, assistant professor in the Department of Psychiatry; Neeral Sheth, DO, a psychiatrist; and Shay Phillips, an assessment coordinator, Rush has already developed a curriculum for second-year medical students that rolled out earlier this year.
Systemwide sensitivity training is also available through the efforts of Jay Behel, PhD, associate dean of Student Affairs at Rush University, to create a welcoming clinical experience from ancillary staff/services to physician encounters.
I have had the good coincidence of having my interests in endocrinology intersect with my passion for gender management. I was fortunate to be part of a fellowship program that had been practicing a comprehensive, multidisciplinary approach to gender-affirming care for years. I was excited to be welcomed to Rush as my desire to start a multidisciplinary center mirrored the University’s own intentions.
Rush has fiercely maintained a culture of inclusion and has been a champion for the LGBTQ community, being recognized year after year in the Healthcare Equality Index. In January 2016, Rush became the first Illinois medical center to offer employees gender-affirming health coverage. The LGBTQ Leadership Council has tackled multiple endeavors that have established Rush as a prominent advocate for the community.
A new care model begins
Within the forward-thinking environment at Rush, we are excited to move the needle in gender-affirming and overall LGBTQ+ care.
Together with Sloane York, MD, director of Family Planning, and Sally Lemke, DNP, WHNP-BC, director of Community Based Practices, we are working toward creating a comprehensive, multidisciplinary center addressing all aspects of LGBTQ+ care.
We’ve already begun this work with our LGBTQ liaison at Rush, Matt Vail, LCSW, who helps direct patients to appropriate providers and services. By building out our patient navigation system, we can truly support our patients to find the care they need.
Specifically, with transgender and gender-diverse individuals, we recognize the need for accessibility and transparency and are working closely with the community and our community partners to build a model that is patient-centered.
The components are in place, and by continuing to listen to our patients, community, and partners, we can work toward eliminating disparities long faced by this population.
Ravi Iyengar, MD, (pronouns: he/him/his) specializes in endocrinology, diabetes and metabolism at Rush University Medical Center with clinical expertise in gay, lesbian, bisexual and transgender health.