Evidence Bite: Medical Education and caring for transgender patients

In Medical Concepts by Alexandre CoutinLeave a Comment

Transgender (trans) people make up 0.6% of the population1, yet are among the most underserved in health care.2–5 Barriers to accessing care have been linked to unsafe surgical practices, self-prescribed hormone therapy, and even in the high rate of suicidality among trans Ontarians.6–10 Just over half of trans people report having negative Emergency Department (ED) experiences specifically related to their identity, while one fifth avoid the ED altogether out of fear of discrimination, suboptimal care, or violence.10 Trans patients are additionally at higher risk for mental health co-morbidities, substance misuse, sexual and physical violence, HIV transmission, marginalized housing, sex work, suboptimal screening, and lack of access to primary care.6–15 Depending on transition-related treatments, higher risk for thromboembolic, cardiovascular, and cerebrovascular events may also be present.11

A lack of trans-care education has been identified in both undergraduate and postgraduate curricula.16–19 Increased content and exposure to trans patient have been suggested as starting points for overcoming barriers to adequate care. However, there exists no baseline of the current trans-care educational landscape for many specialties.

Within this post we aim to translate the findings of the following article 20: Coutin, A., Wright, S., Li, C., & Fung, R. (2018). Missed opportunities: are residents prepared to care for transgender patients? A study of family medicine, psychiatry, endocrinology, and urology residents. Canadian Medical Education Journal9(3), 41-55.

Central Questions:

  • What is the nature of education gaps for residents?
  • How might these gaps influence residents’ perceptions of their responsibilities to learn about trans-care?
  • What are the attitudes, knowledge, and training in trans-care among family medicine, psychiatry, endocrinology, and urology residents?

Methods:

Resident surveys to assess perceptions of and attitudes towards trans-care, exposure to trans patients, knowledge of trans-specific clinical care, and the state of trans-care education within their training. Likert scale data was used to identify similarities and differences between residency programs. We collected open-ended responses to further explain quantitative findings where appropriate.

Results:

Of 556 residents approached, 319 participated (response rate = 57.4%). Nearly all endocrinology and psychiatry residents agreed that trans-care falls within their scope of practice, while only 71% and 50% of family medicine and urology residents did, respectively. Though participants were at different stages of their postgraduate training when surveyed, only 17% of all participants predicted they would feel competent to provide specialty-specific trans-care by the end of their residency and only 12% felt that their training was adequate to care for this population.

Why does this matter for us in the ED?

EDs have historically served as safe havens for those at the furthest margins of our society. Many ED staff have expressed wanting to do right for all their patients, yet feeling unprepared to care for trans patients in a sensitive and positive way.

This paper points to a lack of both availability and uptake of trans-care education amongst primary care trainees. Demand for care may inadvertently shift to the ED setting as a result of inadequate primary care for this community. A large portion of ED physicians in Canada are trained as family doctors and are thus unlikely to have received any training in trans-care. This likely also applies to Royal College-trained emergentologists in the current postgraduate educational climate. Is it reasonable to expect to create a positive space for trans patients in the ED with this current state of training?

Additionally, this research shows us that we may not be able to rely on our specialist colleagues to care for trans patients when transfer of care or consultation is indicated, as they too are unlikely to have received sufficient training to care for this community.

What’s Next?

We need to characterize the current status of emergency medicine training to sensitively and competently care for a diversity of patients, including trans people. Where gaps exist, we ought to develop ED-specific educational interventions for trainees and other front-line staff. This likely will not be possible without large-scale faculty development in trans-care.

Lastly, we should encourage research and quality improvement initiatives to better the experience of trans and other gender-diverse patients in the ED. This is a field that has (unfortunately at times deliberately) been silenced in the literature, and we should empower our learners to not shy away from difficult topics like this one.

P.S. We invite you stay tuned for a follow-up qualitative study submitted for publication!

This post was uploaded and copy-edited by Anson Dinh (@AnsonDinh)

References:

1.
Flores A, Herman J. How many adults identify as Transgender in the United States? . The Williams Institute. williamsinstitute.law.ucla.edu. Published 2016.
2.
Winter S, Diamond M, Green J, et al. Transgender people: health at the margins of society. Lancet. 2016;388(10042):390-400. [PubMed]
3.
Roberts T, Fantz C. Barriers to quality health care for the transgender population. Clin Biochem. 2014;47(10-11):983-987. [PubMed]
4.
Corliss H, Belzer M, Forbes C, Wilson E. An evaluation of service utilization among male to female transgender youth: qualitative study of a clinic-based sample. J LGBT Health Res. 2007;3(2):49-61. [PubMed]
5.
White H, Reisner S, Pachankis J. Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions. Soc Sci Med. 2015;147:222-231. [PubMed]
6.
Snelgrove J, Jasudavisius A, Rowe B, Head E, Bauer G. “Completely out-at-sea” with “two-gender medicine”: a qualitative analysis of physician-side barriers to providing healthcare for transgender patients. BMC Health Serv Res. 2012;12:110. [PubMed]
7.
Bauer G, Scheim A, Deutsch M, Massarella C. Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: results from a respondent-driven sampling survey. Ann Emerg Med. 2014;63(6):713-20.e1. [PubMed]
8.
Rotondi N, Bauer G, Scanlon K, Kaay M, Travers R, Travers A. Nonprescribed hormone use and self-performed surgeries: “do-it-yourself” transitions in transgender communities in Ontario, Canada. Am J Public Health. 2013;103(10):1830-1836. [PubMed]
9.
Grant J. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey – National LGBTQ Task Force. National LGBTQ Task Force. http://www.thetaskforce.org/injustice-every-turn-report-national-transgender-discrimination-survey/. Published February 4, 2011.
10.
Bauer GR, Scheim AI, Pyne J, Travers R, Hammond R. Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada. B. 2015;15(1). doi:10.1186/s12889-015-1867-2
11.
Veltman A, Chaimowitz G. Mental Health Care for People Who Identify as Lesbian, Gay, Bisexual, Transgender, and (or) Queer. Can J Psychiatry. 2014;59(11):1-7. [PMC]
12.
Shires D, Stroumsa D, Jaffee K, Woodford M. Primary care providers’ willingness to continue gender-affirming hormone therapy for transgender patients. Fam Pract. 2018;35(5):576-581. [PubMed]
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Rosendale N, Goldman S, Ortiz G, Haber L. Acute Clinical Care for Transgender Patients: A Review. JAMA Intern Med. August 2018. [PubMed]
14.
Guidelines & Protocols for Trans Care – Sherbourne Health. Sherbourne Health. http://sherbourne.on.ca/guidelines-protocols-for-trans-care/. Published 2015.
15.
Coleman E, Bockting W, Botzer M, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. I. 2012;13(4):165-232. doi:10.1080/15532739.2011.700873
16.
MacKinnon KR, Tarasoff LA, Kia H. Predisposing, reinforcing, and enabling factors of trans-positive clinical behavior change: A summary of the literature. I. 2016;17(2):83-92. doi:10.1080/15532739.2016.1179156
17.
Morrison S, Dy G, Chong H, et al. Transgender-Related Education in Plastic Surgery and Urology Residency Programs. J Grad Med Educ. 2017;9(2):178-183. [PubMed]
18.
McPhail D, Rountree-James M, Whetter I. Addressing gaps in physician knowledge regarding transgender health and healthcare through medical education. Can Med Educ J. 2016;7(2):e70-e78. [PMC]
19.
Obedin-Maliver J, Goldsmith E, Stewart L, et al. Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. JAMA. 2011;306(9):971-977. [PubMed]
20.
Coutin A, Wright S, Li C, Fung R. Missed opportunities: are residents prepared to care for transgender patients? A study of family medicine, psychiatry, endocrinology, and urology residents. Can Med Educ J. 2018;9(3):e41-e55. [PubMed]

Reviewing With The Staff

Awareness of transgender health care needs within the medical population has increased. Unfortunately, this awareness hasn’t been paralleled by an increase in medical knowledge or training, and a number of gaps exist in our ability to deliver optimal health care to this population. As a result, transgender patients face a number of health disparities and have poorer health outcomes. It is imperative that we meet the demands of this underserviced population. An initial step includes incorporating the education of medical trainees on how to care for gender diverse individuals in the medical curriculum. This will enable future physicians to provide quality health care and will help to address some of the current gaps.

Dr. Helen Paciocco
FRCPC, Pediatric Endocrinology Fellow
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Alexandre Coutin

Alexandre Coutin

Alexander Coutin is a medical student at the University of Toronto. He has a passion for LGBTQ health, POCUS, and FOAMed; reflecting his interests he is the current president of Out in Medicine. He has interests in musical theater, biking, and skiing.
Alexandre Coutin
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Alexandre Coutin

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