In her knee-length jumper and cobalt blue tights, Hannah Simpson cuts a neat figure. The vibrant 29-year-old student of osteopathic medicine throws back her thick chestnut-brown hair when she laughs, but she turns serious when talking about her experience as a patient rather than a caregiver. That’s because for the past few years she has had a tough time finding a doctor, not because of geography or lack of insurance, but rather because Simpson was born physically male and now lives as a woman.
It is hard to determine the exact number of transgender people in the United States, although some estimates put the figure around 700,000. Like Simpson, many of them have known since they were very young that the gender with which they identify is not the gender they appear to be. Yet research has shown that finding a doctor can often be a challenge and a source of stress for transgender people due to a combination of provider prejudice and lack of knowledge.
“A lot of it is ignorance,” Simpson said, “and not being aware of what transgender people are and what their needs are.” Examples of insensitivity have been all too common in her experience, including a mental healthcare provider who did not realize he was being insulting when he equated being transgender with diaper fetishism, and a pharmacist who snickered when she deduced from Simpson’s prescription list that she was transgender (Simpson now gets her prescriptions mailed to her home).
Many transgender people will change their name or appearance to fit their gender identity. Some choose to undergo hormone therapy, which essentially changes the body’s chemistry to match an individual's gender identity, and possibly sex reassignment surgery, which changes one’s physical appearance. Such treatments can boost quality of life among transgender people, but finding a clinician willing and able to perform even routine care can be a challenge.
What does healthcare for transgender people entail? In most respects, of course, the same care is required as for everyone else, including preventive care and disease management. With the exception of doctors whose specialties entail administering sex-change hormones or post-op care for those who have undergone surgery, there’s not much providers should do differently when treating transgender individuals. There is, however, a need for greater awareness and understanding. For instance, transgender patients face health risks that may not be intuitive to some providers, such as the continued risk of prostate cancer among male-to-female transgender people.
Transgenderism “is something any primary care provider should be able to handle,” said Simpson. “They should think about this patient as just another person who comes in with diabetes or high blood pressure. There really isn’t much more to it than that.”
Yet among transgender people, “the biggest barrier to healthcare is getting any care at all,” said endocrinologist Joshua Safer, a faculty member and physician at Boston University School of Medicine who routinely administers hormones to the many transgender patients he sees in his clinic.
That was the finding of a 2009 study published in the American Journal of Public Health that examined access to care among 101 male-to-female transgender people living in New York City. Researchers found that about one-third of respondents cited the inability to find a practitioner well-versed in health issues specific to transgender people as the biggest barrier to adequate healthcare. Trouble finding a caregiver willing to provide care to a transgender person—a so-called “transgender-friendly” provider—followed close behind; it was cited by 30 percent of the women in the study as their main obstacle to finding a healthcare provider.
The discomfort among physicians and other clinicians when it comes to caring for transgender patients stems in large part from a lack of knowledge, said Safer, although some clinicians’ personal prejudices may also influence their willingness to provide care.
“The physicians with whom I come in contact act biased when they know nothing” about caring for transgender people, “but when they are informed they become more open-minded,” Safer said. “That leads me to believe the fundamental issue is a lack of knowledge, rather than a social bias that we wouldn’t be able to overcome.” He recently co-authored an editorial in the journal Current Opinions in Endocrinology, Diabetes & Obesity that called for more awareness and greater access for transgender people to healthcare, primary care physicians and specialists.
The lack of knowledge stems from the fact that the basics of transgender care are not taught in most medical schools. To change that, three years ago Safer implemented a one-hour lecture within the month-long endocrinology course for second-year medical students at Boston University School of Medicine. The goal of his lecture is to establish from an early stage of training that transgender care is just as much a part of conventional medicine as the treatment of any other group of people.
Safer and his team used surveys administered before and after the lecture the first year he taught it to gauge the effects of the course on 66 medical students’ openness toward having transgender individuals as patients, and on their confidence in their ability to offer hormonal therapy if needed. The survey also inquired about students’ perceptions of their ability to treat hypogonadism, a medical condition in which the body naturally produces too little of the sex hormones important for growth and development. The remedy for both is the same: administration of hormones. The difference is that hypogonadism treatment has long been considered part of mainstream medicine.
The results were impressive. Students reported a 67 percent drop in discomfort in providing care to transgender people. And after the lecture, not a single student reported that they perceived the treatment of transgender people to be separate from conventional medicine—down from 5 percent of students who felt that way before the lecture. Rates of comfort with treating transgender patients also increased, although they remained lower than those for patients with hypogonadism. The results of the survey of students’ perceptions were recently published in the journal Endocrine Practice.
“If it’s taught in medical school, it is viewed as ‘true,’” he said. “Concepts that are not taught in medical school are presumed to be fringe or alternative—things that may lack scientific validity.”
Simpson feels lucky to have recently found a primary care provider with whom she feels comfortable—who is, in fact, a transgender woman. She calls a lecture like the one Safer has implemented for medical students on transgender healthcare “tremendously important,” and hopes that as a medical student, she can serve as both an example to the medical community and an advocate for transgender patients. She is starting a group at her school to teach students and the administration about being transgender, and to encourage faculty to modify the curriculum to include information about transgender care.
Safer has met with much encouragement within the medical community and aims to bring a lecture like his to medical students nationwide. “I have not come across anybody who would not want this as part of the curriculum,” he said.