Quantcast

Ask a trans med student anything...

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

Guero

2QT2Bcis Plaidapus
Moderator Emeritus
10+ Year Member
Joined
Jan 20, 2010
Messages
5,305
Reaction score
472
As you may've read in the stickies, I'm an intersex medical student identifying within the spectrum of gender nonconformity (they/them pronouns). Yep, that's why the "I" in LGBTQI is so controversial: Many within the gender and sexual minority groups disagree on its inclusion, omission, or exclusion. I choose to include it; because I was born intersex and identify as both intersex and genderqueer. However, as I progressed, I realized that "transitioning" was not right for me, feeling that it neither truly applied nor reflected my evolving identity, among many other reasons.

However, @otterxavier is a medical student identifying as a trans man (he/him pronouns). I'll now defer to him, since he is best suited to update this specific post as time moves on: @otterxavier. Please feel free to pick his brains and the minds of anyone else that would like to contribute. :)
 
Last edited:
  • Like
Reactions: 8 users

Promethean

Syncretist
7+ Year Member
Joined
Jul 2, 2014
Messages
3,336
Reaction score
5,891
Hi! Trans guy, here, too.

This isn't such a question as just something that bears mentioning. I've had a devil of a time finding adequate health care resources for me in the place that I am going to school. I went from my hometown which has few trans resources, to Erie, PA, which has next to none.

I've been on testosterone now for over 10 years, steady dose, no problems. In Pittsburgh, it was managed by a FM doc. I tried two practices here in Erie, one of which was one of my professors. Both say "We don't feel comfortable managing your hormones. Go see an endo for that." So, I called both endocrinology practices here in town and found that both refused to care for transgender patients. One of them just said it, out right, just like that "Our doctors do not feel comfortable providing care to transgender patients." The other had the decency to mask it a little "We don't provide services for your diagnosis." I found out that the other trans people in Erie were trying to put together money to rent a monthly shuttle to Pittsburgh, to be treated by the FM clinic that I'd gone to, there.

The situation is a little better. Pittsburgh noticed all the trans folks coming there from here for care and started asking what was up. They sent a doc up here to recruit some people here to accept trans folks into their practices and to actually meet their needs. Unfortunately, things didn't work out with the one of them that I saw, and so now I'm looking at maybe having to hike back to Pittsburgh for care.

But, yeah... this is an issue that transgender patients everywhere deal with, and one of the problems with being on track to practice medicine is that it almost always involves upheavals that take us away from our support systems. First medical school, then residency, can mean having to leave a place that has resources and a receptive medical community and go to a place that lacks them... and there may not be a great deal of choice about that.

It has also really weighed on me this year that my home state (down South) was trying to pass even more discriminatory laws against people like me, and that even members of my own birth family were making jokes about violence towards trans people. All these things contributed to a sense of oppression that definitely weighed on me and made it harder to study. I think that we have way more pressures on us than our cis- peers, and fewer folks to talk to about it.

I think that a lot of people in administration don't really know what to make of me... not that anyone has been openly hostile, but I am worried that there will be some consequences for not hiding my identity. During a group discussion this week, I mentioned that a sex-segregated health care delivery model that was being discussed was flawed because it didn't take into account someone like me, a man who has been pregnant, and I thought my professor was going to pop a gasket. He wasn't unkind at all, but he really nonplussed, just totally shocked that I would reveal such intimate information. I think he expects that I would want to hide it away, but doing that 1) denies my peers an opportunity to consider that trans people exist and need healthcare just like everyone else, and 2) makes it seem as though having a transgender body and history is something to be ashamed of. My classmates seem to get it though, and that is what matters to me. They are the next generation of docs, and I don't want any of them going out into their practices feeling uncomfortable taking care of someone because of their gender presentation/identity. I feel like me being here is helping prevent that.

Like I said, I'm not really asking questions, because I'm here in the thick of it, and have been for a while. I'm more just saying... that being trans in med school is like being trans everywhere else in life. A little more complicated than it really ought to be, but still worth the effort.
 
  • Like
Reactions: 14 users

Guero

2QT2Bcis Plaidapus
Moderator Emeritus
10+ Year Member
Joined
Jan 20, 2010
Messages
5,305
Reaction score
472
@Promethean, you highlight some acutely important points: (1) Discrimination persists within healthcare settings and exacerbates outcomes. (2) Although trans protocols exist and are easily accessible, the dearth of that knowledge among willing but unknowing practicing physicians further exacerbates inaccessibility, lack of utilization, and thus outcomes for those in need of trans centered healthcare. (3) The LCME's best intentions to improve this education gap among medical students and physicians in training has not yet made a tangible impact: Many schools still lack the most basic of necessary education, let alone exposure, to these topics. These are some of the underlying issues that fueled this forum.

Basic care and hormone replacement therapy (HRT) aside, we also lack research into fundamental questions, such as longitudinal HRT outcomes within various demographic strata and guidelines regarding HRT and anti-epileptic medication management. We especially need more projects led by scientists and policy advocates that identify within the gender minority spectrum. Data and statements originating from within the spectrum will lend credibility and will more likely address questions otherwise missed by those that haven't lived the experience themselves. I hope to eventually help fill some of these gaps as a practicing physician scientist. But the more rising students and residents that are made aware of these issues and eventually target such a path, the better our outlook will become.
 
  • Like
Reactions: 4 users

Promethean

Syncretist
7+ Year Member
Joined
Jul 2, 2014
Messages
3,336
Reaction score
5,891
Thank you for sharing this. I will review those links at a more reasonable hour and determine how to proceed. It has been a few months since my last attempt to be seen by an endocrinologist. I'm really sure that routine transgender care, including maintenance of long standing hormone regimens, falls well within the capacity of primary care providers. I expect, though, that primary care providers will be able to continue to conflate their desire to avoid caring for certain patient populations with their ethical duty to refer patients for whom they cannot provide the appropriate standard of care. It is very easy for a PCP to claim lack of expertise, particularly with a less common condition/demographic, and create a situation where they cannot be blamed for dumping the patient onto a specialist... which is entirely unfair to the specialists.

I don't have a good answer for how to change that. I think that physician autonomy in determining when to refer / consult is extremely important, even if it is sometimes abused. That is why my answer for all the injustice that I have seen with regard to trans people being denied care has not involved any attempt to use legal avenues to force health care providers to do the right thing. Rather, I've sought to educate, thereby to persuade, and to myself step up into role so that I can help stand in the gap and improve access to care.

So, yes, anything that I can do to help change this status quo, for all who need access, I'm on board.
 

Guero

2QT2Bcis Plaidapus
Moderator Emeritus
10+ Year Member
Joined
Jan 20, 2010
Messages
5,305
Reaction score
472
@Promethean, with the final ruling on Section 1557 of the ACA (http://transgenderlawcenter.org/wp-content/uploads/2016/05/2016-05-13-ACA-1557-Fact-Sheet-final.pdf), what the endocrinologists in Erie are doing is without a doubt illegal. I would encourage you to file a complaint with the Department of Health and Human Services Office of Civil Rights (https://ocrportal.hhs.gov/ocr/cp/complaint_frontpage.jsf). Doing so is one way we can try to start changing the system so that individual providers and entire healthcare systems can no longer just say "we're not comfortable/knowledgeable on how to treat transgender folks so we just don't treat them" and get away with it. They actually have to seriously start integrating trans-inclusive care into their practice, or risk being sued. Hopefully, 1557 will create a real demand for trans-inclusive care training across the board of health care professions and practice sites, and we will start seeing more investment in researching, designing, and implementing effective medical professional training on providing transgender-related care. This all starts with giving providers an incentive (i.e. not getting sued), and with filing complaints to OCR when folks are not complying with the law.

Stay strong with your studies - it really makes me hopeful to learn about more physicians of the future who are trans-identified / have trans experience. Although it makes life more complicated, it also gives you valuable perspective and insight that none of your cis-peers have.

Fantastic contribution, thank you! There's an unfortunate legal caveat to the progress of ACA: If your insurance is purchased outside of the healthcare.gov market, the company isn't bound by the new regulations to cover transgender health, including HRT and gender affirming surgical procedures. Thankfully, I've only run across that issue a couple times. The more pressing and prevalent issue continues to emanate from provider reluctance and/or lack of education, especially in conservative regions of the country like the South (e.g., a transwoman that attends our local trans support group couldn't find a local hospital covered by her insurance willing to perform her procedure).


Sent from my iPhone using SDN mobile
 
  • Like
Reactions: 1 user

beautifulrobot

Opinions are my own
15+ Year Member
Joined
Aug 23, 2005
Messages
738
Reaction score
1,274
Thank you for sharing this. I will review those links at a more reasonable hour and determine how to proceed. It has been a few months since my last attempt to be seen by an endocrinologist. I'm really sure that routine transgender care, including maintenance of long standing hormone regimens, falls well within the capacity of primary care providers. I expect, though, that primary care providers will be able to continue to conflate their desire to avoid caring for certain patient populations with their ethical duty to refer patients for whom they cannot provide the appropriate standard of care. It is very easy for a PCP to claim lack of expertise, particularly with a less common condition/demographic, and create a situation where they cannot be blamed for dumping the patient onto a specialist... which is entirely unfair to the specialists.

I don't have a good answer for how to change that. I think that physician autonomy in determining when to refer / consult is extremely important, even if it is sometimes abused. That is why my answer for all the injustice that I have seen with regard to trans people being denied care has not involved any attempt to use legal avenues to force health care providers to do the right thing. Rather, I've sought to educate, thereby to persuade, and to myself step up into role so that I can help stand in the gap and improve access to care.

So, yes, anything that I can do to help change this status quo, for all who need access, I'm on board.

I hear you on wanting to have more of a collaborative relationship with health care providers, and I agree with you that it is not necessarily appropriate or always the best solution to utilize legal avenues to resolve a dispute between a health care provider and a patient. You should do what you feel comfortable doing, and what you think is worth your time and effort.

I do want to offer another perspective: the Office of Civil Rights (OCR) has similar concerns that many patients, such as yourself, have, about not wanting to "force" health care providers to do things they do not want to do. Most health policy experts would agree that it is not great practice to penalize and subjugate HCPs to do whatever the folks up in Washington DC think they should do. OCR carries out its mission of protecting patients' right to nondiscriminatory care through some of the same methods you just mentioned : teaching HCPs about civil rights, and trying to work with HCPs to correct violations of the law. The more forceful legal avenues, such as monetary penalties, are not usually the first action OCR will take to resolve a violation of the law (disclaimer: I do not work for OCR and do not know for sure what their procedures are, this is an assumption based on other experiences in federal government regulatory affairs, and not meant to be any kind of official policy statement by OCR or HHS). Think of filing a complaint with OCR as a way to get some additional support when your own individual efforts of advocating for yourself have not resulted in a desirable outcome.

Another way to think about filing a complaint with OCR is that even if OCR can't help you, or you decide you do not want to further advance your complaint, you at least have done your due diligence in documenting the injustice you've experienced. The more data OCR and other government agencies have about these kinds of discriminatory cases that adversely affect access to care, the better job government health policy analysts can do in recognizing the root of problems - such as the issue that you brought up of PCPs claiming lack of expertise for something that should be within their capacity, and dumping on to specialists - and create better policies to address those problems. Data drives decision-making. I am almost certain you could file a complaint with OCR and specifically state that you are not interested in pursuing any legal actions against the providers, but you just want to let them know this happened. That would help change the status quo as well.
 
  • Like
Reactions: 1 user

Guero

2QT2Bcis Plaidapus
Moderator Emeritus
10+ Year Member
Joined
Jan 20, 2010
Messages
5,305
Reaction score
472
I hear you on wanting to have more of a collaborative relationship with health care providers, and I agree with you that it is not necessarily appropriate or always the best solution to utilize legal avenues to resolve a dispute between a health care provider and a patient. You should do what you feel comfortable doing, and what you think is worth your time and effort.

I do want to offer another perspective: the Office of Civil Rights (OCR) has similar concerns that many patients, such as yourself, have, about not wanting to "force" health care providers to do things they do not want to do. Most health policy experts would agree that it is not great practice to penalize and subjugate HCPs to do whatever the folks up in Washington DC think they should do. OCR carries out its mission of protecting patients' right to nondiscriminatory care through some of the same methods you just mentioned : teaching HCPs about civil rights, and trying to work with HCPs to correct violations of the law. The more forceful legal avenues, such as monetary penalties, are not usually the first action OCR will take to resolve a violation of the law (disclaimer: I do not work for OCR and do not know for sure what their procedures are, this is an assumption based on other experiences in federal government regulatory affairs, and not meant to be any kind of official policy statement by OCR or HHS). Think of filing a complaint with OCR as a way to get some additional support when your own individual efforts of advocating for yourself have not resulted in a desirable outcome.

Another way to think about filing a complaint with OCR is that even if OCR can't help you, or you decide you do not want to further advance your complaint, you at least have done your due diligence in documenting the injustice you've experienced. The more data OCR and other government agencies have about these kinds of discriminatory cases that adversely affect access to care, the better job government health policy analysts can do in recognizing the root of problems - such as the issue that you brought up of PCPs claiming lack of expertise for something that should be within their capacity, and dumping on to specialists - and create better policies to address those problems. Data drives decision-making. I am almost certain you could file a complaint with OCR and specifically state that you are not interested in pursuing any legal actions against the providers, but you just want to let them know this happened. That would help change the status quo as well.
This is a very good point I didn't even think to make. Thanks for contributing!
Thankfully, the law recognizes the issue of provider-driven discrimination, and the law also applies to any health care provider who receives federal funds (e.g. Medicare), and there may be other situations where the law still applies. Even if you're not sure a specific case is covered by the law, it doesn't hurt to let the lawyers at the Office of Civil Rights take a look at it and figure it out (it's your tax money that covers their salary!).

http://out2enroll.org/out2enroll/wp-content/uploads/2015/11/Non-Discrimination-Postcard-Final.pdf

Thanks for the clarification and link! I'll check it out as soon as I can. :)


Sent from my iPhone using SDN mobile
 
  • Like
Reactions: 1 user
D

deleted480308

I hear you on wanting to have more of a collaborative relationship with health care providers, and I agree with you that it is not necessarily appropriate or always the best solution to utilize legal avenues to resolve a dispute between a health care provider and a patient. You should do what you feel comfortable doing, and what you think is worth your time and effort.

I do want to offer another perspective: the Office of Civil Rights (OCR) has similar concerns that many patients, such as yourself, have, about not wanting to "force" health care providers to do things they do not want to do. Most health policy experts would agree that it is not great practice to penalize and subjugate HCPs to do whatever the folks up in Washington DC think they should do. OCR carries out its mission of protecting patients' right to nondiscriminatory care through some of the same methods you just mentioned : teaching HCPs about civil rights, and trying to work with HCPs to correct violations of the law. The more forceful legal avenues, such as monetary penalties, are not usually the first action OCR will take to resolve a violation of the law (disclaimer: I do not work for OCR and do not know for sure what their procedures are, this is an assumption based on other experiences in federal government regulatory affairs, and not meant to be any kind of official policy statement by OCR or HHS). Think of filing a complaint with OCR as a way to get some additional support when your own individual efforts of advocating for yourself have not resulted in a desirable outcome.

Another way to think about filing a complaint with OCR is that even if OCR can't help you, or you decide you do not want to further advance your complaint, you at least have done your due diligence in documenting the injustice you've experienced. The more data OCR and other government agencies have about these kinds of discriminatory cases that adversely affect access to care, the better job government health policy analysts can do in recognizing the root of problems - such as the issue that you brought up of PCPs claiming lack of expertise for something that should be within their capacity, and dumping on to specialists - and create better policies to address those problems. Data drives decision-making. I am almost certain you could file a complaint with OCR and specifically state that you are not interested in pursuing any legal actions against the providers, but you just want to let them know this happened. That would help change the status quo as well.
It's a little odd for you to say most policy experts agree it's not great practice to force physicians to do things they don't want/know how to do while promoting a govt agency with that as their primary mission...

but I also think it's important to delineate that a number of physicians may just be discriminatory jerks....and a number may just not know the full scope of risks/effects/benefits of treatments and not feel comfortable taking responsibility for that scope. I think the claim of "I just don't feel comfortable in my knowledge base" is more understandable for PCP than an endo specialist but some people just don't do/know certain things
 

Promethean

Syncretist
7+ Year Member
Joined
Jul 2, 2014
Messages
3,336
Reaction score
5,891
@giga - Fantastic points, and thank you again for sharing them with me. I do plan on following up with this.

@sb247 - I appreciate your position. In the kind of truly free market that you often advocate, there would be other options that would allow people to route around such discrimination. For instance, in a truly free market, patients like me wouldn't require gatekeepers in order to access care, and could buy our hormones and order our own labs without having to go through a physician. That would solve some problems, and create a lot of others. And many of the ones it would create are the very reasons we don't have such a system.

We've collectively decided that it is better for everyone if some people, who have educated sufficiently and demonstrated adequate competency, are privileged to practice medicine. And that everyone else will need to go through those few in order to access the care that they need. Privileges bring responsibility, and one of the responsibilities incurred is that it isn't acceptable to allow personal biases to interfere with the care of patients. Government (which is merely a form of collective will, in our democratic society) grants physicians protected rights to practice medicine, so it also has a role to play in ensuring that they hold up their end of the deal. This is really just a complicated and advanced form of contract enforcement, not an overreach of power.
 
  • Like
Reactions: 1 users
D

deleted480308

@giga - Fantastic points, and thank you again for sharing them with me. I do plan on following up with this.

@sb247 - I appreciate your position. In the kind of truly free market that you often advocate, there would be other options that would allow people to route around such discrimination. For instance, in a truly free market, patients like me wouldn't require gatekeepers in order to access care, and could buy our hormones and order our own labs without having to go through a physician. That would solve some problems, and create a lot of others. And many of the ones it would create are the very reasons we don't have such a system.

We've collectively decided that it is better for everyone if some people, who have educated sufficiently and demonstrated adequate competency, are privileged to practice medicine. And that everyone else will need to go through those few in order to access the care that they need. Privileges bring responsibility, and one of the responsibilities incurred is that it isn't acceptable to allow personal biases to interfere with the care of patients. Government (which is merely a form of collective will, in our democratic society) grants physicians protected rights to practice medicine, so it also has a role to play in ensuring that they hold up their end of the deal. This is really just a complicated and advanced form of contract enforcement, not an overreach of power.
I share your opinion that having the govt half way into something creates some unique issues...
 
  • Like
Reactions: 1 user

smq123

John William Waterhouse
Staff member
Administrator
Volunteer Staff
15+ Year Member
Joined
Jan 9, 2006
Messages
14,721
Reaction score
5,764
Basic care and hormone replacement therapy (HRT) aside, we also lack research into fundamental questions, such as longitudinal HRT outcomes within various demographic strata and guidelines regarding HRT and anti-epileptic medication management. We especially need more projects led by scientists and policy advocates that identify within the gender minority spectrum. Data and statements originating from within the spectrum will lend credibility and will more likely address questions otherwise missed by those that haven't lived the experience themselves. I hope to eventually help fill some of these gaps as a practicing physician scientist. But the more rising students and residents that are made aware of these issues and eventually target such a path, the better our outlook will become.

YES. This has been an issue for me, as a family doctor at a community health center. I have seen a few transgender patients there, mostly because they don't have insurance and we will see them at a discounted price if their income is low enough.

I have seen almost exclusively MTF transgender patients (no reason for why, that's just how it's shaken out). I'm familiar with prescribing these same hormones for other things (dysmenorrhea, contraception, etc), and I would like to think that I'm reasonably open minded. But I have to admit to a great deal of trepidation when I have prescribed these meds. At what age do I stop? Do you ever stop prescribing hormones? What if I give this very pleasant 63yo MTF transgender patient a stroke or a DVT or a PE or something, because her age and the hormone use put her at increased risk for a clot? Do I taper off the hormones, thereby mimicking the menopause that a biologic female would experience? Do I give her the hormones AND an aspirin, hoping that that somehow mitigates the risk? I really have no idea, and there is very little guidance on this. Even the guidelines released by medical societies don't make this clear....I assume that this means that no one really knows the answer? I can't send her to endocrine because she doesn't have insurance and lives on a pretty fixed income. The best I can do is have an open discussion that I'm not a specialist, I don't really know the answers to my own questions, and there is a risk of a clot (although I could be overblowing the risk)....but I still feel like I'm doing her a disservice.

<sigh> So many questions.
 
  • Like
Reactions: 2 users

Promethean

Syncretist
7+ Year Member
Joined
Jul 2, 2014
Messages
3,336
Reaction score
5,891
YES. This has been an issue for me, as a family doctor at a community health center. I have seen a few transgender patients there, mostly because they don't have insurance and we will see them at a discounted price if their income is low enough.

I have seen almost exclusively MTF transgender patients (no reason for why, that's just how it's shaken out). I'm familiar with prescribing these same hormones for other things (dysmenorrhea, contraception, etc), and I would like to think that I'm reasonably open minded. But I have to admit to a great deal of trepidation when I have prescribed these meds. At what age do I stop? Do you ever stop prescribing hormones? What if I give this very pleasant 63yo MTF transgender patient a stroke or a DVT or a PE or something, because her age and the hormone use put her at increased risk for a clot? Do I taper off the hormones, thereby mimicking the menopause that a biologic female would experience? Do I give her the hormones AND an aspirin, hoping that that somehow mitigates the risk? I really have no idea, and there is very little guidance on this. Even the guidelines released by medical societies don't make this clear....I assume that this means that no one really knows the answer? I can't send her to endocrine because she doesn't have insurance and lives on a pretty fixed income. The best I can do is have an open discussion that I'm not a specialist, I don't really know the answers to my own questions, and there is a risk of a clot (although I could be overblowing the risk)....but I still feel like I'm doing her a disservice.

<sigh> So many questions.

There is some guidance out there. Dr. Nick Gorton, (et al) wrote a manual for the care of FTM patients which I printed out and presented as a gift to one or two docs that have been willing to work with me. http://nickgorton.org/ I heartily recommend reading it, or at least skimming it. You may find it helpful for your patients, even though many of them are travelling in the opposite direction.

I'm not as familiar with resources for MTF patients. I'd also appreciate if anyone else had resources to share.

The Gorton text is founded in a model of informed consent and compassionate care intended to maximize benefits while minimizing harm. There are risks associated with receiving healthcare. We are able to predict many of the risks that may be associated with hormone therapy, but probably not all. So, we do all we can to mitigate those risks, and to monitor as seems prudent. But ultimately, if the patient is as aware of the risks as we can manage, and aware that there may be others we didn't anticipate, and still remains unwavering in their desire for treatment... then you aren't doing anyone a disservice by helping them fulfill their wishes for their own body.

The harm done by denying access to treatment, when the patient is so adamant that it is necessary, is much harder to measure than the harm done by treating when that results in a bad outcome. It isn't as easy to gather numbers about various forms of harm that don't come to attention as acutely as a clot: anxiety, depression, agoraphobia, self-injurious behaviors, lost opportunities, lost wages, failed relationships, wasted human potential.

I know that for myself, I'd always choose quality of life over quantity, and the quality of my life is so much better than it would be without HRT that it also effects the quantity. I sincerely doubt that I would have survived this past decade had I not been able to access the surgery and hormonal therapy which I needed in order to be comfortable in my body. I think you are doing exactly the right thing, in providing the care the patient needs and desires to the best of your ability given the information that you have available, and continuing to seek out more knowledge as you go. It may not be the ideal situation, but it is definitely not doing any disservice to your patients.
 

Guero

2QT2Bcis Plaidapus
Moderator Emeritus
10+ Year Member
Joined
Jan 20, 2010
Messages
5,305
Reaction score
472
YES. This has been an issue for me, as a family doctor at a community health center. I have seen a few transgender patients there, mostly because they don't have insurance and we will see them at a discounted price if their income is low enough.

I have seen almost exclusively MTF transgender patients (no reason for why, that's just how it's shaken out). I'm familiar with prescribing these same hormones for other things (dysmenorrhea, contraception, etc), and I would like to think that I'm reasonably open minded. But I have to admit to a great deal of trepidation when I have prescribed these meds. At what age do I stop? Do you ever stop prescribing hormones? What if I give this very pleasant 63yo MTF transgender patient a stroke or a DVT or a PE or something, because her age and the hormone use put her at increased risk for a clot? Do I taper off the hormones, thereby mimicking the menopause that a biologic female would experience? Do I give her the hormones AND an aspirin, hoping that that somehow mitigates the risk? I really have no idea, and there is very little guidance on this. Even the guidelines released by medical societies don't make this clear....I assume that this means that no one really knows the answer? I can't send her to endocrine because she doesn't have insurance and lives on a pretty fixed income. The best I can do is have an open discussion that I'm not a specialist, I don't really know the answers to my own questions, and there is a risk of a clot (although I could be overblowing the risk)....but I still feel like I'm doing her a disservice.

<sigh> So many questions.
Thank you SO much for your post! I was really hoping we'd reach someone like yourself. As Promethean said, there are some guidance statements and anecdotal data out there to help guide these decisions. In terms of hypercoagulability, the transdermal estrogen has shown reduced risk. I'll cite this source when I have more time. I just wanted to offer a little help along with the praise for contributing and speaking up.
There is some guidance out there. Dr. Nick Gorton, (et al) wrote a manual for the care of FTM patients which I printed out and presented as a gift to one or two docs that have been willing to work with me. http://nickgorton.org/ I heartily recommend reading it, or at least skimming it. You may find it helpful for your patients, even though many of them are travelling in the opposite direction.

I'm not as familiar with resources for MTF patients. I'd also appreciate if anyone else had resources to share.

The Gorton text is founded in a model of informed consent and compassionate care intended to maximize benefits while minimizing harm. There are risks associated with receiving healthcare. We are able to predict many of the risks that may be associated with hormone therapy, but probably not all. So, we do all we can to mitigate those risks, and to monitor as seems prudent. But ultimately, if the patient is as aware of the risks as we can manage, and aware that there may be others we didn't anticipate, and still remains unwavering in their desire for treatment... then you aren't doing anyone a disservice by helping them fulfill their wishes for their own body.

The harm done by denying access to treatment, when the patient is so adamant that it is necessary, is much harder to measure than the harm done by treating when that results in a bad outcome. It isn't as easy to gather numbers about various forms of harm that don't come to attention as acutely as a clot: anxiety, depression, agoraphobia, self-injurious behaviors, lost opportunities, lost wages, failed relationships, wasted human potential.

I know that for myself, I'd always choose quality of life over quantity, and the quality of my life is so much better than it would be without HRT that it also effects the quantity. I sincerely doubt that I would have survived this past decade had I not been able to access the surgery and hormonal therapy which I needed in order to be comfortable in my body. I think you are doing exactly the right thing, in providing the care the patient needs and desires to the best of your ability given the information that you have available, and continuing to seek out more knowledge as you go. It may not be the ideal situation, but it is definitely not doing any disservice to your patients.
Thanks so much for contributing literature and guidance. This is exactly what I was hoping to see! :D I can't wait until I have more time to provide additional sources.


Keep it up everyone!



Sent from my iPhone using SDN mobile
 
  • Like
Reactions: 3 users

smq123

John William Waterhouse
Staff member
Administrator
Volunteer Staff
15+ Year Member
Joined
Jan 9, 2006
Messages
14,721
Reaction score
5,764
I'm really sure that routine transgender care, including maintenance of long standing hormone regimens, falls well within the capacity of primary care providers. I expect, though, that primary care providers will be able to continue to conflate their desire to avoid caring for certain patient populations with their ethical duty to refer patients for whom they cannot provide the appropriate standard of care. It is very easy for a PCP to claim lack of expertise, particularly with a less common condition/demographic, and create a situation where they cannot be blamed for dumping the patient onto a specialist... which is entirely unfair to the specialists.

Well...yes and no.

Speaking as a primary care doctor, who does not harbor any personal discomfort with transgender people, I'm not in total agreement with that bolded statement.

What defines your "capacity" as a physician is largely self-defined, and involves some honor code/personal ethics - i.e. being honest about your own boundaries as a physician, and admitting what you're good at, and not so good at. Which involves setting aside some personal ego, which is hard for a lot of people.

It is "easier" for me to care for MTF patients, hands down - and this is for a number of reasons. Like I said in my previous post, I already have a lot of experience prescribing estrogen-related medications, because I do a ton of that for other medical indications (birth control, heavy periods, painful periods, alleviating menopause symptoms, etc). I am very aware of the risks and side effects of those medications, and could probably counsel someone on those medications while half-asleep. I've even had to counsel patients on these risks in my fair-to-middling Spanish, and have been able to do it.

Estrogen-related compounds are also very easy to prescribe and dispense. Certain forms of them are even available over the counter.

Testosterone supplementation, on the other hand, is less common - aside from FTM transgender patients, we really only prescribe that for hypogonadism, and, honestly, the urologists and endocrinologists have kind of cornered that market...the number of men with hypogonadism is miniscule compared to the number of women who want contraception, as you can imagine. Testosterone carries a lot of side effects, but I prescribe it so rarely that can I legitimately say that I can do a good job counseling you on the risks? Can I honestly say that I will remember to screen you appropriately, at appropriate intervals, when I do it so infrequently?

Plus, testosterone, unlike estrogen, is a controlled substance that requires a DEA, and it also carries a fairly high street value. So, if you lose the prescription for it, it can cause some legal/paperwork issues for the office, that they may just prefer not to deal with. In some states, NPs and PAs are not allowed to hold a DEA license, which means that you can only ever see the physician whenever you come for refills....logistically a tall order, in some primary care clinics.

Now, the offices that you went in order to try and establish care should have explained this to you, fully and with dignity. It sounds like they did not, and THAT is definitely not fair to you. And the endocrinologist has no excuse - that's just discrimination. But I wanted to explain non-discriminatory reasons why a PCP might not be able to care for you. I hope that my post makes sense....

(And, in all honesty, if a FTM patient came to me and said that they needed refills, they had been stable on their meds for a long time, no one else would help them, and that they understood that this is not my forte but were willing to chance it anyway, I'd probably prescribe them their meds. I would just be a little anxious, that's all, and spend a lot of nights re-reading hormone guidelines. :))

I know that for myself, I'd always choose quality of life over quantity, and the quality of my life is so much better than it would be without HRT that it also effects the quantity. I sincerely doubt that I would have survived this past decade had I not been able to access the surgery and hormonal therapy which I needed in order to be comfortable in my body. I think you are doing exactly the right thing, in providing the care the patient needs and desires to the best of your ability given the information that you have available, and continuing to seek out more knowledge as you go. It may not be the ideal situation, but it is definitely not doing any disservice to your patients.

Thank you. Your post was very helpful.

If I understand what you are saying correctly, you would be willing to chance the risk of a complication, and getting sick or possibly even dying, if that means that you can live life on your own terms. And if that's the case, and my MTF patient feels the same, then I feel a lot better about refilling her meds.

I wish that she would have told me this, but she's in her 60s and British, and hyper-polite and soft-spoken in a way that only the English can really pull off. When I explained my concerns about hormones and clots to her, she just smiled sweetly and said, "Well, doctor, you know best." <GULP> No, no, ma'am....I really don't. Really.

Based on your posts, I see that you're a pre-clinical med student, but trust me....there is no better way to make a young physician's heart spasm in fear than to assure them that they know best and that you trust them. I don't know if I'll ever get used to it.
 
  • Like
Reactions: 3 users

Promethean

Syncretist
7+ Year Member
Joined
Jul 2, 2014
Messages
3,336
Reaction score
5,891
You make good sense, and I do certainly understand that there are limitations on what a PCP may feel comfortable with, based upon their experience and expertise level. I should clarify that my position is that continuing a treatment regimen that is long established for a young, healthy patient with no comorbidities is within the realm of primary care (particularly if it is a practice that already provides testosterone prescriptions to older cisgender men with multiple co-morbidities for that well-hyped condition of "Low T.") If a physician is unfamiliar with the medication, or with its associated recommended monitoring, risks, etc, then it is, as you noted, more understandable that they might feel a referral to be in the best interest of the patient, if there were someone to whom a referral could be made. I certainly have less irritation at being denied treatment by a PCP than by the endocrine specialists.

You did understand me correctly when I said that I'd happily risk severe complications in order to receive a treatment which has provided such substantial benefit for my total quality of life. Prior to transitioning, my global functioning was probably less than half what it is now. I was plagued by severe anxiety and depression, and had several periods of months at a time when my agoraphobia was so profound that I couldn't leave the house at all. For almost 10 years after high school, I was working low wage service industry jobs, interspersed with periods of unemployment, because with persistent dysphoria and severe anxiety, that was the best I could manage. I transitioned early in nursing school, and even before beginning testosterone therapy, just being able to live in the appropriate gender made an extraordinary difference in my life. I was not only happier, and more productive, but I stopped feeling too anxious to interact with the world, because I was finally able to present myself as I saw myself. I probably could have gone to medical school 15 years sooner, if I hadn't had to cope with untreated gender dysphoria for so long.

Many of my MTF friends and loved ones have had very different experiences, where they have suffered severe losses in social and economic status as a result of their transitions. I know an aerospace engineer who works as a telephone operator now, and an MD/PhD who endured discrimination during her residency and no longer works in medicine, largely because of bias against transgender women. In both cases, despite being subjected to greater difficulties in accessing employment opportunities and the greater risk of violence and harassment in various settings, they still feel that the difficulties that they face are endurable in order to be able to live as the gender with which they identify. The inner peace of being recognized as the women that they know themselves to be has been worth the costs, even those that were not as foreseeable.

The world is changing, slowly. Transgender folks these days are not met with as much blatant discrimination as my friends experienced ten and twenty years ago. Heck, a few weeks back, we even had the head of the DOJ address us directly and affirm that we are people, and that we are deserving of basic human rights. I had the good fortune to catch that live streaming. I don't cry much since testosterone (it makes emotional crying very much less frequent, almost impossible, even when I might want to cry,) but I bawled during Loretta Lynch's speech. A lot of us did, because we'd spent the weeks prior feeling as though we were under attack by our own home states. As if our right to exist and participate equally in public life were up for referendums, and we'd been truly afraid that no one had our back.

So, I can assure you, even if your patient is too reserved to do so herself... none of us is doing this lightly. None of us would choose this path, except that it is the only way available to us to live authentically and fully. All of us are paying some enormous costs, whether financial, professional, social, reproductive, filial, etc, in order to access the care that we need. If you explain your concerns to us, and it doesn't scare us away, that is because the benefits do outweigh the risks.

Thank you for this conversation, and for modelling a strong desire to do what is in the best interests of your patients.
 
  • Like
Reactions: 2 users

smq123

John William Waterhouse
Staff member
Administrator
Volunteer Staff
15+ Year Member
Joined
Jan 9, 2006
Messages
14,721
Reaction score
5,764
So, I can assure you, even if your patient is too reserved to do so herself... none of us is doing this lightly. None of us would choose this path, except that it is the only way available to us to live authentically and fully. All of us are paying some enormous costs, whether financial, professional, social, reproductive, filial, etc, in order to access the care that we need. If you explain your concerns to us, and it doesn't scare us away, that is because the benefits do outweigh the risks.

Thank you for this conversation, and for modelling a strong desire to do what is in the best interests of your patients.

While your post hurts my heart, because it's sad to reflect on how unfairly hard the path is (and how some state governors are trying to make it harder), it also helped me tremendously. It helps me understand some of my patients better. Thank you so very much. :)
 
  • Like
Reactions: 1 users

Ceke2002

Purveyor of Strange
10+ Year Member
Joined
Sep 26, 2009
Messages
6,021
Reaction score
5,266
Thank you so much to the trans members here who have spoken from personal experience about the absolute necessity of transitioning in so many cases, and how not only life changing, but life saving it can be. I've followed the journey of two FtM trans friends, from their initial coming out through to transition, and the positive changes in their lives cannot be overstated.

'B' I met on a support forum for sufferers of eating disorders/mental health conditions in general almost 15 years ago. For the first few years he still maintained his female assigned gender identity, and was openly gay - he was also completely miserable: diagnosed with severe depression, anxiety, anorexia and bulimia nervosa, substance addiction problems, issues of self harm, going from one therapist or psychiatrist to the next, trying different medications and treatments that never worked for very long. One day he'd just had enough of carrying the burden of what to him felt like this huge weight of a secret that he just couldn't hold onto anymore, so he announced to the forum that although he was scared of how we'd react, or whether or not we would reject him, he was not female, he was male, and he'd felt this way for as long as he could remember; when he was with a woman it had never felt to him like a same sex relationship, because he felt like a man having a heterosexual encounter. From that point on he asked that we call him by his chosen male name, and that we use male pronouns; the forum was overwhelmingly supportive with this and with his desire to transition. Later he admitted that he had tried to commit suicide when he was 8 years old, because he had been raised in a very religious household and was taught that God could do anything, so every night he prayed for God to please let him wake up in the right body, and every morning he woke up he was still stuck in a body that felt alien and wrong to him - eventually he realised that his prayers would never be answered, and wasn't just going to go to sleep one night and wake up as the boy he should have been, so he tried to hang himself. And for well over a decade more after that, especially when he went through female puberty, his mental health status continued to go down hill. Once he made the decision to live full time as a male, and to seek out HRT, because he lived in an area of the bible belt it did take him some time to access proper care and assistance (from memory he had to travel a fair distance to one of the major cities, and even then the waiting lists to see experienced practitioners working in this area were always long), in the meantime he did become desperate enough to score testosterone off the street. Eventually he was granted permission/a script to receive regular T injections and from the on it was so great to see him celebrating all these different milestones - the first time he noticed his voice deepening, the first time someone addressed him as 'sir', the first time he'd grown enough facial hair to start shaving, when he realised he was growing a 'treasure trail' on his lower stomach, and so on. When he finally got his top surgery done he posted pictures from when he was still in the recovery room, and I don't know if I've seen anyone look happier, he was positively glowing with sheer joy.

There were some difficulties and set backs along the way, bureaucratic red tape and form after form to get through just to change his gender on things like his birth certificate and passport; his family took a while to accept his transition and there were a lot of periods of hurt and frustration there (they eventually came round, and B also eventually realised that as long as his family were trying then he had to be willing to meet them where they were at). Although he'd always assumed he was solely attracted to women, and therefore identified as straight, he did end up falling in love with another man at one stage and had to go through a period of questioning his sexual orientation - he eventually decided that 'Queer' was the label that best matched how he felt. Later on he moved overseas to a country in Europe and married a gender assigned woman, who eventually also came out as a trans guy and began a transition of his own. They are both still married, last I heard, B no longer self harms, or abuses drugs, and his eating disorder, depression and anxiety have all been in complete remission for some time now. Over the years B has become more and more comfortable with his identity as a trans guy, and now runs a successful bakery business, where he ices pink cups, and bakes biscuits, and doesn't give a f**k if anyone thinks that isn't 'manly' enough - both he and his husband also have fun dressing in drag and heading out to the clubs from time to time. If people could see the way he was, to the way he is now, I doubt there would be too many who couldn't see just how beneficial transitioning has been to him.

~~~~~~~~~

My friend Adrian, who is from Germany, I met around 6-7 years ago when we were both part of the same fandom. I was one of the first people he came out to, and I also got to follow his transition process and to watch him go from being someone who was shy, had trouble meeting people for fear of judgement, to someone who became gradually stronger, more confident and more self assured in his identity. He remains one of my dearest friends and I think I will let him tell part of his own story himself (I have permission to share this, it is in German but there are English subtitles). This was the first time he came out publicly as trans, after previously having lived primarily as stealth.

 
Last edited:
  • Like
Reactions: 1 user

Promethean

Syncretist
7+ Year Member
Joined
Jul 2, 2014
Messages
3,336
Reaction score
5,891
I wanted to pop in and give everyone an update.

I tried again. A different FM doctor here in town. I related the experiences I'd had seeking care and that I've been on a steady dose for a decade, with no issues other than difficulty finding someone to care for me. I provided access to several years worth of labs which show that everything is steady state and nothing to be concerned about. I explained that I'm getting tired of fighting this battle and that I was prepared to come off testosterone if he wouldn't prescribe it. I have mild HTN and a few other concerns that really need to be addressed with a stable primary care provider, and I couldn't afford to let those things slide anymore while I doctor shopped. I laid everything on the line, including that, if he wasn't willing to prescribe my hormone for me, I was going to need him to help me cope with the side effects of castration, starting with at least one antidepressant and probably a referral to psych to manage the inevitable mental and emotional crisis that would soon manifest.

This proved an effective argument, and he is willing to prescribe for me, at least while I'm in school.

I talked to him the way that I want to talk to my patients... I presented him with information, options, and likely outcomes and invited him to make the decision about how he wanted to proceed, while I was equally ready to accept and implement his choice. This is a kind of backwards approach to informed consent, but it wasn't reverse psychology. There was a real meeting of minds, as I was very honest about what his decision would mean for me and sincere in my acceptance of it either way, and he was actually listening and demonstrating respect for me, too.

Blessedly, with that out of the way, we were able to make some good progress on some of the more mundane issues, and it was probably one of the most thorough primary care visits I've ever had. I left with homework - a prescription for diet and exercise modifications as well as for the meds that I needed.

It is wonderful to have some good role models to balance against some of the negative examples that I've acquired along the way.
 
  • Like
Reactions: 7 users

otterxavier

Full Member
Moderator Emeritus
7+ Year Member
Joined
Dec 30, 2012
Messages
193
Reaction score
587
I wanted to pop in and give everyone an update.

I tried again. A different FM doctor here in town. I related the experiences I'd had seeking care and that I've been on a steady dose for a decade, with no issues other than difficulty finding someone to care for me. I provided access to several years worth of labs which show that everything is steady state and nothing to be concerned about. I explained that I'm getting tired of fighting this battle and that I was prepared to come off testosterone if he wouldn't prescribe it. I have mild HTN and a few other concerns that really need to be addressed with a stable primary care provider, and I couldn't afford to let those things slide anymore while I doctor shopped. I laid everything on the line, including that, if he wasn't willing to prescribe my hormone for me, I was going to need him to help me cope with the side effects of castration, starting with at least one antidepressant and probably a referral to psych to manage the inevitable mental and emotional crisis that would soon manifest.

This proved an effective argument, and he is willing to prescribe for me, at least while I'm in school.

I talked to him the way that I want to talk to my patients... I presented him with information, options, and likely outcomes and invited him to make the decision about how he wanted to proceed, while I was equally ready to accept and implement his choice. This is a kind of backwards approach to informed consent, but it wasn't reverse psychology. There was a real meeting of minds, as I was very honest about what his decision would mean for me and sincere in my acceptance of it either way, and he was actually listening and demonstrating respect for me, too.

Blessedly, with that out of the way, we were able to make some good progress on some of the more mundane issues, and it was probably one of the most thorough primary care visits I've ever had. I left with homework - a prescription for diet and exercise modifications as well as for the meds that I needed.

It is wonderful to have some good role models to balance against some of the negative examples that I've acquired along the way.

Thanks for sharing what your experience has been -- I'm glad you were finally able to get your T prescribed locally, and had a positive experience with him otherwise. I'm curious whether this may open the door for him to prescribe for other trans patients as well, or if he's regarding this as an unusual case because you were so exceptionally direct in advocating for yourself. Please keep us posted on how things are going.
 
  • Like
Reactions: 1 users

DiscusKeeper

Full Member
2+ Year Member
Joined
Jul 1, 2016
Messages
205
Reaction score
281
As a gay man, I'm always curious about the experiences of other LGBT individuals, especially in the field of medicine. This is kind of a broad question, but how do you feel being transgender has changed your journey relating to medicine? What are some benefits and what are some of the negatives? How do you think your career in medicine would have differed if your gender identity had matched your sex at birth?
 
  • Like
Reactions: 1 user

Guero

2QT2Bcis Plaidapus
Moderator Emeritus
10+ Year Member
Joined
Jan 20, 2010
Messages
5,305
Reaction score
472
As a gay man, I'm always curious about the experiences of other LGBT individuals, especially in the field of medicine. This is kind of a broad question, but how do you feel being transgender has changed your journey relating to medicine? What are some benefits and what are some of the negatives? How do you think your career in medicine would have differed if your gender identity had matched your sex at birth?

I could answer your question with an epistle. But in the interest of concision, I'll try to keep it brief:

I've faced so many challenges in my road to becoming a physician, let alone the aspects of working toward a physician scientist track, all of which have shaped my goals. I've survived an attempt on my life, overt discrimination from peers and administration alike, and have struggled to receive the treatments and medications I need to live both a physically and mentally healthy life as a gender minority. I've been denied services at my school. I've struggled to eat and fear ruined credit as I endure poverty from medical bills that exacerbate forced repayment of my private undergrad loans. I've lost friends and colleagues after I came out. I've had cisgendered, heterosexual and homosexual colleagues and personal providers alike that easily and ignorantly offend me despite claiming achieving a niche of education and experience in the field of LGBTQ health. And these are but a few examples.

But most importantly, having faced and persevered through these challenges, I have so many unique perspectives and a privy edge going into the field of medicine as a student physician scientist. These experiences will allow me to address the disparities of which our cisgendered and sexual majority or minority colleagues are not privy. This allows me to provide solid research data from future lab and clinical studies that will help improve LGBTQ health policy, innovate protocols, correct educational policies, and work toward improving the overall health of those too scared to seek help in our community due to continued institutionalized discrimination and ignorance.

Had I been born a cisgender woman, I would neither have been able to learn firsthand the privilege of masculinity nor the subjugation of femininity, something my degrees in sociology, psychology, neuroscience, and now, medicine could never truly teach. I likely would have pursued a different yet equally necessary career path in medicine. And I'd likely have lived a far longer, healthier life without physical, mental, and sexual abuse as a child, and may have avoided some very violent situations and poor choices as a child and teen. But, again, more importantly, all of this made me who I am today; and I wouldn't change it for the world, even if I succumbed to the injuries I sustained during that fateful hate crime in 2001.


Sent from my iPhone using SDN mobile
 
Last edited:
  • Like
Reactions: 2 users

Promethean

Syncretist
7+ Year Member
Joined
Jul 2, 2014
Messages
3,336
Reaction score
5,891
I'm not the original poster, but I'll give my answers to this.

It is hard to separate the role gender variance has played from my over all personality, since it is an important facet of me, but it isn't what brought me into health care. Indeed, I was halfway through nursing school before I became aware that female to male hormone treatment was even an option... and then, it wasn't at school that I learned about transgender health, but out in the community.

I think that being trans is one of the things has given me experience with overcoming adversity, so that it has helped me develop strong coping mechanisms for dealing with the stresses of obtaining a medical education. It has also provided me the opportunity to think pretty deeply about ethical and philosophical matters relating to patient autonomy, human potential, and values conflicts. My classmates seem to think that I am "wise." I joke that they are really saying that I am old. But this is really what they are commenting on, that I have had problems that they haven't faced, which has helped me have a different perspective on a lot of things.

That is something that I deeply appreciate about having lived on both sides of the binary gender divide, that I would have missed out on if I'd been born with a Y chromosome. I have a first hand understanding of what it is like to be seen as female compared to what it is like to be seen as male. There is a difference in how each gender is treated in many social situations and that is very informative. It isn't that a man can't imagine what a female patient is experiencing, or vice versa, but there is something to be said for having been there oneself. I'm not just guessing.

Applying to medical school as a transgender person is that much more of a hassle and worry. There are some schools that were just off limits to me entirely, like Liberty University's COM is obvious, but there are others that are less so and that I might not be aware of. All it would take is one transphobic person in a position of power to quietly close doors to me and I'd never be able to know or to prove that is why. I didn't apply to the medical school up the road from my house in Pittsburgh, because Pitt's official policy was that transgender people were required to use the restroom on their birth certificate. That policy was in force up until earlier THIS year, when a dear friend -- who Pitt had expelled over his refusal to use the women's facilities -- reached a settlement with them that seems to have included changing the policy. I had a lot of connections at Pitt, including among the medical school faculty, and it would have been a lot easier on me and my family if I could have gone there... but I didn't want to even remotely risk getting a year into medical school and being expelled. As you know, you really only get one shot at medical school... no one wants to take someone who had that shot and lost it for whatever reason. Someone who isn't transgender has that one less thing to be concerned about.

So, there was this big worry about whether to try to hide my trans identity or to be open about it in the application process. I walked a middle ground. I talked in my PS about having seen a transgender patient denied appropriate medical care due to bias on the part of a provider. I didn't identify that person as my girlfriend and and I didn't say that it had also happened to me. I definitely didn't hide anything, but I didn't go out of my way to waste space harping on details of my gender history that are irrelevant to my potential to become the physician that I want to be. So, even at my current school, there has been this sense of waiting for the other shoe to drop, worrying whether my very conservative school administration's opinions of me might be swayed by this very superficial issue. I have a consistently upbeat personality and am very pro-social, taking care of others and always seeking to lighten the mood and make things go smoothly for everyone. I'm a positive force on campus with many fans among faculty and admin. And yet, you just never know. I have heard general comments from faculty that were insensitive at best and sometimes frankly trans/homophobic. Like when, recently, one of my professors misgendered me repeatedly when mentioning me to classmates (who had my back, thankfully.) He didn't mean it to be malicious... he thought he was making a joke, that we were friendly enough that it would be a kind of funny thing to say and that I wouldn't really mind being called a girl. *sigh* (Incidentally, my presentation is not at all ambiguous. It isn't a slip of the tongue because I am not at all androgynous. I'm a middle aged balding dude with a scruffy beard who has to wear a tie due to dress code. Passing is another form of privilege, and it is one that I enjoy. Said professor wouldn't think call me a girl if we just met randomly. This was a deliberate decision to call me the wrong gender based on awareness that I am trans. For lulz. So, this is someone that I'm supposed to trust and look up to as a role model for the profession that I am entering.)

That is what makes discrimination so awful. It stabs you in the back and erodes the ground from beneath your feet. There is a sense that you must always try harder, do more, be further above reproach because you can't guess what kind of opposition you might be secretly up against. I still have one more major round through that gauntlet, in my residency application. I'm headed for FM and I have faith that I will find a spot. But if it isn't among my top choices, I'll never know whether my gender history played a role in missing out on that opportunity. It only takes one PD who disapproves of my "lifestyle." This concern is not unfamiliar to anyone who is LGBT. The world is changing, attitudes are changing, but there is so much bias out there, and medicine is very conservative in many ways. It may seem to some people who live their lives in the straight, cis, white world that folks who talk about discrimination are just belly-aching. I don't know how to convince someone who has never been burned that fire is hot. They'll just have to live long enough until it happens to them for one reason or another, and then they can see what we were talking about.

It is one of the reasons that I want to be a solo doc, doing private practice and not working as an employee of others. I want to get into a position where I can minimize the amount of control that others can exert over me, and thus limit the impact that anti-trans bias can have on my career. Patients can discriminate all they like and I welcome having patients choose to go to a different doctor if they aren't comfortable being treated by someone like me. That will free up my time to care for those who've had trouble to find doctors willing to care for people like them.

Sorry, this is long. I even edited to be more concise. There is just a lot to unpack for you, and you seemed to want real answers.
 
  • Like
Reactions: 2 users

DiscusKeeper

Full Member
2+ Year Member
Joined
Jul 1, 2016
Messages
205
Reaction score
281
Wow, both of you have some pretty incredible stories. Thank you so much for sharing. I can relate to experiencing discrimination, but I think it's obvious that the trans community is forced to deal with it on a whole different level. Both of your posts definitely improved my perspective on the challenges the trans community faces. As a LGBT person, I'm always trying to learn more about the discrimination other minority groups face, whether it's sexual, gender, or ethnic minorities. I seriously appreciate your taking the time to help educate me.

I wish you both the best of luck continuing with medical school. It's certainly a challenge being a minority in medicine. You both should be incredibly proud of how much you've overcome. Succeeding in medical school is quite the feat on its own, but having to do that while dealing with discrimination and ignorance takes incredible strength.
 
  • Like
Reactions: 1 user

Guero

2QT2Bcis Plaidapus
Moderator Emeritus
10+ Year Member
Joined
Jan 20, 2010
Messages
5,305
Reaction score
472
Wow, both of you have some pretty incredible stories. Thank you so much for sharing. I can relate to experiencing discrimination, but I think it's obvious that the trans community is forced to deal with it on a whole different level. Both of your posts definitely improved my perspective on the challenges the trans community faces. As a LGBT person, I'm always trying to learn more about the discrimination other minority groups face, whether it's sexual, gender, or ethnic minorities. I seriously appreciate your taking the time to help educate me.

I wish you both the best of luck continuing with medical school. It's certainly a challenge being a minority in medicine. You both should be incredibly proud of how much you've overcome. Succeeding in medical school is quite the feat on its own, but having to do that while dealing with discrimination and ignorance takes incredible strength.

Thank you so much for the kind words. As a parting addition, FWIW, I've also experienced intra LGBTQ discrimination. Meaning others identifying as lesbian, gay, and bisexual have said and done a few very hurtful things through the years. I always find those instances the most painful, assuming they'd know better themselves after coming out and enduring the various social issues associated with their own sexuality. But it is improving.

Take care and thanks for stopping by.


Sent from my iPhone using SDN mobile
 
  • Like
Reactions: 1 user

mvenus929

Full Member
15+ Year Member
  • Joined
    Jul 6, 2006
    Messages
    7,245
    Reaction score
    2,084
    Bumping an old thread, sorry, but I have a question for whoever feels like answering.

    I'm interested in the medicine side of DSD and transgender care, and consider myself an ally to the LGBTQ population as a whole. But, I am a white, cis-gendered, heterosexual female who beyond the typical bull that all females experience, I haven't had to deal with any discrimination or difficulties that LGBTQ people do. I do, however, want to help the community, especially as it comes to awareness amongst providers and health disparities amongst patients. To that end, I am working on developing a curriculum for my residency program to help address some of these issues that I feel aren't discussed all that much. I'm not sure how much education is actually needed--I'm working on a needs assessment currently, but we had a brief SafeZone training several months ago and most of the students and residents rolled with the scenarios without blinking.

    So, my question is: how is the best way for me to be involved as an ally? Am I overstepping in my interest in the community despite not being LGBTQ myself?
     

    Guero

    2QT2Bcis Plaidapus
    Moderator Emeritus
    10+ Year Member
    Joined
    Jan 20, 2010
    Messages
    5,305
    Reaction score
    472
    Bumping an old thread, sorry, but I have a question for whoever feels like answering.

    I'm interested in the medicine side of DSD and transgender care, and consider myself an ally to the LGBTQ population as a whole. But, I am a white, cis-gendered, heterosexual female who beyond the typical bull that all females experience, I haven't had to deal with any discrimination or difficulties that LGBTQ people do. I do, however, want to help the community, especially as it comes to awareness amongst providers and health disparities amongst patients. To that end, I am working on developing a curriculum for my residency program to help address some of these issues that I feel aren't discussed all that much. I'm not sure how much education is actually needed--I'm working on a needs assessment currently, but we had a brief SafeZone training several months ago and most of the students and residents rolled with the scenarios without blinking.

    So, my question is: how is the best way for me to be involved as an ally? Am I overstepping in my interest in the community despite not being LGBTQ myself?

    Thank you so much for stopping by and helping us spread much needed education, especially in GME settings. You're not at all overstepping by showing interest. That does however happen on occasion when we as LGBTQ identified individuals are overshadowed by allies speaking as self-proclaimed, authoritative figures and make mistakes in verbiage or make blanket statements assuming one thing applies to all. It perpetuates misinformed hegemony. This very thing has happened in the past at LGBTQ specific educational conference sessions and the like.

    I'll post a link to this thread to some of my trans and gender non-conforming colleagues that might have more time than I currently do to provide additional and more specific substance (currently on surgery).

    Thanks again for stopping by! I look forward to seeing more replies soon.


    Sent from my iPhone using SDN mobile
     
    Last edited:

    Guero

    2QT2Bcis Plaidapus
    Moderator Emeritus
    10+ Year Member
    Joined
    Jan 20, 2010
    Messages
    5,305
    Reaction score
    472
    Just as an update, someone replied and said she'd make an account to post a reply. Stay tuned :)

    I'll also offer more substantive advice myself as soon as I'm able. Are you working on a deadline, @mvenus929 ?


    Sent from my iPhone using SDN mobile
     

    mvenus929

    Full Member
    15+ Year Member
  • Joined
    Jul 6, 2006
    Messages
    7,245
    Reaction score
    2,084
    Just as an update, someone replied and said she'd make an account to post a reply. Stay tuned :)

    I'll also offer more substantive advice myself as soon as I'm able. Are you working on a deadline, @mvenus929 ?


    Sent from my iPhone using SDN mobile

    I'm giving a lecture at the end of March, but this is one of my chief projects, so realistically a year or so
     

    witch-doctor

    New Member
    2+ Year Member
    Joined
    Jan 25, 2017
    Messages
    4
    Reaction score
    6
    YES. This has been an issue for me, as a family doctor at a community health center. I have seen a few transgender patients there, mostly because they don't have insurance and we will see them at a discounted price if their income is low enough.

    I have seen almost exclusively MTF transgender patients (no reason for why, that's just how it's shaken out). I'm familiar with prescribing these same hormones for other things (dysmenorrhea, contraception, etc), and I would like to think that I'm reasonably open minded. But I have to admit to a great deal of trepidation when I have prescribed these meds. At what age do I stop? Do you ever stop prescribing hormones? What if I give this very pleasant 63yo MTF transgender patient a stroke or a DVT or a PE or something, because her age and the hormone use put her at increased risk for a clot? Do I taper off the hormones, thereby mimicking the menopause that a biologic female would experience? Do I give her the hormones AND an aspirin, hoping that that somehow mitigates the risk? I really have no idea, and there is very little guidance on this. Even the guidelines released by medical societies don't make this clear....I assume that this means that no one really knows the answer? I can't send her to endocrine because she doesn't have insurance and lives on a pretty fixed income. The best I can do is have an open discussion that I'm not a specialist, I don't really know the answers to my own questions, and there is a risk of a clot (although I could be overblowing the risk)....but I still feel like I'm doing her a disservice.

    <sigh> So many questions.
    As a transgender female, I would say that that is where informed consent comes in. If the patient is aware of the risks and wants to proceed, then it is probably best to do so. The hormones reduce the risk of suicide, a risk that is probably higher than the risk of a stroke, DVT or PE.
     
    • Like
    Reactions: 1 user

    witch-doctor

    New Member
    2+ Year Member
    Joined
    Jan 25, 2017
    Messages
    4
    Reaction score
    6
    Am I overstepping in my interest in the community despite not being LGBTQ myself?

    Not at all. We need people who are not LGBTQ in our corner in order to increase society's acceptance of the LGBTQ community.
     
    • Like
    Reactions: 2 users

    FutureDrLGBTQ

    New Member
    Joined
    Feb 14, 2017
    Messages
    1
    Reaction score
    0
    Does anyone have any experience being upfront (and center) with your identity while applying to medical school?

    I'm obviously going to emphasize my science chops, research background, and other features of being a "non-traditional student," but have others applied highlighting their identity as a gender and/or sexual minority?

    Thanks!

    As you may've read in the stickies, I'm currently a third year medical student identifying as transfemme and genderqueer, more of a non-binary swaying identity. I came out during my second year. And @otterxavier is a first year medical student identifying as a transman. I'll update this specific post as time moves on, eventually leaving it all to @otterxavier and creating a new thread, "Ask a trans resident" once I graduate. Please feel free to pick our brains. We're happy to help. :)
     

    Guero

    2QT2Bcis Plaidapus
    Moderator Emeritus
    10+ Year Member
    Joined
    Jan 20, 2010
    Messages
    5,305
    Reaction score
    472
    I'm giving a lecture at the end of March, but this is one of my chief projects, so realistically a year or so
    I'm so sorry for the delay. My surgical hours have been on par. I'm also sorry that none of my colleagues have yet had a chance to offer additional advice.

    Here are some resources that might help in the interim:
    A premier source for LGBTQ Med-Ed: http://med.stanford.edu/lgbt/
    AAMC's 2014 statement and guidelines: http://offers.aamc.org/lgbt-dsd-health
    An osteopathic resource: http://jaoa.org/article.aspx?articleid=2488030

    I'd also be more than happy to answer specific questions you might have now that we're so close to your presentation. My shelf is next week; so I'll have much more time than the last two months to communicate further. I'm also eager to work further with you in the coming year if you're open to collaborating. Please feel free to send me a PM. :)

    I hope this helps. And once again, I can't thank you enough for your interest in taking a giant leap forward to integrate LGBTQ issues into the realm of GME.
     
    • Like
    Reactions: 1 user

    Guero

    2QT2Bcis Plaidapus
    Moderator Emeritus
    10+ Year Member
    Joined
    Jan 20, 2010
    Messages
    5,305
    Reaction score
    472
    Does anyone have any experience being upfront (and center) with your identity while applying to medical school?

    I'm obviously going to emphasize my science chops, research background, and other features of being a "non-traditional student," but have others applied highlighting their identity as a gender and/or sexual minority?

    Thanks!
    I've known many friends and colleagues that fell on all sides of this complex issue, some that highlighted their experiences in applications with narratives that guided them to medicine, others that left it completely out while surveying each school on interviews, and some that said nothing in applications, but opened up during interviews or at diversity sponsored sessions. If you look at the resource sticky, there are links to forums where others have debated the pros and cons of being Out, highlighting their narratives, and flying under the radar. :)
     

    mvenus929

    Full Member
    15+ Year Member
  • Joined
    Jul 6, 2006
    Messages
    7,245
    Reaction score
    2,084
    I'm so sorry for the delay. My surgical hours have been on par. I'm also sorry that none of my colleagues have yet had a chance to offer additional advice.

    Here are some resources that might help in the interim:
    A premier source for LGBTQ Med-Ed: http://med.stanford.edu/lgbt/
    AAMC's 2014 statement and guidelines: http://offers.aamc.org/lgbt-dsd-health
    An osteopathic resource: http://jaoa.org/article.aspx?articleid=2488030

    I'd also be more than happy to answer specific questions you might have now that we're so close to your presentation. My shelf is next week; so I'll have much more time than the last two months to communicate further. I'm also eager to work further with you in the coming year if you're open to collaborating. Please feel free to send me a PM. :)

    I hope this helps. And once again, I can't thank you enough for your interest in taking a giant leap forward to integrate LGBTQ issues into the realm of GME.
    I already had the AAMC article, but thanks for the others. I'm hopefully submitting my non research IRB within the next day or two to do a needs assessment of the residents and the health system. I've gotten pretty overwhelming support in to from my PD and the faculty members I've approached. I haven't looked at my PowerPoint lately, as I've been doing other research in my free time, but I have a research block coming up and will work in it more then. I'll definitely PM you when I start working on things again :)
     
    • Like
    Reactions: 1 user

    azael5petra

    Full Member
    Joined
    Apr 8, 2015
    Messages
    36
    Reaction score
    1
    Are any of you getting training for being able to provide and manage hormones or even do surgeries for trans patients? Also how did you get involved with that? Also besides the actual transition aspect of gender identity the risk for suicide is a serious thing. I've lost a trans friend to suicide and was wondering how doctors were able to address that aspect of the individuals health. Can you describe how you want doctors to handle addressing mental health and preventing suicide?
     

    tantacles

    Full Member
    Moderator Emeritus
    Lifetime Donor
    10+ Year Member
    Joined
    Sep 28, 2009
    Messages
    9,187
    Reaction score
    3,695
    Are any of you getting training for being able to provide and manage hormones or even do surgeries for trans patients? Also how did you get involved with that? Also besides the actual transition aspect of gender identity the risk for suicide is a serious thing. I've lost a trans friend to suicide and was wondering how doctors were able to address that aspect of the individuals health. Can you describe how you want doctors to handle addressing mental health and preventing suicide?

    Not to be overly brusque, but simply asking about it would be a good start. Asking explicitly about mental health is something that often simply doesn't happen in many appointments.
     

    Guero

    2QT2Bcis Plaidapus
    Moderator Emeritus
    10+ Year Member
    Joined
    Jan 20, 2010
    Messages
    5,305
    Reaction score
    472
    Are any of you getting training for being able to provide and manage hormones or even do surgeries for trans patients? Also how did you get involved with that? Also besides the actual transition aspect of gender identity the risk for suicide is a serious thing. I've lost a trans friend to suicide and was wondering how doctors were able to address that aspect of the individuals health. Can you describe how you want doctors to handle addressing mental health and preventing suicide?
    Sadly, most programs fail to incorporate HRT training in their curriculum. However, UCSF makes these simple guidelines readily available on their website and have been added to UpToDate (our main resource for guidance on standardized evaluation and treatment, known as evidenced based medicine). Despite its simplicity, many providers blame their inexperience and discomfort practicing management for declining to provide such care. It happened at our own student health and among providers in our community. But we're working tirelessly to end such ignorance and reluctance via policy changes and increasing graduate medical education in trans health.

    Gender affirming surgery training comes after completing a surgical residency (urology, plastics, pelvic) and either doing a formal fellowship or training as an apprentice under an experienced surgeon.
    Not to be overly brusque, but simply asking about it would be a good start. Asking explicitly about mental health is something that often simply doesn't happen in many appointments.

    Exactly, asking "What do you do for fun?" has an extraordinarily high specificity for depression when the patient struggles heavily to respond or has nothing to offer, hinting that anhedonia may be present.

    Furthermore, asking pediatric and adult patients of every gender and sexual orientation if they "feel safe and supported at home" not only screens for domestic violence, but also child abuse, depression, neglect, and hostile living environments.


    Sent from my iPhone using SDN mobile
     

    Gauss44

    Full Member
    5+ Year Member
    Joined
    Oct 28, 2012
    Messages
    3,185
    Reaction score
    416
    So, my question is: how is the best way for me to be involved as an ally? Am I overstepping in my interest in the community despite not being LGBTQ myself?

    I don't think there is any one answer to that question. My answer is to get other people to question their assumptions and generalizations. Set a positive tone and demonstrate inclusiveness and tolerance.
     
    • Like
    Reactions: 1 user

    Guero

    2QT2Bcis Plaidapus
    Moderator Emeritus
    10+ Year Member
    Joined
    Jan 20, 2010
    Messages
    5,305
    Reaction score
    472
    Bumping for those subscribed to see the updated introduction. Have a great day!
     
    • Like
    Reactions: 1 user

    Slytherclaw

    Full Member
    2+ Year Member
    Joined
    Apr 25, 2017
    Messages
    23
    Reaction score
    20
    Does anyone have any experience being upfront (and center) with your identity while applying to medical school?

    I'm obviously going to emphasize my science chops, research background, and other features of being a "non-traditional student," but have others applied highlighting their identity as a gender and/or sexual minority?

    Thanks!

    Thank you all for this forum. I'm a non-trad re-applicant who started medically transitioning this summer and came out as a trans woman on my app this year. Coming out trans was central to my app this year, especially detailing how I progressed since last year when I was identifying outwardly as a gay man to all but a few faculty, friends and admin. Last year I did a lot of contextualizing on my app about coming to my conservative immigrant parents as gay many years ago, before I realized that I could obtain the resources to transition. This year, I focused significantly on the leadership skills I have being honing through the last 10 years, my research and GPA/MCAT remediation. Due to the stereotypical things transitioning, low-income trans women of color face, it was hard being personal enough last year on my primary statement given I was just exhausted with delaying medical transition for any longer due to money insurance and personal issues.

    Nevertheless, this cycle, I've had really positive experiences talking with folks from Office of Diversity and Inclusion, Student Affairs staff as well as a few faculty at various institutions. I very much appreciated being able to have multiple options to indicate my gender as genderqueer/trans woman on AMCAS this year as well. Because my employer (ironically under HHS) has coverage exclusions against all care for gender dysphoria, I plan to present conventionally as a woman full-time after FFS in spring/summer next year. If I'm lucky enough to be granted an interview again this year, I plan to present in masculine clothing probably being interpreted by my fellow applicants as a man, to avoid unwanted attention during the application cycle.

    I was also surprised to learn about the inclusive curriculum and pedagogy initiatives being championed by multiple schools, other the usual ones on the coasts, particularly in the South and Midwest. It's inspiring to witness the the tide slowly changing from perspective outside the medical community, as a trans woman of color in her late 20s. It's scary to think that a trans woman MD-PhD left medicine from discrimination during residency, though that's unfortunately not surprising. Being a physician scientist has been my dream for a decade and I hope somewhat cautiously that enough progress has been made wherever I end up.

    Have any current trans med students presented on any research for conferences and the like related to LGBTQIA+ care that could talk about it here or via PM?
     
    Last edited:
    • Like
    Reactions: 2 users

    Guero

    2QT2Bcis Plaidapus
    Moderator Emeritus
    10+ Year Member
    Joined
    Jan 20, 2010
    Messages
    5,305
    Reaction score
    472
    Welcome! Thank you for sharing your bravery, struggles, and successes. You've certainly come a long way. I wish you the best of luck in moving forward and hope to hear good things in the coming months. :)
     
    • Like
    Reactions: 1 user

    JMoto

    Full Member
    7+ Year Member
    Joined
    Jan 23, 2010
    Messages
    11
    Reaction score
    4
    Anyone know of any type of community classes open to those who'd like to be advocates? I'm a lesbian but would love to better understand the Trans population! (I live in SF so that might be easier to find?)
     

    Guero

    2QT2Bcis Plaidapus
    Moderator Emeritus
    10+ Year Member
    Joined
    Jan 20, 2010
    Messages
    5,305
    Reaction score
    472
    Anyone know of any type of community classes open to those who'd like to be advocates? I'm a lesbian but would love to better understand the Trans population! (I live in SF so that might be easier to find?)
    There are usually plenty of workshops available through UCSF and Kaiser SF. I'd google around to see if you can find any upcoming events. Failing that, contacting a coordinator from one of the Trans oriented clinics would be a good idea. Good luck and thanks for your support!
     
    • Like
    Reactions: 1 user

    harkas

    MD C/O 2022
    2+ Year Member
    Joined
    May 2, 2017
    Messages
    448
    Reaction score
    362
    I wanted to pop in and give everyone an update.

    I tried again. A different FM doctor here in town. I related the experiences I'd had seeking care and that I've been on a steady dose for a decade, with no issues other than difficulty finding someone to care for me. I provided access to several years worth of labs which show that everything is steady state and nothing to be concerned about. I explained that I'm getting tired of fighting this battle and that I was prepared to come off testosterone if he wouldn't prescribe it. I have mild HTN and a few other concerns that really need to be addressed with a stable primary care provider, and I couldn't afford to let those things slide anymore while I doctor shopped. I laid everything on the line, including that, if he wasn't willing to prescribe my hormone for me, I was going to need him to help me cope with the side effects of castration, starting with at least one antidepressant and probably a referral to psych to manage the inevitable mental and emotional crisis that would soon manifest.

    This proved an effective argument, and he is willing to prescribe for me, at least while I'm in school.

    I talked to him the way that I want to talk to my patients... I presented him with information, options, and likely outcomes and invited him to make the decision about how he wanted to proceed, while I was equally ready to accept and implement his choice. This is a kind of backwards approach to informed consent, but it wasn't reverse psychology. There was a real meeting of minds, as I was very honest about what his decision would mean for me and sincere in my acceptance of it either way, and he was actually listening and demonstrating respect for me, too.

    Blessedly, with that out of the way, we were able to make some good progress on some of the more mundane issues, and it was probably one of the most thorough primary care visits I've ever had. I left with homework - a prescription for diet and exercise modifications as well as for the meds that I needed.

    It is wonderful to have some good role models to balance against some of the negative examples that I've acquired along the way.

    Thank you sharing your experience. I'm hoping to work in some kind of primary care field or internal medicine subspecialty and hopefully become known in my community as physician who is competent for providing LGBTQIA medical care. It sounds like most doctors aren't very good with this, but I'm glad you were able to make progress with your PCP.

    I would love to learn more. As a trans individual and in your own opinion/experiences, what other problems do physicians have when it comes to providing competent care and making sure their patients continue to come back to them? I know using proper pronouns is very important, but what other things can they (and eventually, me) do better?
     
    • Like
    Reactions: 1 user

    TotesFetch

    New Member
    Joined
    Nov 5, 2017
    Messages
    3
    Reaction score
    8
    Hello all! I'm currently an M1 (and an out trans woman). I finally made the effort (i.e. found the time) to look for a thread such as this. I don't have any particular questions, but I'm excited to join this conversation and offer whatever help/support I can!

    @harkas I deeply respect the kindness and humility you've displayed by asking such a question. To answer your question, I am of the opinion that providing quality care to sexual and gender minorities has two major facets: respect and (appropriate) specificity.

    Respect is honestly the easier of the two. Based on what I perceive about you, you care deeply for people, and thus, for patients. That is 90% of the battle! The rest (beyond appropriate titles/pronouns) is maintaining appropriate boundaries. For example, if you have a patient who you perceive to be trans, try to avoid asking questions of curiosity unless they open the door to the subject. However, if the question is directly related to the visit, or if you just want to ask if they are managing well/finding adequate support, then feel free to ask (gently)!

    Regarding the other portion, members of the LGBTQI community do have unique health needs and are at greater risk for certain conditions. As one example, if a gay AA male presents to your clinic, then one thing that should come to mind is that he faces a statistically higher risk for contracting HIV. However, it is key to remember that this ignores individual variables (e.g. number of partners, condom usage, etc.). As another example, if a trans woman presents, then comprehensive care would require a knowledge of past surgeries (if any) so that current/preventative care can be tailored. For example, if she previously underwent GCS (i.e. surgical change of genitals) and is currently on estrogen, then she would likely need preventative care related to her breasts and vagina. However, it is not widespread knowledge that the prostate is almost always (if not always) left intact. Thus, she would still need age-appropriate prostate screening.

    I hope this was helpful. Note that I am not a physician (yet), so this is simply my opinion based on personal experience and personal research. Feel free to ask any further questions!
     
    • Like
    Reactions: 3 users

    harkas

    MD C/O 2022
    2+ Year Member
    Joined
    May 2, 2017
    Messages
    448
    Reaction score
    362
    Hello all! I'm currently an M1 (and an out trans woman). I finally made the effort (i.e. found the time) to look for a thread such as this. I don't have any particular questions, but I'm excited to join this conversation and offer whatever help/support I can!

    @harkas I deeply respect the kindness and humility you've displayed by asking such a question. To answer your question, I am of the opinion that providing quality care to sexual and gender minorities has two major facets: respect and (appropriate) specificity.

    Respect is honestly the easier of the two. Based on what I perceive about you, you care deeply for people, and thus, for patients. That is 90% of the battle! The rest (beyond appropriate titles/pronouns) is maintaining appropriate boundaries. For example, if you have a patient who you perceive to be trans, try to avoid asking questions of curiosity unless they open the door to the subject. However, if the question is directly related to the visit, or if you just want to ask if they are managing well/finding adequate support, then feel free to ask (gently)!

    Regarding the other portion, members of the LGBTQI community do have unique health needs and are at greater risk for certain conditions. As one example, if a gay AA male presents to your clinic, then one thing that should come to mind is that he faces a statistically higher risk for contracting HIV. However, it is key to remember that this ignores individual variables (e.g. number of partners, condom usage, etc.). As another example, if a trans woman presents, then comprehensive care would require a knowledge of past surgeries (if any) so that current/preventative care can be tailored. For example, if she previously underwent GCS (i.e. surgical change of genitals) and is currently on estrogen, then she would likely need preventative care related to her breasts and vagina. However, it is not widespread knowledge that the prostate is almost always (if not always) left intact. Thus, she would still need age-appropriate prostate screening.

    I hope this was helpful. Note that I am not a physician (yet), so this is simply my opinion based on personal experience and personal research. Feel free to ask any further questions!

    This was incredibly helpful, thank you. Do you have any resources you would recommend to gain a better understanding of LGBTQI health needs? I never thought about considering the prostate in a trans woman who underwent GCS. I guess it's possible to learn this stuff in residency or my rotations in the future but I highly doubt it.
     

    TotesFetch

    New Member
    Joined
    Nov 5, 2017
    Messages
    3
    Reaction score
    8
    @harkas In terms of trans info, WPATH probably offers quality stuff. For relevant research articles, Pubmed is definitely not lacking. Items of interest for research might involve the following: LGBT discrimination in healthcare, GCS (or any synonyms like vaginoplasty, phalloplasty, etc.), disparities with infections, disparities in cancer screening, increased risk of depression and suicide, HRT (and the trans woman/trans man gap for treatment access; also, regional disparities regarding HRT access for anyone). Note that this is not all inclusive, and it also reflects my own fledgling understanding of the diverse needs of the broader LGBT community (for example, I am not well-studied with the challenges faced by those who are intersex). However, I'm sure these will allow you to stumble upon other relevant topics as well!
     
    • Like
    Reactions: 1 user
    Top