Care of the Transgender Patient

CARE OF THE TRANSGENDER PATIENT

Roy C. Ziegelstein, MD, MACP
Johns Hopkins University School of Medicine, Baltimore, Maryland

Address for Correspondence:

Roy C. Ziegelstein, MD, MACP
Sarah Miller Coulson and Frank L. Coulson, Jr., Professor of Medicine
Mary Wallace Stanton Professor of Education
Vice Dean for Education, Johns Hopkins University School of Medicine
Miller Research Building, 733 N. Broadway, Suite 115
Baltimore, MD 21205
 
TO THE EDITOR:

Safer and Tangpricha’s well-written guide to the care of transgender patients(1) provides helpful recommendations to clinicians about this important topic. However, one question the article does not address is the training needed for health care providers to become competent to care for transgender individuals. The authors note that it is reasonable for transgender patients to be cared for by primary care clinicians "with appropriate knowledge" or “with appropriate training” however what constitutes appropriate knowledge or training is not defined. The article provides a Care of the Transgender Patient “Tool Kit” with helpful resources, and this tool kit might have been even more helpful if the section labeled “Information for Health Professionals” had been annotated to indicate how primary care clinicians might obtain appropriate knowledge or training to care for transgender patients.

In their guide, Safer and Tangpricha note, "For adult patients, primary care providers with fewer patients on their panels may find it useful to refer transgender patients to qualified mental health providers for assistance with transgender assessment and to endocrinologists for guidance on initiation of hormone therapy (if desired by the patient)."1 This begs the question of when, and under what circumstances, it is medically appropriate for a primary care clinician to provide care to a transgender patient and instead when referral might be in the patient’s best interest.

Barbara Starfield, the renowned primary care advocate, described four cardinal functions of effective primary care, including comprehensiveness, which she defines as “addressing all health-related needs in the population except those too uncommon to maintain competence.”(2)It is estimated that roughly 1.4 million adults in the United States identify as transgender, approximately 0.58% of the population.(3) Depending on the size and characteristics of a primary care clinician’s panel, it is possible that the provider will have very few, if any, transgender patients and this type of care may therefore be too uncommon for certain providers to maintain competence. In this context, it is noteworthy that the British Medical Association’s General Practitioners Committee has indicated that prescribing hormonal therapy is outside of a general practitioner’s expertise and the General Medical Council has indicated several scenarios when it may be appropriate for a general practitioner to prescribe hormonal therapy until patients are seen by a specialist.(4) Could the authors provide some guidance on this important issue?

References
1. Safer JD, Tangpricha V. Care of the transgender patient. Ann Intern Med 2019 Jul 2;171(1):ITC1-ITC16. doi: 10.7326/AITC201907020.

2. Flores AR, Herman JL, Gates GJ, et al. How many adults identify as transgender in the United States? Los Angeles, CA: The Williams Institute, 2016.

3. Cliffe C, Hillyard M, Joseph A, et al. The transgender patient in primary care: practical advice for a 10-minute consultation. BJGP Open. 2017 Oct; 1(3): bjgpopen17X101001

4. Starfield B. Primary care and equity in health: the importance to effectiveness and equity of responsiveness to peoples’ needs. Humanity Soc 2009; 33: 56-73.

Dr. Ziegelstein raises two important issues. The first concern is the training need for health care providers to be able to provide transgender care. Incorporation of transgender training in conventional medical curricula will eventually obviate the need for specialized training for most clinicians. However, in the interim, training by the World Professional Association for Transgender Health (WPATH) and specialty societies fills the gap in part. There are limited data regarding the degree to which existing training fills the need and what further programming would be required to upgrade the capacity of the current clinician workforce to provide quality transgender care (1). Guidance like that provided in our Annals of Internal Medicine In the Clinic piece on Care of the Transgender Patient serves as part of the solution. The second concern is that transgender care may be too uncommon for providers to maintain competence. Like for other areas in medicine, different clinicians will have different degrees of exposure with a range of elements of transgender care that they would feel safe providing. Some will initiate hormone therapy routinely and only refer patients with more complex scenarios to specialists and some will see transgender patients only rarely with the referral to the specialist to initiate a hormone regimen being the norm. We would not make a blanket statement that prescribing hormone therapy is per se outside the general practitioner’s expertise. Any physician with a panel size greater than 200 patients is likely to see transgender patients and should have comfort providing care at some level including cancer surveillance like for other patients, hormone refills like for other medication regimens that might have been specialist initiated, and essential primary care.

JDS, VT


1. Korpaisarn S, Safer JD. Gaps in transgender medical education among healthcare providers: A major barrier to care for transgender persons. Rev Endocr Metab Disord 2018;19:271-5.

As a provider of transgender care, I read with appreciation and interest In the Clinic: Care of The Transgender Patient. Having been a provider of menopausal hormones for many years before becoming a trans provider, and as a member of the North American Menopause Society (NAMS) since its inception, I have always followed the NAMS evidence-based Position Statements and treatment guidelines through the years. To my knowledge, NAMS has never endorsed injectable estradiol because of the lack of safety data and the variable pharmacokinetics including unequable bioavailability and notable peak/trough effect. The article by Drs Safer and Tangpricha reflects the commonly accepted recommendation that oral, transdermal and injectable estradiol valerate are all reasonable options. However, I can find no evidence that supports the use of injectable estradiol. If we are to support evidence based practice, it raises concern to use a different safety standard for transwomen than for cis women. It also seems objectionable to incur the risk of putting more needles and syringes into the general population, creating more plastic and sharps waste, and potential health hazards that are avoidable, especially when other options are effective and available. While exceptions sometimes need to be made, the use of transdermal and oral estradiol are supported by data. Is there a rationale for promoting injectable estradiol?

“Care of the Transgender Patient”(1) provides a comprehensive summary of the unique clinical considerations relevant to the care of transgender and gender nonconforming individuals. Gender minorities are at higher risk of hazardous substance use and substance use disorders, due to gender minority stress, stigma, discrimination, trauma, and isolation(2). Screening, brief intervention, and referral to culturally competent treatment for hazardous substance use, including psychiatric treatment if indicated, are essential in this population.

Notably, current screening methods for hazardous drinking may be insufficient for transgender patient populations. Current drinking guidelines in the United States (U.S.) for hazardous alcohol use (greater than 4 standard drinks per day or greater than 14 drinks per week for men below age 65 (one standard drink=14 grams pure alcohol) and greater than 3 standard drinks per day or greater than 7 standard drinks per week for women of any age and men over 65) are based on epidemiological data for cisgender men and women(3). However, no hazardous alcohol use cutoffs have been established for transgender individuals, who may be vulnerable to the adverse effects of alcohol at lower levels than established U.S. cutoffs. Heavy alcohol use is associated with interpersonal violence, sexual assault, physical assault, depression, sexually transmitted infections, and suicide, and this risk may be increased in transgender patients relative to cisgender patients(2). It is also unknown whether osteoporosis, cancer, and other adverse health outcomes associated with alcohol use may occur at lower drinking levels for transgender and gender nonconforming patients receiving hormonal therapies, given hypogonadism and hormonal shifts. For these reasons it may be prudent to use the lower screening cutoffs established for women and individuals over 65 for hazardous drinking in transgender patients until more data is available.

Tobacco use should also be proactively screened for and treated in transgender populations. Some studies report that use of tobacco products is higher in transgender youth relative to cisgender youth(4), though recent data suggest that the prevalence of tobacco use in adult transgender and cisgender populations is similar(5). The high risk of thromboembolic events with concurrent cigarette use and chronic estrogen administration warrants a proactive approach to screening and treatment.

In summary, screening and referral to trauma-informed substance use and psychiatric treatment, surveillance for hazardous substance use at low levels, and awareness of potential medical complications associated with hormonal therapies in the setting of problematic substance use are best practices in the care of transgender patient.

References

1. Safer JD, Tangpricha V. Care of the Transgender Patient. Ann Intern Med. 2019;171(1):ITC1-ITC16. doi: 10.7326/AITC201907020. PubMed PMID: 31261405.
2. Gilbert PA, Pass LE, Keuroghlian AS, et al. Alcohol research with transgender populations: A systematic review and recommendations to strengthen future studies. Drug Alcohol Depend. 2018;186:138-46. Epub 2018/03/10. doi: 10.1016/j.drugalcdep.2018.01.016. PubMed PMID: 29571076; PubMed Central PMCID: PMCPMC5911250.
3. US Department of Health and Human Services. Dietary Guidelines for Americans 2015-2020, Appendix 9: Alcohol. https://health.gov/dietaryguidelines/2015/guidelines/appendix-9/. Accessed July 15, 2019.
4. Johnson SE, O'Brien EK, Coleman B, et al. Sexual and Gender Minority U.S. Youth Tobacco Use: Population Assessment of Tobacco and Health (PATH) Study Wave 3, 2015-2016. Am J Prev Med. 2019;57(2):256-61. doi: 10.1016/j.amepre.2019.03.021. PubMed PMID: 31326009.
5. Wheldon CW, Wiseman KP. Tobacco Use Among Transgender and Gender Non-conforming Adults in the United States. Tob Use Insights. 2019;12:1179173X19849419. Epub 2019/05/23. doi: 10.1177/1179173X19849419. PubMed PMID: 31205426; PubMed Central PMCID: PMCPMC6535756.

Disclosures: The views expressed in this comment do not represent the views of the Department of Veterans Affairs or the United States Government.

Dr. Klein raises important concerns regarding the relative safety among routes of estrogen administration and makes a logical argument for the potential that there is greater risk for harm with injectable estrogens. Absent data, there is no rationale for promoting injectable estradiol over other products but neither are there data to definitively proscribe it.


Drs. Herbst, Harris, Pennington, and Batki present a thoughtful, conservative approach to screening transgender individuals for substance use, mental health morbidity, and medical concerns. Future research will be needed to learn the utility of specific elements of their proposal.



JDS, VT

You are incorrect to assert the following:

"Targeting specific medical conditions for discriminatory behavior is a straightforward violation of standard professional practice. Most major medical societies are developing best practices related to transgender health care."

It is a federal crime that is in violation of the Religious Freedom Act to force a clinician to act against his or her moral and ethical beliefs. It also violates the the Medical Conscience Objection clause.

The following is the federal standard regarding this topic:

"Federal statutes protect health care provider conscience rights and prohibit recipients of certain federal funds from discriminating against health care providers who refuse to participate in these services based on moral objections or religious beliefs."

I respectfully ask you to correct the author's disinformation.