Caring for your Trans Patients
Doctors’ attitudes can make a difference
By Stuart Foxman
As Elijah Colgan was leaving his appointment, the doctor said, “Have a good day, ma’am,” which struck Colgan as odd. For one, he’s a transgender male and the doctor was well-aware of that. After all, the doctor had just seen him for a hormone shot.
It wasn’t an isolated incident. Colgan was once talking to another Ontario doctor when the topic of gender arose. It was unrelated to the purpose of the visit. The doctor asked Colgan if he played with Barbies or Lego as a kid. “I got pissed off.”
Such encounters can do more than create negative experiences; they can drive trans people away from care.
In 2020, Trans PULSE Canada reported 45 percent of transgender and non-binary people surveyed had one or more unmet health care needs in the previous year. That’s despite the fact 81 percent had a primary health care provider. The 45 percent contrasts with just 4 percent of the general population who said they had an unmet health care need.
Trans PULSE also found 12 percent of trans and non-binary respondents avoided going to emergency in the past year despite requiring care.
That’s alarming, says Dr. Greta Bauer, principal investigator on the study and a professor at Western University’s Schulich School of Medicine & Dentistry. Some people, she says, clearly feel safer outside the emergency room than inside. The anticipation of mistreatment or discrimination becomes a barrier to care.
Dr. Carys Massarella gets it. She has worked in a clinic for transgender patients and is an emergency room physician at St. Joseph’s Healthcare in Hamilton. How bad can the comments and judgments get? “It’s not even subtle,” says Dr. Massarella.
In health care, she says trans patients can be misgendered, called by their dead name (their birth name, not what they use now), considered confused, or seen as a curiosity.
“It limits access to affirming, competent transgender health care,” says Dr. Massarella.
One explanation is a lack of training, but maybe that’s being generous. There’s transphobia in society and the medical community isn’t immune. “Physicians are like anyone else,” says Dr. Massarella.
It’s no wonder so many trans patients avoid visiting the doctor or get apprehensive about seeing one. Dr. Massarella has felt it as a trans person herself. She transitioned in 2008, at age 42, and is now a leading transgender advocate.
As a patient, she admits to being anxious about her own health care. “Even when I’d go see my colleagues, I’d be nervous,” she said.
What are some biases that doctors might bring when seeing trans patients, how can that manifest, and what would make for better care?
What is trans health?
Being trans isn’t a pathology; it’s an identity that relates to your internal experience of gender. That may or may not be distinct from gender expression, i.e., the way you publicly present that identity. (Sex, meanwhile, refers to physical aspects of the body, like genitals, hormones, etc. And sexual attraction is about desire or interest.)
Like any segment of the population, trans people have all sorts of backgrounds, stories, hopes, needs, worries and wants. Yet, common myths follow people who are trans, even to the doctor, such as they’re misguided, depressed or ill. These are stereotypes. Anyone is best cared for when seen as an individual.
“Just treat the person in front of you as the whole person they are,” says Dr. Michael Marshall, president of the Canadian Professional Association for Transgender Health.
This doesn’t always happen with trans patients.
“They’ve had so many traumatic experiences talking to health-care providers,” says Dr. Kate Greenaway, lead physician at Connect-Clinic, a telemedicine-based trans health care program for people across Ontario.
So much so, Dr. Greenaway says, patients can be relieved just by feeling they’re not in a high-stakes encounter.
This isn’t ancient history. “The perception of trans and non-binary people as mentally ill persists in some facets of the medical community,” says Dr. Amy Bourns, a physician on the LGBT2SQ Health Team at Sherbourne Health in Toronto.
People can face physician biases in many ways. Dr. Bauer was lead author of a study that asked trans patients who had a regular family doctor (83 percent did) how often they ran into certain experiences with them. About 6 percent said the doctor simply refused to see them because they’re trans. Another 10 percent had a doctor tell them they weren’t really trans. About 7 percent said a doctor belittled or ridiculed them for being trans. And 11 percent said a doctor used hurtful or insulting language about trans identity or experience.
Those numbers are disturbing enough. Perhaps just as troubling: 27 percent of trans patients reported their doctor said they didn’t know enough about trans-related care to provide it. Which raises two questions. Why don’t you know enough? And just what is trans health?
Most care needs have nothing to do with transition events, says Dr. Massarella. It doesn’t involve hormones, genitals or anything else specific to being trans.
“Some doctors will literally ask, ‘Have you had the surgery?’ I say, ‘Yeah, I’ve had my gall bladder out,’” Dr. Massarella says.
In her view, “95 percent of health care is irrelevant to whether you’re transgender.”
So, in one sense, you don’t have to look at trans health as a specialized area, says Dr. Kat Butler, an anesthesia resident at the University of Toronto and co-author of a recent paper on transgender health in medical education (Bulletin of the World Health Organization, 2021).
“Every clinician will take care of people who are trans, whether or not they disclose that identity,” says Dr. Butler. “Trans people are people who need health care, period.”
Trans broken arm syndrome
Some doctors don’t see it that way. Dr. Marshall mentions the phenomenon of trans broken arm syndrome. That’s when a doctor assumes any medical condition a trans person experiences — from a broken bone to headaches — is related to the fact they’re trans, like a side effect of hormones.
Dr. Bauer adds it can be tougher for people who are trans to get mental health services because the provider often makes it all about gender. “That presents an additional barrier,” she says.
Here’s another: “The biggest myth I’ve spent my career trying to dispel is that transgender care is complicated,” says Dr. Greenaway. “Primary care is complicated, but I don’t feel that transgender care is more complicated.”
Dr. Marshall agrees: “If we see people as people, everybody is complicated.”
A broader assumption, says Colgan, is there’s a norm and, if someone deviates from it, that changes everything. “It doesn’t,” he says.
He has had his share of other bad medical experiences. Once, Colgan needed an ECG. He wanted to keep his chest binder on and wondered where the electrodes would go. He was shown. Explaining he’s trans, Colgan said the binder doesn’t cover those areas. So, would he still have to remove it? Yes, he was told.
It didn’t seem right, but Colgan, now upset, agreed. The results of the ECG were unclear. Colgan was informed it was because he was “too stressed and jittery”.
Dr. Massarella feels fortunate herself. Her experiences as a patient have been mostly positive. She also feels embraced in her workplace. After she came out publicly, one colleague, who she described as an old-school doctor, stopped her in the hallway. “He said, ‘I want you to know I support you 100%.’ It came from a really unexpected source.”
One day, one of the nuns in her Catholic hospital called Dr. Massarella and told her this: “Don’t ever worry about working here. You’re a wonderful role model, someone we should celebrate.”
Not every trans person feels as supported, in life or in the health-care system.
Coming out as trans to a doctor is not always easy. Dr. Massarella knows the response is too often a pat on the shoulder and an admission that “I don’t know what to do.” Other times, she says, doctors flat out tell patients they don’t believe in being trans and it will ruin the patient’s life.
“Historically, that has led to a lot of distrust,” says Dr. Massarella.
Bad experiences can come in many forms. Dr. Massarella says doctors might think they’re being complimentary when they tell a trans patient it’s amazing how good they look. Or that they wouldn’t be able to tell. “It’s insulting,” she says.
The message is that the trans person is defying expectations about how they should appear, or that they’re out to trick the world. Those “compliments” aren’t so innocent or well-meaning.
Some of that might come from discomfort. “When you break the mold, they don’t know what to do with you,” says Daniel Thompson-Blum, who is trans.
Thompson-Blum is completing his Masters in community psychology at Wilfried Laurier University and has a research interest in transgender access to health care. One barrier, he says, is a belief that being trans is less “real” than being cisgender (someone whose gender identity matches their sex birth). “Cis people can feel that trans people are deceiving in the way they present, when it’s the opposite. They are presenting their true identity,” says Thompson-Blum.
That identity is often dismissed, either overtly or from perhaps unintentional yet still painful oversights.
“There is a sense of invisibility for trans and non-binary individuals accessing health care, perpetuated by the lack of inclusive intake forms, hetero- and cis-normative posters and handouts, and electronic medical record systems that do not allow for diversity in gender identity and anatomical makeup,” says Dr. Bourns.
What makes for a positive environment?
Posters can indicate your practice is a gender-affirming space. Ask patients for their preferred name and pronoun. Don’t ask about the patient’s trans identity or anatomy if it doesn’t relate to the medical issue at hand.
But it’s more than that.
“I think doctors can improve interactions with trans patients by assuming everyone is trans — you can’t tell and they might not tell you,” says Thompson-Blum.
The point is the principles of sound doctor-patient relationships transcend any encounter. Restrict questions to the presenting complaint. Explain the medical rationale for any questions that aren’t obviously related. Use non-gendered language. Explain what you’re going to do and why you’re doing it. Don’t make assumptions. If you make a mistake in something you said or did, apologize and move on. Get to know the individual.
What is good trans health care? The same as any of the best health care.
“Take care of the person competently and treat them respectfully,” says Dr. Butler, who is trans as well.
Think about the possible mindset of some patients, says Dr. Bourns. “Trans people sometimes approach health care interactions with a sense of guardedness and other protective strategies utilized by those who have been subjected to trauma and microaggressions,” she says. “Without awareness of this, providers may perceive and label trans patients as ‘difficult patients,’ resulting in further stigma and discrimination.”
View the individual as your patient first and foremost, not as your crash course on all things trans.
People who are trans often say they tire of educating their doctors and answering questions as if they’re a tour guide at an exhibit — or the exhibit themselves. That takes emotional labour and it’s not the patient’s responsibility.
There’s a balance to strike, says Dr. Butler. Doctors can certainly learn from a patient’s lived experiences. But if you really want to learn about trans people, take the time to increase your skills and knowledge on your own.
Dr. Butler’s paper makes a case for prioritizing improved education in medical schools on the specific health needs of transgender (and gender-diverse) people, as part of addressing global health inequities in care. That can include cultural humility and anti-oppression training, involving trans community members, integrating trans health into curricula, and improving access to careers in medicine for trans people.
Improved provider knowledge is always important, whether that comes in med school or during a career. Especially if the model doesn’t lump that learning in an island (See A Continent of Care, Not an Island). Is that enough to improve the care for people who are trans?
A study reported in 2019 in Medical Education found more education around trans health may not, alone, be sufficient to boost providers’ competence. Decreased transphobia, not increased education, is a better predictor of the level of care.
That’s a bigger challenge. Doctors are no more likely than anyone else to demonstrate biases, says Dr. Butler. But they’re also no less likely.
And if doctors don’t think about the realities of the trans population or about their potential biases? “Ignorance and blissful innocence are privilege in action,” says Dr. Marshall.
Transphobia is a societal issue. Combatting it across all realms, including health care, requires policies, action and a shift in thinking. It’s not easy. As Colgan says, “There’s no course on how to not be transphobic as a human being.”
If trans people experience more transphobia in life, they’re probably less likely to seek health care, says Thompson-Blum. If they feel more social support, they’re more likely to seek care.
Dr. Massarella has publicly shared the story about a powerful moment in her journey. She had long known she was transgender, but wasn’t living life that way. Until one day, when she was treating someone in the emergency room.
This patient was a transgender woman who experienced a heart attack. She didn’t survive. As Dr. Massarella was driving home from the hospital, she recalls thinking, “I just can’t die like this. I have to die as who I really am.”
Anyone who is trans just wants to live as they really are and be treated like anyone else, whether it is within their families, schools, work, communities, or when seeing a doctor.
“For someone to think you’re lying about who you are, that’s still the biggest barrier for transgender people,” says Dr. Massarella.
- Sherbourne Health has Guidelines for Gender-Affirming Primary Care with Trans and Non-Binary Patients, an accompanying quick reference guide, plus an interactive tool based on the guidelines.
- LGBT2SQ Health Connect is an online learning platform from Rainbow Health Ontario, dedicated to clinical and cultural competency training for Ontario health care and social service providers.
- Trans PULSE Canada has links to several reports, journal articles, infographics and stats related to community-based surveys of the health and well-being of trans and non-binary people in Canada.
- Earlier Trans PULSE studies included research from an Ontario context.
- The World Professional Association for Transgender Health offers a Standards of Care document.
- The Canadian Professional Association for Transgender Health has ethical guidelines, position statements and links to provincial, national and international resources.
Supporting Young Trans Patients
“It’s a phase.” Dr. Joey Bonifacio hears that from parents and health-care professionals alike when the subject is children or teens who identify as trans.
Assuming that your trans child is just going through a phase interferes with what young people need most: support. Dr. Joey Bonifacio is a staff pediatrician and adolescent medicine specialist at St. Michael’s Hospital in Toronto, where his focus of care is the LGBTQ population. Here are the most common questions he hears in his practice and how he responds.
Why are there suddenly trans and non-binary kids? What has changed?
First, we as a culture are talking about gender more because we know more about gender. We have learned from older persons who shared their stories, both good and bad. Second, it is easier learning about gender now through the internet. Many trans children and teens probably kept it to themselves because they couldn’t connect with anyone.
Do you do gender surgery on children? If not, what do you actually do for them?
There is no surgery on children. If they identify as another gender, I talk about what would allow them to be the best person they can be. If pubertal changes are causing distress and affecting them at school, I can address the use of medications that put puberty on hold until they figure out what they want to do. A lot of the work is talking to parents and seeing how they can support their child. We have the same goal — to have a kid who plays with their friends, enjoys school and is happy at home with their family.
What are the dangers of not supporting a trans kid?
My clinical experience shows that rates of poorer mental health outcomes, such as depression and anxiety, and other markers of functioning, such as poor school performance, are higher in families who are not supportive. Hiding or being shamed for having an identity like being transgender may negatively affect the way children look at themselves. If parents do not give them the self-confidence to talk about gender, or do not advocate for them at schools, then trans kids aren’t given the same opportunities to lead a happy healthy life.
What do you tell parents of children who are expressing a trans or gender-independent identity?
Listen. Create the space so you can talk about gender with your child in an open and non-judgmental way. It’s okay to be overwhelmed. But the overarching approach should be to understand your kid and listen to what they are telling you.
A Continent of Care, Not an Island
How might doctors learn best about trans health and trans patients? Get off the metaphorical island.
That was the message from a paper published in Education for Primary Care this February called, “Integrating trans health knowledge through instructional design.” It says the prevailing model used to teach primary care learners — from “trans 101” educational interventions to trans health “clinical pearls” — uses time-limited and cultural competency-based education. The result is an isolated education island.
The paper challenges educators to design instruction that encourages learners to integrate this knowledge with foundational principles of primary care, structured within existing curricula. The authors suggest that can build bridges across a continent of primary care practice landscapes.
One of those authors is Dr. Nanky Rai, 2SLGBTQIA+ Health Education Theme Lead with the Temerty Faculty of Medicine, Undergraduate Medical Education, University of Toronto. She told Dialogue, “The paper is presenting a pedological intervention, but it’s also an ethical intervention.”
Ideally, she says, learning can centre the experiences of people at the margins. That can also shift the conversation so it’s not just about inclusion, but about the social determinants of health, and the systems and structures that shape them.
Dr. Rai and her co-authors say limited trans health units might have unintended consequences. They can tokenize or stigmatize trans individuals. Or render them as “knowable” because they’re seen as one group, not as individuals with distinct needs.
The island approach isn’t unique to trans health education. It can marginalize other patient populations too. What’s the alternative?
The paper suggests a critical rethinking of how to do trans health primary care education. We learn by making connections between prior and new knowledge, often with the goal of transferring the knowledge acquired from one context to another. Instructional design supports that transfer, for example, by integrating procedural and conceptual knowledge. Procedural knowledge is knowing how to effectively perform a task or skill; conceptual knowledge is knowing why they’re performed that way.
Curriculum designers and educators could connect trans health content to other clinical competencies, and integrate trans patients in case examples and simulation-based learning. That could include primary care topics that aren’t usually associated with trans health. Talk about a trans individual and diabetes, for example, and you reinforce that trans people have primary care needs that are similar to any other and unrelated to their gender identity.
When teaching about a topic like informed consent procedures, lessons could again use an example about a trans patient, like initiating hormone replacement therapies. This lesson focuses on a specific clinical skill in primary care practice in general, relevant to a range of contexts, without “othering” trans people.
“How you do informed consent with a trans person will improve your ability to get informed consent overall,” says Dr. Rai.
And that leads to better health care for all.