It was a battle for Jaden Fields to even get the appointment. When he, a trans man, tried to make arrangements with a gynecologist’s office, he was met with disrespect and disbelief. So much so that his primary care provider had to make the appointment for him. When he arrived at the office, he was dismissed, misgendered by the staff and eventually had the police called on him.
Fields, who described his experiences for Hello Beautiful, is far from the only transgender person to have a problem finding respect and affirmation from the health care establishment.
“Engaging with the medical system as a trans person is always a scary proposition,” Katelyn Burns, a trans woman, freelance writer and Vox contributor, told HuffPost. “The health care system’s lack of general competence with trans people absolutely is a deterrent for all trans people to go to the doctor, but when we do find good medical providers, we tend to stick with them.”
Burns encountered this general lack of competence after seeking treatment for minor post-surgery complications. The gynecologist she was referred to was inexperienced in dealing with her issues and offered few solutions. After this, she decided it was time to find a new doctor. Her search ended when a trusted friend recommended one in the Georgetown neighborhood of Washington, D.C. Here, she was treated with respect by a physician who was “worth every penny” despite being out of network.
While there are excellent providers like Burns’ out there, the medical field in general still falls short of providing proper care to transgender patients. Deadnaming, improper pronouns and a general lack of knowledge about transgender issues lead many from the trans community to avoid the doctor altogether. General questioning of patients’ transgender identities is another common reason for doctor avoidance, said Kristie Overstreet, a licensed psychotherapist based in Orange County, California.
“Engaging with the medical system as a trans person is always a scary proposition.”
Research supports this. A 2018 study from Ontario, Canada, found that 54% of trans men surveyed avoided going to the gynecologist. Approximately 59% of those who avoided it cited being misgendered as one of the main reasons; 70% cited having to educate their providers themselves was another deterrent; 86% said it was due to the gynecological exam itself, which many respondents found physically and emotionally distressing.
Ian Harvie, a trans comedian, actor, and writer, explained his issues with the medical system in a series of emails to HuffPost.
“Initially, for me, I think the problem was fear of going to a doctor at all. I think that’s one of the major obstacles for getting trans people health care, is getting us over our own fears of the unknown in the doctor’s office,” he said. “I told myself a lot of negative ‘what if’ stories. What if physician or office staff are not understanding, or don’t know what trans is? Will I be mistreated or misgendered, intentionally or unintentionally? A more graphic fear was: ‘As a man, will getting in the stirrups for an exam make me feel like a girl?’”
Tales of medical bigotry have spread through the community by word of mouth. In Harvie’s case, this had a big effect.
“I had heard stories of trans women having to get their hormones on the black market because doctors wouldn’t give them prescriptions. The doctors either didn’t believe they were trans or they made them prove it by waiting and living their life as women before they’d prescribe them hormones. I guess some of those stories, even if they weren’t mine, made me worry about what might happen when I ask for what I need,” he said. “Doctors hold the keys to medical transition, and we hold the keys to our identities, and it was still an era when we all didn’t trust each other, and I definitely think some of that seeped in and made me fearful.”
How The Current System Hurts Trans Patients
A 2018 study published in the Annals of Family Medicine found that support for providing supportive services to transgender patients wasn’t exactly universal. Researchers surveyed over 300 clinicians in an integrated health system in the Midwest on providing transgender patients care, with 53% responding. Approximately 85.7% said they were willing to provide routine care to transgender patients, and 78.6% of respondents said they were willing to provide Pap tests to transgender men.
“Willingness to provide routine care decreased with age; willingness to provide Pap tests was higher among family physicians, those who had met a transgender person, and those with lower transphobia,” the study authors wrote. “Medical education should address professional and personal factors related to caring for the transgender population to increase access.”
Marki Knox, an OB-GYN and the co-chair of the Los Angeles LGBT Center Board of Directors, has dedicated a good deal of her career to providing supportive gynecological services to the trans community. A lesbian who came out as a teenager before Stonewall, she said trans people were a part of the group she hung out with.
“I always had a lot of compassion for them because there were no resources at that time,” she said.
Knox makes an effort to create a safe and welcoming environment for her patients. She has addressed proper pronouns with her staff. While she is clearly an empathetic and dedicated provider, she sometimes finds it difficult to determine the best course of treatment for trans patients.
Knox said she struggles to find “nuts and bolts” type of research articles on specific practices and procedures for trans patients. Statements from others in the medical field show they have encountered similar issues. Because of this, Knox said physicians who focus on trans individuals often consult each other. Patients themselves sometimes give her the best information.
“There’s probably research that I’m not aware of, but when I go to look for things in the literature to guide what I do, there’s nothing. So I end up networking with other physicians who do trans care to try to get some clue,” she said.
Knox has been dealing with issues like this for much of her career (she’s retiring at the end of December). In her early days as a doctor, she had to figure out how to give trans patients hormone therapy properly. She called this “seat of your pants medicine.”
“The first thing I always say to my trans patients is ‘I do not have a textbook here.'”
She attributes this to the fact that the trans community is a small, though very in need, population that requires dedicated researchers. While she has seen some articles start to emerge, she believes there is a long way to go.
“The first thing I always say to my trans patients is ‘I do not have a textbook here. Now, we’re going to treat you to the desired outcome, and how we get there may vary from person to person, and it’ll be you and I working together, not me telling you what to do,’” she said.
She explained that when doctors don’t know what to do it can come off as “fear” or “I can’t see you” to the patient. This can lead to doctor avoidance and possibly missing vital screenings for issues like HPV, which is linked to diseases like cervical cancer.
Overstreet, the psychotherapist, pointed to the broader problem of society’s failure to accept trans people. She said this can contribute to severe mental health problems such as depression and anxiety.
‘Be Kind, Believe Us … Educate Yourselves’
In addition to giving a Ted Talk on this issue, Overstreet has created a program called the “Dignity Model” to help train medical providers how to give respectful care to the transgender community. She pointed to programs at Vanderbilt and The University of California, San Francisco as positive examples of affirming care.
There are other promising signs that some in the medical establishment are taking these issues more seriously. On July 1, the University of California, Los Angeles launched a LGBTQ healthcare fellowship for physicians trained in family medicine, internal medicine or internal medicine and pediatrics. According to UCLA Health’s website, the fellowship will “train future primary care physicians to be sensitive, comfortable, clinically knowledgeable and culturally competent in delivering healthcare to sexual and gender minority patient populations.”
“A lot of the faculty kind of came together, and we thought there were not a lot of providers who were comfortable dealing with issues that LGBTQ communities face. A lot of our own residents who graduate from training also do not feel comfortable with many of the issues,” said George Yen, a practicing physician and the program’s co-founder and director.
He explained that many people from the LGBTQ community sought out his private practice after online searches for a friendly provider. Due to the fact that there are so few supportive physicians, he became very focused on those patients. This further emphasized to him the need for the program.
Yen pointed to a 2011 study in the Journal of the American Medical Association to demonstrate how little attention LGBTQ issues are given during medical training. According to the research, “the median reported time dedicated to LGBT-related content in medical school in 2009-2010 was 5 hours, but the number of hours in the required curriculum, as well as number of LGBT-related topics covered, varied widely. In many schools, deans of medical education endorsed dissatisfaction with their institutions’ coverage of LGBT-related topics and provided potential strategies for increasing curricular content.”
More recent studies have shown this trend hasn’t gotten much better, despite nascent efforts to include trans health in medical education curriculums.
While UCLA’s program is working to mitigate this problem, it is still only educating one fellow at a time. Yen attributes this to the issue of the government not funding the fellow’s salary, leading the school to fund it instead. The reason for this is LGBTQ medicine is not an American Council for Graduate Medical Education accredited subspecialty. LGBTQ medicine is very new, unlike other specialties like cardiology or neurology. This requires programs to create their own curriculum and apply for accreditation.
Still, a 2007 joint statement by the Association of American Medical Colleges Group on Student Affairs and Organization of Student Representatives shows the importance of a program like UCLA’s. It recommends “medical school curricula ensure that students master the knowledge, skills, and attitudes necessary to provide excellent, comprehensive care for GLBT patients.”
This should include “training in communication skills with patients and colleagues regarding issues of sexual orientation and gender identity. Visible faculty members and administrators who model behaviors reflecting respect and appreciation for each student, regardless of the student’s sexual orientation or gender identity. Faculty development programs for faculty members and residents regarding GLBT issues. Comprehensive content addressing the specific health care needs of GLBT patients.”
“Be kind, believe us when we tell you who we are, educate yourselves on trans people’s medical needs ... and if you mess up, apologize and try again.”
In terms of solving this problem broadly, Overstreet emphasized the need for providers to create a feeling of safety. She also highlighted the need to train not only doctors, but other health care personnel like receptionists.
Harvie said he hopes more physicians seek education on trans issues in order to alleviate some of the fears he discussed.
“Be kind, believe us when we tell you who we are, educate yourselves on trans people’s medical needs, make sure your staff is educated as well, every member of a medical office has to be on board of the kindness train, make great effort with pronouns, and if you mess up, apologize and try again,” he said.
In his essay, Fields stressed the need to understand how this all intersects with race and historical trauma as well as the need to simply treat people with humanity.
“First, medical providers need to check their conscious and unconscious biases. They also need to be aware of the historical trauma the medical industrial complex has inflicted on people of color. There is a legacy of distrust because of that. I think medical providers need to understand the impact of systemic oppression on communities of color and how that trauma can lead to negative health outcomes,” he wrote. “When it comes to trans people specifically, I think they need to move away from gendering body parts and look at us as human beings.”