Gender identity is becoming more fluid today. And, this makes transgender healthcare more complicated; especially for doctors and therapists who lack the experience and expertise in treating these patients.

The lack of an inclusive trans-specific curriculum in medical school puts these patients at risk, which could result in limited healthcare access and poorer outcomes.

Emily Ashcroft is one example.

Three years ago, Emily met with a bad car accident and consulted a specialist about a broken nose. She was then transitioning to a female – but, had not changed her male name on the insurance card.

Her encounter with the doctor was disappointing. "You could just see he was very standoffish, and... didn't want to approach me," described Ashcroft.

The doctor put on a face mask, glasses, and gloves to prepare for the endoscopy procedure. However, just as he was about to begin, he abruptly stopped and walked across the room for another pair of gloves.

When asked about the extra gloves, the doctor told her, "It's purely a precaution in a situation where I don't understand what the potential repercussions might be for me.'

"That was upsetting," she lamented. When Ashcroft explained to the doctor how marginalised and upset she had felt, he apologised, but that marked her last visit to that doctor.

Caring for transgender patients: The medical knowledge needed

Emily’s experience was not an isolated case.

A 2015 survey conducted by the National Centre for Transgender Equality (NCTE) found that 33% of transgender people who saw a physician in the past year reported a negative health care interaction related to their gender, which could include harassment, being denied treatment, and encountering unknowledgeable practitioners. Among those surveyed, 23% having avoided seeing a doctor due to fear of mistreatment.

Often, doctors who are not in favour of gay marriages are labelled as ‘racists’ who push these LGBTQs to the brink of suicide. There have been reports that the National Health Service (NHS) is failing as more homosexuals are being denied equal medical treatment.

As medical professionals disagree over support for gay marriages, a petition, signed by 2,000 doctors and backed by the Australian Medical Association (AMA), says doctors with socially conservative views are making homosexuals suffer ‘increased depression, anxiety, self-harm and suicidal behavior”.

Attached to the petition is an open letter, written by Perth third-year medical student Carolyn O’Neil who accused doctors such as former Tasmanian AMA president Chris Middleton and 400 others opposed to the AMA position on same-sex marriage, of contributing to “increased depression, anxiety, self-harm, and suicidal behaviour”.

Third-year medical student Carolyn O’Neil stands by references to racism in the open letter. Photo credit: Colin Murty/The Australian
Third-year medical student Carolyn O’Neil stands by references to racism in the open letter. Photo credit: Colin Murty/The Australian

The letter also reads, “As a body of medical professionals, we are concerned at the move by some of our colleagues to speak out against marriage equality,” adding the term 'same-sex marriage' was a hurdle that had to be overcome.

Dr Middleton, who resigned from the AMA over its support for same-sex marriage, claimed he had been “abused” and “smeared” as a racist in an “astonishing and intemperate” attack.

“May we suggest that such ad hominem attacks on any who question the LGBT orthodoxy is precisely what the public is repulsed by,” he expressed.

“We have made no such attacks, and we advise the authors and signatories of the rival document to reconsider their words.”

Ms O’Neil stood by the references to racism as being “valid historical parallels with previous experience”. “I think part of the problem is that there is discomfort with the fact that we have been racist,” she added. “On both sides, there has been quite vocal and nasty abuse, which makes both sides look bad.”

AMA president Michael Gannon respected the right of Dr Middleton and his group, which includes former AMA state presidents and members, to have a different perspective. However, he said the open letter indicated that not all the 30,000 AMA members share Dr Middleton’s view.

Tasmanian doctor Chris Middleton says he has been 'smeared' and 'abused' by the petition. Photo credit: Dailymail
Tasmanian doctor Chris Middleton says he has been 'smeared' and 'abused' by the petition. Photo credit: Dailymail

NHS: “Trans people are people” and want to be treated like people

Representatives from charities that assist people in their gender transition attributed the unequal treatment of LGBTQs to a lack of understanding and sometimes hostility.

“You find a lot of trans people are passed from pillar to post, a lot of GPs deny healthcare to trans people illegally based on the fact that they don’t agree with the choices that they’ve made,” said Jess Bradley from the Action for Trans Health Committee.

The group had received reports of some people being subjected to “unnecessary genital examinations as a result of clinicians’ curiosity”.

Terry Reed of the Gender Identity Research and Education Society cited an occasion when a doctor had refused to treat someone on religious grounds. “That’s relatively rare that someone would say that out loud, but they did,” she said.

Dr John Dean, the chair of the NHS England committee on gender identity services, said clinicians’ training rarely covered gender identity issues in detail and that it was having a worrying effect on access to healthcare.

“People working in the service try to be emphatic and sympathetic. But they lack a great deal of background knowledge,” he said at a hearing of parliament’s equality committee.

“It is something not covered in medical training… they get very little training about gender identity and development and the different experiences people have.

“Trans people are people and want to be treated like people and want to be able to access healthcare in parts of the NHS just like other people,” the NHS chair asserted.

He recommended that the General Medical Council make awareness of trans issues a “fundamental part of medical training”.

Curriculum to change the way students learn to care for LGBTQ patients

There is a void in resources providing healthcare professionals in this aspect, and advocates for transgender patients see the need for doctors to be "trans-competent," which translates to treating transgender patients with the same compassion and curiosity extended to all patient encounters. A review of 2015-2016 medical school curricula revealed only 30 of 144 schools included transgender-related material in their curricula.

While medical educators have developed formal benchmarks for trans-competence in practice, medical students will need time to catch up with these competencies.

Among those competencies are what some doctors say are universal principles of primary care: asking sensitively yet effectively about sexual anatomy, development, behaviour, history, and identity; developing rapport with patients; and recognising the historical and systemic factors underlying health care disparities. They also include an understanding of terminology used to talk about gender identity, and the basics of the medical and surgical options available to transgender people, among other skills.

Dr Jesse Ehrenfeld, who directs the Program for LGBTQ Health at Vanderbilt University Hospitals, says health care systems began to recognise that "you can't deliver [equitable care to transgender people] if you don't teach on these issues”.

Giving voice to LGBTQ: The petition signed by 2,000 doctors is clearly aimed at doctors with conservative values. Photo credit: Dailymail
Giving voice to LGBTQ: The petition signed by 2,000 doctors is clearly aimed at doctors with conservative values. Photo credit: Dailymail

Greater fluidity among LGBTQs in understanding their identities and bodies

In a 2016 study from Appalachian State University in North Carolina, author Stef Shuster, said, “More recently, trans people’s understandings of their selves and bodies have become more fluid, and ‘cross’-gender transitioning is not always the ultimate goal.”

The study, published in Sage, interviewed 23 doctors and psychologists who have chosen to work in transgender medicine and found that doctors and therapists in the US often have limited knowledge when dealing with transgender people.

Besides, uncertainty about how best to treat a trans patient was something that was regularly experienced by all of the respondents in the study. To manage this uncertainty, providers relied on current guidelines for decision-making.

New healthcare practitioners and those with a decade or more experience tended to be more rigid, expecting trans people to be “100% certain” about their desire to undergo sex reassignment surgery.

One reason, said Shuster, is that more experienced providers may be slower to accept changing notions of what it means to be trans, while those new to their profession lacked the experience to confidently chart their own course.

A respondent named Sarah, a therapist in private practice, said she closely followed guidelines to ensure a patient didn’t come to regret their decision to transition later on.

“I can’t have you wake up on a surgeon’s table and say, “Who are you and what are you doing to my body?’” That has happened,” she said. “So, I am really good about wanting to be holistic with people, and saying, please just let me be your therapist.”

“From a trans patient perspective, healthcare encounters might feel easier to negotiate if providers stopped emphasising this narrow definition of ‘transgender’,” shuster says. “And opened up more dialogue for their trans patients to describe how they understand their own identities and bodies.”

With greater efforts targeted at enhancing better healthcare for transgender patients, the question inevitably arises: Will the next generation healthcare professionals be better at treating these silent trans victims? MIMS

Read more:
LGBT community faces stigma and healthcare restrictions globally
The challenges of treating transgender patients
Can doctors refuse to treat trans people or women who have had abortions?