Healthcare facilities in the United States often do not provide inclusive care for transgender patients, and limited research exists on the specific medical risks and clinical needs of this population. In response to this, JAMA Internal Medicine published guidelines for optimizing acute clinical care for transgender patients.1

According to the 2015 US Transgender Survey,2 33% of transgender respondents who had seen a clinician in the prior year reported at least 1 negative experience related to being transgender, and 23% reported avoiding medical treatment altogether for fear of mistreatment. These statistics highlight the medical care limitations for many transgender individuals.

Healthcare facilities can begin practicing inclusivity by collecting gender identity information from their patients at intake, wrote Nicole Rosendale, MD, of the Department of Neurology at the Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center, and colleagues. Failure to identify patients by their chosen name or pronoun can have negative effects on care quality and psychological health, studies report. As such, a section dedicated to gender information in the electronic health record could improve clinical care and medical well-being for transgender patients. Authors also recommended the use of gender-neutral terminology at initial meeting to allow patients the opportunity to identify any appropriate pronouns or terms.

Dr Rosendale suggested that practitioners take an anatomic inventory and note when patients use hormone replacement therapy. Clinicians should clarify to patients that their collection of this information is for medical purposes, so that a proper assessment of any disease risks or potential medication interactions can be made. Regarding hormone therapy specifically, studies indicate that transgender women receiving estrogen may have an elevated risk for cardiovascular and cerebrovascular events, including ischemic stroke. Antiandrogen therapy, an adjunct to estrogen therapy, is associated with increased risk for thrombosis, and testosterone therapy given to transgender men is associated with significantly elevated serum triglycerides and cholesterol levels. Additionally, estrogen therapy may have certain drug-drug interactions, including with some antiretroviral therapies used for the treatment of HIV. Although additional studies are necessary to further elucidate these risks and interactions, existing data emphasize the necessity of due consideration to the specific hormonal and anatomic circumstances of transgender patients.

Laboratory values may be affected by type and duration of hormone replacement therapy, the authors added, and should be interpreted with this in mind. For transgender patients who are hospitalized, Dr Rosendale emphasized that often a patient may wish for information regarding their gender to remain private, including from their families. Clinicians should also be proactive in providing private rooms for transgender patients, or when unavailable, shared rooms according to gender identity.

To improve the medical care available to transgender patients, clinicians must make a concerted effort for inclusivity. In addition, healthcare institutions as a whole should work to incorporate more comprehensive sections for gender information in the electronic health record to coordinate gender-appropriate care across practitioners and facilities. Much of the existing risk and treatment data used to guide transgender patient care is extrapolated from data collected from cisgender populations. Dr Rosendale and colleagues thus called for expanded research efforts for transgender patients to provide the same quality of care given to cisgender patients.

References

  1. Rosendale N, Goldman S, Ortiz GM, Haber LA. Acute clinical care for transgender patients: a review [published online August 27, 2018]. JAMA Intern Med. doi:10.1001/jamainternmed.2018/4179
  2. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M.  The Report of the 2015 U.S. Transgender Survey. https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf. December 2016. Accessed September 21, 2018.