American Medical Student Association

Circle One: Male/Female


For most of us, this choice doesn't present much of a challenge. But for a great many patients-far more than you might expect-this simple item on an intake form doesn't offer a selection that truly fits.


For the transgendered, there is the sex of their birth, the sex with which they feel psychologically comfortable and, sometimes, the sex into which they have transitioned, medically and/or socially. But choosing which answer to mark on patient questionnaires is often the least of their problems as they prepare to meet any physician for the first time.


"Many transgender persons fear doctors—so they simply don't see them," says Phoenix cardiologist Dr. Rebecca Allison, a member of the American Medical Association’s (AMA) gay, lesbian, bisexual and transgender advisory committee and a male-to-female (MtF) transsexual. "There is a potential for great harm here. A person can be hurt very much if the physician is not compassionate."


The word 'transgender' is not a medical term, and its use can be as fluid as the gender distinctions it attempts to define. A label self-adopted by the transgender community, the word broadly refers to individuals who do not feel comfortable in the gender of their birth. And like the concept of gender itself, the term encompasses a spectrum-from people who live all or part time as the opposite gender of the one they were assigned at birth, to transsexuals who have undergone complete medical and surgical gender reassignment-and all those living in the space between.


But wherever they land on the spectrum, transgender people face difficulties the rest of us can't imagine. One of the most critical can be getting quality medical care.


Which Patient Will It Be?


There are few reliable data points on the actual number of people who consider themselves transgendered. With so many still "in the closet," population estimates tend to be loose at best. The DSM-IV gives it a go, estimating that
1 in 30,000 males and 1 in 100,000 females would like to have gender reassignment surgery. When you include transgender people who do not, for a variety of reasons, want surgery, the number is certainly much higher, although there are no reliable estimates as to how much. If the DSM numbers are taken as a guideline-although transgender advocates believe they are conservatively low-it is very likely that every practicing physician will encounter at least one transgender patient during his or her career. If that physician is an endocrinologist or a psychiatrist, it is a virtual certainty. But it is equally likely that when that happens, the physician will not be adequately prepared.


Providing good health care to transgender people calls for a very specific set of skills, but none are beyond the capacity of a competent primary care physician who is willing to learn, believes Dr. Melanie Spritz, a psychiatrist and attending physician at a New York teaching hospital. Spritz is an MtF transsexual who believes she was one of the first resident physicians in the United States to be fully "out" with regard to her transformation.


"I was actually forced out [of one position] because I had to have a physical exam for the job, and I was honest on the form-I'm always honest with health-care providers," Spritz explains.


The reception she gets is sometimes shocking. "I've been called a "gelding" among other things," she recalls. When a physician interviewing her for a postresidency job asked how people deal with her "problem," she responded, "It's not really a problem unless people perceive it as a problem." Unfortunately, many people do perceive the transgendered as having a problem. And when it comes to health care, they often do.


Beyond Primary Care


Certainly, transgender surgical patients need good postoperative care, a closely monitored and individually tailored hormone regimen, follow-up care to catch and treat side effects from the hormone therapy, and routine care for reproductive organs, such as ovaries and the prostate, that remain in the body. In addition, transgender people are at high risk for affective disorders such as depression.


Rachael St. Claire, a psychotherapist in Boulder, Colorado, and an MtF transsexual, agrees that generalist physicians can provide most of the care, but "patients are enormously grateful for physicians who take the trouble to develop special expertise in this area."


Expertise is only half the equation, however. The other is compassion. Fear of mistreatment or unkind remarks are some reasons transgender people avoid medical care. Other causes are more psychologically complex. Female-to-male (FtM) transsexuals often skip routine gynecological exams because they do not want to acknowledge, even to themselves, that they still have female organs. It can also be very embarrassing for a man to visit a gynecologist. In her book The Riddle of Gender, science writer Deborah Rudacille tells of an FtM patient who called to make an appointment with a gynecologist and was condescendingly asked, "Do you know what we do in gynecology?" At the very least, seeking health care can involve lengthy explanations to receptionists and technicians as well as physicians.


Spritz points out that health-care avoidance seriously complicates the medical risks transgender patients naturally face as a consequence of the strong hormones they often take for a lifetime; many who shun medical care seek their hormones on the black market—a very dangerous practice.


Discomfort


Avoiding care is only one danger to the transgendered. Insensitive practitioners create their own hazards. One cautionary tale often cited by advocates is that of Robert Eads, an FtM transsexual from rural Georgia who, after being diagnosed with ovarian cancer, was turned away by more than two dozen physicians who feared that taking him on as a patient might harm their practices. Eads died of the cancer in 1999, but his struggles with the medical community are immortalized in the documentary "Southern Comfort," which won a Grand Jury Prize at the 2001 Sundance Film Festival.


The solution, Spritz believes, is openness and education. A physician who wants to provide good care to transgender patients has to do the same thing as when encountering any unfamiliar medical situation: Learn the medicine, develop the skills. "There are plenty of resources out there, and doctors must be willing to read and learn. They also need to learn to see these people as patients." And transgender patients have to do their part in reducing their defensiveness, too, she believes. "They can be difficult to deal with. They can be manipulative. But they have to be willing to deal with how things are said."


Learning to treat the specific medical needs of transgender patients is easier than it used to be, thanks to a variety of resources. (See "Learning Transgender Medicine," below.) And becoming comfortable with the particular social issues and concerns of transgender people is not as hard as you might expect. Dr. Nick Gorton, a physician at Sutter Davis Hospital in Davis, California, and an FtM transsexual, recommends that physicians do three things in order to provide compassionate care to transgender people: "Develop cultural competency. Show sensitivity to the needs of the patient. And approach patients from where they are instead of where you are." He also points out that "this applies to all patients, transgender or not. Don't make [treating transgender patients] into a difficult thing."


Sometimes the trick to conveying sensitivity and cultural competency in what for most physicians is a very unfamiliar and potentially uncomfortable situation is simply to ask questions. St. Claire suggests asking, "How do you consider yourself? What pronoun do you prefer?"-simple questions that not only help doctors give patients what they need, but also signal that the doctor is willing to learn and is truly interested in their needs, she says.


On the Margins


Although finding competent and compassionate caregivers is an obvious health-care problem for many transgender people, some can’t even get through the door. Jessica Carlsen, a premed at the University of North Carolina at Charlotte and transgender health adviser to the American Medical Student Association, points out that transgender people face widespread employment discrimination, so are less likely to have jobs with adequate health insurance. Their consequent low socioeconomic status can mean no access to basic health care, compassionate or not. "Transgender people are marginalized in many ways," she points out. And even when they do have good jobs and insurance, that coverage is likely to exclude sex reassignment surgery and hormone therapy.


But this is beginning to change, Carlsen reports. "Some big insurance companies are starting to cover these expenses-some even going so far as to cover sex reassignment surgery. However, "employers are often able to dictate what plans [employees are offered] and what those plans will and will not cover," effectively excluding many people from coverage even when the insurance company itself is willing to pay.



Transitional Times


Awareness of the health-care needs of the transgender community is growing. Perhaps one of the best signs is the AMA’s creation last year of an advisory committee on gay, lesbian, bisexual and transgender issues. Steven Heatherly, Ph.D., a medical student at Eastern Virginia Medical School, is on the committee. "This is a huge step for the AMA," he says, and asserts that attitudes toward transgender people are slowly improving.

Gorton agrees. "The perception is that medicine is very transphobic. In my experience, the reality is not quite as bad as people think." And Gorton isn’t merely speaking for the trans-friendly San Francisco Bay Area. He went to medical school in North Carolina and was a resident in Louisiana when he transitioned.


Society at large is coming around as well. Films such as "Southern Comfort" help create an awareness of the problems transgender people face. They also introduce us to the transgendered so that we can see them as individuals, and not freaks or medical anomalies.


"These people need help," says Carlsen. "Anyone who went into medicine for reasons of compassion should understand this." From that point on, good care for transgender people is just good medicine.