Addressing Healthcare Inequities: Improving Specialty Care for Transgender and Gender-Diverse Patients

Posted on by BUJPH

By William Borges

 

In recent years, transgender and gender-diverse healthcare has been brought to the forefront of public discourse. Discussions have shed light on the unique challenges faced by the transgender and gender-diverse (TGD) community. Some progress has been made in addressing these challenges but there are still critical gaps in our healthcare system. While mental health and primary care are often discussed as major gaps in TGD care, his article will focus on the gaps that exist in specialty care affecting the community. Low-quality urological and gynecological care poses a risk to the health and well-being of TGD individuals. To guarantee adequate urological and gynecological care for TGD patients, experts should focus on improving medical education and training, research on health disparities, TGD-focused clinics, standardized national clinical protocols, TGD provider and patient representation, and integration with emerging technology platforms.

According to data from national surveys, approximately 1 in every 250 adults in the United States is transgender.1 Despite comprising a substantial number of Americans, TGD individuals have reported negative experiences in healthcare settings. Around 33 percent of TGD patients have reported at least one negative experience with medical providers related to gender identity and around 23 percent avoided seeking care due to fear of mistreatment.2 TGD patients can often be made to feel neglected and invisible in critical aspects of their healthcare, such as urological and gynecological care. Such experiences can foster distrust of healthcare providers among TGD individuals and lead to negative health outcomes. 

Distrust in providers has been experienced by TGD patients historically experiencing discrimination in healthcare settings. Prior research has explored the negative encounters TGD patients report, such as being refused care due to their gender identity or facing insensitivity from staff.2 This discrimination relates to the minority stress model, which posits that stigma, prejudice, and discrimination create a hostile social environment that causes excess stress and health problems for minority groups. The chronic experiences of discrimination and hypervigilance in healthcare settings have severe psychological impacts and act as barriers to TGD patients seeking necessary medical care.

This year, the American Cancer Society (ACS) released its annual Statistics Report, which included, for the first time, a section on cancer in people who identify as Lesbian, Gay, Bisexual, Transgender, Queer, or Gender Nonconforming. This section highlighted the available data on prostate and gynecological cancer disparities impacting the TGD population but concluded that the disparities remain inadequately studied and addressed.3 Cancer disparities encountered by populations with intersectional identities, e.g., TGD patients of color are particularly understudied.  

The ACS report highlighted the available data on prostate cancer disparities in the TGD population. Researchers hypothesize that estrogen-based gender-affirming hormone therapy (GAHT) may play a role in preventing prostate cancer development in transgender women.4 In 2023, the University of California, San Francisco, and Cedars-Sinai conducted the most extensive retrospective study to date. Published in the Journal of the American Medical Association, their research revealed that transgender women undergoing gender-affirming hormone therapy (GAHT) had notably lower rates of prostate cancer diagnosis compared to cisgender men.5  However, the results suggested a higher prevalence of aggressive prostate cancer in transgender women, potentially attributable to transgender women on GAHT having delayed prostate cancer diagnosis.5 Another study published in European Urology found that transgender women have a lower prevalence of PSA screening, which was likely attributed to a lack of prostate cancer risk awareness, stigma, and inadequate inclusion of the transgender male population in prostate cancer screening guidelines.6 More research is needed to determine the true extent of the underlying disparities in prostate cancer among transgender women. Importantly, future research should isolate the likely intersectional causes of disparities, such as language barriers, lack of insurance, poverty, structural racism, and medical stigma, and develop interventions to address the causes. 

The ACS report also highlighted the available data on gynecological cancer disparities in the TGD population. Transgender men remain at risk for gynecological cancers as evidenced by reports of endometrial, ovarian, and cervical cancers.7 While it has been theorized that testosterone-based GAHT increases the risk of hormone-responsive endometrial and ovarian cancers because it can get converted to estrogen in the body, population-based incidence data including transgender individuals is unavailable to support this.7 The American Cancer Society data reveals that transgender men have a lower rate of cervical cancer screening compared to cisgender women, which may leave transgender men at a higher risk for cervical cancer.3 This disparity in cervical cancer screening rates could be explained by TGD discrimination by providers, discomfort with female sex organs, and fear of receiving a gynecological exam, although more epidemiological data is needed for a definitive answer. Fears of disclosing sensitive medical information and being mistreated may mean that transgender men delay diagnosis, leading to worse health outcomes. 

In addition to gynecological cancers, disparities in outcomes among TGD patients may extend to other urological malignancies such as bladder, kidney, and testicular cancer. To date, there is little data exploring population-level cancer disparities among TGD patients with these other urological malignancies.  It is important to keep in mind that the evidence for prostate and gynecological cancer disparities among TGD patients is also limited, and more substantial research is needed before making any definitive population-level conclusions. Future research efforts should identify cancer disparities among TGD patients, determine their intersectional causes, and propose interventions to address the disparities. 

Urologic and gynecological problems, including cancers, grow as populations age, increasing the demand for relevant specialists. Worryingly, only 38 percent of American counties have practicing urologists and there is a projected 46 percent shortage of urologists by 2035.8 It is also projected that there will be a similar 40 percent shortage of gynecologists by 2030.9 With the increasing disease burden, TGD specialty care will likely be sidelined as the limited number of providers deal with the increasing volume of non-TGD urological and gynecological issues. Without proper advocacy efforts to improve the current and future state of TGD specialty care, TGD patients will be severely negatively impacted. A significant effort is necessary to increase the supply of medical specialists available to adequately address the future population’s urological and gynecological needs, particularly within the TGD population. Various models are available to address provider shortages including increasing incentives for medical students to specialize in urology and gynecology, integrating emerging technologies like artificial intelligence to extend provider reach, and training more cost-effective mid-level providers like certified nurse assistants and physician assistants.

Most medical providers do not feel well-equipped to provide TGD specialty care, despite expressing interest in providing such care. Medical specialists in Urology and Gynecology must be prepared to address transition-related genitourinary procedures (e.g., vaginoplasty, phalloplasty, and orchiectomy), fertility, urinary and sexual function, urinary tract infections/sexually transmitted infections, lifestyle medicine, and malignancies like prostate cancer and gynecological cancers. However, according to a 2018 multi-specialty survey published in the Canadian Journal of Medical Education, 100 percent of urology residents surveyed would not feel competent enough to provide urology-specific TGD care by the end of their residency and 100 percent felt their training was inadequate to provide care for this population.10 Moreover, more than 50 percent of residents in psychiatry, endocrinology, and family medicine indicated an interest in providing TGD care in their future practice, whereas only 29 percent of residents in urology felt the same way.10 A cross-sectional survey of obstetrics and gynecology residents published in Transgender Health revealed that overall, residents felt an intermediate level of comfort and competency in caring for patients who identified as TGD.11 Despite inadequate preparation, the residents expressed a high level of interest in caring for TGD patients.10 Providers reporting low confidence in their ability to address the needs of TGD patients highlights the need for improved cultural competency training across specialties. Incentives should also be implemented to increase trainees’ interest in providing care to TGD patients. 

The lack of preparedness for TGD specialty care may be traced back to medical school. Based on a study published in the Journal of Primary Care Community Health in 2023, only 27 percent of medical students surveyed in the US reported confidence in their knowledge of the health needs of transgender patients.12 Based on the data, this lack of provider preparedness for providing TGD care has to be addressed starting in medical school. Without confronting gaps in education regarding TGD health, intersectional factors, and care standards, providers will remain ill-equipped to deliver compassionate care.

Plenty can be done to improve TGD specialty care access and delivery. The following are some material policy recommendations:

  • Medical school curricula should be redesigned to include more information about TGD patients. Redesigned curricula should include education on historical barriers to access for TGD patients, intersectionality, minority stress, risk factors, pronouns, gender identity, and standards of care for common TGD procedures. 
  • Governments and healthcare systems should invest in clinics and community health centers that deliver high-quality, specialized care tailored to the needs of TGD patients. This may help address provider limitations in TGD-competent care. 
  • More large-scale research should be conducted to evaluate the true extent of health disparities among TGD patients, especially in cancer. It is imperative that research also addresses the root causes of disparities so that follow-up studies can propose and validate interventions to address identified disparities.
  • TGD patients should be proportionally included in standardized national clinical protocols, such as screening protocols for prostate and cervical cancer, to minimize negative health outcomes from inadequate or discriminatory treatment.  
  • Representation of TGD providers should be increased in medical education and leadership positions. This would combat stigma while improving cultural understanding of TGD communities. 
  • TGD patient advocates should be engaged by healthcare systems to provide input on improving TGD patient experiences and reducing discrimination. Involving more TGD patient advocates would likely help normalize a broad range of patient backgrounds, including TGD patients of different disability statuses, races, income levels, and sexual orientations. 
  • Emerging technology platforms, such as those being developed by startups like Plume and Folx,13 should be promoted. These platforms can achieve substantial scale and help improve patient access to TGD-competent navigation, resources, and telehealth services. 

Policies such as the ones proposed above are a positive first step but should be evaluated as to whether they reduce discrimination-induced stresses experienced by TGD patients in healthcare settings and empower providers to deliver compassionate and competent care to TGD patients. 

In a time where it is legal for medical providers to refuse care to TGD patients in nine US states based on gender and sexual identity, leaders in medicine should consider work to safeguard adequate care for vulnerable TGD patient populations.14 Negative experiences, structural barriers, and a lack of navigation support or TGD-competent providers have historically led TGD patients to delay or avoid specialty care. Specialized clinics, advocacy services, and technology platforms are urgently needed to help TGD patients overcome discrimination and access appropriate urological or gynecological care. Most importantly, medical providers must work together with policymakers and institutional leaders to ensure the healthcare system is addressing the healthcare needs of TGD patients.

 

References

 

  1. Meerwijk EL, Sevelius JM. Transgender Population Size in the United States: a Meta-Regression of Population-Based Probability Samples. Am J Public Health. 2017;107(2):e1-e8. doi:10.2105/AJPH.2016.303578 
  2. James SE, Herman JL, RAnkin S, Keisling M, Mottet L, Anafi M. The Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality; 2016. https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf
  3. Dizon DS, Kamal AH. Cancer statistics 2024: All hands on deck. CA: A Cancer Journal for Clinicians. Published online January 17, 2024. doi:https://doi.org/10.3322/caac.21824
  4. Schmidt C. Prostate cancer in transgender women. Harvard Health. Published March 24, 2023. Accessed February 24, 2024. https://www.health.harvard.edu/blog/prostate-cancer-in-transgender-women-202303242905#:~:text=But%20transgender%20women%20can%20still
  5. Farnoosh Nik-Ahd, De AM, Butler C, et al. Prostate Cancer in Transgender Women in the Veterans Affairs Health System, 2000-2022. Published online April 29, 2023. doi:https://doi.org/10.1001/jama.2023.6028
  6. Nik-Ahd F, Jarjour A, Figueiredo J, et al. Prostate-Specific Antigen Screening in Transgender Patients. European Urology. Published online November 4, 2022:S0302-2838(22)026379. doi:https://doi.org/10.1016/j.eururo.2022.09.007
  7. Stenzel AE, Moysich KB, Ferrando CA, Starbuck KD. Clinical needs for transgender men in the gynecologic oncology setting. Gynecologic Oncology. 2020;159(3):899-905. doi:https://doi.org/10.1016/j.ygyno.2020.09.038
  8. Nam CS, Daignault-Newton S, Kraft KH, Herrel LA. Projected US Urology Workforce per Capita, 2020-2060. JAMA Network Open. 2021;4(11):e2133864. doi:https://doi.org/10.1001/jamanetworkopen.2021.33864
  9. Satiani B, Williams T, Landon M, Ellison C, Gabbe S. A Critical Deficit of OBGYN Surgeons in the U.S by 2030. Surgical Science. 2011;02(02):95-101. doi:https://doi.org/10.4236/ss.2011.22020
  10. Coutin A, Wright S, Li C, Fung R. Missed opportunities: are residents prepared to care for transgender patients? A study of family medicine, psychiatry, endocrinology, and urology residents. Canadian medical education journal. 2018;9(3):e41-e55. Accessed February 24, 2024. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6104317/
  11. Qin LA, Estevez SL, Radcliffe E, Shan WW, Rabin JM, Rosenthal DW. Are Obstetrics and Gynecology Residents Equipped to Care for Transgender and Gender Nonconforming Patients? A National Survey Study. Transgender Health. Published online September 22, 2020. doi:https://doi.org/10.1089/trgh.2020.0063
  12. Karpel H, Sampson A, Charifson M, et al. Assessing Medical Students’ Attitudes and Knowledge Regarding LGBTQ Health Needs Across the United States. Journal of Primary Care & Community Health. 2023;14. doi:https://doi.org/10.1177/21501319231186729
  13. Axios. LGBTQ health startups see funding surge as need grows. February 2, 2021. https://www.axios.com/2021/02/02/lgbtq-health-startups-funding. Accessed January 23, 2024.
  14. Equality Maps: Religious Exemption Laws. Movement Advancement Project. Accessed July 25, 2023. https://www.lgbtmap.org/equality-maps/religious_exemption_laws
William Borges