A simple 2013 change in terminology has led to improved health care for trans individuals over the past 10 years, but we still have a long way to go.
In 2013, the term “gender identity disorder” was replaced with “gender dysphoria” in the U.S. Diagnostic and Statistical Manual of Mental Disorders. Six years later, the World Health Organization (WHO) released its new International Classification of Diseases (ICD-11) with the same revision. Such a simple change made it official – a difference between gender identity and biological sex was only considered pathological if it caused distress. In other words, being transgender was no longer a condition to cure or a problem to fix.
This de-medicalization of trans identities has helped promote trans health. Access to gender-affirming care across Canada has also improved over the past year, with increased government coverage and hospital program capacities for top and bottom surgeries and hormone replacement therapy.
Despite these advancements, trans people still face worse mental and physical health outcomes than the cisgender population because of barriers to accessing gender-inclusive health care.
One medical specialty where these barriers are becoming increasingly apparent is obstetrics and gynecology. While traditionally viewed as the “women’s health” field, both trans men and women can have a vagina, cervix and breasts, and thus may consult obstetrician-gynecologists (OB/GYNs) for issues related to their sexual and reproductive health. In fact, trans individuals are at increased risk of OB/GYN-related health problems, including late-stage cancers, sexually transmitted infections and undesired pregnancies.
Who, or what, can we blame?
Firstly, the system. Part of the problem is the fear of potential discrimination and mistreatment at health-care facilities. Aleah Hazan, an OB/GYN and fellow at Mount Sinai Hospital, notes that many “LGBTQ families choose homebirth and midwifery care to not be misgendered in hospital and to have control of their bodies in a system that is heteronormative and cisgender focused.” Patient intake forms may not allow trans individuals to disclose their gender identity; medical histories may not include an individual’s transition journey or use inclusive language; and OB/GYNs and other health-care workers may not ask patients for their preferred pronouns.
Far too few OB/GYNs are prepared.
There is also the issue of education and training: It is an OB/GYN’s responsibility to appropriately address trans obstetric and gynecological concerns, but far too few OB/GYNs are prepared. A survey of 141 OB/GYNs found that only a third were comfortable caring for trans individuals, with more than half (59 per cent) unaware that trans females require breast-cancer screening and 11 per cent unwilling to perform Pap smears on trans males; 80 per cent of OB/GYNs reported receiving no training for transgender care in residency. A cross-sectional study of 365 Canadian medical students supports this alarming trend – only 6 per cent of students said they had enough knowledge to provide trans care, and only 24 per cent agreed transgender health was sufficiently taught.
How can we expect the trans community to seek out doctors who do not trust their own abilities to help them?
Mandatory training, that’s how. Hazan recalled that during her time at medical school, there was only a week of designated training on sexuality and inclusive language, with other opportunities for LGTBQ2IA+-focused training being “opt-in.” Carly Morin, a family doctor in Toronto, said that while she decided to complete several training days at transgender clinics to supplement her learning, the extent of transgender care training she received in medical school was limited to cervical-cancer screening guidelines and the definitions of basic LGTBQ2IA+ terms.
The truth is that a curriculum on providing transgender care exists and works at increasing OB/GYN students’ knowledge and comfort levels. But it cannot be opt-in. There is a systemic gap in knowledge in providing trans gynecological care that can only be tackled through longitudinal curriculum in medical schools and residency that is required for OB/GYN certification.
What should this mandatory curriculum include?
- Inclusive language – Creating a welcoming environment for trans patients starts with using the right words. Not only should OB/GYNs ask trans individuals for their gender pronouns, but they should try to avoid language and questions that enforce the gender-binary (e.g., making assumptions about partnership, emphasizing the sex of a baby or saying “breast-feeding” instead of “chest-feeding” in reference to lactating trans parents). According to Morin, “It is also important that care providers are not ‘othering’ to trans folk, and not making assumptions about health or risk behaviours based on how a patient presents in the clinic.”
- Trans health needs – Depending on their anatomy, trans individuals can have a variety of health concerns. For example, both trans women who have had chest feminization surgery and/or are on estrogen and trans men who have not had a mastectomy are at risk for breast cancer. Similarly, trans men who have a cervix and trans women who have had a vaginoplasty are at risk for cervical cancer. OB/GYNs should be educated of these risks so they can order the right screening tests for patients. Moreover, long-term exogenous hormone use can reduce fertility in trans individuals, so it is important for OB/GYNS to consult patients about fertility preservation options such as the freezing of sperm or eggs prior to transitioning.
- Involvement of the trans community – Developing a comprehensive curriculum for trans care requires a person-centric approach, and the best way to accomplish this is by reaching out to trans individuals and asking what inclusive and holistic care looks like to them. Trans representation is also incredibly important when teaching the curriculum to medical students since people from the community are experts in explaining their community’s needs.
- Practice-focused – “One negative interaction with a health-care provider can alienate patients from care,” says Hazan. Including case studies and practice patient consultations allows students to gain experience applying their knowledge of trans health in an environment where they can make mistakes without consequences and learn together.
A Canadian study conducted in 2013 reported that 63 per cent of trans patients had to provide education to their doctor about transgender care. This onus of education should not fall upon the patient. It is time we listen to the trans community and mandate transgender care education. After all, trans patients are still patients in need.