AND HEALTH 9

Supporting trans people in clinical practice

KEVAN WYLIE AND REBECCA WYLIE

As the number of transgender people accessing healthcare/presenting within healthcare settings increases, their needs have to be considered when designing and delivering healthcare services. This article outlines current key issues surrounding trans healthcare and clinical guidelines, and signposts readers to essential resources as a step towards ensuring practitioners are equipped to respond appropriately to any health needs a trans person may present in a clinical setting.

he number of transgender people Taccessing healthcare for dysphoria and related treatments is on the rise, with people increasingly presenting at both younger and older ages.1,2,3,4 Trans people also access health services for non- It is argued that knowledge and trans-related health issues prior to, during, understanding of trans issues remains and following gender transition. Healthcare suboptimal. In a recent survey on the professionals run the risk of being fined mental health and wellbeing of trans up to £5000 and receive a criminal record people, 84% of respondents had thought if they divulge a patient’s gender history about ending their lives at some point, when this has been obtained in an official and the lifetime prevalence of actual capacity and the individual has a gender suicide attempts was 48%.5 Access to recognition certificate. Given these facts, health services for trans people is a major Kevan Wylie, Honorary Professor of how prepared are healthcare professionals issue; long waiting lists exist, funding Sexual Medicine, University of Sheffield; to deliver appropriate services to the for treatment is limited, and being Rebecca Wylie, Medical Writer, Brighton trans community? trans can present unique dilemmas, for

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example decisions about which gendered transgender discrimination, since it has disorders (eg depression, anxiety) and ward patients should stay in.6 Patients been found that attitudes towards trans improved following gender-confirming have reported prejudiced, demeaning, people are significantly less favourable medical interventions.13 incompetent and, in some cases, even than towards LGB individuals.11 abusive treatment from healthcare HOW DO HEALTH SERVICES RESPOND? professionals. Respondents cited these For many practitioners, an understanding of Trans people are a marginalised group in factors as having contributed towards their transgenderism may arise from familiarity society who face stigma and discrimination reasons for self-harm or suicidal thoughts.5 with its inclusion within psychiatric in many aspects of life.6 This state of classification systems. The latest revision of affairs, unfortunately, often extends into WHAT IS TRANSGENDERISM the American manual (DSM-5) has made the healthcare setting (see Box 1 for some Transgender people do not conform to progress in depathologising transgenderism, examples). A European study surveying conventional descriptors of gender as ‘male’ an issue that has been hotly debated.12,7 trans men and women on their experiences or ‘female’, ie in line with anatomical .7 Diagnosis of (previously of healthcare found that between 18% and As such, they experience incongruence disorder) is dependent 31% of respondents felt that being trans between the gender they identify on an individual experiencing persistent impacted how healthcare professionals themselves as having (gender identity) and incongruence between their experienced treated them; between 15% and 23% felt the sex assigned to them at birth.8 and assigned gender, and a strong desire that it affected the ways they accessed to be the opposite gender that causes routine non-trans-related care; and more It is important to note that gender identity clinically significant distress or impairment than 25% reported that they had been is independent of an individual’s sexual in functioning.12 Notably, the etiology of refused treatment because a practitioner orientation relating to sexual attraction.8 gender incongruence remains unknown. did not approve of gender reassignment.14 The acronym LGBT (, , bisexual Classification as a psychiatric disorder At best, trans needs are unmet when and transgender) is frequently used, is assumed to have influenced medical practitioners want to be able to help but do but has been criticised as it assumes a treatment and psychopathology is not not have sufficient knowledge.6 homogenous group with coextensive confirmed.13 One review found that health issues.9,10 This grouping may lead trans people appear to have a higher The consequences of this exclusion to inaccurate conclusions in the literature; risk of psychiatric morbidity, although from health services, previous negative for example, studies may underestimate the majority of these related to affective experiences of care, long waiting times and lack of access to knowledgeable practitioners can lead individuals to avoid Box 1. Common pitfalls healthcare settings and/or seek alternative The following are some of the common pitfalls that occur when transgender means of making gender changes. A patients are accessing healthcare: recent study found that nearly a quarter of patients attending a national gender ● Healthcare professionals and reception staff using the incorrect pronoun for clinic were self-prescribing cross-sex a patient hormones, including hormones that are not ● Failing to include a patient’s chosen name on the medical care record or recommended. Knowledge of side-effects prescriptions – this can lead to embarrassment and/or confusion at the was poor and potentially avoidable adverse 15 practice and pharmacy outcomes were thought to be likely. ● Inconsistency with regard to completion of blood request forms, gender-specific When patients do access healthcare, fear care (eg breast, cervix and prostate) and offer of a chaperone of denial of care or mistreatment may lead ● Access to gender-specific toilets them to avoid disclosure of their gender ● Assuming that all people with gender dysphoria will require mental health status. This can lead to inappropriate interventions treatment, with potentially significant ● Healthcare professionals’ assuming that concurrent health issues are directly implications, eg adverse interactions 6 related to a patient’s trans status between HIV medications and hormones. ● Insisting that people change their before starting endocrine therapies ● Misunderstanding issues surrounding . For example, patients RECENT ADVANCES do not wish for their trans status to be incorrectly equated to orientation and These issues have not continued it is important that physicians do not assume a patient’s orientation unrecognised and important developments have been made. Initiatives such as the

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National LGBT partnership have been formed specifically to reduce health inequities and to tackle (and LGB issues) within public services. Guidelines articulating standards of best practice of care for assessing and treating trans patients have been disseminated. For example, the Royal College of Psychiatrists has developed The Good Practice Guidelines, which aim to enable health professionals to assist trans people with safe and effective pathways to finding lasting comfort with their gendered self, thereby maximising their overall psychological wellbeing and self-fulfillment.16 The treatment to achieve this will vary according to the individual.

Using the appropriate pronoun when calling out patients’ names is very important MANAGING GENDER DYSPHORIA (© Adam Gault/Science Photo Library) A formal diagnosis of gender dysphoria should be established before endocrine Gender affirming surgery (both genital shown to be positive. It is essential that therapy is commenced, an essential aspect and non-genital) is a medically necessary patients receive comprehensive details of gender affirming treatment. This usually intervention for many patients with regarding surgery and its related risks prior comprises suppression of natal hormones gender dysphoria. This can resolve a to commencement, and that there are and the introduction of gender affirming self-perceived mismatch between body realistic expectations. In less than 10% of hormones. Providers should seek further and gender identity, as well as enhancing individuals there may be a less favourable information on the risks associated with an individual’s assimilation into society change of mental health that may be due to hormone therapy so that these can be within their reassigned gender. Standards factors such as complications from surgery, discussed with patients. It is not necessary of care recommend that patients receive poor coping skills and a general lack of for patients to live in their gender 12 months of hormone therapy prior to postoperative support. Permanent regret is congruent role prior to starting hormone gender confirming surgery. For genital very unusual and it occurs in less than 2% therapy. Consent for treatment should reconstruction, 12 months of continuous of individuals following surgical transition. be formally noted and decisions should living in the gender role congruent with a be made prior to commencing hormone patient’s gender identity is recommended. Post-transition, patients may have therapy with regard to gamete storage, In contrast, the criteria for breast or concerns about long-term health issues; as fertility options may be limited once chest surgery are the same as those for for example, trans women may harbour endocrine therapy begins. Once started, hormone therapy; however, a minimum concern about the risk of prostate cancer.6 the endocrine therapy can be managed of 6-12 months of feminising hormones It is therefore important that physicians by either a gender clinic or the primary is recommended prior to any breast encourage discussion and explore any care practice. construction surgery in trans women to potential symptoms. Patients may request improve outcomes. Before genital surgery, that the sex indicated on their medical When patients present with trans issues, it letters from two independent, qualified record be changed and this should be is most likely that they have been dealing mental health professionals are required. respected. It is a criminal offence for an with these issues for many years and they More details on gender affirming therapies individual who has obtained information are usually keen to move onto treatment and specific transition care management, for in an official capacity to divulge an without further delay. However, a thorough example speech and language therapy, can be individual’s gender history for any person assessment is necessary before potentially found in contemporary guidance.16,18,19 with a gender recognition certificate. irreversible treatment begins.15 Support and There is an exception to this for healthcare sufficient information should be available Outcomes following gender affirming professionals where the disclosure is made to patients during transition.17 medical interventions have largely been to a healthcare professional for medical

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should be assessed and adolescents must KEY POINTS provide written agreement to treatment alongside that provided by parents or legal • Expect and accept potential diversity within your patient population. There guardians. It is likely that parents will have is an increase in the number of referrals to specialist services, so demand is many questions and may need support and likely to increase in the practice. signposting to further information. • Pronouns should be used correctly and consistently; if unsure, ask your patient. THE ROLE OF THE PRIMARY CARE PHYSICIAN • Ensure a welcoming clinical practice that is prepared to deal with trans Trans people face many of the same health issues.21 needs as (non-transgender) • Remember that trans people still face the same health issues as the people; the management of their general general population, including issues involving the prostate (trans women), health and wellbeing is therefore without reproductive organs (trans men) and breasts (both). differentiation. General healthcare and support throughout gender transition can be managed within the primary care purposes and when the person making Further, little research has examined the setting.18 Primary healthcare providers the disclosure reasonably believes that long-term impact of hormone suppression, must be able to assess basic mental health the subject has given consent or is unable although much of the existing literature and recognise when psychopathology may to do so.20 supports its use as a safe treatment option be present and referral to a mental health for gender dysphoria in adolescence. professional is needed. CHILDREN AND ADOLESCENTS Gender variant behaviour has been shown For adolescents seeking hormone- CONCLUSIONS to be frequent in children.2 However, suppression, the WPATH Standards of Trans people have frequently experienced treatment options for children presenting Care state that the individual should difficulties accessing healthcare, and with gender dysphoria are contentious. The demonstrate a long-lasting and intense healthcare providers are often unprepared predictors of persistence of dysphoria into pattern of gender non-conformity or for trans patients presenting with both trans adulthood are unclear. gender dysphoria that intensifies with and non-trans-related health needs. This has is the key issue in decision-making with the onset of puberty.19 Co-existing led to an increase in psychological distress, regard to treatment options for children. factors that could lead to poor adherence suicide rates, avoidance of healthcare settings, and patients seeking alternative Resources sources of treatment. Most health needs of trans people require no differentiation. ● Royal College of Psychiatrists (RCPsych) Good Practice Guidelines CR181 Guidelines exist to assist providers to deliver (http://www.rcpsych.ac.uk/usefulresources/publications/collegereports/cr/ care and mentorship can be sought. It is cr181.aspx) and CPD training module on gender dysphoria (http://www. essential that practitioners are well informed, psychiatrycpd.co.uk/learningmodules/genderdysphoria.aspx) have access to the necessary resources and ● World Professional Association for Transgender Health (WPATH) Standards can eliminate any negative or misguided of Care (http://www.wpath.org/site_page.cfm?pk_association_webpage_ personal beliefs in order to provide both menu=1351) support through transition and optimum ● General Medical Council advice for doctors treating transgender patients care post-transition. (http://www.gmc-uk.org/guidance/28851.asp) Declaration of interests: none declared. ● NHS England National Programmes of Care and Clinical Reference Groups interim guidelines for clinicians (https://www.england.nhs.uk/commissioning/ REFERENCES spec-services/npc-crg/group-c/c05/) 1. Bouman WP, de Vries ALC, T’Sjoen G. Gender ● Recommended charities include GIRES (http://www.gires.org.uk/), Mermaids dysphoria and gender incongruence: an (http://www.mermaidsuk.org.uk/), Gender Trust (http://gendertrust.org.uk/) evolving inter-disciplinary field.Int Rev ● Royal College of General Practitioners (RCGP) CPD training module on gender Psych 2016;28:1–4. dysphoria (http://elearning.rcgp.org.uk/course/info.php?popup=0&id=169) 2. Costa R, Carmichael P, Colizzi M. To treat or not to treat: puberty suppression in

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