Driving Care for Our Trans Patients
How can we ensure better care for transgender patients? Here, Timothy Craig Allen shares his lessons learned – and his vision for the future
Michael Schubert interviews Timothy Craig Allen
How did you enter the conversation on transgender patient care?
Like many others, I learned about transgender patients’ issues and difficulties through news, social media, and conversations with friends and colleagues. My understanding has built slowly over the last few years, and I continue to seek out information and update my knowledge.
Discussions with colleagues at the University of Mississippi Medical Center (UMMC) who have specific expertise in transgender issues, as well as diversity, inclusion, and equity educational programs, have furthered my understanding of transgender difficulties. I asked myself what more I could do – and that started me thinking about how pathologists and laboratorians could engage in the discussion and be part of the solution.
What do you think are the key needs pathologists and laboratory medicine professionals must keep in mind when treating trans patients?
The goal is equitable treatment for transgender patients by all health care personnel. Stigmatizing behavior keeps these patients away and insensitive behavior adds to their discomfort. This is a responsibility borne by everyone involved in health care – including pathologists and laboratorians.
In our discipline, there are a few first steps with which we can quickly involve ourselves – specifically, the use of proper pronouns in patients’ charts and medical records and the development of appropriate reference ranges for certain tests, especially hormone-related tests.
Clinical laboratory testing of hormones is the most obvious place to start, with consideration of reference ranges appropriate for our transgender patients. It’s clear that tissue excisions from organs that have been affected by hormones – for instance, breast and prostate – will need special consideration related to hormonal changes and cancers that may be hormone-related.
More research is needed to assess differences between cis and trans men, and cis and trans women, in all aspects of their health, as transgender patients age and chronic diseases become more prevalent in gender-affirmed patients.
What training do pathologists and lab medicine professionals currently receive in addressing the healthcare needs of trans patients?
The issues surrounding transgender medicine are relatively new to many folks. Training and education vary; however, from my conversations with colleagues, I’ve found that most pathologists and laboratorians have little or no training regarding medical issues specific to the transgender population beyond what may arise in a basic institutional diversity lecture or course.
Unfortunately, I doubt that this lack of training is unique to pathology and laboratory medicine. Other health care professionals face the same barrier. There is a great need for expanded education overall in the health care setting.
Beyond the standard diversity training pathologists and laboratorians receive, I believe we need additional focused training and education that puts transgender patients’ issues in perspective, reinforces a professional culture, promotes discussion, and helps pathologists and laboratorians consider next steps in our journey to improve the lives of our transgender patients.
How prevalent are trans patients in your healthcare system?
Without knowing exact numbers, I would say that transgender patients are at least as prevalent at UMMC as at any other institution that does not specialize in transgender care. In fact, as a state medical school, it is likely that UMMC sees more transgender patients than surrounding hospitals due to the socioeconomic factors many transgender patients face. Furthermore, our institution’s active focus on providing services for our transgender patients, championed by several institutional leaders, may draw additional transgender patients to UMMC.
I will share one of my own cases – a lung biopsy from a transgender patient. I paid close attention to the patient’s name and made sure to use the appropriate pronouns when referring to the patient in the report’s comment. This experience may sound mundane, but it highlights the fact that all pathologists and laboratorians are likely to be involved in transgender patients’ care – not just those specialties that deal with gender-affirming surgery, such as breast, gynecologic, and urologic pathology. As such, we should all recognize the need to educate ourselves fully so that we can best care for our transgender patients.
Do pathologists and lab medicine professionals face any potential issues with billing and reimbursement for gender-related health care?
Billing issues may occur in cases of gender-affirming surgery; however, they can likely be avoided by the pathologist carefully indicating in the surgical pathology report that the surgical procedure is “gender-affirming surgery” and not merely “hysterectomy” or “breast reduction,” which would perhaps cause confusion with transgender patients who are medically transitioning.
For procedures and tests that are not part of the continuum of gender-affirming surgery, appropriate use of pronouns – and diligent tactful comments – should assist the billing folks and avoid denials. The same holds true in the clinical laboratory; for instance, when performing a prostate-specific antigen test on a trans female patient.
What effects might new legislation surrounding gender-related healthcare have on trans patients?
Evolving legal, social, and cultural issues exist with regard to transgender medicine. In this situation, reasonable minds can reasonably differ and society will continue to work to balance the equities involved, including issues of patient autonomy, civil rights, and parental rights.
The best thing pathologists and laboratorians can do right now to benefit our transgender patients is to fully engage in learning – and educating others – about our transgender patients. Dispel myths. Explain terminology. Get involved in research to assess the questions that will guide public health policy.
What one key takeaway message would you like pathologists and lab medicine professionals to keep in mind when treating trans patients?
These are our patients. Even if we do not see them, we can have a remarkable impact on the quality of their medical encounters, on the quality of their medical care, and on the quality of their lives. We can reduce their anxiety, increase their feelings of acceptance, and ultimately provide them equitable health care free of gender-related stigma and discomfort. It’s our job to support these patients and champion their care – and it’s our job to make sure they know we’re there for them.
A New Gender Gap
By Scott M. Rodgers
Regarding the unique healthcare challenges facing the transgender population, access to caring, nonjudgmental, and competent providers is perhaps the single greatest challenge. In Mississippi, only three clinical practice groups in the entire state have developed specific programming in transgender health, and two of these three are in Jackson. Many patients in the rural areas of the state have no one nearby with the capacity or willingness to provide care.
Second, inclusive health insurance benefits depend to a great extent on where a person lives in the United States. In Mississippi, insurance companies are not required to cover the costs of gender-affirming care, which means that patients are left with only self-pay options – and therefore often cannot afford treatment. To provide some contrast, Massachusetts requires all insurance companies to cover these costs, allowing patients in Massachusetts to get the care they need.
Third, transgender individuals face discrimination at higher rates in housing, schools, and the workplace, and they are more likely to be unemployed (and therefore without workplace health insurance). In states like Mississippi without expanded Medicaid to cover the uninsured, this creates massive problems for the transgender community.
Regarding recent legislation targeting this community, many of us who serve this population are very worried about the potential for real harm. By restricting and eliminating affirming healthcare for the community, we expect a resultant worsening of mental and physical health. We will likely see an increase in rates of depression, suicide, anxiety, and addictions, to name just a few potential problems. This runs entirely counter to our purpose in medicine, which involves the relief of suffering. Such legislation is regrettable, unfortunate, and unnecessary.
Scott M. Rodgers is Professor and Chair of the Department of Psychiatry and Human Behavior at the University of Mississippi Medical Center, Jackson, Mississippi, USA.
A Care Collaboration
By Jane F. Reckelhoff
Because the field of transgender studies is relatively young, the overall health of transgender individuals is not clear, especially in individuals taking gender-affirming therapies (GAT) long term. For example, most studies on cardiovascular disease risk in transgender individuals, including lipid and triglyceride levels and insulin resistance, are made in individuals who have been taking GAT for relatively short times (months to a couple of years). Thus, the long-term cardiovascular consequences of GAT are unknown.
It is well known that cisgender men have a higher incidence of cardiovascular disease and earlier incidence of first myocardial infarction than do cis women; cis women develop myocardial infarction approximately 10 years later than cis men on average, but their recovery is not as rapid – perhaps due to the increased incidence of comorbid conditions present with aging. Due to the lack of long-term studies in transgender individuals, there is little information as to whether the same gender differences in myocardial infarction that are present in cisgender patients are present in trans men and women.
The data from transgender studies are also inconsistent; some studies show that transgender men have little cardiovascular disease risk, whereas others show that they have increased incidence of myocardial infarction. In addition, there are no consistent reports on the cardiovascular health of aging transgender individuals who have been receiving GAT for many years. This is partly due to the changes in GAT guidelines over time and partly due to the relatively small populations of transgender individuals.
Given this lack of data and the need for careful testing and record-keeping, it’s clear that pathologists and laboratorians can provide significant support for endocrinologists, cardiologists, and other healthcare practitioners. Together, we can define the health consequences of long-term GAT in transgender individuals with the intent to be proactive in their health care, thus improving our trans patients’ long-term quality of life.
Jane F. Reckelhoff is Billy S. Guyton Distinguished Professor and Chair of Cell and Molecular Biology, Director of the Women’s Health Research Center, and Director of the Mississippi Center of Excellence in Perinatal Research at the University of Mississippi Medical Center, Jackson, Mississippi, USA
Timothy Craig Allen is Professor and Chair of the Department of Pathology at The University of Mississippi Medical Center, Jackson, USA
