Supporting the health of trans patients in the context of Australian general practice

There is an increasing number of trans, gender diverse and non-binary (TGDNB) people – those whose gender does not match the sex assigned to them at birth – seeking medical intervention worldwide. Approximately 2.7% of the high school–aged population in Australia are trans or gender diverse,¹ with a similar estimate of 2.3% in the USA.² The estimated number of TGDNB adults ranges from 0.5% to 0.9%.^3,4 However, these are likely underestimates of the true population due to inconsistencies in data collection methods. TGDNB individuals frequently face barriers to accessing medical services in Australia.^5,6 It is important that primary care environments are supportive and inclusive of all gender identities and expressions because negative experiences within primary care can lead to future hesitation towards accessing medical care.⁷ Appropriate healthcare options for TGDNB individuals play a central part in overcoming barriers to care and reducing the high rates of mental and physical health concerns in this population.

There are a small number of well-established key principles that healthcare providers (including general practitioners [GPs]) should adhere to when working with TGDNB patients. A number are listed in the World Professional Association for Transgender Health Standards of Care.⁸ Beyond these general principles, there are multiple best practice guidelines to which medical practitioners can refer when treating a TGDNB patient.^9–12 This article focuses on guidelines that are particularly relevant to Australian GPs. The aim of this article is to clarify and emphasise factors that are highly relevant to GPs when treating a TGDNB patient. The authors highlight the importance of applying these factors in two areas of practice: first, the many ways in which primary care can be improved for TGDNB people regardless of their reason for accessing care, and second, the ways in which primary care can be improved for TGDNB people seeking gender-affirming care. Holistic and respectful care of TGDNB people includes using the individual’s preferred name and title, not making assumptions about the individual or their desires to pursue gender-affirming medical intervention and advocating for the patient in other settings when appropriate. GPs are able to support TGDNB people in their healthcare; however, GPs may also benefit from seeking additional training if they do not feel they have the expertise to do so.

Primary care of the TGDNB patient

Information on gender diversity is not frequently offered in the education curricula that GPs receive,^13,14 which can create difficulties for practitioners working with TGDNB patients.¹⁵ However, treating a patient for general medical needs while respecting their gender does not always require specific training; rather, it requires an openness to all forms of human diversity, which helps to reduce stigma often associated with gender diversity. The risk of providing care that is not wholly supportive of the TGDNB person’s identity (eg misgendering the patient)¹⁴ is that they may be deterred from the health system later in life, leading to preventable illnesses occurring.⁷ This is an important consideration, because medical issues often go undetected in TGDNB patients as a result of lower screening rates within this population and hesitation towards accessing medical providers.¹⁶

The importance of the physical environment

A key aspect of care is to treat TGDNB patients with respect in regard to their gender, which means it is important not to ‘other’ the patient or pathologise the patient’s gender identity and/or gender expression. This begins with the physical environment of the service. Primary care services can signal to TGDNB patients that they are inclusive by displaying flags, posters and other physical attributes expressing welcoming attitudes towards diverse genders and sexualities.¹⁷ Further to that, bathrooms available to patients should be inclusive of all genders, ideally by having facilities that are marked as all-gender or unisex, or by providing a single bathroom that is non-gendered. Services can also indicate their inclusivity by displaying pride flags, health information leaflets specific to TGDNB people, inclusion statements and other physical resources specific to TGDNB people. Local TGDNB community services are able to suggest relevant and up-to-date resources to display.

Collection of personal and clinical information about the patient

Documentation used by health services should be inclusive of TGDNB identities as a signal that the service is a safe place to seek medical help. It is important for all staff working at the practice, including auxiliary staff, to maintain an awareness of the patient’s gender identity. This includes noting that Medicare and private health insurance cards may not match how the person identifies themselves, such as their preferred name, form of address or gender marker. Clinic intake or registration forms should capture necessary legal information for the appointment, as well as the patient’s preferred information, to enable the service to operate within Australian medical law while simultaneously respecting the individual’s identity. By including a correctly worded question on gender identity as standard protocol, the number of TGDNB people within the practice will also be more accurately identified.¹⁸

Pronouns, misgendering and respecting the patient

TGDNB patients are more likely to develop successful relationships with specific service providers and the broader health system if clinicians ensure that intake or registration forms are inclusive of the person’s name that they use (regardless of legal documents), pronouns and gender marker. TGDNB individuals have reported discrimination in accessing primary care through being misgendered and being refused care.¹⁹ The ‘two-step’ model of asking about gender on intake forms involves first inquiring about sex assigned at birth (what was on one’s original birth certificate) and then asking about gender identity,²⁰ and should include an additional question regarding pronouns (Box 1). This approach results in more patients being open about their gender identities and, in turn, ensures clinician awareness of their patient’s TGDNB status.¹⁸

Services should also consider including questions related to forms of address (eg Ms/Mrs/Mr/Mx) and preferred name, as the person’s name may not yet be changed on legal documents. Pronouns are important to ask about (eg he/him, she/her, they/them) so that the practitioner is aware of what language to use when addressing the patient.¹⁴ It is important to maintain accuracy within the patient’s records so that their name and pronouns reflect their true identity, and this means forms and electronic databases need to be updated so they have the capability to collect this information. Updating records with this information, and training staff to respect and use the correct information, means that there is a lower risk of misgendering the individual. It is important to ask which name and form of address should be used when contacting the individual or in referrals. For example, a different name and title may be preferred for physical mail because the individual may not use the same name in all circumstances; for example, they may not be ‘out’ in all environments. Furthermore, GPs could assist their patients (with permission) with referrals by calling ahead or providing an accompanying letter for the appointment to brief the service on the correct name, pronouns and title to use for the patient.

Once the clinician is aware of the patient’s gender, name and pronouns, this information should be updated in the patient’s file and the proper terminology should be used when referring to the patient. Other authors have highlighted the significance of using the individual’s correct name and pronouns in medical settings irrespective of the information listed on legal documents.²¹ If there are circumstances under which it is necessary for the patient’s legal name and/or gender marker to be used, it is important that the clinician explicitly explains why this is necessary and notifies the patient that it will happen so they are prepared for the situation (eg when providing the patient with a blood test form that has their legal name and sex marker listed).

Mental health risks

TGDNB individuals experience mental health issues at rates higher than the general population. The risk is especially elevated for young people (aged 14–25 years) in this population, of whom three in four have ever been diagnosed with depression and/or anxiety.²² Transgender adults are also at risk of mental health issues: 57.2% have ever been diagnosed with depression and 39.9% with anxiety.⁶ The risk of suicide is also higher for TGDNB individuals, with 48.1% of TGDNB individuals in Australia aged 14–25 years having ever attempted suicide.²² Thirty-five per cent of trans adults in the UK have ever attempted suicide, with 25% of this cohort attempting suicide more than once.²³ Given that the risk of mental health concerns is elevated in this population, routine screening for mental health issues should be considered, especially if the physician notices any significant changes in the individual’s demeanour.

Provision of gender-affirming care

A number of studies have indicated that gender-affirming medical intervention often improves the mental health and wellbeing of TGDNB patients who desire such care.^6,23 If a patient is experiencing gender dysphoria (which not every TGDNB person experiences), it is important that this is addressed in a manner that is guided by the patient and their desires. TGDNB people in Australia commonly access their GPs to discuss gender-affirming care and to obtain necessary referrals to other specialist services. These include referrals to psychological support and/or referrals to practitioners specialising in gender-affirming care (namely endocrinologists, surgeons or general practice colleagues with experience in providing gender-affirming care). In areas where there are no practitioners specialising in TGDNB available, and as TGDNB care becomes more mainstream, GPs are increasingly being relied on for TGDNB healthcare.¹⁹ Using the informed consent model, GPs can prescribe gender-affirming hormones to patients.¹² However, an awareness of one’s limits is key to the provision of gender-affirming care. It is important to know when this limit is reached and refer the patient to more knowledgeable colleagues so that the burden of obtaining the desired care does not fall on the patient. Further steps could then be taken by the GP to upskill themself to be better able to help the next TGDNB patient who comes into their care.

Training and professional development

It is beneficial for GPs to seek education on the healthcare needs of TGDNB individuals. Training is offered through multiple organisations in Australia and globally. These range from introductory ‘Trans 101’ workshops that are appropriate for all staff within general practice to advanced training for those specialised in TGDNB care. Introductory training is often delivered by local community organisations, such as through TransFolk of WA in Western Australia and the Zoe Belle Gender Collective in Victoria. At the time of writing, some examples of training providers for professional development for medical providers include the World Professional Association of Transgender Health (WPATH) and the Australian Professional Association for Trans Health (AusPATH). In addition, the North Western Melbourne Primary Health Network with the University of Melbourne currently provides free online training for primary care physicians endorsed by AusPATH, whereas some other training has an associated cost. Some of these courses provide continuing professional development credits, and GPs can find out more information by checking with the specific course. It would be beneficial for GP-specific professional bodies such as The Royal Australian College of General Practitioners (RACGP) to provide training in this area. In addition to GPs seeking supplementary training, other staff need to be educated on inclusive practice so that the patient is supported and respected in all aspects of attendance at the service.

Medical education opportunities may be specifically focused on:

• the benefits and risks associated with gender-affirming medical intervention (eg puberty-blocking hormones, gender-affirming hormones, surgeries)
• dosing of hormones
• how to determine (with the patient) what medical intervention, if any, they desire
• when to refer to non-GP specialists for appropriate care
• discussing and assessing informed consent of the patient for medical intervention.

Education on gender diversity can help to guide decisions related to referral for gender-affirming medical intervention for those patients who are seeking more information about such options. Central to this is the expectation that the patient’s GP will be able to provide ongoing and follow-up care in relation to medical interventions.

A holistic focus on wellbeing

The care of TGDNB patients extends beyond immediate medical needs and gender-affirming medical intervention. TGDNB young people²² and adults⁶ in Australia are exposed to high rates of discrimination, bullying, abuse and other negative experiences. GPs can improve these experiences by emphasising the importance of wellbeing for their patients, including the GP’s willingness and availability to support and advocate for their patients in non-clinical settings, such as with families, schools and workplaces. For example, the clinician can assist patients with family support through organising family meetings if that is in the patient’s interests. In addition, they can advocate for patients by providing letters of support for patients changing their gender markers on identification documents, including for Medicare, Centrelink, driver’s licence, passports and other forms of legal identification.

It may be beneficial for GPs to consider keeping up-to-date resources on peer support and community networks so that they can facilitate connections to these networks. For rural and remote areas, it is suggested that TGDNB people seek online platforms to develop connections and find peer support. Primary health networks and local peak bodies could help to support GPs in this aim, specifically by maintaining lists of, and relationships with, local community organisations through which TGDNB people can obtain peer support. GPs can also help this process by providing resources for community organisation contacts in their waiting and clinical rooms.

Conclusion

There are many dimensions to providing supportive care to TGDNB patients, and many of these overlap with broader principles of providing general patient-centred care. Clinicians are now seeking training and ongoing professional development in the area of gender diversity because the field is evolving relatively quickly and there is an increase in the number of TGDNB patients seeking services worldwide. A proactive stance towards learning about how to care for TGDNB patients in a safe and inclusive manner allows the patient to focus on their specific needs and situation rather than using their limited appointment time to educate health providers on the fundamentals of TGDNB healthcare.²⁴ Such training would ideally begin in medical school and be incorporated into standard curricula that GPs receive. Primary care, as the entry point into the healthcare system, is a vital bridge to improving health outcomes of TGDNB Australians. Further research should evaluate any barriers that GPs feel they have when providing care to TGDNB patients. Treating a TGDNB patient extends beyond providing medical care to emphasising general wellbeing and quality of life. It includes assisting the person to access mental health support if needed or desired, referring them to medical transition services and ensuring that the individual is adequately supported in other aspects of their life (eg by family, friends, employment).

Key points

• Regardless of their expertise in the field of TGDNB healthcare, it is crucial for all GPs to provide care that respects and values their patient’s gender identity, framing it as diversity rather than disease or disorder.
• Although not all GPs will feel adequately trained to address specific TGDNB healthcare concerns, many consultations may be about everyday clinical issues that are well within their scope of practice.
• TGDNB healthcare needs include information on, and access to, options for medical intervention that are available (including the benefits and risks associated with those interventions).
• There is a high risk of mental health issues within this population, so appropriate screenings for such issues should be considered, with referral for additional support as appropriate.
• Every TGDNB patient has their own specific needs in regard to gender healthcare, and patients should be referred to services specialising in TGDNB care where appropriate.
• All patients should be asked how they would like to be addressed (preferred name, title, pronouns) regardless of the name and gender marker on identification documents.
• A positive relationship with a TGDNB patient includes reducing any gender dysphoria that might be present and encouraging a positive relationship with health services for ongoing care and prevention of illness.
• Where appropriate, general practitioners may consider acting as an advocate within their TGDNB patients’ families and beyond.