American College of Physicians Releases Comprehensive Transgender Care Guide

For the first time, the American College of Physicians has released a comprehensive guide for transgender care -- a significant endorsement of gender-affirming care from the nation's second-largest physician group.

The central aim of the document is to encourage primary care physicians to care for their transgender patients rather than turning them away or referring them to specialty centers. The guidance was published Monday in Annals of Internal Medicine, the official journal of the American College of Physicians.

"The biggest barrier to care for transgender people is a lack of knowledgeable providers," said lead author Joshua D. Safer, M.D., FACP, executive director of the Center for Transgender Medicine and Surgery at Mount Sinai in New York City.   "Education of providers is still a high-priority item," he said, noting that many doctors believe transgender patients should be treated by providers who specialize in transgender care. "That's not true -- a trans individual ought to be able to go to a primary care provider," Safer said.

According to estimates, somewhere between 0.5% and 0.7% of adults in the United States identify as transgender. The passage of the Affordable Care Act in 2010 prohibited insurers and providers that receive federal funding from discriminating against transgender patients. Still, transgender patients consistently report lack of provider competency, with many reporting that they have had to teach providers about transgender health in order to receive proper care. With this guidance document, Safer hopes that more providers will have the confidence to care for transgender patients.

"Most physicians will think of themselves as good, critical scientists," said Safer. "They want a well-referenced, data-driven guide. On the other hand, people are busy, so they're going to look to credible sources. The credibility of the organizations putting out the documents influences how seriously people take what's put out."

The guidance itself is a 16-page manual describing proper steps in caring for transgender patients based on the most up-to-date medical evidence. It includes basic terminology, proper procedures during initial evaluation, and a review of medical management, including hormone treatment and surgery.

The guidance document is intended for the care of adult patients, although it touches on specific treatments for children and adolescents, such as hormone blockers. (Safer said there is no equivalent guidance document for pediatric care of transgender patients).

Although HIV is over-represented among transgender people, the guidance document recommends a customized evaluation of each patient's HIV risk rather than blanket screening.

"The focus is taking care of transgender people generally," said Safer. "It's wrong to think that just because somebody is transgender they are at increased risk for HIV."

The guidance also reviews scientific data to suggest that differences in gender expression have biological underpinnings, rather than the prevailing view that all transgender individuals are experiencing a mental health disorder.

"Although the mechanisms are not known, data suggest a biological underpinning to gender identity that is present at birth," the document reads, pointing to evidence that gender identity is malleable and transgender identity is more likely among people who experience certain conditions that expose them to extra hormones.

The authors acknowledge that transgender health care is a politically charged topic, and the guidance includes a brief summary of the societal and legal issues that persist in transgender care, such as the challenges of reconciling name and gender markers in the electronic medical record, and the fact that only 20 states consider insurance coverage obligatory for transgender care.

According to a March 2019 white paper from Amida Care, "private health insurance companies routinely deny coverage for procedures for transgender individuals" and few states "provide Medicaid plans to transgender individuals." Worse, the paper also reported that "transgender individuals are often refused treatment due to their gender identity, and many individuals have been harassed in a doctor’s office."

Safer acknowledged that the guidance document is only one step in a long march toward improving transgender care in the United States. Another major barrier, he said, is the logjam created by the current electronic medical-record-keeping system, which only allows for binary male or female gender allocations. Meanwhile, he emphasized the importance of also training non-clinical staff members on the proper terminology and respect for transgender patients.

According to Safer, mainstream medicine is eager to learn more about transgender care. And as physicians learn to incorporate gender-affirming care as a routine part of their clinical practice, this will help ease anti-trans stigma more broadly in society.

"Society does look to the medical community as to what is 'true' in greater science and medicine," Safer said, noting that "the average individual is still going to be heavily influenced if mainstream medicine" starts practicing gender-affirming care.