A person who has a scary symptom like chest pain is probably worried and stressed. For some people, their worry includes not only their health, but also whether they will be refused treatment, called by a name and pronouns that don’t reflect their identify, laughed or gawked at, assumed to have behavioral or sexual health issues, or offered treatments that have not been assessed in people like them. This is the reality that many transgender people face.
Fellow AHA Early Career Blogger, Allison Webel, PhD, recently wrote about cardiovascular disease in the transgender population. Please check out her post— it’s excellent. Some key background to remember is that transgender people live in all 50 states and over 1.4 million Americans identify as transgender1. This means that no matter where you work and what your specialty is, you are likely to encounter transgender and other gender non-conforming folks (including people who identify as genderqueer, non-binary, or other designations). It is up to you to decide to meet their needs— the systems currently in place will not ensure this. For the medical community to effectively reach transgender people, we must address their needs through research, clinical practice and education. Early career professionals need to be leaders in this effort — changing long-established ideas and practices is not easy.
Historically, the research community hasn’t done a great job of ensuring gender equity in science. As Dr. Paul Chan notes in a recent editorial, gender disparity research has picked up in recent years, but very little of it explicitly includes transgender people2. We are only beginning to generate evidence to direct our care of transgender people, and much of that evidence focuses on sexual or behavioral health. Thanks to a recent article by Dr. Talal Alzarhani and colleagues, however, we now know that the transgender population has a higher incidence of myocardial infarction than the cisgender population3. This finding is not surprising, but it is a clear sign that we must do better designing research to advance understanding the unique health needs of transgender people. But how?
- Don’t make excuses. Women were excluded from medical research for a long time because of concerns about hormonal cycling and pregnancy. This choice has created persistent disparities4. Don’t perpetuate such inequality with the transgender population. Develop research and analysis strategies to deal with the diversity that exists rather than collapsing it or ignoring it for the sake of convenience or cost.
- Use inclusive language to capture accurate data about gender. Dr. Chan suggests gender categories that include at a minimum cisgender male, cisgender female, transgender male, transgender female, and other2. Importantly, this strategy removes assumption that cisgender is normal and expected and allows people of all gender identities to respond authentically.
Much as women’s health isn’t limited to OB/GYN care, trans health is not limited to hormone therapy. Transgender people need the full spectrum of health care that cisgender people do, but many have been refused care or felt unwelcomed and mistreated in medical settings5. Primary care providers, behavioral health providers, and endocrinologists are likely to encounter transgender patients, but so are cardiologists, oncologists, surgeons, and others. Culturally and medically competent care is imperative in all of these contexts. Provider discomfort should not be a barrier. Here’s what you can do to improve:
- Educate yourself about gender diversity. Remember that it is not your patient’s job to teach you the basics. Go to sessions at conferences, seek out knowledgeable colleagues, and read up.(Resources are listed at the end of this post to get you started).
- Be welcoming: ask your patients what their pronouns are, and train staff to do this also. Don’t avoid addressing people because you are unsure or uncomfortable. Make sure your forms allow people to self-identify their gender with inclusive options. If you make a mistake, apologize and move on.
- Practice with a trauma-informed approach (read an introduction to the topic here. Recognize that trust must be built. Transgender people are more likely to face significant psychosocial stressors and discrimination, including in health care. This will affect their experience.
Though health professions students report a high level of comfort with lesbian, gay, bisexual, and transgender health, they receive little formal training6. Educators in the health professions can explicitly include transgender people across curriculums to improve this perception. Here are some strategies:
- Use gender diverse images in your education materials. Find some here.
- Create cases and content including trans people when teaching about common health concerns.
- Invite an expert. Find someone who cares for transgender people in your community to speak to your students.
So, early career professionals, the ball is in your court. What are you doing to enhance gender inclusivity in your work?
National LGBT Health Education Center (lgbthealtheducation.org)
UCSF center of excellence for transgender health (http://transhealth.ucsf.edu/)
- Flores, A.R, Herman, J.L., Gates, G.J. & Brown, T.N.T. (2016). How Many Adults Identify as Transgender in the United States? Los Angeles, CA: The Williams Institute.
- Chan, P. (2019). Invisible gender in medical research. Circulation: Cardiovascular Quality & Outcomes, 2019(12).
- Alzahrani, T. et al. (2019). Cardiovascular disease risk factors and myocardial infarction in the transgender population. Circulation: Cardiovascular Quality & Outcomes, 2019(12).
- Shansky, R. (2019). Are hormones a “female problem” for animal research? Science, 364(6442),.
- Liszewski, W., Peebles, J., Yeung, H., & Arron, S. (2018). Persons of nonbinary gender— Awareness, visibility, and health disparities. The New England Journal of Medicine, 379(25).
- Greene, M., France, K., Kreider, E., Wolfe-Roubatis, E.,, Chen, K., & Yehla, B. (2018). Comparing medical, dental, and nursing students’ preparedness to address lesbian, gay, bisexual, transgender, and queer health. PLoS One, 13(9).
Elizabeth Knight, PhD, DNP is a family nurse practitioner, scientist, and educator at Oregon Health & Science University. Since arriving in Portland this year, she splits her non-work time between finding awesome trails and finding awesome restaurants. Her clinical interest is in primary care for underserved populations and her research interests include women’s cardiovascular health and access to care. She tweets @TheKnightNurse.