WOKE MED

How the next generation of doctors is learning to treat transgender people

Alex Izaguirre/FUSION

Anna thought she had finally found an endocrinologist who could treat her.

“It went great initially the first day,” the 27-year-old transgender woman told me. “I got in, got a prescription that day because I had a therapist’s letter, and it was going really well.”

Anna felt lucky at first. Endocrinologists typically treat hormonal problems like diabetes or thyroid diseases—not all are willing to prescribe sex hormones like estrogen or testosterone to help transgender patients transition, or develop secondary sex characteristics that correspond to their gender identity.

But Anna’s luck quickly ran out. Her doctor prescribed her an unusually low dose of estrogen and over time, she says, it became clear that he had never treated a transgender patient before. So she took matters into her own hands.

“I wound up having to do research on my own figuring out what my levels should actually be, print it out, bring it in, and basically educate him on it,” Anna told me.

The endocrinologist eventually adjusted Anna’s dose, but she later moved from California to Portland, Oregon, where she was fortunate to find a doctor who was well-versed in transgender hormone therapy. Making an appointment with a new endocrinologist, Anna told me, “just seems like this huge shot in the dark.”

She’s right. A recent study suggests that a transgender person walking into an endocrinologist’s office to begin medical transition has less than a two-thirds chance of receiving that treatment. That study, published in Endocrine Practice, found that only 63% of endocrinology providers at a 2015 conference were willing to provide hormone therapy for transgender patients. Half hadn’t even read the Endocrine Society’s 2009 readily available guidelines for that treatment.

But there was a silver lining: 70% of providers under age 40 had read the guidelines. If that’s indicative a broader trend, the next generation of endocrinologists could change the map for transgender health care. Someday in the not-too-distant future, as pioneering young doctors reshape the medical world, transgender patients may be able to access state-of-the-art hormone therapy as easily as diabetics receive insulin prescriptions.

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My own experience could not have been more different from Anna’s. When I started hormones while working toward my doctorate at Emory University, I was referred to Vin Tangpricha, the director of the school’s endocrinology fellowship program and the president-elect of the World Professional Association of Transgender Health.

As one of the modern-day experts in transgender health, Tangpricha is excited by the shift he has seen among his students in the past few years.

“It’s refreshing that there are a lot of young doctors who want to educate themselves,” Tangpricha told me. “They’re very open-minded and they don’t think anything of it. That was different from when I went through training.”

When Tangpricha was younger—he started medical school in 1992—his professors were wary of his interest in transgender hormone therapy. But he “felt like no one was doing anything,” so he persisted. After publishing an article on the subject in 2003, he was asked to help develop the Endocrine Society’s 2009 guidelines for transgender hormone therapy—the ones too many of his colleagues still haven’t read.

Even though those guidelines exist, making sure that endocrinologists actually learn them has been a challenge. The World Professional Association of Transgender Health has been conducting trainings around the country—reaching about 1,000 doctors so far by Tangpricha’s estimation—but that’s still not enough.

“You would think that doctors would want to educate themselves, but until you force them to do stuff, they don’t,” Tangpricha told me.

But even if all practicing endocrinologists learned the guidelines, most medical schools still aren’t teaching transgender hormone therapy to a rising generation of young physicians.

Joshua Safer, the director of Boston University’s endocrinology fellowship program and a spokesperson for the Endocrine Society, has been trying to change that. “Transgender medical care is not a part of conventional medical education and has not been a part of conventional medicine ever,” he told me.

It’s not that prescribing hormones for transgender patients is challenging—the process is “not that complicated,” Safer assured me—but that medical schools are “very conservative.” A 2011 Stanford study found that only about 30% of 176 U.S. and Canadian medical schools cover transitioning in their required curriculum, even though the American Medical Association has supported transition-related health care since 2008.

Safer has observed some recent progress in medical students being taught how to be culturally competent in their interactions with transgender patients—knowing the right pronouns, using the proper language, et cetera—but he wants to see more of them trained in the actual medical treatment itself.

“Transgender individuals who want medical intervention—and that’s a sizable number of people who are transgender who are showing up to doctors—are not looking for the doctors to simply be respectful,” he told me. “They’re looking for doctors to actually know what to do, and that’s still missing.”

Learning about transgender hormone therapy is not even a guarantee for medical school graduates who choose to pursue an endocrinology residency or fellowship —despite the fact that these training programs are meant to offer doctors an in-depth, immersive education in the field. Out of the 104 fellowship program directors who were surveyed for a recent Endocrine Society presentation, only 52% responded and less than three-quarters of those respondents said their programs teach transgender hormone therapy.

But much like Anna did with her own treatment, some young endocrinologists are taking transgender health care disparities into their own hands.

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Farah Naz Khan first became aware of hormone therapy during a high school debate competition when she was assigned to argue a case about health care for incarcerated transgender people. She didn’t learn about it in medical school nor did she see any transgender patients during residency. But now, thanks to Vin Tangpricha’s fellowship program at Emory, she is revisiting the subject at long last.

“The fact that I look back and my initial exposure to this was in high school and I haven’t dealt with it again until years later in endocrine training—that’s terrible, in my opinion, and that shouldn’t be happening,” she told me.

Khan currently sees transgender patients at a weekly continuity clinic at Grady Memorial Hospital in Atlanta and she is eager to become more involved.

There’s strong evidence, too, that today’s medical students share Khan’s willingness to treat transgender patients. In a 2016 study co-authored by Safer, thousands of Canadian medical students across 14 schools answered a survey about transgender topics on their curricula. Almost all—95%—believed that transgender issues “should be addressed by physicians” but fewer than 10% said they were “sufficiently knowledgeable to do so.”

That matches Khan’s experience working with doctors who are uncomfortable with transgender health care “not because of any sort of stigma” but because they never got the right training.

“If you have an interest in it or if you are aware of it, you need to seek it out,” she explained. “It’s not something that’s readily available.”

In the meantime, Sonya Haw, who just joined the Emory endocrinology faculty in 2014, doesn’t want Atlanta’s large transgender population to have to wait for more doctors to get trained. Along with a working group of medical residents, most of whom are in their mid-to-late twenties, Haw has applied for a grant to set up a multi-discipline “one-stop shop” for transgender health care at Grady.

Transgender people could visit the clinic for hormone therapy, yes, but they could also see a psychiatrist or an OB/GYN. Haw envisions it as an “entryway into the health care system” that can help transgender people now, rather than later.

“We don’t see this as a place that trans patients come back to for ten, twenty, thirty years like they would do for a family practice clinic,” she told me, imagining a future in which transgender health is integrated into general health care. “But right now, there’s such a need for more formal and informal medical education for not only residents, medical students, and trainees but also senior physicians.”

And like many younger physicians, Haw is completely unfazed by the cultural controversies around transgender issues. To her, this is a medical issue—and a fairly straightforward one at that.

“Caring for transgender patients has a lot of societal, political baggage that comes with it,” she told me. “But if we can just think of trans care as caring for any other patient that we have, addressing their medical and physical needs, it’s not that difficult or convoluted.”

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All of the people I interviewed were optimistic about the future of transgender health care.

Tangpricha and Safer believe they will have an easier case to make with medical schools as a more accurate picture of the size of the transgender population comes into focus. The Williams Institute, a UCLA-based think tank that conducts independent research on gender and sexual identity, estimates that there are 1.4 million transgender adults in the U.S. alone—a much higher prevalence, Tangpricha says, than some of the rare endocrine conditions that medical students “learn so much about” in school.

And both Tangpricha and Safer pointed out that as New York’s Mt. Sinai Health System and other prestigious hospitals open their own transgender health care centers, other medical schools and hospitals are likely to get envious.

“Once you start getting that competition, all the other hospitals will follow suit,” Tangpricha suggested.

“Institutions are beginning to step up and put this together,” Safer added. “If you’re talking about looking forward to a brighter future, that’s happening.”

But change will have to come from the bottom up, too, and that means training new students. Studies that Safer has co-authored have shown that even “simple” changes in instruction can significantly boost medical students’ and residents’ willingness to treat transgender patients. And if curricula can become more inclusive, Haw predicts that it is only a matter of time before we see a massive shift in accessibility for transgender health care.

“As we are able to train residents and medical students and continue their exposure—and as they move on to be attending physicians themselves—I think we will see a change in the landscape of how easy it is to care for trans patients from an access standpoint and a quality standpoint, too,” she said.

Today’s physicians may be able to address the gaps in transgender health care access, but tomorrow’s physicians will close them.

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