Editorial
JOURNAL OF WOMEN’S HEALTH Volume 24, Number 2, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/jwh.2015.1518
Time for OBGYNs to Care for People of All Genders Juno Obedin-Maliver, MD, MPH
here are at least 1.5 million transgendera individuals (0.5% by a household population based survey) in the United States.1 Although transgender individuals are often closeted, marginalized, and maligned there is growing social, political, and medical awareness. In June 2014, actress Laverne Cox became the first openly transgender person to be on the cover of Time Magazine. In the political arena, President Obama—the first president to use the word ‘‘transgender’’ in a speech—facilitated protection of transgender individuals in hate crimes legislation and coverage of gender affirmation surgery for transgender government employees. Furthermore, Medicare recently reversed its position on denying payment for transition related surgery (National Coverage Determination 140.3, 2013). Alongside expanded awareness of transgender people’s lived experience comes a growing understanding of the health disparities transgender individuals face. Although data is woefully deficient, these include a prevalence of human immunodeficiency virus infection among transgender womenb 34 times that of reproductive age adults in United States.2 30% smoking prevalence among transgender adults versus 21% among U.S. adults,3 a 35% lifetime prevalence of intimate partner violence for transgender adults (exceeding that experienced by lesbian, gay, and cisgenderc adult women4), and lifetime rates of depression and suicide attempt as high as 67% and 79% respectively.5 Many documented health disparities stem from diminished access to care and trained providers as well as social and medical discrimination.5–7 In a recent survey of 646 transgender adults in California, over 21% were denied mental health services, 15% were denied gender-specific care (such as pap smears for transgender men), and 10% were denied primary health care.8 Disturbingly, in a national report, over 70% of transgender adults reported harsh or abusive lan-
T
a An individual whose gender identity differs from their natal or birth sex. b Individuals whose gender identity is female and whose birth sex is male. c Cisgender individuals’ gender identity match their natal or birth sex. Cisgender women are natal females who identify as women and cisgender men are natal males who identify as men.
guage, blame for their health status, or physical roughness or abuse from health care professionals.6 Unsurprisingly, 90% of transgender individuals agree that there are ‘‘not enough health professionals adequately trained to care for transgender people.’’6 This begs the question: Who is being trained to provide care for transgender individuals? Motivated by significant health care disparities transgender individuals face,3,7 Dr. Unger (see this volume and number, pages 114–118) presents an important cross-sectional study of practicing obstetricians and gynecologists (OBGYNs) to understand clinician training, knowledge base, and care provision for transgender patients.9 The study included 141 respondents from 9 academic institutions (40% response rate, 62% generalist OBGYNs) whom completed an online, selfreported, questionnaire. Respondents were predominantly in the Northeast (41%) and Midwest (31%). Though most questions focused on transgender patient care, others regarded care of lesbian, gay, and bisexual patients to highlight differences in care provision between sexual and gender minority patients. Notwithstanding the limitations of a cross-sectional study with a convenience-sampling frame and the instrument validation issues inherent to a newly explored field, Unger’s study has compelling results. Although 31% of respondents knowingly care for transgender patients, 80% of respondents, regardless of residency training recency, had not received any formal training to do so. Furthermore, few providers were ‘‘comfortable’’ taking care of either transgender mend (29%) or transgender women (35%), despite having the requisite skills to do routine health care maintenance and organspecific screening. This is highlighted in that 11% of respondents were unwilling to perform routine Pap smears for transgender men and 20% were unwilling to perform routine breast exams for transgender women on hormone therapy. Most (59%) did not know the breast cancer screening recommendations for transgender women. Further knowledge gaps included requirements for genital reconstructive surgery and routine health care maintenance (e.g., lipid, diabetes, and prostate cancer screening) for transgender people.
d Individuals whose gender identity is male and whose birth sex is female.
Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California. Department of Internal Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California. Lesbian, Gay, Bisexual, and Transgender Medical Education Research Group, Stanford University School of Medicine, Stanford, California.
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How should we interpret physicians’ discomfort and unwillingness to provide routine care for transgender individuals? Discomfort and unwillingness go together and often stem from deficits in knowledge, skills, or attitudes. Although transgender health is under-studied7 and under-taught,5,10 much of the knowledge necessary for OBGYNs to provide health care for transgender individuals is highly teachable and increasingly available.11 OBGYNs already have many of the skills to care for transgender patients, and the rest are teachable. Through caring for cisgender women, OBGYNs have become specialists in the medical and surgical management of the reproductive system specifically: the vagina, cervix, uterus, adnexa, and breast tissue. Regardless of gender identity, any individual with these organs needs and deserves the same medical care for them, thus the frequent transgender preventative care adage, ‘‘if you have it, screen it.’’ Therefore, the biggest hurdle is not knowledge or skills. The challenge to good care is thus a conceptual one for providers and health care systems. OBGYNs can immediately apply their organ-specific knowledge to the care of transgender patients. For example, a transgender man who has heavy painful menses has the same hormonal and surgical options available to him as a cisgender woman. But, having a conversation about menstrual bleeding or desired pregnancy12 with a fully bearded man is initially mentally incongruous, and insurance reimbursement for treatment (e.g., hysterectomy for a man) is often administratively incongruous. Therefore, caring for transgender individuals, as with all patients, is about more than caring for sex-specific organs; it requires seeing and acknowledging the whole person (e.g., a man a uterus or a woman a prostate). For OBGYNs, broadening our understanding of our patients as whole individuals may shift how we define ourselves. The field of OBGYN is facing a gender identity service conflict. Obstetrics and gynecology is synonymous with the care of cisgender women, and OBGYNs are professionally labeled as ‘‘Women’s Health Care Physicians’’ (American College of Obstetricians and Gynecologists [ACOG]). Recently however, OBGYNs treatment of cisgender men with anal dysplasia and pelvic pain was controversial.13–15 Despite having an appropriate skill set, caring for cisgender men challenged the identity of OBGYNs as women’s health care providers, and some feared it would dilute OBGYNs advocacy for cisgender women. Similar concerns have been raised regarding OBGYN’s care for transgender patients despite the urging of ACOG to do so.16 Expanding our practices to provide for transgender individuals will not diminish our care of cisgender women, but rather will extend our services to others in need. Let’s make the pie bigger and apply our prior baking lessons; let’s bring our knowledge, skills, and passion for advocacy to a marginalized group while redefining ourselves as reproductive health physicians. Consider Dr. Unger’s study as a call for action. All specialties need to ensure unfettered access to quality health care for transgender individuals, but OBGYNs in particular have the much-needed foundational knowledge and skills transgender people need. We just need to shift our attitudes. OBGYNs have the potential to be strong transgender advocates and allies by ensuring that in every aspect of what we do transgender individuals are considered and welcomed. This means supporting gender disclosure at intake and ensuring
OBEDIN-MALIVER
that all office staff maintain consistent and respectful pronoun usage. It means having a physical space that promotes comfort for people of every gender including omnisex bathroom facilities and comprehensive educational materials that reflect human diversity. It means supporting social, medical, and surgical transition through education and caring, hormone administration, and appropriate surgery. It also means ensuring gender diversity in research studies, teaching gender diversity to our students, and advocating for sensitive and comprehensive health care provision for all genders. Acting means joining the larger movement supporting expanded rights for transgender individuals. By taking these actions we can ensure that one day, all transgender individuals have OBGYNs, commensurate ‘‘reproductive health physicians,’’ when and where they need them. References
1. Conron KJ, Scott G, Stowell GS, Landers SJ. Transgender health in Massachusetts: Results from a household probability sample of adults. Am J Public Health. 2012;102:118–122. 2. Baral SD, Poteat T, Stromdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis 2013;13:214–222. 3. Grant JM, Mottet L, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at every turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011. 4. Ard KL, Makadon HJ. Addressing intimate partner violence in lesbian, gay, bisexual, and transgender patients. J Gen Intern Med. 2011;26:930–933. 5. Erickson-Schroth L, ed. Trans bodies, trans selves: A resource for the transgender community. Oxford University Press, 2014. 6. When Health Care Isn’t Caring: Lambda Legal’s Survey of Discrimination Against LGBT People and People with HIV. New York: Lambda Legal; 2010. 7. Institute of Medicine (U.S.); Committee on Lesbian G, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: National Academies Press, 2011. 8. Hartzell E, Fraser MS, Wertz K, Davis M. The state of transgender California: Results from the 2008 Transgender Economic Health Survey. San Francisco: Transgender Law Center, 2009. 9. Unger CA. Care of the transgender patient: a survey of gynecologists’ current knowledge and practice. J Womens Health (Larchmt) 2015;24:114–118. 10. Obedin-Maliver J, Goldsmith ES, Stewart L, et al. Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. JAMA. 2011;306:971–977. 11. Unger CA. Care of the transgender patient: The role of the gynecologist. Am J Obstet Gynecol 2014;210:16–26. 12. Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL. Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstet Gynecol 2014;124:1120–1127. 13. American Board of Obstetrics and Gynecology. Definition of an obstetrician and gynecologist and American Board of Obstetrics and gynecology certification. ABOG, 2014. Available at: www.abog.org/policies.asp?pol_type = definitinon Accessed on November 30, 2014.
EDITORIAL
14. American Board of Obstetricians and Gynecologists News, ‘‘The American Board of Obstetrics and Gynecology (ABOG) Revises Definition of an Obstetrician and Gynecologist and Clarified information about Certification.’’ Available at: www.abog.org/news.asp. Accessed on November 30, 2014. 15. Grady D. Responding to critics, gynecology board reverses ban on treating male patients. New York: The New York Times, January 30, 2014. 16. Committee on Health Care for Underserved Women. Committee opinion no. 512: Health care for transgender individuals. Obstet Gynecol. 2011;118:1454–1458.
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Address correspondence to: Juno Obedin-Maliver, MD, MPH Department of Obstetrics, Gynecology, and Reproductive Sciences University of California San Francisco 505 Parnassus Avenue San Francisco, CA 94143 E-mail: [email protected]
JOURNAL OF WOMEN’S HEALTH Volume 24, Number 2, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/jwh.2015.1518
Time for OBGYNs to Care for People of All Genders Juno Obedin-Maliver, MD, MPH
here are at least 1.5 million transgendera individuals (0.5% by a household population based survey) in the United States.1 Although transgender individuals are often closeted, marginalized, and maligned there is growing social, political, and medical awareness. In June 2014, actress Laverne Cox became the first openly transgender person to be on the cover of Time Magazine. In the political arena, President Obama—the first president to use the word ‘‘transgender’’ in a speech—facilitated protection of transgender individuals in hate crimes legislation and coverage of gender affirmation surgery for transgender government employees. Furthermore, Medicare recently reversed its position on denying payment for transition related surgery (National Coverage Determination 140.3, 2013). Alongside expanded awareness of transgender people’s lived experience comes a growing understanding of the health disparities transgender individuals face. Although data is woefully deficient, these include a prevalence of human immunodeficiency virus infection among transgender womenb 34 times that of reproductive age adults in United States.2 30% smoking prevalence among transgender adults versus 21% among U.S. adults,3 a 35% lifetime prevalence of intimate partner violence for transgender adults (exceeding that experienced by lesbian, gay, and cisgenderc adult women4), and lifetime rates of depression and suicide attempt as high as 67% and 79% respectively.5 Many documented health disparities stem from diminished access to care and trained providers as well as social and medical discrimination.5–7 In a recent survey of 646 transgender adults in California, over 21% were denied mental health services, 15% were denied gender-specific care (such as pap smears for transgender men), and 10% were denied primary health care.8 Disturbingly, in a national report, over 70% of transgender adults reported harsh or abusive lan-
T
a An individual whose gender identity differs from their natal or birth sex. b Individuals whose gender identity is female and whose birth sex is male. c Cisgender individuals’ gender identity match their natal or birth sex. Cisgender women are natal females who identify as women and cisgender men are natal males who identify as men.
guage, blame for their health status, or physical roughness or abuse from health care professionals.6 Unsurprisingly, 90% of transgender individuals agree that there are ‘‘not enough health professionals adequately trained to care for transgender people.’’6 This begs the question: Who is being trained to provide care for transgender individuals? Motivated by significant health care disparities transgender individuals face,3,7 Dr. Unger (see this volume and number, pages 114–118) presents an important cross-sectional study of practicing obstetricians and gynecologists (OBGYNs) to understand clinician training, knowledge base, and care provision for transgender patients.9 The study included 141 respondents from 9 academic institutions (40% response rate, 62% generalist OBGYNs) whom completed an online, selfreported, questionnaire. Respondents were predominantly in the Northeast (41%) and Midwest (31%). Though most questions focused on transgender patient care, others regarded care of lesbian, gay, and bisexual patients to highlight differences in care provision between sexual and gender minority patients. Notwithstanding the limitations of a cross-sectional study with a convenience-sampling frame and the instrument validation issues inherent to a newly explored field, Unger’s study has compelling results. Although 31% of respondents knowingly care for transgender patients, 80% of respondents, regardless of residency training recency, had not received any formal training to do so. Furthermore, few providers were ‘‘comfortable’’ taking care of either transgender mend (29%) or transgender women (35%), despite having the requisite skills to do routine health care maintenance and organspecific screening. This is highlighted in that 11% of respondents were unwilling to perform routine Pap smears for transgender men and 20% were unwilling to perform routine breast exams for transgender women on hormone therapy. Most (59%) did not know the breast cancer screening recommendations for transgender women. Further knowledge gaps included requirements for genital reconstructive surgery and routine health care maintenance (e.g., lipid, diabetes, and prostate cancer screening) for transgender people.
d Individuals whose gender identity is male and whose birth sex is female.
Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California. Department of Internal Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California. Lesbian, Gay, Bisexual, and Transgender Medical Education Research Group, Stanford University School of Medicine, Stanford, California.
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How should we interpret physicians’ discomfort and unwillingness to provide routine care for transgender individuals? Discomfort and unwillingness go together and often stem from deficits in knowledge, skills, or attitudes. Although transgender health is under-studied7 and under-taught,5,10 much of the knowledge necessary for OBGYNs to provide health care for transgender individuals is highly teachable and increasingly available.11 OBGYNs already have many of the skills to care for transgender patients, and the rest are teachable. Through caring for cisgender women, OBGYNs have become specialists in the medical and surgical management of the reproductive system specifically: the vagina, cervix, uterus, adnexa, and breast tissue. Regardless of gender identity, any individual with these organs needs and deserves the same medical care for them, thus the frequent transgender preventative care adage, ‘‘if you have it, screen it.’’ Therefore, the biggest hurdle is not knowledge or skills. The challenge to good care is thus a conceptual one for providers and health care systems. OBGYNs can immediately apply their organ-specific knowledge to the care of transgender patients. For example, a transgender man who has heavy painful menses has the same hormonal and surgical options available to him as a cisgender woman. But, having a conversation about menstrual bleeding or desired pregnancy12 with a fully bearded man is initially mentally incongruous, and insurance reimbursement for treatment (e.g., hysterectomy for a man) is often administratively incongruous. Therefore, caring for transgender individuals, as with all patients, is about more than caring for sex-specific organs; it requires seeing and acknowledging the whole person (e.g., a man a uterus or a woman a prostate). For OBGYNs, broadening our understanding of our patients as whole individuals may shift how we define ourselves. The field of OBGYN is facing a gender identity service conflict. Obstetrics and gynecology is synonymous with the care of cisgender women, and OBGYNs are professionally labeled as ‘‘Women’s Health Care Physicians’’ (American College of Obstetricians and Gynecologists [ACOG]). Recently however, OBGYNs treatment of cisgender men with anal dysplasia and pelvic pain was controversial.13–15 Despite having an appropriate skill set, caring for cisgender men challenged the identity of OBGYNs as women’s health care providers, and some feared it would dilute OBGYNs advocacy for cisgender women. Similar concerns have been raised regarding OBGYN’s care for transgender patients despite the urging of ACOG to do so.16 Expanding our practices to provide for transgender individuals will not diminish our care of cisgender women, but rather will extend our services to others in need. Let’s make the pie bigger and apply our prior baking lessons; let’s bring our knowledge, skills, and passion for advocacy to a marginalized group while redefining ourselves as reproductive health physicians. Consider Dr. Unger’s study as a call for action. All specialties need to ensure unfettered access to quality health care for transgender individuals, but OBGYNs in particular have the much-needed foundational knowledge and skills transgender people need. We just need to shift our attitudes. OBGYNs have the potential to be strong transgender advocates and allies by ensuring that in every aspect of what we do transgender individuals are considered and welcomed. This means supporting gender disclosure at intake and ensuring
OBEDIN-MALIVER
that all office staff maintain consistent and respectful pronoun usage. It means having a physical space that promotes comfort for people of every gender including omnisex bathroom facilities and comprehensive educational materials that reflect human diversity. It means supporting social, medical, and surgical transition through education and caring, hormone administration, and appropriate surgery. It also means ensuring gender diversity in research studies, teaching gender diversity to our students, and advocating for sensitive and comprehensive health care provision for all genders. Acting means joining the larger movement supporting expanded rights for transgender individuals. By taking these actions we can ensure that one day, all transgender individuals have OBGYNs, commensurate ‘‘reproductive health physicians,’’ when and where they need them. References
1. Conron KJ, Scott G, Stowell GS, Landers SJ. Transgender health in Massachusetts: Results from a household probability sample of adults. Am J Public Health. 2012;102:118–122. 2. Baral SD, Poteat T, Stromdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis 2013;13:214–222. 3. Grant JM, Mottet L, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at every turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011. 4. Ard KL, Makadon HJ. Addressing intimate partner violence in lesbian, gay, bisexual, and transgender patients. J Gen Intern Med. 2011;26:930–933. 5. Erickson-Schroth L, ed. Trans bodies, trans selves: A resource for the transgender community. Oxford University Press, 2014. 6. When Health Care Isn’t Caring: Lambda Legal’s Survey of Discrimination Against LGBT People and People with HIV. New York: Lambda Legal; 2010. 7. Institute of Medicine (U.S.); Committee on Lesbian G, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: National Academies Press, 2011. 8. Hartzell E, Fraser MS, Wertz K, Davis M. The state of transgender California: Results from the 2008 Transgender Economic Health Survey. San Francisco: Transgender Law Center, 2009. 9. Unger CA. Care of the transgender patient: a survey of gynecologists’ current knowledge and practice. J Womens Health (Larchmt) 2015;24:114–118. 10. Obedin-Maliver J, Goldsmith ES, Stewart L, et al. Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. JAMA. 2011;306:971–977. 11. Unger CA. Care of the transgender patient: The role of the gynecologist. Am J Obstet Gynecol 2014;210:16–26. 12. Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL. Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstet Gynecol 2014;124:1120–1127. 13. American Board of Obstetrics and Gynecology. Definition of an obstetrician and gynecologist and American Board of Obstetrics and gynecology certification. ABOG, 2014. Available at: www.abog.org/policies.asp?pol_type = definitinon Accessed on November 30, 2014.
EDITORIAL
14. American Board of Obstetricians and Gynecologists News, ‘‘The American Board of Obstetrics and Gynecology (ABOG) Revises Definition of an Obstetrician and Gynecologist and Clarified information about Certification.’’ Available at: www.abog.org/news.asp. Accessed on November 30, 2014. 15. Grady D. Responding to critics, gynecology board reverses ban on treating male patients. New York: The New York Times, January 30, 2014. 16. Committee on Health Care for Underserved Women. Committee opinion no. 512: Health care for transgender individuals. Obstet Gynecol. 2011;118:1454–1458.
111
Address correspondence to: Juno Obedin-Maliver, MD, MPH Department of Obstetrics, Gynecology, and Reproductive Sciences University of California San Francisco 505 Parnassus Avenue San Francisco, CA 94143 E-mail: [email protected]
