From the Journals

Primary care can embrace gender-affirming policies, approaches



Transgender health care can be a successful component of a primary care practice, with sufficient commitment to staff training and a host of practical matters.

In a new “blueprint” for practices planning to implement a transgender care program, Anna M. Morenz, MD, and her coauthors emphasized that more than technical skills are needed to build an effective and welcoming transgender health practice.

All patient-facing staff – from schedulers and receptionists to nurses and billers – should “receive a foundational level of training in cultural sensitivity and effective communication with transgender and gender-diverse persons,” they wrote. In addition, they emphasized, “the workplace culture must ensure that chatter behind closed doors does not differ from patient-facing language.”

One thing that’s become clear over time, noted the authors of the blueprint, is that transgender care is no longer limited to the endocrinologist’s office. “After years of referring transgender and gender-diverse patients to specialty clinics and endocrinologists, transgender health experts have come to agree that gender-affirming hormone therapy can be safely delivered as part of routine care by a trained primary care clinician,” wrote Dr. Morenz, an internal medicine resident at the University of Washington, Seattle, and her coauthors.

Nor do most adults receiving gender-affirming care require mental health services, unless the patient or the primary care clinician sees a need or utility for psychological care. The blueprint was published in the Annals of Family Medicine.

The first step to setting up transgender services within a primary care practice is to conduct a needs assessment, suggested Dr. Morenz and her colleagues. Whether in-person focus groups or online surveys or questionnaires are best might depend on the community climate, they wrote. When stigma is high, the opportunity for anonymity might provide more robust results. Other considerations include whether there’s a concentration of transgender people with particularly high need or risk in the community – for example, transgender women of color, who might be at higher risk of HIV/AIDS than the general population. Depending on the needs of a particular community, initial transgender care efforts may have a focus on such a population.

A practice also should conduct a realistic appraisal of its own strengths and areas of weakness: Is signage inclusive? Do intake forms afford flexibility in gender and pronoun preference? Are front office staff comfortable greeting members of the lesbian-gay-bisexual-transgender-queer-intersex-asexual (LGBTQIA) community? What about restroom signage – is there a gender-inclusive option?

Competent provision of trauma-informed care goes hand in hand with assessment and preparation for providing transgender care, noted the blueprint authors, because “transgender and gender-diverse people experience high levels of trauma and stress related to minority status.”

Performing outreach within an organization and community also can unearth existing services, so that a primary care transgender practice dovetails with and complements those ongoing efforts, avoiding unnecessarily duplicative services. “All transgender health programs can benefit from developing broad relationships with external agencies, community-based organizatons, and individual practitioners who provide a range of services and can function as a network for knowledge-sharing and referrals,” noted Dr. Morenz and her coauthors.

“Starting a new program, especially one focused on a stigmatized population, can generate staff concerns and resistance,” acknowledged Dr. Morenz and her colleagues. Efforts at getting organizational buy-in can emphasize that providing transgender care helps meet ethical obligations within medicine. Emphasizing that making such care available is really at the vanguard of best practices might help overcome some resistance, they said.

The best success in implementation will be seen when at least two internal “champions” who are knowledgeable and committed lead the transition, with at least one champion having a leadership role within the organization, wrote Dr. Morenz and her colleagues.

A variety of care models can work when a practice is initiating transgender care, depending on community needs, internal resources, and the commitment level of various stakeholders. An evening clinic staffed by a small number of clinicians can be a good way to test the waters in some cases. Other facilities might wish to identify clinicians who are competent to offer hormone therapy, while still other clinics might be able to incorporate transgender care more globally within their practice. Regardless of which service model a practice opts for, however, it’s crucial to have staff members who are savvy navigators of insurance reimbursement for gender-affirming care.

And when transgender care is nested within a practice, those patients must not feel like second-class citizens of the clinic, or that they’re receiving care that’s somehow different or substandard. For example, wrote Dr. Morenz and her coauthors, a facility must consider what will happen when a transgender patient presents for urgent health needs and the primary care clinician is not available.

The nuts and bolts of providing safe and effective gender-affirming hormone therapy, said the blueprint authors, can be mastered with training and practice. “Despite common concerns that transgender health care is complicated, it is in fact as straightforward as managing common chronic diseases.”

The first step, they said, is providing risk-benefit education and counseling to patients, and reviewing fertility preservation considerations and options. Then, either estradiol or testosterone is initiated; Further suppression of endogenous hormones also might be indicated in feminization therapy in particular. The authors provided several continuing education resources for clinicians and other health care team members, and noted that a “train the trainer” model can prove effective, with a core team training others once they’ve become comfortable with the ins and outs of hormone prescribing and monitoring.

Having a staff that looks like the patient panel can go a long way toward promoting authentic inclusivity, but Dr. Morenz and her colleagues cautioned against hiring practices that amount to tokenism, or expecting transgender or gender-diverse staff to be ambassadors or spokespeople for others.

Taken together, the start-up costs for providing transgender care can be “minimal,” wrote the blueprint authors, because many free and low-cost educational resources are available. Some of the only real outlays may come from altering restroom signage and tweaking the electronic health record to accommodate gender diversity.

A practice that goes forward with transgender care, they conclude, “will provide a unique opportunity to holistically improve wellness and quality of life for transgender and gender-diverse people,” joining the “growing and passionate network of clinical practice teams who are committed to health care, innovation, and equity for transgender and gender-diverse communities.”

Dr. Morenz reported no outside sources of funding and reported that she has no relevant conflicts of interest.

SOURCE: Morenz AM et al. Ann Fam Med. 2020 Jan;18(1):73-9.

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