Caring for Transgender Patients, Body and Mind

Walter Bockting is one of the world’s leading researchers on transgender health. He is internationally known for his expertise in the assessment and treatment of gender dysphoria – the incongruence a person may feel between their sex assigned at birth and their gender identity – and in the general mental health and psychosocial adjustment of transsexual, transgender, and gender nonconforming individuals and their families. He received his doctoral degree in psychology from the Vrije Universiteit, Amsterdam, the Netherlands, and went on to become a tenured professor at the University of Minnesota Medical School before joining the faculty of Columbia University. In 2010-2011, he served on the Institute of Medicine (IOM) Committee of the National Academies whose work culminated in the IOM report “The Health of Lesbian, Gay, Bisexual and Transgender People: Building a Foundation for Better Understanding.” This spring, Bockting was part of a task force that wrote practice guidelines for the American Psychological Association for working with transgender and gender nonconforming people. He has published numerous scientific articles and textbook chapters in the area of LGBT health. He is currently the principal investigator of Project AFFIRM, a multi-site longitudinal study of transgender identity development funded by the National Institutes of Health, the MAC AIDS Fund, and a number of other private foundations.

Q: During the past decade, nursing and medical schools have placed an emphasis on teaching students to provide culturally competent and patient-sensitive care. How should current efforts to educate health care professionals be applied to the transgender community? What specific questions should providers be taught to ask patients and what do they need to know about this population?

Learning how to work with this population in a respectful and sensitive manner is an ongoing process. After gaining a baseline of knowledge, providers need to periodically update their understanding of the health issues facing transgender people. Words used to describe gender and sexual identity evolve.  Don’t assume you know what it means when someone identifies as transgender. The transgender experience is diverse. Not every patient takes hormones or undergoes genital surgery for example.

The Standards of Care published by the World Professional Association for Transgender Health can help familiarize providers with a comprehensive approach to transgender-specific health care, including changes in gender role and feminizing or masculinizing medical procedures. In a clinical setting, transgender patients should be asked about how they define their identity and about their transition goals.  It’s important to ask patients if they smoke, because tobacco is a major issue in the LGBT community and smoking poses extra risks for transgender women taking hormones.

Paying close attention to mental health issues when caring for this population is as important as caring for their physical health. Coming out and changing gender roles can be difficult.  Many transgender patients experience changes in their relationships with families, friends, and coworkers during transition. The social stigma that many have experienced – actual or perceived—can take an emotional toll. Taking time to establish a trusting provider-patient relationship is critical. This can be challenging because many transgender people have experienced negative interactions with uninformed health providers.

Providers also need to be aware of their patient’s sensitivity regarding their bodies. For example, a provider working with a transgender man who hasn’t had a pap smear in many years may need to build trust during several visits before the patient feels comfortable having an internal exam.  Working with a transgender patient is like working with any other patient. You treat the whole person, both mind and body.

Q: Appropriate health care is broader than just the patient-provider relationship. It starts the second the patient enters the health care environment or when they make an appointment on the phone. How does the culture of the provider’s office influence the delivery of LGBT sensitive care?

The patient’s experience in the waiting room can set the tone for the entire visit. Health care providers should make their clinical environments more welcoming to transgender patients by displaying LGBT friendly brochures. Signs for gender-neutral bathrooms send a strong message welcoming transgender and gender nonconforming patients.

It’s especially important to put people at ease who recently changed gender roles. Train receptionists to use gender-neutral pronouns or ask what name or pronoun the patient prefers. Intake forms should ask patients to fill in the sex on their birth certificate and how they describe their current gender identity. Checkboxes for male, female, transgender woman, transgender man, gender queer, or other, should be included. When the provider or staff member sees that the patient’s birth sex and gender identity differ, they will know immediately that this person is transgender.

Q: What challenges does the lack of homogeneity among this population pose for health providers?

Transgender identities can be expressed in many ways. Not every transgender man takes masculinizing hormones and not every transgender woman has genital surgery, for example. Providers need to pay attention to transgender people’s need to affirm their gender identity in light of their presenting concerns. Some transgender women worry about HIV medications reducing the effect of their feminizing hormones, for example. Providers should educate themselves on their patient’s hormones to properly counsel them. Don’t make assumptions. Not every transgender woman is at risk for HIV, although it’s a big concern among transgender subgroups such as women of color and sex workers. A transgender woman may identify as a lesbian and not have sex with men, for example. In that instance, the provider might not need to have a discussion with the patient about PrEP, a medication that can help prevent HIV infection.  

Q: Tell us about your current research studies as part of the LGBT Initiative at CUMC.

Our current research study, Project AFFIRM, examines transgender people’s identity development across the lifespan. We’re investigating what characterizes resilience, meaning how transgender people cope effectively with some of their stigma-related challenges. We’ve found that intimate relationships with an accepting partner play an important role in helping transgender people come out and develop their gender identities. We know very little about dating and relationships among this population, and plan to examine its impact on health and wellbeing further.

We also found that when transgender patients had positive experiences with health care providers, many credited these relationships with saving their lives. Many reported that these providers helped them through difficult times, such as when they came out to their families. Some considered these providers as chosen family members.  We want to glean what attributes account for positive patient-provider relationships so other providers can learn to replicate them.

Q: In the last two years, there has been an increase in public awareness of LGBT and transgender issues, from the recent Supreme Court decision to legalize gay marriage, to Bruce Jenner openly revealing his gender role transition, and Laverne Cox appearing on the cover of Time. What do you think have been the forces at work that has made these milestones possible? 

It’s gratifying to see transgender role models and transgender issues being discussed in the media. But it’s important to understand that the groundwork for this shift was laid by many pioneers over several decades, even though it may seem like a recent development.

Transgender care was pioneered in New York City in the 1950s, and a number of surgical centers were founded in the late 1960s and early 1970s. Transgender consciousness was developed by a generation of transgender people in the 1980s and 90s. The transgender community organized to combat stigma and redefine gender identity as being on a spectrum, no longer limited to a binary conceptualization as either male or female, man or woman, masculine or feminine. They built a coalition with the lesbian, gay, and bisexual community. Now that people have become more accepting of gay people and support gay marriage, transgender issues have become the next frontier. 

The late Virginia Prince, who popularized the term transgender in the 1980s, advocated for this minority population to gain visibility and live openly without shame. I remember asking her in the early 1990s if people would ever think of gender outside of male and female. She told me “Yes, Walter, of course it’s going to happen. The train has left the station.”