Transgender Care Is Family Medicine: A Call to Action

Currently in the United States, transgender^* individuals account for 1.6 million people 13 years of age and older. ¹ Unfortunately, they face a litany of health disparities when compared to their cisgender counterparts, including higher rates of death and disability from a variety of causes. ^{2, 3} The most notable discrepancies involve mental health conditions, with one study finding that transgender adults were more than six times as likely to have had suicidal ideation and more than four times as likely to have attempted suicide in their lifetimes. ⁴

Many factors contribute to these poor health outcomes. But lack of access to culturally competent evidenced-based health care is a likely contributor—and it is one that we can all do something about. Many studies have suggested that transgender individuals are reluctant to seek care because of prior discrimination perpetrated against them at the hands of providers. ⁵ When transgender individuals connect with clinicians who can provide them with gender-affirming care, however, many of the observed health disparities abate. In one study, gender diverse youth showed a 73% reduction in suicidality in the year after receiving gender-affirming care. ⁶ Another study similarly showed continual, progressive, and persistent positive mental health effects after initiating gender-affirming care over the 2 years of the study. ⁷

The issue, as stated, is that access to such care is limited. In a 2018 survey study of primary care physicians (PCPs), 86% were willing to provide routine care to transgender patients, but 52% expressed lack of familiarity with guidelines, and 48% expressed lack of training in transgender health. ⁸ Of note, in the same study, the family physicians surveyed were five times more likely to be willing to provide gender-affirming care than the internal medicine physicians surveyed. So, while a large percentage of surveyed physicians reported a willingness to treat transgender patients, many did not have the expertise, skills, or confidence to do so.

The discrepancy between clinician desire to provide gender-affirming care and having the training and skills to offer it, unfortunately, extends to medical students and residents as well. Despite calls from the American Academy of Family Physicians, ⁹ American Academy of Pediatrics, ^{10, 11} and the Association of American Medical Colleges ¹² for medical school and residency curricula to include education on the unique needs of transgender patients as well as eagerness from medical students and residents to receive training in gender-affirming care, ^{13, 14} such broad training continues to be lacking. Recent Council of Academic Family Medicine Educational Research Alliance (CERA) surveys highlighted this fact with only 26% of family medicine clerkship directors reporting comfort in teaching gender-affirming care to medical students ¹³ and 25% of family medicine residency program directors reporting comfort. ¹⁴ This discrepancy, however, also offers a tangible and timely opportunity to address the equity gap.

Treatment of, and compassion toward, underserved populations is at the heart of family medicine. Family physicians are trained to provide longitudinal, coordinated, and holistic care to patients within their communities and thus are uniquely qualified to provide comprehensive gender-affirming care. The World Professional Association for Transgender Health recently reaffirmed that PCPs can manage gender-affirming hormone therapy with the caveat that they “need distinct competencies in the care of [transgender] persons, apart from what is expected of all PCPs who may otherwise care for a diverse population.”¹⁵ Standards of care and guidelines for providing gender-affirming care exist, ¹⁵ but most family medicine clinicians need additional training to be able to implement comprehensive, high-quality gender-affirming care in their practices.

Furthermore, many transgender individuals want to receive their gender-affirming care from their PCPs. In one qualitative interview study, participants lamented having to receive their gender-affirming care from a specialty clinic and expressed desire for such care to be provided by knowledgeable PCPs instead. ¹⁶ Providing gender-affirming care in the primary care setting rather than in a specialty clinic could both improve long-term access and normalize and destigmatize this type of care.

Ultimately, more training in gender-affirming care is needed. But while curricula exist, a more robust effort at standardization, dissemination, and broad implementation will be needed to address this clear and pressing need. As one avenue to further this goal, a group of faculty from across North America came together in 2022 to form the Gender-Affirming Primary Care Residency Research Collaborative (GAPCRRC). Over the next years, the GAPCRRC aims to address barriers to implementing graduate medical education curricula in gender-affirming care by (a) developing recommended competencies for residency programs, and (b) creating a repository of durable evidence-based educational resources for primary care residency programs to use when providing this education.

Family medicine as a specialty should lead in the effort to ensure that patients who identify as transgender can receive the care they need through expanded education and advocacy. Improving undergraduate and graduate medical education around gender-affirming care will be paramount to overcoming the present deficiencies and achieving parity and justice in this area of medicine. Therefore, establishing pedagogical rubrics and facilitating a broader dissemination of curricula around gender-affirming care must be a priority to address the growing chasm of care facing transgender individuals. This is the eventual goal of the GAPCRRC. In the meantime, Table 1 lays out institutional and individual suggestions for family physicians to increase collective expertise in treating patients who identify as transgender and to establish leadership in this area. Readers also can join the efforts of the GAPCRRC by contacting the authors.^†

Family medicine has a long history of siding with patients over politics, ¹⁷ which makes providing gender-affirming care a natural part of our identity and responsibility. This stance is even more relevant because a broad swath of politically conservative US jurisdictions have moved to intentionally limit access to gender-affirming care through harmful legislation. In extreme cases, as in Idaho, North Dakota, Oklahoma, Alabama, and Florida, for a physician to provide gender-affirming care to a minor is a felony. Other southern, western, and midwestern states have banned certain procedures or therapies, have limited insurance coverage, or have banned school support for gender diverse children. ¹⁸ This movement to undermine the health care of transgender communities is an unprecedented attack on bodily autonomy, and family physicians have a moral duty to stand up and speak out against this politicized persecution of transgender individuals. Our voice carries weight, and fulfilling our sacred oaths to ensure equitable and just care means using our voices to defend and fight for deliberately and methodically marginalized populations. When our patients are being harmed through intersectional and systemic discrimination, advocacy becomes an obligation, not just an option.

Myriad opportunities are available for family physicians to get involved in transgender care. The authors of the current commentary, for example, work with transgender youth advocacy groups (author R.N.), write op-eds about transgender health (R.N., R.S., E.S., B.K., T.H.), testify to legislators (E.S., D.S.), mobilize clinicians against harmful legislative efforts (S.S.), and sit on state-mandated boards to set quality and training standards for health plans (R.S.). But providers have still other ways to engage in advocacy for their transgender patients that are less overt, but just as impactful. Teaching patient-centered, gender-affirming care to medical students, residents, faculty, health systems, and schools is advocacy. Making your clinic a welcoming environment for transgender patients is advocacy. Stating your pronouns to your patients is advocacy. Saying yes when a patient asks you whether you will provide care to them is advocacy.

Medicine is not a spectator sport. The glaring medical inequities facing the transgender community necessitate action—through both education and continued advocacy. Dr Martin Luther King is often quoted as saying, “The arc of the moral universe is long, but it bends towards justice.” If you are taking the long view, Dr King’s words may be true. But up close, when you are amidst oppression and inequity, recognizing that the moral arc of the universe does not bend by itself is important. Effecting change takes the determination and grit of those willing to stand up and make noise. Passivity in the face of continued injustices only deepens our own moral injury. Now is the time to act. We physicians took an oath when entering our profession: “First, do no harm.”

Doing nothing is harm.

^*The authors appreciate and acknowledge that the nomenclature in this space changes frequently and that no one term may perfectly encapsulate an individual’s identity or experience. Within the confines of this article, we use “transgender” as an umbrella term to describe any person of diverse gender experience. To join the

^†GAPCRRC please send an email to GAPCRRC@gmail.com.