For family doctors: Support and care of transgender patients 101

An article recently published by Medical Post's sister publication ProfessionSanté.ca on the three-month suspension of a family doctor due to his inappropriate treatment of a trans man sparked numerous comments. Many of these comments were “troubling,” to Dr. Jonathan Picard, a general practitioner specializing in transgender and non-binary clients who practises at the Quorum clinic in Montreal. Troubling, but not so surprising, he said. “They bear witness to the realities experienced by these patients who have negative experiences in the health system. They are so often stigmatized and discriminated against that they think about it 10 times before seeking a consultation. This raises the question of their access to care.”According to a study by the pan-Canadian organization JusticeTrans conducted in 2021 among 700 non-binary, trans and gender non-conforming individuals, 43% faced problems accessing healthcare. The majority noted a “general lack of expertise and knowledge” among health professionals and several declared that they were “rejected” by frontline doctors on the grounds that they were not specialized in this clientele. Another study, carried out in France, showed that half of LGBTQ+ people have already felt discriminated against in their healthcare journey and that 40% of them kept quiet about their sexual orientation or gender identity to avoid this discrimination.In Quebec, 16,225 people identified as trans or non-binary in 2021, according to Statistics Canada.In Canada, one in 300 people aged 15 and over identify as trans or non-binary.0.79% of Generation Z Canadians (born between 1997 and 2012) identify as trans or non-binary, compared to 0.15% of Canadian baby boomers.The reluctance of certain professionals as well as their lack of knowledge, in general, of the feelings and health issues specific to transgender people, results in inappropriate or delayed medical care for these patients who present several risk factors. Several studies report a significant increase in the risk of psychological distress and depression as well as higher rates of suicide attempts, drug abuse issues and sexually transmitted diseases.To remedy this and offer inclusive care, ProfessionSanté.ca consulted doctors specializing in transgender clients and leaders of LGBTQ+ community organizations. Here is their advice:Get informed and trainedThe first thing “is to be aware of your biases and recognize them in order to be able to control them,” said the general director of the Coalition of LGBT+ Families, Mona Greenbaum. A trainer at the National Institute of Excellence in Health and Social Services, she notes that several prejudices and myths persist within the medical community. Foremost among them is the idea that gender variance is a mental illness. "Gender identity disorder was removed from the DSM-5 [Diagnostic and Statistical Manual of Mental Disorders] in 2013,” she noted, emphasizing that “not all trans people are unhappy. There are plenty of them who are thriving.”Dr. Picard believes it's necessary to understand the psychosocial issues of this clientele in order to be sensitive to them in consultation. “Gender incongruence is not a pathology, but many mental disorders can be associated with it because of the discrimination these people experience daily. When we are interested in their experiences, it reassures them and gives them confidence.” He therefore encourages his peers to read on the subject as for any other medical issue and, if necessary, not to hesitate to refer the patient to a colleague.Several training courses for physicians to develop the knowledge and skills to treat the trans population are available across Canada.Read: Manitoba moves forward with gender-diverse patient recordsRespect the gender affirmed by the personTrans-identity is an intrapsychic phenomenon that therefore involves self-diagnosis. Thus, the question of the “true” existence of gender incongruence should not occupy a central place in the anamnesis. “The person does not need the doctor to determine their gender identity. (The latter) must simply accept it and respect it,” said Dr. Richard Montoro, co-founder of the McGill University Sexual Identity Centre. It is then appropriate to ask the patient the name and pronouns by which they wish to be referred. When he welcomes a transgender person, Dr. Pierre-Paul Tellier introduces himself with his pronouns before asking the patient for their own. “It starts the relationship on a good basis,” said Dr. Tellier, a GP and the lead doctor at the Mauve Clinic in Montreal, which offers services to racialized people of diverse sexualities. He advises noting the name and pronouns chosen by the patient in their EMR, but keeping their legal name there. “Before, we wrote the desired name, but when we generated a request for a test, the lab could not send us the results, because the names did not match,” he said, noting that with certain EMRs, “matching can work.”Before carrying out a clinical examination, Dr. Tellier always asks what the person would like their organs to be named to avoid possible discomfort. “I ask, for example, if I can use vagina or penis. If no, I ask them which words they prefer.” For a trans man, breasts can thus be replaced by the chest or torso while with a trans woman, the term sex will seem less gendered than penis.Avoiding “broken arm syndrome”This expression is used when a transgender patient comes to see about their arm and their doctor asks them, for example, about their genitals. “Trans or non-binary people who consult for any health problems often face indiscreet or even inappropriate questions related to their gender identity,” said Greenbaum. “We are used to being sexualized, but we must avoid misplaced curiosity,” she added, specifying that if the doctor has legitimate questions to ask about the sexual health of his patient, “He must put them in context, specify that he asks the questions of all his patients and that if the person is not comfortable, they can refuse to answer them." Show InclusivitySmall signs or visible markers demonstrating openness can help build trust and make transgender people feel safe. “The doctor can wear a badge with the rainbow flag. We can put up posters in the waiting room about discrimination and respect for diversity. These are little things that show that we are aware of that,” says Dr. Montoro for whom gender-neutral toilets are not a trivial detail. “It avoids forcing these people to go into a gendered space in which they do not recognize themselves—and it provides another signal of inclusiveness.”Stay humble“Not all family doctors are experts in the field of trans-identity,” said Mykaell Blais, the general director of the Trans Mauricie-Centre-du-Québec organization. “And that’s OK. What helps a lot in the relationship of trust is when the professional shows humility and engages in dialogue as an equal. He can suggest to his patient that he see him again once he has done his homework." Or, he can direct him to a therapist who can take care of him. "The worst would be to leave him without resources and without a reference.”Prescribe hormone therapy (or not)Some general practitioners are hesitant to prescribe hormone therapy to their transgender patients who want to make a physicial transition. “It doesn’t take an endocrinologist, lots of family doctors do it,” said Greenbaum.Dr. Montoro, however, said that, “We do not give medication if there is no problem.” In other words, before prescribing hormone therapy, a diagnosis of gender dysphoria must be established which, according to the DSM-5 criteria, requires the presence of two elements: “a marked incongruence between the experienced or expressed gender and the assigned gender at birth”; and “clinically significant distress or functional impairment resulting from this incongruence.” According to the psychiatrist, establishing such a diagnosis “is not necessarily within the field of expertise of family doctors, but there are some who are comfortable making it.”Read: Alberta announces major changes to transgender policies around healthcare, schools and sportThis is the case of Dr. Teillier who carries out the psychological assessment of his patients. “Not everyone can afford a consultation with a psychologist, and few have availability. We are more accessible, and endocrinologists have many other things to do,” he said, adding that he meets the person three or four times before giving them their prescription.To do this, Mykaell Blais recommends using the guides created by the TransEstrie organization in collaboration with the Conseil québécois LGBT (or other such guides). They detail the effects of taking hormones in the context of transition and allow trans people to evaluate whether hormone therapy meets their needs, and to share their goals and concerns with the healthcare professionals who care for them. "They are very well done and provide an excellent basis for discussion between doctor and patient.”

For family doctors: Support and care of transgender patients 101

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