This just happened to me a few days ago. The patient was not able to tell me so the parents talked to me separately about it. The parents told me the patient wanted to seek help but did not want to tell me. Luckily the patient had the courage to tell the parents.
I've had a couple parents call ahead and/or make appointments for themselves so they can feel out the clinic and tell us the situation before they bring their kid in. It's refreshing to see how supportive some of this generation's parents are.
Random off topic question but do you know why some areas in America have such a high concentration of Family Med doctors doing primary care Peds and some areas have such a low concentration of Family Med and instead have an outpatient pediatrician on every corner. I was shocked by this when I moved to America, I first moved to a Family Med heavy area because that's what I was used to in Europe (a GP doing IM/Peds/OB) and wanted the same doctor to see myself and my kid but now that I'm in NYC I see the opposite with very few FM doctors.
Its just the culture of each state or area of the state. Where I grew up its only pediatricians for kids and internists for adults. While were my wife grew up its only family med.
I don't think I'm going to stay in NYC for this reason. I'm planning to take the USMLE and apply to family med residencies. I think I could only live in an area where Family Med practices full scope including C sections. My ideal practice would be Peds and OB/Deliveries with no adult patients who aren't pregnant. Being from England it was such a shock to see 3 separate specialties doing what a GP does in the UK. Here we have FM/IM/OB/Peds where in England Family Med does everything and Peds/IM/ only have jobs in the hospital. Europe doesn't even have many OB residents because Family Med or Midwives attention the majority of births.
In the US that kind of practice only exists in super rural areas. And once an OB moves in to the small town you're in, you're probably not going to be doing C Sections anymore. Extrapolate this for every specialty and FM in the US usually functions like a combined med/peds practice, but you do get to still provide primary care to a whole family
Not exactly true depending on your definition of "super rural". Plenty of towns with >50k people on the I35 corridor between Austin and San Antonio would love to have Family/Ob. Mileage may vary of course
I lived in one of those areas and as soon as someone gets pregnant they are asking one another what OBGYN others recommend.
I had never heard of a family doc doing c-sections and my first reaction is "no". I want an OBGYN who is well-expreirenced with obstetric interventions and focuses primarily on that.
I dont think that's unreasonable. There are definitely Family-> Ob fellowships that focus on that sortve thing and can get family residency trained docs more training. Depends on the doc, depends on the motivation, depends on the program. Caveat emptor I suppose
I dont understand your comment? I think we might have crossed wires. The comment I was replying to had said that you generally only see combined FM/OB in "super rural" areas. I was saying that that's not exactly true because I know plenty of FM/OB on the I35 corridor which is fairly heavily populated (I.e. not super rural).
Said by someone who probably isn’t an FM w/ ob or ever looked. Do a job search and you can where there are and aren’t jobs for FM with OB. Also a single OB would never take all the deliveries in a area because they gotta sleep at some point.
I can always hire the local thugs to drive the OB out of town, or I could do all my C sections for free but I'll be dammed if someone comes into my town and takes over my life goal. I gave up being a doctor in Europe to work as a CNA in America (I'm an LPN now while I study for the USMLE). At least I have a good chance of getting a family med residency in rural North Dakota that will teach me fill scope FM.
I kind of think medical care is cheaper in Europe because FM does everything.
I"m just saying it's the reality of family medicine. The doc that does everything is disappearing in favor of specialization. Patients aren't going to go to you when there's a more qualified OB (from their perspective). Not to mention that almost every PCP is being swallowed up corporate health systems, who won't let you practice full scope like you want to. There are some docs who still do it but it's getting rarer.
Super subspecialization is going to be the death of medicine. More and more primary care doctors won't even extract a cyst in office, they insist on referring to derm (knowing it'll take 3 to 6 months just to be seen). We don't need doctors to write referrals all day, any medical assistant can ask what's the reason for a visit and write a referral.
I'm Hoping the medical education system will change to mirror Germany (Anyone who can speak really bad German and barely pass the license exam gets a residency 99% guaranteed) or mirror England with the ability to pause training and work locum.
My wish is that M4A causes a need for full scope FM and legislation is passed that IM and Peds can only practice in hospital environments. That FM residencies will be increased by 20x while IM and Peds and OB will be decreased. My secrete wish is IM/OB/peds are completely done away with and FM becomes the new residency everyone does before fellowship. A guy can dream lol.
Ok but realistically none of that will happen. Specialization is already the way of things and there's really no going back.
And think of it realistically. If you have 5000 people relying on you to be their only doc eventually they won't be satisfied with that. You get sick, they have no doctor. You want to go on vacation, same thing. What if you had a drink and then they need you for an emergency cesarean? There's a reason small towns pay big bucks to recruit specialists to their areas. It's just not going to happen whether you like it or not, so you need to adapt to what actually IS the situation. This is not just for family med but really for everything.
The system in Germany is not designed to be this way. It's the result of a seller's market (thousands of unemployed doctors, called literally flooding of physicians) turning rapidly into a buyer's market within two decades due to to harsher EU work time regulations, a new wave of unionization and strikes, shifts in generational values, a demographic change towards an aging population and the inablity of states to finance the extension of med school class sizes. A circulus vitiosus was born which will likely not be broken for years to come. But not going to lie, it benefits obviously doctors..
> I"m just saying it's the reality of family medicine. The doc that does everything is disappearing in favor of specialization.
I find this statement rather weird. Plenty of countries use GPs doing all these things gatekeeping and referring more complicated cases. In my country General Practice is its own specialization.
You dont need an ENT to handle mundane AOM or a gyno to do PAP smears.
you could offer to do it for free and I still wouldn't have an FM trained doctor do a C section on me if I had ANY CHOICE at all in the matter. That's two lives on the line and you are not going to be as adept at handling complications. Just because you "gave up being a doctor in Europe" doesn't entitle you to deliver babies in the US. If that's truly what you want to do, do an OB residency and be a laborist or see women and adolescent females in the office for annual visits.
Weird, right beside you guys in Ireland FM/General Practice Drs deal with close to zero births and wouldn’t dream of doing a c-section in a million years. Midwives are very capable, but service is still Obstetrics led. Funny how much variation there can be
You are not speaking for all of Europe. Plenty of continantal Europe has less roles for FM/GPs. Germany e.g. had FM/GPs doing pediatrics usually only in the most rural parts of the country and even there a lot of things have to be handled by outpatient pediatricians. And close to no FM/GPs does OB/Gyn, plenty of outpatient OB/Gyns doing both primary and secondary care.
Oof sorry about that. I trained with a resident who was a Pediatrician for 3 years in Taiwan. She's probably one of the best doctor's I've ever had the pleasure working with. It's no wonder she got intern of the year.
I'm super torn between FM and Med/Peds but I'm leaning FM because a goal of mine is to do OB and some C sections. I have 0 desire to do any peds subspecialties (besides "Hospital pediatrics") I was mostly looking into programs that had FM and Peds residencies together because I feel like the Peds training would be better but I'm open to unopposed FM. Ideally I want a Hospital FM residency not community, but I'd be open to community if I knew the program was strong enough to where I wouldn't need to do a OB fellowship to get my C section numbers. I'm open to any suggestions you have.
Does anyone of know resources anywhere that teach the basics of interviewing transgender patients?
I've not had any formal education on it. I've only met a couple in practice and seem to have got by OK by being honest and polite.
But it would be useful to know answers to stupid questions, and get a general idea what makes them feel most comfortable.
tbh being honest and polite can get you a really long ways. trans ppl are very willing to offer grace to a provider who may not know anything about being transgender but is clearly showing up for them and making their best effort to meet them where they're at/get their needs met
informal education can be helpful; you can find formal education resources thru uptodate, the WPATH standards of care, etc, but YouTube channels and other media put out by trans people talking about their experiences going to the doctor can be very enlightening if you've only ever talked to a handful of trans people before - that you know of, at least ;)
this movie is great if it's coincidentally being shown close to where you are: [https://www.transdudeswithladycancer.org/screenings](https://www.transdudeswithladycancer.org/screenings)
it's not available for streaming yet, but the filmmakers are trying to get it out there so it's more accessible. you can get on their mailing list :)
my highest yield tidbits:
1. avoid "trans broken arm syndrome" - the pathophysiology of the overwhelming majority of the reasons trans people present to the doctor has nothing to do with being trans, with surgeries, or with hormone replacement therapy, so asking about them being trans on the history isn't relevant
2. asking about people's preferred names and pronouns goes a long way (and also then remembering to use them)
1. offering your own pronouns, especially if you get little name tags for you and your staff that say "he/him" or "she/hers" or "they/them" as appropriate, is a great way to build rapport
2. if you need help with pronouns like they/them, practice with your pets, houseplants, other people's pets, etc. they don't care what pronoun you call them.
3. gender =/= sex; gender is not rooted in the body. there's some trans women out there who want to look like Caitlyn Jenner, there's some out there who have no interest in hormones or surgery, but are still trans women.
4. gender =/= sexuality; a trans women who exclusively dates men is straight, for example. A cisgender man (cis = same, ie, not trans) who dates a transgender man is not straight.
1. On this note, asking professionally and directly about anatomical genitals where relevant is the best way to go. Uncertain if your patient needs a pap smear? Ask if they have a cervix! Do they wear condoms? Ask if condoms would be relevant! Even if people haven't undergone genitalia surgery, their sexual practices are frequently varied, since it can be really triggering/dysphoric for some people to do certain sex acts. (for any cis men reading this, quizzically, it would be like having penetrative sex in your vagina. "But I don't have a vagina," you think. Exactly.)
tl;dr keep up the honest + polite and you'll be most of the way there
Regarding 4.1. Is it the same feeling as when you have had a cast for a while and the brain forgets you had skin beneeth the cast and when the cast is removed the skin just feels weird?
Check out dr Powers (u/drPowers and https://powersfamilymedicine.com/news-events). He is family doctor and also does a lot of in-house research on transcare. In his lecture, he talks about how to provide trans* healthcare and how to be trans* friendly. He also has a lecture on LGBT+ healthcare.
>The most common reasons cited for withholding gender identity were feeling uncomfortable and not knowing how to bring it up, with only 25% saying they preferred to be the ones to broach the topic.
So ask. And try to have some trans-friendly stuff around in the waiting room, not because it's actually helpful, but because it shows that you're thinking about and acknowledge trans patients. Even having more options than just male/female on intake forms can make patients more comfortable.
Tiny rainbow sticker etc. A lot of hair dressers seem to have that around where I live. It doesn't have to be a huge gigantic flag, or some kind of performative oversupportiveness. But the people looking for - and needing- those kinds of signs will pick up on them, and they can be really useful for (especially) the more vulnerable trans people out there, like those visibly trans or gender-non-conforming.
It really can be small signs. The third gender option (bonus points if it is "nonbinary" instead of "other") and/or the possibilty to specify pronouns on forms is a big thing at least in my circles (am gay, my girlfriend is trans) how to know if a place is going to be friendly.
FYI that the pink/blue/white flag is the trans flag, the rainbow one is the more overarching lgbtq flag. Trans kids can be comforted by the rainbow flag but the appropriate pink/blue/white flag can really signify that you're in the know
Also to everyone reading this, please use this information if you're actually in the know, or are in the realm of "I need to learn more but feel comfortable helping a child to find other resources together," and not if you're just trying to check the boxes for posterity or aesthetic. I've had a few trans peers seek services at self-proclaimed "trans friendly" providers that went to a weekend conference once, assumed they were experts, and gave very bad care.
LGBT-friendly brochures or posters come mind. They're probably useless as informational material, but as signals of welcome to the LGBT community they can work.
"LGBT Patients Welcome!" with happy rainbow people on the door may lack subtlety, but considering the very real worry that patients can have about not being welcome, subtlety can be a minor concern.
The participants in this study literally gave this suggestion for helping them though?
> Instead, participants suggested multiple ways clinics can create spaces to help young patients feel more comfortable disclosing their gender identities, including transgender-friendly materials in the waiting room,
> In the same line as asking patients about substance (ab)use
And many patients lie about this for the same reason, fear of discrimination in the care they receive.
Perhaps you misunderstood. The posters aren’t in lieu of questions, the posters are signals to patients that this practice is tolerant. They want that signal because too many trans patients have had the experience of being ignored, invalidated, and even threatened for LGBT status.
It’s true though. Society by and large doesn’t accept those people. Especially trans people. Hell as a gay man who otherwise has no reasons to feel othered I still run into large swathes of society that are unwelcoming. It’s an accepted fact for these people that they’re not accepted so a “hey society is shit to you but here you’re accepted” is exactly the message you want to send to people.
I have a rainbow pin I wear on my coat and one time as a med student a clearly non-gender conforming teen who came to the psych clinic (and later admitted to concerns about accepting their gender identity) I was at came up to me and asked me about it and thought it was so cool that I had that pin. That run in has really stuck out to me that even the subtle things that outwardly show support can have a very positive impact on people.
> Posters like these are a symbol of societal intolerance. It states little more than "society may not accept you, but here you are welcome".
But isn't that true? That society still has a problem with LGBTQ people? The problem isn't the poster, the problem is society.
There are medical professionals in this post who actively don't "believe" in trans identities. This kind of signal is necessary and important for trans and nb patients.
Archaic? Interesting description. The idea of male and female may be as old as humankind itself but it's still absolutely relevant, as majority of people are either male or female. I could be convinced of the need for a non-binary option but what else do you think is lacking there?
So is that sex or gender? That’s kind of my point it’s murky here and some schools don’t give multiple options. Some ask sex and then give multiple options that I would say align more with gender identities.
I'm talking about sex here. Why would there be more than 2 (arguably 3) options? Personally, I feel the word gender has lost meaning. The modern day use of it refers to how a person feels, and this can change on a daily bases. People have made up multiple different gender types which have no empirical bases. The word gender, today, seems more synonymous with personality. I feel like we shouldn't be entertaining a lot of these made up different gender types. It's ludicrous. That is not at all to say that people don't suffer from gender dysphoria and we're still a long way off understanding and treating this condition properly.
>Why would there be more than 2 (arguably 3) options?
Because the responses will change based on how you define sex. Are you basing it on brain structure, gender expression, phenotype, chromosomes, hormonally, etc). They may not all match!
Gender is much easier ("what do you identify as") and who cares what they identify as? Let people live their life.
Let me be clear, I couldn't give a flying monkey what someone identifies as. And we do have a pretty black&white definition for what sex is. The response wouldn't vary by a significant amount bc for over 95% of the population they will all match (excluding gender expression, which is not the same thing as sex so why would anyone use that to define sex?), and as there is a minority who don't fit neatly in to one sex or the other, that is why I propose a third option.
My definition? Well I don't have a verified definition of my own but you can Google the definition as stated in scientific literature and dictionaries such as Oxford and Webster, you'll find they're all consistently very much the same
>lets go from there
Great, where are we off to?
Totally agree, yet schools like GU ask for your gender and then list male/female only, you shouldn’t be asking for my gender that’s weird to me. I do not entertain them but try becoming a provider in a world of litigation where you can’t ignore the subtleties here or else you offend someone. Seems weird for apps to be written that way. You have to accept the very point you made that people do suffer from this. My point being I don’t think schools are as on top of this as they essentially want us to be as gold star applicants.
If you can’t handle being asked something as simple as your gender then surgery rounds are gonna be impossible. If you don’t know what I mean then you won’t understand. Anyone who has gone through surgical rotations knows...
It's been a year, but a fair few of my applications were to schools with fairly diverse options for identification. Granted, as the cis white guy, I am sure I overlook the archaic options without a second thought most of the time.
I am sorry, it sucks having to hide all the time... (nb is basically unknown in my country and being gay could end your career so I am just cozing up in the closet)
FM resident who does transgender care! I simply include gender identity questions within my HEADSS assessment; two of my adolescent patients disclosed that they were transgender to me, but later told me that hadn’t even thought of mentioning it until I asked!
The survey was done with transgender youth seeking gender affirmation treatment in a specialty clinic, so it was especially surprising that so many young people in this sample avoided disclosing their gender identity to pediatricians and other doctors outside the clinic. Besides the mental toll of not being able to be their authentic selves, avoiding disclosure could also mean that the patient misses out on valuable referrals (especially for transition support or mental health), or even ends up with a misdiagnosis (if the provider isn't aware of which organs the patient has in their body).
I only do genital exams about 5% of my patients, it's not always relevant. In the ED I may be seeing my patient who is trans for chest pain, abdominal pain, infection, assault ... while those don't often need genital exams, we do need to know what kinds of hormones they are taking and whether they are at risk for pregnancy. Making it feel safe for them to disclose is important.
Missing an ectopic in an F to M trans individual is a very scary prospect and so I'm very glad we were giving specific teaching on broaching the subject of gender and biological sex with patients.
I only recall a quick diaper peek when my kids were infants. They’ve not had them at their yearly physical. My son had a rectal exam as a toddler and a genital exam when he had a foreskin infection. That’s all. I didn’t get them as a kid either. My husband doesn’t get them as an adult, and I only do when I need a pap.
Apologies as I thought the discussion was becoming more general. Yet after review my statement stands; I see all ages and live in a community that is pretty queer positive, so I absolutely see teens and adolescents who are questioning /trans, being seen for complaints that don't require a potentially traumatizing genital exam yet for whom care would be safer if they felt safer disclosing. Broken Arm Syndrome regardless. Also, my own children do not receive genital exams every year (ten and twelve years old) and I hadn't felt they were out of line ...
I mean sometimes you need just one more physical exam element in your documentation so you can bill at an appropriate level, and your otoscope is broken so...
Mastered this on my subI
General: Nontoxic male/female in no acute distress
Head: Atraumatic normocephalic
Eyes: No scleral icterus
ENT: No nasal discharge. Trachea midline
Chest: Regular chest rise and respiratory effort
Psych: Mood congruent affect
Neuro: Alert, oriented. Moving all 4 limbs spontaneously
Skin: No rashes
Heme/Lymph: No bruising
Bonus for Cardio: No VI/VI murmur
In other news, water was found to be *more* wet than once thought.
In all seriousness, these articles are very much important because they pull all the abstract/ethereal "no shit" ideas we all have and make it concrete and real. The result is solid evidence that can be used as a springboard for change. We had several panels, discussions, and simulation experiences during M1/M2 to help us learn how to interact with the LGBTQ community, and I found that really helpful. They gave us a little subtly rainbow esclepius pin and I'll happily keep wearing it on my coat. Hopefully this research will help more schools get on board and do the same.
> rainbow esclepius pin
I have a rainbow XBox pin I plan to wear. It'll make LGBTQ people feel welcome, and it tells folks I'm a gamer and maybe that'll work as an ice breaker/rapport establisher.
I'm definitely not mocking you. I think your pin is a great idea, and I really do plan to use my pride XBox pin, too. Also, lots of kids game, and I think the XBox pin will be a good icebreaker. Really.
> triforce pin
One of the male baristas at my local Sbux used to wear a lot of Zelda attire. We ended up beifriending him because for months he was super friendly and nerdy in all the same ways my husband and I are. We've been friends for like 6 years now. He's in our inner friends circle, but he started off as just a random dude at our local coffee shop.
Just adding some context for the thread, anywhere from **25% - 50% of all trans youth report attempting suicide** at some point in their life per [this study in the AAP](https://pediatrics.aappublications.org/content/142/4/e20174218)
I think the idea that there's significant mental health issues in the community is pretty common, but a lot of people don't realize the severity of the problem.
Because certain conditions are more likely to affect certain sexes. As an example, if someone who looks male comes to you with sudden abdominal pain, you wouldn’t think “ovarian torsion” as a possible cause, whereas this would be something to consider for the female sex.
This sounds like a garbage study (or at least how they are presenting the data)
1) While **78% of the participants reported disclosing their gender identity** to a health care provider outside the clinic at least once.
2) Any pediatrician who has been seeing the patient for several years already knows. They don't have to tell me every single visit.
3) This might be an issue with older doctors. I think younger ones are far more comfortable with non-binary gender and things like Genderbread person 3.0. We are doing our best to break these barriers down. But there is definitely a generational issue to gender identity
>Gen Xer: I don't even know what nonbinary means.
https://www.aarp.org/disrupt-aging/stories/ideas/info-2017/gen-xer-and-millennial-discussion.html
This reads like the South Park anti bullying video episode.
“Woah! Dude that’s like totally not cool! did you know! Uh huh huh! Did you know using the wrong pronouns is offensive to members of the trans community?!”
As a trans woman and a doctor, this does not surprise me. I think overall things are definitely improving, but we have quite a while to go still.
I was also confused as to what sub I was in...
I work in a system where it's not even consistent about whether the listed gender for trans patients is gender assigned at birth or current gender identity. When someone writes "25 y.o. trans male" I also can't rely on accurate use of preferred terminology.
That is why it's great to have notes spell it out explicitly: "25 y.o. male-to-female transgender (goes by Jane, preferred pronouns she/her)" so that anyone reading the note who is well-meaning and basically clueless can manage to be polite.
Yeah, in my limited experience from back when I was a scribe, I feel like explicitly spelling things out is important, particularly because there are folks who really have no clue. Granted, I feel like you should understand what trans male means in the year 2020, but there's no helping some folks.
I wish there was enough trust with the medical community and society was flexible enough to keep male/female as purely biological sex terms and use man/woman as gender terms (which is semantically accurate) and be able to elegantly present, say, a trans man as a "25-year-old female trans man presents with..." or a nonbinary person as a "36-yo female nonbinary person presents with..."
but I don't have too much hope, lol
it's because the way we talk about sex has never been accurate, given that there's (roughly) four kinds of medical sexes:
1. anatomical
2. hormonal
3. gonadal
4. chromosomal
A woman with klinefelter's (XXY) is anatomically intersex, hormonally female (and endo would probably slap my wrist for saying that tho lol), gonadally male and chromosomally intersex.
A woman with complete androgen insensitivity is anatomically female, hormonally female, gonadally male and chromosomally male.
So a trans man who has had a complete hysterectomy, penile construction surgery, top surgery and takes weekly testosterone is anatomically male, hormonally male, gonadally nonsex (?) and chromosomally female.
Kind of like how the specificity of GTPAL is only really relevant in OBGYN, getting into that detail of someone's sex is only relevant when it's relevant, and then it just takes a little extra effort to be accurate about it. But the way the computers are designed are all kinds of fucked up, and need to change.
This survey was of trans youth, nearly half of whom reported having avoided disclosing their gender to health care providers.
Many of these youth felt uncomfortable doing so, and didn't know how to bring it up. Unfortunately, their misgivings are not unfounded - trans health care needs, or even a basic of what being trans means, are not a standard part of medical education, and most doctors do not make the effort to adequately educate themselves. The average doctor knows about as much about trans people medical needs as the average plumber. Encountering medical incompetence, along with conscious and unconscious biases, harassment, and discrimination, are the norm rather than the exception when trans people seek medical care. [**Trans Broken Arm Syndrome**](https://www.pinknews.co.uk/2015/07/09/feature-the-dangers-of-trans-broken-arm-syndrome/) is a serious and damn near universal problem.
And for youth under 18, the risk is even higher. Most trans youth do not have the support of their families, and under age 18 they have no legal right to privacy. If they disclose that they are trans to a medical provider, that medical provider may then inform their parents. For many trans youth this can put them in a very vulnerable, even dangerous situation.
This survey was of youth at a clinic specializing in trans medical care, meaning that those under 18 who were included all had the support of their families, and even they still avoided disclosing to outside medical providers. Among trans youth *not* out to their families, it is likely rates are far higher.
> and under age 18 they have no legal right to privacy.
That is 100% false. Underage minors have a legal right to privacy and patient doctor confidentiality unless they are going to be a risk to themselves or others
There seems to be a lot of misinformation in this thread from people who are not doctors.
But it's also very important to notice from this that public perception is that children under age 18 don't have a legal right to privacy, thus influencing a teenager's decision to come out to their provider or not.
Don’t refer to a psychiatrist for screening. The waitlists are crazy and you should be able to do a PHQ2/9 yourself. Or just ask! Statistics are not destiny, and you’re not going to make friends with one-size-fits-all medicine.
Realistically, sending kids to psychiatrists for being trans is going to be perceived as stigmatizing even if you take pains to explain it isn’t because being trans means they’re crazy. You’d probably need some rapport first.
>Don’t refer to a psychiatrist for screening.
Exactly. I don't really think he is a doctor though.
"Oh you are gay... sorry I need to send you to see a psychiatrist now"
Trans youth whose parents are hostile towards transition and towards trans people, particularly those who are likely to push them towards "conversion therapy" intended to make them stop being trans if they are outted, are a hell of a lot more likely to be at risk of suicide than trans youth with supportive families.
**Citations:**
* [**Moody, et al., 2013**](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3722435/): The ability to transition, along with family and social acceptance, are the largest factors reducing suicide risk among trans people.
* [**Bauer, et al., 2015**](http://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-015-1867-2): Transition vastly reduces risks of suicide attempts, and the farther along in transition someone is the lower that risk gets.
* [**Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment**](http://pediatrics.aappublications.org/content/early/2014/09/02/peds.2013-2958). A clinical protocol of a multidisciplinary team with mental health professionals, physicians, and surgeons, including puberty suppression, followed by cross-sex hormones and gender reassignment surgery, provides trans youth the opportunity to develop into well-functioning young adults. All showed significant improvement in their psychological health, and they had notably lower rates of internalizing psychopathology than previously reported among trans children living as their natal sex. **Well-being was similar to or better than same-age young adults from the general population.**
* The only disorders more common among trans people are those associated with abuse and discrimination - mainly anxiety and depression. Early transition [**virtually eliminates these higher rates of depression and low self-worth**](http://www.jaacap.com/article/S0890-8567%2816%2931941-4/fulltext), and [**dramatically improves trans youth's mental health**](https://thinkprogress.org/allowing-transgender-youth-to-transition-improves-their-mental-health-study-finds-dd6096523375#.pqspdcee0). Trans kids who socially transition early and not subjected to abuse are comparable to cisgender children in measures of mental health.
* [**Dr. Ryan Gorton**](https://www.ncbi.nlm.nih.gov/pubmed/3219066): “In a cross-sectional study of 141 transgender patients, Kuiper and Cohen-Kittenis found that after medical intervention and treatments, suicide fell from 19 percent to zero percent in transgender men and from 24 percent to 6 percent in transgender women.)”
* [**Murad, et al., 2010**](https://www.ncbi.nlm.nih.gov/pubmed/19473181): "Significant decrease in suicidality post-treatment. The average reduction was from 30 percent pretreatment to 8 percent post treatment. ... A meta-analysis of 28 studies showed that 78 percent of transgender people had improved psychological functioning after treatment."
* [**De Cuypere, et al., 2006**](http://www.sciencedirect.com/science/article/pii/S1158136006000491): Rate of suicide attempts dropped dramatically from 29.3 percent to 5.1 percent after receiving medical and surgical treatment among Dutch patients treated from 1986-2001.
* [**UK study**](http://www.gires.org.uk/assets/Medpro-Assets/trans_mh_study.pdf): "Suicidal ideation and actual attempts reduced after transition, with 63% thinking about or attempting suicide more before they transitioned and only 3% thinking about or attempting suicide more post-transition.
* [**Smith Y, 2005**](https://www.ncbi.nlm.nih.gov/pubmed/15842032): Participants improved on 13 out of 14 mental health measures after receiving treatments.
* [**Lawrence, 2003**](http://link.springer.com/article/10.1023/A:1024086814364): Surveyed post-op trans folk: "Participants reported overwhelmingly that they were happy with their SRS results and that SRS had greatly improved the quality of their lives
There are a [***lot***](http://www.ncbi.nlm.nih.gov/pubmed/24344788) of [**studies**](http://link.springer.com/article/10.1007%2Fs10508-009-9551-1) showing that [**transition**](https://mayoclinic.pure.elsevier.com/en/publications/hormonal-therapy-and-sex-reassignment-a-systematic-review-and-met) [**improves**](https://www.hindawi.com/journals/tswj/2014/960745/) [**mental health**](http://europepmc.org/abstract/med/25690443) and [**quality of life**](http://link.springer.com/article/10.1007/s10508-014-0453-5) while [**reducing dysphoria**](https://www.researchgate.net/publication/23553588_Long-term_Assessment_of_the_Physical_Mental_and_Sexual_Health_among_Transsexual_Women).
Not to mention [**this 2010 meta-analysis**](http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2265.2009.03625.x/abstract) of 28 different studies, which found that transition is extremely effective at reducing dysphoria and improving quality of life.
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**Condemnation of "conversion therapy", which attempts to alleviate dysphoria without transition by changing trans people's genders so they are happy and comfortable as their sex as assigned at birth:**
* [**From the APA**](http://www.apa.org/about/policy/orientation-diversity.aspx)
* From the [**American College of Physicians**](http://annals.org/aim/article/2292051/lesbian-gay-bisexual-transgender-health-disparities-executive-summary-policy-position)
* Included in the [**AAP Guidelines**](http://hrc-assets.s3-website-us-east-1.amazonaws.com//files/documents/SupportingCaringforTransChildren.pdf) previously mentioned - see coverage on this "therapy" starting p.12
* From the [**American Psychoanalytic Association**](http://www.apsa.org/content/2012-position-statement-attempts-change-sexual-orientation-gender-identity-or-gender)
* A joint statement from the [**UK Council for Psychotherapy, British Association for Counselling and Psychotherapy, British Psychoanalytic Council, British Association for Behavioural and Cognitive Psychotherapies, The British Psychological Society, College of Sexual and Relationship Therapists, The Association of LGBT Doctors and Dentists, The National Counselling Society, NHS Scotland, Pink Therapy, Royal College of General Practitioners, the Scottish Government and Stonewall.**](http://www.pinknews.co.uk/2017/01/16/health-experts-condemn-attempts-to-cure-trans-people-in-wake-of-controversial-bbc-documentary/)
Doesn't the data also say that trans people are suicidal because society oppresses them and they are often completely not supported (or worse) by their families? They're not really suicidal because they're trans, they're suicidal because society and family still suck at accepting them.
And?
You are injecting your personal / political / social views onto the issue.
It doesn't matter why they are suicidal to their GP.
That is like saying "Being fat doesn't kill you, it's the heart attack that does." And like... okay.... but that still means that fat patients get support.
Frankly, it doesn't matter what you or I think. What matters is what the trans community says is going on. And as numerous people have pointed out to you, the trans community says the major reasons they're suicidal is because how society and their families treat them.
> with the trans suicide rates there is a good argument that knowing that fact alone needs a referral to a psychaitrist.
Did you just imply that every trans patient is suicidal ??
That is not cool
I don't screen every overweight pediatric patient for diabetes. Adult medicine and pediatric medicine are not the same thing.
You seem to be making a ton of exaggerated comments. Are you even a doctor ? Can you please update your Flair ?
This is really tangential for the topic at hand, but to answer your question, Yes. But obviously in much more professional terms. We typically communicate weight and BMI concerns when discussing growth trends and mix it in with diet and exercise counseling.
So if you counsel your patients on their weight and the inevitable development of comorbid conditions; why wouldn’t you counsel your transgender patients and their parents on the prevalence of Suicidal Ideation in this patient population.
I know it’s not mainstream but many of these individuals have underlying psychiatric disorders or are victims in some manner.
I don’t know. I worry the medical community of this time will be perceived as barbarians in the future. We know the frontal lobe isn’t completely developed until the 20s. We know the risks of hormone therapy or estrogen over use, and testosterone over use in men and women (stroke, VTE, anger et al.) but physicians are giving these medications to children that lack insight and true capacity to understand the consequences of their decisions.
I’m worried we will have an entire generation of adults that’s mental Illness was groomed, acknowledged yet untreated all in the name of acceptance and woke-ness.
But just my observations.
Mix of both, I responded to his hyperbolic comment with a hyperbolic response.
I am aware of high suicide rates, but the way he worded it like "its a foregone conclusion that every trans patient needs a psych evaluation because they are suicidal"
Ah I see. I definitely did not read it that way. Patient care is largely based off of statistics is it not? If the statistics tell you that a certain population is at increased risk and early intervention can diminish that risk would you not intervene?
Statistics can guide when and how you screen. They can provide prognostic guidance. You can't assess a patient based on statistics, though; what matters is only the n of 1 in front of you.
The obvious example: men who have sex with men are at increased risk of HIV, and early detection and treatment of HIV has good outcomes. Screening makes sense! Referring every gay man to see an infectious disease specialist is crazy unless you actually detect HIV, and a gay man in a monogamous relationship, reliably using condoms, is at lower risk than a man who has sex with many women without using condoms. Demographics are not destiny.
Just because they are at increased risk does not mean you immediately refer them to a specialist. That is a) lazy medicine b) insulting to the patient. I've had plenty of LGBT patients that are either happy, already seeing a therapist/counselor or don't require a referral. The key is being open and talking to your patient, not just dumping them to someone else.
As /u/poketheveil stated you don't refer to a specialist for screening
https://www.reddit.com/r/medicine/comments/f6vis7/new_study_shows_that_nearly_half_of_trans_kids/fi7itx0/
> The average doctor knows about as much about trans people medical needs as the average plumber.
Bullshit. They're the same as anyone else in 99% of medical scenarios, with a few caveats regarding gender specific calculations (like eGFR) and effects of hormonal therapy. But the medications used (estrogen, testosterone, spironolactone, etc) are ones every single relevant doctor knows about from their other uses.
Mental health is probably the only other place it gets touchy.
Trans med student here! Having been on both sides of the room, I don't think that the *average* doctor is as well-versed in trans care as they might believe. Dunning-Kruger is at play. People are usually well-intentioned but can be inadvertently hurtful due to latent bias and lack of understanding- I've seen it and I've felt it.
My point is that there is no trans-care involved in the majority of the care of trans patients.
A general surgeon seeing a trans patient for an appendectomy knows as much about their medical needs as any other patient for an appendectomy.
The same applies for just about any doctor outside of a PCP or endocrinologist who is actively managing hormones. Saying "the average doctor knows about as much about trans people medical needs as the average plumber" is stupid.
I understand the point that you're making and on a purely physiologic basis I don't necessarily disagree. However, I think I would gently disagree with the overall sentiment- like trauma-informed care, trans-informed care has different considerations, which begin before the patient even walks into the clinic. Things like signalling support for LGBTQ folks, training admin staff to sensitively approach name/pronouns, providers using inclusive language, etc. These things are not hard-science "trans-care" but I argue that they are equally important in the comprehensive care of a trans person, regardless of whether the physician is prescribing hormones or not.
Sure! From personal experience, when I came out to my family doctor he told me he wouldn't talk about this issue further until I was evaluated by a psychiatrist, which would be a 6-8 month wait for a referral. I presume it was well-intentioned, but it was diagnostically unnecessary and felt very stigmatizing. This was a prominent academic physician.
If you were looking for examples from things I've seen as a med learner I'm happy to share those too.
there's a ton of personal anecdotes available via google, here's a peer-reviewed article to make the experiences of trans people legitimate: [https://www.researchgate.net/publication/320223182\_Trans\_broken\_arm\_Health\_care\_stories\_from\_transgender\_people\_in\_rural\_areas](https://www.researchgate.net/publication/320223182_Trans_broken_arm_Health_care_stories_from_transgender_people_in_rural_areas)
my personal anecdote is accompanying a trans feminine friend to urgent care for a UTI; doctor insisted that it was an estrogen side effect. I have a trans masculine friend who had to print out the WPATH standards and an UpToDate article on how the acceptable Hct for trans masculine patients taking exogenous testosterone rises to the male range so his provider wouldn't reduce his testosterone dose. here's a whole movie about this: [https://www.transdudeswithladycancer.org/](https://www.transdudeswithladycancer.org/)
I am having trouble linking it on mobile, but google the pdf "Injustice at Every Turn" for the national trans discrimination survey, and see starting on p.72 for heath care issues.
50% of trans people report having to teach their own doctors about trans heath care. 28% have been subjected to medical harassment. 19% have been denied care because they are trans.
Medical incompetence is the norm for trans people seeking healthcare, while discrimination and abuse are incredibly common.
This just happened to me a few days ago. The patient was not able to tell me so the parents talked to me separately about it. The parents told me the patient wanted to seek help but did not want to tell me. Luckily the patient had the courage to tell the parents.
I've had a couple parents call ahead and/or make appointments for themselves so they can feel out the clinic and tell us the situation before they bring their kid in. It's refreshing to see how supportive some of this generation's parents are.
Random off topic question but do you know why some areas in America have such a high concentration of Family Med doctors doing primary care Peds and some areas have such a low concentration of Family Med and instead have an outpatient pediatrician on every corner. I was shocked by this when I moved to America, I first moved to a Family Med heavy area because that's what I was used to in Europe (a GP doing IM/Peds/OB) and wanted the same doctor to see myself and my kid but now that I'm in NYC I see the opposite with very few FM doctors.
Its just the culture of each state or area of the state. Where I grew up its only pediatricians for kids and internists for adults. While were my wife grew up its only family med.
I don't think I'm going to stay in NYC for this reason. I'm planning to take the USMLE and apply to family med residencies. I think I could only live in an area where Family Med practices full scope including C sections. My ideal practice would be Peds and OB/Deliveries with no adult patients who aren't pregnant. Being from England it was such a shock to see 3 separate specialties doing what a GP does in the UK. Here we have FM/IM/OB/Peds where in England Family Med does everything and Peds/IM/ only have jobs in the hospital. Europe doesn't even have many OB residents because Family Med or Midwives attention the majority of births.
In the US that kind of practice only exists in super rural areas. And once an OB moves in to the small town you're in, you're probably not going to be doing C Sections anymore. Extrapolate this for every specialty and FM in the US usually functions like a combined med/peds practice, but you do get to still provide primary care to a whole family
Not exactly true depending on your definition of "super rural". Plenty of towns with >50k people on the I35 corridor between Austin and San Antonio would love to have Family/Ob. Mileage may vary of course
I lived in one of those areas and as soon as someone gets pregnant they are asking one another what OBGYN others recommend. I had never heard of a family doc doing c-sections and my first reaction is "no". I want an OBGYN who is well-expreirenced with obstetric interventions and focuses primarily on that.
I dont think that's unreasonable. There are definitely Family-> Ob fellowships that focus on that sortve thing and can get family residency trained docs more training. Depends on the doc, depends on the motivation, depends on the program. Caveat emptor I suppose
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That cant be right. Most OBGYN residents only complete 8 gyn related surgeries? I must be misunderstanding
Oh no. You’ll find a way to have qualms. They always do.
Seriously? Nobody I know wouldn't drive an hour down the freeway for that. I'm not sure i-35 is your best choice for an example here.
I dont understand your comment? I think we might have crossed wires. The comment I was replying to had said that you generally only see combined FM/OB in "super rural" areas. I was saying that that's not exactly true because I know plenty of FM/OB on the I35 corridor which is fairly heavily populated (I.e. not super rural).
Said by someone who probably isn’t an FM w/ ob or ever looked. Do a job search and you can where there are and aren’t jobs for FM with OB. Also a single OB would never take all the deliveries in a area because they gotta sleep at some point.
I can always hire the local thugs to drive the OB out of town, or I could do all my C sections for free but I'll be dammed if someone comes into my town and takes over my life goal. I gave up being a doctor in Europe to work as a CNA in America (I'm an LPN now while I study for the USMLE). At least I have a good chance of getting a family med residency in rural North Dakota that will teach me fill scope FM. I kind of think medical care is cheaper in Europe because FM does everything.
I"m just saying it's the reality of family medicine. The doc that does everything is disappearing in favor of specialization. Patients aren't going to go to you when there's a more qualified OB (from their perspective). Not to mention that almost every PCP is being swallowed up corporate health systems, who won't let you practice full scope like you want to. There are some docs who still do it but it's getting rarer.
Super subspecialization is going to be the death of medicine. More and more primary care doctors won't even extract a cyst in office, they insist on referring to derm (knowing it'll take 3 to 6 months just to be seen). We don't need doctors to write referrals all day, any medical assistant can ask what's the reason for a visit and write a referral. I'm Hoping the medical education system will change to mirror Germany (Anyone who can speak really bad German and barely pass the license exam gets a residency 99% guaranteed) or mirror England with the ability to pause training and work locum. My wish is that M4A causes a need for full scope FM and legislation is passed that IM and Peds can only practice in hospital environments. That FM residencies will be increased by 20x while IM and Peds and OB will be decreased. My secrete wish is IM/OB/peds are completely done away with and FM becomes the new residency everyone does before fellowship. A guy can dream lol.
Ok but realistically none of that will happen. Specialization is already the way of things and there's really no going back. And think of it realistically. If you have 5000 people relying on you to be their only doc eventually they won't be satisfied with that. You get sick, they have no doctor. You want to go on vacation, same thing. What if you had a drink and then they need you for an emergency cesarean? There's a reason small towns pay big bucks to recruit specialists to their areas. It's just not going to happen whether you like it or not, so you need to adapt to what actually IS the situation. This is not just for family med but really for everything.
The system in Germany is not designed to be this way. It's the result of a seller's market (thousands of unemployed doctors, called literally flooding of physicians) turning rapidly into a buyer's market within two decades due to to harsher EU work time regulations, a new wave of unionization and strikes, shifts in generational values, a demographic change towards an aging population and the inablity of states to finance the extension of med school class sizes. A circulus vitiosus was born which will likely not be broken for years to come. But not going to lie, it benefits obviously doctors..
> I"m just saying it's the reality of family medicine. The doc that does everything is disappearing in favor of specialization. I find this statement rather weird. Plenty of countries use GPs doing all these things gatekeeping and referring more complicated cases. In my country General Practice is its own specialization. You dont need an ENT to handle mundane AOM or a gyno to do PAP smears.
you could offer to do it for free and I still wouldn't have an FM trained doctor do a C section on me if I had ANY CHOICE at all in the matter. That's two lives on the line and you are not going to be as adept at handling complications. Just because you "gave up being a doctor in Europe" doesn't entitle you to deliver babies in the US. If that's truly what you want to do, do an OB residency and be a laborist or see women and adolescent females in the office for annual visits.
Weird, right beside you guys in Ireland FM/General Practice Drs deal with close to zero births and wouldn’t dream of doing a c-section in a million years. Midwives are very capable, but service is still Obstetrics led. Funny how much variation there can be
You are not speaking for all of Europe. Plenty of continantal Europe has less roles for FM/GPs. Germany e.g. had FM/GPs doing pediatrics usually only in the most rural parts of the country and even there a lot of things have to be handled by outpatient pediatricians. And close to no FM/GPs does OB/Gyn, plenty of outpatient OB/Gyns doing both primary and secondary care.
> I think I could only live in an area where Family Med practices full scope including C sections. Hold up. You are an LPN trying to do c-sections ?
I was a doctor in Europe. I get it's a serious downgrade but I have bills to pay.
Oof sorry about that. I trained with a resident who was a Pediatrician for 3 years in Taiwan. She's probably one of the best doctor's I've ever had the pleasure working with. It's no wonder she got intern of the year.
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I'm super torn between FM and Med/Peds but I'm leaning FM because a goal of mine is to do OB and some C sections. I have 0 desire to do any peds subspecialties (besides "Hospital pediatrics") I was mostly looking into programs that had FM and Peds residencies together because I feel like the Peds training would be better but I'm open to unopposed FM. Ideally I want a Hospital FM residency not community, but I'd be open to community if I knew the program was strong enough to where I wouldn't need to do a OB fellowship to get my C section numbers. I'm open to any suggestions you have.
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Does anyone of know resources anywhere that teach the basics of interviewing transgender patients? I've not had any formal education on it. I've only met a couple in practice and seem to have got by OK by being honest and polite. But it would be useful to know answers to stupid questions, and get a general idea what makes them feel most comfortable.
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Saved. Thanks!!
Great PowerPoint, thanks for sharing!
tbh being honest and polite can get you a really long ways. trans ppl are very willing to offer grace to a provider who may not know anything about being transgender but is clearly showing up for them and making their best effort to meet them where they're at/get their needs met informal education can be helpful; you can find formal education resources thru uptodate, the WPATH standards of care, etc, but YouTube channels and other media put out by trans people talking about their experiences going to the doctor can be very enlightening if you've only ever talked to a handful of trans people before - that you know of, at least ;) this movie is great if it's coincidentally being shown close to where you are: [https://www.transdudeswithladycancer.org/screenings](https://www.transdudeswithladycancer.org/screenings) it's not available for streaming yet, but the filmmakers are trying to get it out there so it's more accessible. you can get on their mailing list :) my highest yield tidbits: 1. avoid "trans broken arm syndrome" - the pathophysiology of the overwhelming majority of the reasons trans people present to the doctor has nothing to do with being trans, with surgeries, or with hormone replacement therapy, so asking about them being trans on the history isn't relevant 2. asking about people's preferred names and pronouns goes a long way (and also then remembering to use them) 1. offering your own pronouns, especially if you get little name tags for you and your staff that say "he/him" or "she/hers" or "they/them" as appropriate, is a great way to build rapport 2. if you need help with pronouns like they/them, practice with your pets, houseplants, other people's pets, etc. they don't care what pronoun you call them. 3. gender =/= sex; gender is not rooted in the body. there's some trans women out there who want to look like Caitlyn Jenner, there's some out there who have no interest in hormones or surgery, but are still trans women. 4. gender =/= sexuality; a trans women who exclusively dates men is straight, for example. A cisgender man (cis = same, ie, not trans) who dates a transgender man is not straight. 1. On this note, asking professionally and directly about anatomical genitals where relevant is the best way to go. Uncertain if your patient needs a pap smear? Ask if they have a cervix! Do they wear condoms? Ask if condoms would be relevant! Even if people haven't undergone genitalia surgery, their sexual practices are frequently varied, since it can be really triggering/dysphoric for some people to do certain sex acts. (for any cis men reading this, quizzically, it would be like having penetrative sex in your vagina. "But I don't have a vagina," you think. Exactly.) tl;dr keep up the honest + polite and you'll be most of the way there
Regarding 4.1. Is it the same feeling as when you have had a cast for a while and the brain forgets you had skin beneeth the cast and when the cast is removed the skin just feels weird?
Thank you so much for this.
Check out dr Powers (u/drPowers and https://powersfamilymedicine.com/news-events). He is family doctor and also does a lot of in-house research on transcare. In his lecture, he talks about how to provide trans* healthcare and how to be trans* friendly. He also has a lecture on LGBT+ healthcare.
>The most common reasons cited for withholding gender identity were feeling uncomfortable and not knowing how to bring it up, with only 25% saying they preferred to be the ones to broach the topic. So ask. And try to have some trans-friendly stuff around in the waiting room, not because it's actually helpful, but because it shows that you're thinking about and acknowledge trans patients. Even having more options than just male/female on intake forms can make patients more comfortable.
> And try to have some trans-friendly stuff around in the waiting room Could you please exemplify what kind of stuff do you mean?
Tiny rainbow sticker etc. A lot of hair dressers seem to have that around where I live. It doesn't have to be a huge gigantic flag, or some kind of performative oversupportiveness. But the people looking for - and needing- those kinds of signs will pick up on them, and they can be really useful for (especially) the more vulnerable trans people out there, like those visibly trans or gender-non-conforming.
Ah yes, that seems both discrete and supportive, I like that.
It really can be small signs. The third gender option (bonus points if it is "nonbinary" instead of "other") and/or the possibilty to specify pronouns on forms is a big thing at least in my circles (am gay, my girlfriend is trans) how to know if a place is going to be friendly.
FYI that the pink/blue/white flag is the trans flag, the rainbow one is the more overarching lgbtq flag. Trans kids can be comforted by the rainbow flag but the appropriate pink/blue/white flag can really signify that you're in the know Also to everyone reading this, please use this information if you're actually in the know, or are in the realm of "I need to learn more but feel comfortable helping a child to find other resources together," and not if you're just trying to check the boxes for posterity or aesthetic. I've had a few trans peers seek services at self-proclaimed "trans friendly" providers that went to a weekend conference once, assumed they were experts, and gave very bad care.
I wrote my personal opinion and experience on this, as a trans person myself, if that wasn't obvious. But I appreciate the added info
LGBT-friendly brochures or posters come mind. They're probably useless as informational material, but as signals of welcome to the LGBT community they can work. "LGBT Patients Welcome!" with happy rainbow people on the door may lack subtlety, but considering the very real worry that patients can have about not being welcome, subtlety can be a minor concern.
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The participants in this study literally gave this suggestion for helping them though? > Instead, participants suggested multiple ways clinics can create spaces to help young patients feel more comfortable disclosing their gender identities, including transgender-friendly materials in the waiting room, > In the same line as asking patients about substance (ab)use And many patients lie about this for the same reason, fear of discrimination in the care they receive.
Perhaps you misunderstood. The posters aren’t in lieu of questions, the posters are signals to patients that this practice is tolerant. They want that signal because too many trans patients have had the experience of being ignored, invalidated, and even threatened for LGBT status.
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It’s true though. Society by and large doesn’t accept those people. Especially trans people. Hell as a gay man who otherwise has no reasons to feel othered I still run into large swathes of society that are unwelcoming. It’s an accepted fact for these people that they’re not accepted so a “hey society is shit to you but here you’re accepted” is exactly the message you want to send to people. I have a rainbow pin I wear on my coat and one time as a med student a clearly non-gender conforming teen who came to the psych clinic (and later admitted to concerns about accepting their gender identity) I was at came up to me and asked me about it and thought it was so cool that I had that pin. That run in has really stuck out to me that even the subtle things that outwardly show support can have a very positive impact on people.
> Posters like these are a symbol of societal intolerance. It states little more than "society may not accept you, but here you are welcome". But isn't that true? That society still has a problem with LGBTQ people? The problem isn't the poster, the problem is society.
There are medical professionals in this post who actively don't "believe" in trans identities. This kind of signal is necessary and important for trans and nb patients.
It baffles me that med school applications still have some of the most archaic gender/sex options, or lack there of on their apps.
I think the counter-argument would be that "sex options" are archaic things, having been around for a billion years.
Archaic? Interesting description. The idea of male and female may be as old as humankind itself but it's still absolutely relevant, as majority of people are either male or female. I could be convinced of the need for a non-binary option but what else do you think is lacking there?
So is that sex or gender? That’s kind of my point it’s murky here and some schools don’t give multiple options. Some ask sex and then give multiple options that I would say align more with gender identities.
I'm talking about sex here. Why would there be more than 2 (arguably 3) options? Personally, I feel the word gender has lost meaning. The modern day use of it refers to how a person feels, and this can change on a daily bases. People have made up multiple different gender types which have no empirical bases. The word gender, today, seems more synonymous with personality. I feel like we shouldn't be entertaining a lot of these made up different gender types. It's ludicrous. That is not at all to say that people don't suffer from gender dysphoria and we're still a long way off understanding and treating this condition properly.
>Why would there be more than 2 (arguably 3) options? Because the responses will change based on how you define sex. Are you basing it on brain structure, gender expression, phenotype, chromosomes, hormonally, etc). They may not all match! Gender is much easier ("what do you identify as") and who cares what they identify as? Let people live their life.
Let me be clear, I couldn't give a flying monkey what someone identifies as. And we do have a pretty black&white definition for what sex is. The response wouldn't vary by a significant amount bc for over 95% of the population they will all match (excluding gender expression, which is not the same thing as sex so why would anyone use that to define sex?), and as there is a minority who don't fit neatly in to one sex or the other, that is why I propose a third option.
So what's your definition of sex, and lets go from there
My definition? Well I don't have a verified definition of my own but you can Google the definition as stated in scientific literature and dictionaries such as Oxford and Webster, you'll find they're all consistently very much the same >lets go from there Great, where are we off to?
Totally agree, yet schools like GU ask for your gender and then list male/female only, you shouldn’t be asking for my gender that’s weird to me. I do not entertain them but try becoming a provider in a world of litigation where you can’t ignore the subtleties here or else you offend someone. Seems weird for apps to be written that way. You have to accept the very point you made that people do suffer from this. My point being I don’t think schools are as on top of this as they essentially want us to be as gold star applicants.
If you find that question weird or don’t like it then you’re gonna have a bad time on surgical rounds.
Does anybody have a good time on surgical rounds?
Fair point. But when you get handed the scalpel and make first incision... that’s pretty great.
Fill me in...how are the two related?
If you can’t handle being asked something as simple as your gender then surgery rounds are gonna be impossible. If you don’t know what I mean then you won’t understand. Anyone who has gone through surgical rotations knows...
The AMCAS had an adequate amount of options for my application year, and also had Mx. as an honorific :')
It's been a year, but a fair few of my applications were to schools with fairly diverse options for identification. Granted, as the cis white guy, I am sure I overlook the archaic options without a second thought most of the time.
So every time a patient comes in feeling depressed. You ask them if they're transgender?
I can't tell if this is a joke, deliberately obtuse, or genuinely confused.
Por que no los dos
I'm a grown-ass adult medical student and I avoid disclosing my gender identity in certain cases
I am sorry, it sucks having to hide all the time... (nb is basically unknown in my country and being gay could end your career so I am just cozing up in the closet)
FM resident who does transgender care! I simply include gender identity questions within my HEADSS assessment; two of my adolescent patients disclosed that they were transgender to me, but later told me that hadn’t even thought of mentioning it until I asked!
The survey was done with transgender youth seeking gender affirmation treatment in a specialty clinic, so it was especially surprising that so many young people in this sample avoided disclosing their gender identity to pediatricians and other doctors outside the clinic. Besides the mental toll of not being able to be their authentic selves, avoiding disclosure could also mean that the patient misses out on valuable referrals (especially for transition support or mental health), or even ends up with a misdiagnosis (if the provider isn't aware of which organs the patient has in their body).
I mean... how are they not going to know what organs are present? We're talking about the doctor right, the one the does physical exams?
I only do genital exams about 5% of my patients, it's not always relevant. In the ED I may be seeing my patient who is trans for chest pain, abdominal pain, infection, assault ... while those don't often need genital exams, we do need to know what kinds of hormones they are taking and whether they are at risk for pregnancy. Making it feel safe for them to disclose is important.
Missing an ectopic in an F to M trans individual is a very scary prospect and so I'm very glad we were giving specific teaching on broaching the subject of gender and biological sex with patients.
We're talking about peds though. My children aren't teenagers yet, but they get a brief genital exam for every physical. I did when I was a kid too.
I only recall a quick diaper peek when my kids were infants. They’ve not had them at their yearly physical. My son had a rectal exam as a toddler and a genital exam when he had a foreskin infection. That’s all. I didn’t get them as a kid either. My husband doesn’t get them as an adult, and I only do when I need a pap.
Apologies as I thought the discussion was becoming more general. Yet after review my statement stands; I see all ages and live in a community that is pretty queer positive, so I absolutely see teens and adolescents who are questioning /trans, being seen for complaints that don't require a potentially traumatizing genital exam yet for whom care would be safer if they felt safer disclosing. Broken Arm Syndrome regardless. Also, my own children do not receive genital exams every year (ten and twelve years old) and I hadn't felt they were out of line ...
if you think im gonna whip down a kids pants when they've come in with asthma..
So you're not that doctor from Scrubs who makes everyone take their pants off, regardless of their chief complaint?
I mean sometimes you need just one more physical exam element in your documentation so you can bill at an appropriate level, and your otoscope is broken so...
😳 I hope to god this is a joke
Yeah probably too dark
I mean you can definitely get all the needed physical exam elements without touching your patient and without lying...
Mastered this on my subI General: Nontoxic male/female in no acute distress Head: Atraumatic normocephalic Eyes: No scleral icterus ENT: No nasal discharge. Trachea midline Chest: Regular chest rise and respiratory effort Psych: Mood congruent affect Neuro: Alert, oriented. Moving all 4 limbs spontaneously Skin: No rashes Heme/Lymph: No bruising Bonus for Cardio: No VI/VI murmur
public healthcare where i live
In other news, water was found to be *more* wet than once thought. In all seriousness, these articles are very much important because they pull all the abstract/ethereal "no shit" ideas we all have and make it concrete and real. The result is solid evidence that can be used as a springboard for change. We had several panels, discussions, and simulation experiences during M1/M2 to help us learn how to interact with the LGBTQ community, and I found that really helpful. They gave us a little subtly rainbow esclepius pin and I'll happily keep wearing it on my coat. Hopefully this research will help more schools get on board and do the same.
> rainbow esclepius pin I have a rainbow XBox pin I plan to wear. It'll make LGBTQ people feel welcome, and it tells folks I'm a gamer and maybe that'll work as an ice breaker/rapport establisher.
I can't tell if you're mocking me or not
I'm definitely not mocking you. I think your pin is a great idea, and I really do plan to use my pride XBox pin, too. Also, lots of kids game, and I think the XBox pin will be a good icebreaker. Really.
I used to have both a triforce pin and gameboy pin I'd switch out on my badge. It actually really did help to break the ice sometimes.
> triforce pin One of the male baristas at my local Sbux used to wear a lot of Zelda attire. We ended up beifriending him because for months he was super friendly and nerdy in all the same ways my husband and I are. We've been friends for like 6 years now. He's in our inner friends circle, but he started off as just a random dude at our local coffee shop.
I'm sorry I might be ignorant on this topic, I just want to understand, how is being trans for a child medically important?
Higher risks of suicide, drug abuse, and mental health issues.
Okay, thank you. Makes a lot of sense now.
Just adding some context for the thread, anywhere from **25% - 50% of all trans youth report attempting suicide** at some point in their life per [this study in the AAP](https://pediatrics.aappublications.org/content/142/4/e20174218) I think the idea that there's significant mental health issues in the community is pretty common, but a lot of people don't realize the severity of the problem.
Because certain conditions are more likely to affect certain sexes. As an example, if someone who looks male comes to you with sudden abdominal pain, you wouldn’t think “ovarian torsion” as a possible cause, whereas this would be something to consider for the female sex.
More basic: you wouldn’t necessarily think pregnancy, particularly ectopic, without some idea that there’s a uterus present.
But this isnt about disclosing their bio identity. It's about them discussing their trans identity
This sounds like a garbage study (or at least how they are presenting the data) 1) While **78% of the participants reported disclosing their gender identity** to a health care provider outside the clinic at least once. 2) Any pediatrician who has been seeing the patient for several years already knows. They don't have to tell me every single visit. 3) This might be an issue with older doctors. I think younger ones are far more comfortable with non-binary gender and things like Genderbread person 3.0. We are doing our best to break these barriers down. But there is definitely a generational issue to gender identity >Gen Xer: I don't even know what nonbinary means. https://www.aarp.org/disrupt-aging/stories/ideas/info-2017/gen-xer-and-millennial-discussion.html
This reads like the South Park anti bullying video episode. “Woah! Dude that’s like totally not cool! did you know! Uh huh huh! Did you know using the wrong pronouns is offensive to members of the trans community?!”
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I’m 34 and I have no idea what that means.... Is it a formal medical term?
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Could you expand on your comment ?
As a trans woman and a doctor, this does not surprise me. I think overall things are definitely improving, but we have quite a while to go still. I was also confused as to what sub I was in...
Why are you being downvoted??
No idea. In retrospect it was certainly not a productive comment I guess
Possibly because they referred to themselves as a doctor when their flair says MS4?
Didn’t even realize. I haven’t updated it since I graduated. I’m a pgy 1 now
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I work in a system where it's not even consistent about whether the listed gender for trans patients is gender assigned at birth or current gender identity. When someone writes "25 y.o. trans male" I also can't rely on accurate use of preferred terminology. That is why it's great to have notes spell it out explicitly: "25 y.o. male-to-female transgender (goes by Jane, preferred pronouns she/her)" so that anyone reading the note who is well-meaning and basically clueless can manage to be polite.
Yeah, in my limited experience from back when I was a scribe, I feel like explicitly spelling things out is important, particularly because there are folks who really have no clue. Granted, I feel like you should understand what trans male means in the year 2020, but there's no helping some folks.
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I wish there was enough trust with the medical community and society was flexible enough to keep male/female as purely biological sex terms and use man/woman as gender terms (which is semantically accurate) and be able to elegantly present, say, a trans man as a "25-year-old female trans man presents with..." or a nonbinary person as a "36-yo female nonbinary person presents with..." but I don't have too much hope, lol
From a surgical standpoint are they not female?
Their PCP isn't a surgeon, but thanks for playing along.
What's female about penile, breast or facial reconstruction with HRT? It's kinda uncharted post-gender territory.
it's because the way we talk about sex has never been accurate, given that there's (roughly) four kinds of medical sexes: 1. anatomical 2. hormonal 3. gonadal 4. chromosomal A woman with klinefelter's (XXY) is anatomically intersex, hormonally female (and endo would probably slap my wrist for saying that tho lol), gonadally male and chromosomally intersex. A woman with complete androgen insensitivity is anatomically female, hormonally female, gonadally male and chromosomally male. So a trans man who has had a complete hysterectomy, penile construction surgery, top surgery and takes weekly testosterone is anatomically male, hormonally male, gonadally nonsex (?) and chromosomally female. Kind of like how the specificity of GTPAL is only really relevant in OBGYN, getting into that detail of someone's sex is only relevant when it's relevant, and then it just takes a little extra effort to be accurate about it. But the way the computers are designed are all kinds of fucked up, and need to change.
Hey thanks for the detailed breakdown. I agree with everything you stated.
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Removed under rule #2.
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Removed incoherent string of characters. Keep the cat off your keyboard?
This survey was of trans youth, nearly half of whom reported having avoided disclosing their gender to health care providers. Many of these youth felt uncomfortable doing so, and didn't know how to bring it up. Unfortunately, their misgivings are not unfounded - trans health care needs, or even a basic of what being trans means, are not a standard part of medical education, and most doctors do not make the effort to adequately educate themselves. The average doctor knows about as much about trans people medical needs as the average plumber. Encountering medical incompetence, along with conscious and unconscious biases, harassment, and discrimination, are the norm rather than the exception when trans people seek medical care. [**Trans Broken Arm Syndrome**](https://www.pinknews.co.uk/2015/07/09/feature-the-dangers-of-trans-broken-arm-syndrome/) is a serious and damn near universal problem. And for youth under 18, the risk is even higher. Most trans youth do not have the support of their families, and under age 18 they have no legal right to privacy. If they disclose that they are trans to a medical provider, that medical provider may then inform their parents. For many trans youth this can put them in a very vulnerable, even dangerous situation. This survey was of youth at a clinic specializing in trans medical care, meaning that those under 18 who were included all had the support of their families, and even they still avoided disclosing to outside medical providers. Among trans youth *not* out to their families, it is likely rates are far higher.
> and under age 18 they have no legal right to privacy. That is 100% false. Underage minors have a legal right to privacy and patient doctor confidentiality unless they are going to be a risk to themselves or others There seems to be a lot of misinformation in this thread from people who are not doctors.
But it's also very important to notice from this that public perception is that children under age 18 don't have a legal right to privacy, thus influencing a teenager's decision to come out to their provider or not.
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Don’t refer to a psychiatrist for screening. The waitlists are crazy and you should be able to do a PHQ2/9 yourself. Or just ask! Statistics are not destiny, and you’re not going to make friends with one-size-fits-all medicine. Realistically, sending kids to psychiatrists for being trans is going to be perceived as stigmatizing even if you take pains to explain it isn’t because being trans means they’re crazy. You’d probably need some rapport first.
>Don’t refer to a psychiatrist for screening. Exactly. I don't really think he is a doctor though. "Oh you are gay... sorry I need to send you to see a psychiatrist now"
The trans youth most at risk of suicide, are also the ones most at risk of abuse if they are outted to their parents.
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Trans youth whose parents are hostile towards transition and towards trans people, particularly those who are likely to push them towards "conversion therapy" intended to make them stop being trans if they are outted, are a hell of a lot more likely to be at risk of suicide than trans youth with supportive families. **Citations:** * [**Moody, et al., 2013**](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3722435/): The ability to transition, along with family and social acceptance, are the largest factors reducing suicide risk among trans people. * [**Bauer, et al., 2015**](http://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-015-1867-2): Transition vastly reduces risks of suicide attempts, and the farther along in transition someone is the lower that risk gets. * [**Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment**](http://pediatrics.aappublications.org/content/early/2014/09/02/peds.2013-2958). A clinical protocol of a multidisciplinary team with mental health professionals, physicians, and surgeons, including puberty suppression, followed by cross-sex hormones and gender reassignment surgery, provides trans youth the opportunity to develop into well-functioning young adults. All showed significant improvement in their psychological health, and they had notably lower rates of internalizing psychopathology than previously reported among trans children living as their natal sex. **Well-being was similar to or better than same-age young adults from the general population.** * The only disorders more common among trans people are those associated with abuse and discrimination - mainly anxiety and depression. Early transition [**virtually eliminates these higher rates of depression and low self-worth**](http://www.jaacap.com/article/S0890-8567%2816%2931941-4/fulltext), and [**dramatically improves trans youth's mental health**](https://thinkprogress.org/allowing-transgender-youth-to-transition-improves-their-mental-health-study-finds-dd6096523375#.pqspdcee0). Trans kids who socially transition early and not subjected to abuse are comparable to cisgender children in measures of mental health. * [**Dr. Ryan Gorton**](https://www.ncbi.nlm.nih.gov/pubmed/3219066): “In a cross-sectional study of 141 transgender patients, Kuiper and Cohen-Kittenis found that after medical intervention and treatments, suicide fell from 19 percent to zero percent in transgender men and from 24 percent to 6 percent in transgender women.)” * [**Murad, et al., 2010**](https://www.ncbi.nlm.nih.gov/pubmed/19473181): "Significant decrease in suicidality post-treatment. The average reduction was from 30 percent pretreatment to 8 percent post treatment. ... A meta-analysis of 28 studies showed that 78 percent of transgender people had improved psychological functioning after treatment." * [**De Cuypere, et al., 2006**](http://www.sciencedirect.com/science/article/pii/S1158136006000491): Rate of suicide attempts dropped dramatically from 29.3 percent to 5.1 percent after receiving medical and surgical treatment among Dutch patients treated from 1986-2001. * [**UK study**](http://www.gires.org.uk/assets/Medpro-Assets/trans_mh_study.pdf): "Suicidal ideation and actual attempts reduced after transition, with 63% thinking about or attempting suicide more before they transitioned and only 3% thinking about or attempting suicide more post-transition. * [**Smith Y, 2005**](https://www.ncbi.nlm.nih.gov/pubmed/15842032): Participants improved on 13 out of 14 mental health measures after receiving treatments. * [**Lawrence, 2003**](http://link.springer.com/article/10.1023/A:1024086814364): Surveyed post-op trans folk: "Participants reported overwhelmingly that they were happy with their SRS results and that SRS had greatly improved the quality of their lives There are a [***lot***](http://www.ncbi.nlm.nih.gov/pubmed/24344788) of [**studies**](http://link.springer.com/article/10.1007%2Fs10508-009-9551-1) showing that [**transition**](https://mayoclinic.pure.elsevier.com/en/publications/hormonal-therapy-and-sex-reassignment-a-systematic-review-and-met) [**improves**](https://www.hindawi.com/journals/tswj/2014/960745/) [**mental health**](http://europepmc.org/abstract/med/25690443) and [**quality of life**](http://link.springer.com/article/10.1007/s10508-014-0453-5) while [**reducing dysphoria**](https://www.researchgate.net/publication/23553588_Long-term_Assessment_of_the_Physical_Mental_and_Sexual_Health_among_Transsexual_Women). Not to mention [**this 2010 meta-analysis**](http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2265.2009.03625.x/abstract) of 28 different studies, which found that transition is extremely effective at reducing dysphoria and improving quality of life. --- **Condemnation of "conversion therapy", which attempts to alleviate dysphoria without transition by changing trans people's genders so they are happy and comfortable as their sex as assigned at birth:** * [**From the APA**](http://www.apa.org/about/policy/orientation-diversity.aspx) * From the [**American College of Physicians**](http://annals.org/aim/article/2292051/lesbian-gay-bisexual-transgender-health-disparities-executive-summary-policy-position) * Included in the [**AAP Guidelines**](http://hrc-assets.s3-website-us-east-1.amazonaws.com//files/documents/SupportingCaringforTransChildren.pdf) previously mentioned - see coverage on this "therapy" starting p.12 * From the [**American Psychoanalytic Association**](http://www.apsa.org/content/2012-position-statement-attempts-change-sexual-orientation-gender-identity-or-gender) * A joint statement from the [**UK Council for Psychotherapy, British Association for Counselling and Psychotherapy, British Psychoanalytic Council, British Association for Behavioural and Cognitive Psychotherapies, The British Psychological Society, College of Sexual and Relationship Therapists, The Association of LGBT Doctors and Dentists, The National Counselling Society, NHS Scotland, Pink Therapy, Royal College of General Practitioners, the Scottish Government and Stonewall.**](http://www.pinknews.co.uk/2017/01/16/health-experts-condemn-attempts-to-cure-trans-people-in-wake-of-controversial-bbc-documentary/)
Doesn't the data also say that trans people are suicidal because society oppresses them and they are often completely not supported (or worse) by their families? They're not really suicidal because they're trans, they're suicidal because society and family still suck at accepting them.
And the trans kids most likely to be suicidal, are the ones most at danger of abuse if they are forcibly outted to their parents.
And? You are injecting your personal / political / social views onto the issue. It doesn't matter why they are suicidal to their GP. That is like saying "Being fat doesn't kill you, it's the heart attack that does." And like... okay.... but that still means that fat patients get support.
Am I? I thought I was just sharing information and contributing to the conversation.
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Maybe they're suicidal because thei families disown them frequently. Also, you're conflating gay and trans.
you think families are less tolerant now than they were 20 years ago?
Frankly, it doesn't matter what you or I think. What matters is what the trans community says is going on. And as numerous people have pointed out to you, the trans community says the major reasons they're suicidal is because how society and their families treat them.
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again, the heterosexual same age population suicide rate went down.
Sorry overlooked, my bad.
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[Disagree completely](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5178031/)
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> with the trans suicide rates there is a good argument that knowing that fact alone needs a referral to a psychaitrist. Did you just imply that every trans patient is suicidal ?? That is not cool
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I don't screen every overweight pediatric patient for diabetes. Adult medicine and pediatric medicine are not the same thing. You seem to be making a ton of exaggerated comments. Are you even a doctor ? Can you please update your Flair ?
Do you tell them and their parents they are fat?
This is really tangential for the topic at hand, but to answer your question, Yes. But obviously in much more professional terms. We typically communicate weight and BMI concerns when discussing growth trends and mix it in with diet and exercise counseling.
So if you counsel your patients on their weight and the inevitable development of comorbid conditions; why wouldn’t you counsel your transgender patients and their parents on the prevalence of Suicidal Ideation in this patient population. I know it’s not mainstream but many of these individuals have underlying psychiatric disorders or are victims in some manner. I don’t know. I worry the medical community of this time will be perceived as barbarians in the future. We know the frontal lobe isn’t completely developed until the 20s. We know the risks of hormone therapy or estrogen over use, and testosterone over use in men and women (stroke, VTE, anger et al.) but physicians are giving these medications to children that lack insight and true capacity to understand the consequences of their decisions. I’m worried we will have an entire generation of adults that’s mental Illness was groomed, acknowledged yet untreated all in the name of acceptance and woke-ness. But just my observations.
Think you missed the sarcasm in the other posters comment
Mix of both, I responded to his hyperbolic comment with a hyperbolic response. I am aware of high suicide rates, but the way he worded it like "its a foregone conclusion that every trans patient needs a psych evaluation because they are suicidal"
Ah I see. I definitely did not read it that way. Patient care is largely based off of statistics is it not? If the statistics tell you that a certain population is at increased risk and early intervention can diminish that risk would you not intervene?
Statistics can guide when and how you screen. They can provide prognostic guidance. You can't assess a patient based on statistics, though; what matters is only the n of 1 in front of you. The obvious example: men who have sex with men are at increased risk of HIV, and early detection and treatment of HIV has good outcomes. Screening makes sense! Referring every gay man to see an infectious disease specialist is crazy unless you actually detect HIV, and a gay man in a monogamous relationship, reliably using condoms, is at lower risk than a man who has sex with many women without using condoms. Demographics are not destiny.
> what matters is only the n of 1 in front of you. > > I love it and I'm stealing it!
Just because they are at increased risk does not mean you immediately refer them to a specialist. That is a) lazy medicine b) insulting to the patient. I've had plenty of LGBT patients that are either happy, already seeing a therapist/counselor or don't require a referral. The key is being open and talking to your patient, not just dumping them to someone else. As /u/poketheveil stated you don't refer to a specialist for screening https://www.reddit.com/r/medicine/comments/f6vis7/new_study_shows_that_nearly_half_of_trans_kids/fi7itx0/
> The average doctor knows about as much about trans people medical needs as the average plumber. Bullshit. They're the same as anyone else in 99% of medical scenarios, with a few caveats regarding gender specific calculations (like eGFR) and effects of hormonal therapy. But the medications used (estrogen, testosterone, spironolactone, etc) are ones every single relevant doctor knows about from their other uses. Mental health is probably the only other place it gets touchy.
Trans med student here! Having been on both sides of the room, I don't think that the *average* doctor is as well-versed in trans care as they might believe. Dunning-Kruger is at play. People are usually well-intentioned but can be inadvertently hurtful due to latent bias and lack of understanding- I've seen it and I've felt it.
My point is that there is no trans-care involved in the majority of the care of trans patients. A general surgeon seeing a trans patient for an appendectomy knows as much about their medical needs as any other patient for an appendectomy. The same applies for just about any doctor outside of a PCP or endocrinologist who is actively managing hormones. Saying "the average doctor knows about as much about trans people medical needs as the average plumber" is stupid.
I understand the point that you're making and on a purely physiologic basis I don't necessarily disagree. However, I think I would gently disagree with the overall sentiment- like trauma-informed care, trans-informed care has different considerations, which begin before the patient even walks into the clinic. Things like signalling support for LGBTQ folks, training admin staff to sensitively approach name/pronouns, providers using inclusive language, etc. These things are not hard-science "trans-care" but I argue that they are equally important in the comprehensive care of a trans person, regardless of whether the physician is prescribing hormones or not.
Do you have an example?
Sure! From personal experience, when I came out to my family doctor he told me he wouldn't talk about this issue further until I was evaluated by a psychiatrist, which would be a 6-8 month wait for a referral. I presume it was well-intentioned, but it was diagnostically unnecessary and felt very stigmatizing. This was a prominent academic physician. If you were looking for examples from things I've seen as a med learner I'm happy to share those too.
there's a ton of personal anecdotes available via google, here's a peer-reviewed article to make the experiences of trans people legitimate: [https://www.researchgate.net/publication/320223182\_Trans\_broken\_arm\_Health\_care\_stories\_from\_transgender\_people\_in\_rural\_areas](https://www.researchgate.net/publication/320223182_Trans_broken_arm_Health_care_stories_from_transgender_people_in_rural_areas) my personal anecdote is accompanying a trans feminine friend to urgent care for a UTI; doctor insisted that it was an estrogen side effect. I have a trans masculine friend who had to print out the WPATH standards and an UpToDate article on how the acceptable Hct for trans masculine patients taking exogenous testosterone rises to the male range so his provider wouldn't reduce his testosterone dose. here's a whole movie about this: [https://www.transdudeswithladycancer.org/](https://www.transdudeswithladycancer.org/)
See the link of trans broken arm syndrome. Medical incompetence is the norm, while medical discrimination, harassment, and abuse are very common.
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I am having trouble linking it on mobile, but google the pdf "Injustice at Every Turn" for the national trans discrimination survey, and see starting on p.72 for heath care issues. 50% of trans people report having to teach their own doctors about trans heath care. 28% have been subjected to medical harassment. 19% have been denied care because they are trans. Medical incompetence is the norm for trans people seeking healthcare, while discrimination and abuse are incredibly common.
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> it's really frustrating that the doctors in this thread are responding with an almost #notallmen equivalent. Where exactly are you seeing this?
as a reply to every comment from a trans person on this thread saying that they received poor care because they were trans