The Gender Diverse Population – Are They Receiving the Correct Preventive Care?

Preamble

Preventive health care for many in the population is a critical and necessary part of our lives, helping with early disease detection.  It's well known that missed screening can result in missed diagnosis, delayed treatment and reduced chances of survival.

Cancer screening | Cancer Research UK

UK recommendations for the management of transgender and gender-diverse patients with inherited cancer risks | BJC Reports

Nevertheless, the medical system in the United Kingdom is poorly organised and equipped to meet the needs and requirements of gender diverse people.  According to the******Census, approximately 262,000 people (0.5% of the population aged 16+) in England and Wales identified with a gender different from their sex registered at birth. Of those who answered, roughly 48,000 identified as trans men, 48,000 as trans women, 30,000 as non-binary, and 18,000 used another term. 

First census estimates on gender identity and sexual orientation - Office for National Statistics

I am a Clinical Psychiatrist in Rockhampton, Australia and come from a background of general medicine. I study how to improve the lives of gender diverse people and improve their health outcomes through education and information.  My personal area of expertise is guiding transgender people through their transition by way of a support network of therapy and medical experts, answering their needs and questions.

My fellow professionals in primary care in our clinics and hospitals devote much of their time and lives to preventative medicine (I’ve been a service user myself), and the art of preventing disease before it starts is sometimes a challenge for them.  Cancer screening consumes much of their lives, and the fight to prevent, discover, treat, and care consumes much of their time and resources.

Although not my field of expertise directly, I have a concern about the barriers my patients encounter who are transgender or non-binary and their issues with consistent access to adequate cancer screening during and after their transitions.

The Issues with the Binary Model of Care

Health care spaces and providers ordinarily focus on “men's health” or “women's health”, specifically, which we all know has always been the historical model.  At present, intake forms have no option for declaring a gender identity separate from the sex assigned at birth.

Health screening and insurance policies for diseases like cancer tend to be pitched toward a flawed binary male/female model.  Many of my own gender diverse patients inform me that they often find themselves teaching their primary care doctors how to provide them with competent care, as many medical students receive little training on providing gender affirming care.

Providing primary care to transgender patients | Family Medicine and Community Health

Transgender Education in North American Family Medicine Clerkships: A CERA Study

As a result, 1 out of 3 gender diverse adults do not seek preventive care, according to a report by Seelman et al (2017), or they are not offered these services at all when they see a health care provider.  What's even more disturbing is that 19% of transgender people report that they have been refused care altogether.

Transgender Noninclusive Healthcare and Delaying Care Because of Fear: Connections to General Health and Mental Health Among Transgender Adults - PMC

Cancer screening in the transgender population: a review of current guidelines, best practices, and a proposed care model - Sterling - Translational Andrology and Urology

More applicable to the UK, Europe and the USA than Australia, this may contribute to higher rates of tobacco use, obesity, alcohol use and other cancer risk factors in gender diverse people.

NTDS_Report.pdf

Training to reduce LGBTQ-related bias among medical, nursing, and dental students and providers: a systematic review | BMC Medical Education | Springer Nature Link

The Challenges in Cancer Care

Research in******found that transgender adults over the age of 45 are screened for colon cancer at a lower rate than cisgender patients.

Cancer screening rates among transgender adults: Cross-sectional analysis of primary care data - PMC

Furthermore, they are also more likely to be diagnosed at later stages of lung cancer, which can be devastating, as finding lung cancer before it becomes malignant and spreads can literally mean the difference between life and death.

Lung cancer screening - NHS

Cancer Stage, Treatment, and Survival Among Transgender Patients in the United States | JNCI: Journal of the National Cancer Institute | Oxford Academic

In the USA, the University of California, San Francisco are one of the few places that has protocols for the care of transgender patients and recommends that transgender women who are older than 50 and have been taking feminizing hormones for five years begin their screening for breast cancer.

Screening for breast cancer in transgender women | Gender Affirming Health Program

However, according to a recent study by the Canadian College of Family Physicians, about 1 in 3 transgender women who are eligible for breast cancer screening receive mammograms compared with 2 in 3 eligible cisgender women.  Studies in the UK have also found similar figures in their meta-analysis

Cancer screening rates among transgender adults: Cross-sectional analysis of primary care data - PMC

Cancer screening attendance rates in transgender and gender-diverse patients: a systematic review and meta-analysis | BMJ Evidence-Based Medicine

A******study by Jackson et al (2021) found that transgender patients with non-Hodgkin lymphoma, prostate cancer or bladder cancer had roughly twice the death rate of their cisgender counterparts.  Identifying accurately that out of only*****transgender individuals, nearly******million records, they could not accurately compare rates for other types of cancer.

The American Society of Clinical Oncology, since*****, has recommended including data about patients sexual and gender minority status in cancer registries and clinical trials.

American Society of Clinical Oncology Position Statement: Strategies for Reducing Cancer Health Disparities Among Sexual and Gender Minority Populations | Journal of Clinical Oncology

Consequently, the society in******found that only half of oncology care providers are routinely collecting gender identity information, so it's clear here that there is still a lot to take away and learn about the barriers to inclusive cancer care for both the USA and the UK.

Sexual Orientation and Gender Identity Data Collection in Oncology Practice: Findings of an ASCO Survey | JCO Oncology Practice

There is a clear lack of training in both medical schools and residencies throughout the UK, USA and Australia to some degree and intensive training sessions where new doctors hone and perfect their skills, which still sadly perpetuates these disparities.  These countries are all at different levels and are generally either slow or reluctant to move with the advances of culture and medical research at times, affecting the outcomes we have discussed thus far.

Medical ****** Bias

I know from my own experiences that the military and civilian medical schools are plagued by biases that reflect society's stereotypes and prejudices.  Furthermore, researchers have commented that students can unconsciously absorb biases and stereotypes encountered throughout their medical education.

A call for grounding implicit bias training in clinical and translational frameworks - The Lancet

Reducing Racial Bias Among Health Care Providers: Lessons from Social-Cognitive Psychology | Journal of General Internal Medicine | Springer Nature Link

North American Family Medicine Clerkships found in******that courses in which medical students started working and interacting with real patients reported that they felt comfortable teaching transgender health care.  As a result of this, the Association of American Medical Colleges has called for emphasising at all levels of training the health of people who are lesbian, gay, bisexual, transgender, queer or questioning and other identities under the LGBTQI+ umbrella.

Transgender Education in North American Family Medicine Clerkships: A CERA Study

The association recommended that schools take a “layered” approach that integrates education on gender affirming healthcare across their curriculum.  Areas that would be helpful would be to incorporate LGBTQI+ health early in their coursework, or using practice model patients in various live exercises, and creating structured opportunities to care for patients with lived experience.

store.aamc.org/downloadable/download/sample/sample_id/129/

WV STEPS features diverse manikin, standardized patients for students to gain experience working with diverse populations | News | West Virginia University

The researchers have concluded, and the data support it, that medical schools worldwide are still failing to integrate gender-affirming care throughout the curriculum.  The reality is that medical schools often append it to the existing curriculum, offering dedicated lectures or small group activities that address LGBTQI+ health.  Ordinarily, medical schools overall are providing a median of only five hours of direction concerning gender affirming healthcare practices.

Improving Clinical Education and Training on Sexual and Gender Minority Health | Current Sexual Health Reports | Springer Nature Link

Transgender Education in North American Family Medicine Clerkships: A CERA Study

Barriers to Gender Affirming Healthcare

One of the largest barriers in the UK is the extremely long waiting times in the NHS; the system for gender variant patients is dysfunctional, with many waiting years to see a GID (Gender Identity) clinician in a clinic, often waiting in a state of “limbo” for a period in some cases of 5 years; this only further deepens their gender dysphoria.  

The impact of Gender Identity Clinic waiting times on the mental health of transitioning individuals - PMC

To further compound this, there are administrative and systemic hurdles that trans and non-binary people often face difficulty in changing their name, title, and gender markers on GP systems, leading to being misgendered in correspondence or losing access to previous records.

Trans People And The NHS: The Heat Of The Debate Needs The Light Of Evidence | The King's Fund

Trans and non-binary people face hurdles at every stage of primary care | Healthwatch

Accessing and utilising gender-affirming healthcare in England and Wales: trans and non-binary people’s accounts of navigating gender identity clinics - PMC

We have already highlighted the knowledge gaps among practitioners and a lack of training, which results in many healthcare providers being ill-equipped to provide appropriate, respectful care, resulting in poor experiences, especially for non-binary patients.  There are also primary care barriers where some GP’s being reluctant to engage in “shared care” agreements, making it difficult for patients to access prescriptions for Hormone Replacement Therapy (HRT).

Probably one of the most concerning barriers is their negative experiences and the discrimination that gender diverse people receive.  Many reported negative experiences, including being treated disrespectfully, having their care ignored or delayed and in the worst cases, having care refused.

Gender-related self-reported mental health inequalities in primary care in England: a cross-sectional analysis using the GP Patient Survey - The Lancet Public Health

“Trans Broken Arm Syndrome” is a phenomenon where healthcare providers sometimes fixate on a particular patient's trans status, misattributing unrelated health issues to their transition or hormones, according to a parliamentary report.

I have experienced the fallout of this with patients contacting me, their practitioner and relating the exact issues that I have described above; this concords with my belief that this is a worldwide issue.

HSC0045 - Evidence on Health and social care and LGBT communities

Health professionals’ identified barriers to trans health care: a qualitative interview study | British Journal of General Practice

Conclusion & The Momentum for Change

Fortunately, the medical profession has recognized that gender diverse patients have distinct and unique healthcare needs.  I say this with some caution as I am also very aware and up to date with the Trump administration removing a large amount of the funding, support and structure helping gender diverse patients in the USA; although it also affected Canada.  As of early*****, 27 U.S. states have enacted laws restricting or banning access to gender-affirming care (GAC) for minors, affecting over 50% of transgender youth. These legislative actions, often coupled with federal executive orders restricting funding and insurance coverage (e.g., Medicare/Medicaid), have caused widespread clinic closures, loss of care, and negative mental health impacts

Discontinuation of Gender-Affirming Medical Treatments: Prevalence and Associated Features in a Nonprobabilistic Sample of Transgender and Gender-Diverse Adolescents and Young Adults in Canada and the United States

Nevertheless, as far back as*****, the American College of Obstetricians and Gynaecologists published recommendations for healthcare providers on making their practices open and, above all, inclusive for all individuals. Training all staff and creating transparency without a gendered approach is a key recommendation.  As a result of this move towards inclusion, over 20 other medical organisations now provide similar guidance with the hopes of increasing and generating more inclusion through the healthcare system.

Health Care for Transgender and Gender Diverse Individuals | ACOG

Medical Organization Statements | A4TE

There are also some encouraging signs in some medical schools that are integrating gender-affirming care into their coursework. For example, the University of Louisville in Kentucky reports that it now offers 50 hours of LGBTQI+ specific topics, and a faculty student team at Boston University ****** of Medicine has developed a tool to help medical schools assess and improve how they educate students to provide sexual and gender minority healthcare.

Home | ****** of Medicine

Novel Curriculum Assessment Tool, Based on AAMC Competencies, to Improve Medical Education About Sexual and Gender Minority Populations | Academic Medicine | Oxford Academic

To conclude this discussion, I am hopeful that the next generation of healthcare providers will be a force for change in their respective institutions.  My own business model and institution is to offer and support a full gender diverse health outlook that helps, supports, listens and provides to their wants and needs within our medical framework.  I have a quota of medical students who visit my practice for training, and I know they are more aware and attuned to the health disparities than their older generation educators.  I will continue in my own work to champion and raise awareness of when and where I can make a better world for all my patients.