Primary Care for Transgender Patients 

By

Vanessa Pomarico

9 minutes

What do NPs need to know about providing primary care for transgender patients?

Our patients identify in a variety of ways. “LGBTQIA+” is an umbrella term encompassing many different populations who all have their own unique health care needs. This includes: 

  • Lesbian 
  • Gay 
  • Bisexual 
  • Transgender 
  • Queer or questioning 
  • Intersex 
  • Asexual or allies 
  • Other gender non-conforming identities 

Due to the lack of education on caring for this population of patients, the specific needs for each individual group represented under this acronym may be ignored. This can lead to untreated health care problems.  

Related: Transgender Patient Essential Care: Making Healthcare Trans-parent 

Exploring gender identity and sexual orientation 

Gender diverse is a term that demonstrates the uniqueness of one’s self-expression outside of the gender binary: male or female, masculine or feminine. Some people may not identify as one gender at all. As clinicians, it is so important that we understand and respect how patients self-identify by using the appropriate terminology and chosen pronouns especially as more persons identify as non-binary. 

There are several terms that are used to describe how people identify. Many people confuse the terms sexual orientation with gender identity. However, these are two entirely different concepts. Sexual orientation describes who a person is attracted to emotionally, physically and/or romantically. Gender identity is a psychological self-identification or an awareness of belonging to one gender or another, a combination of more than one gender or no gender at all.   

Inclusive language for members of the LGBTQIA+ community 

As a society, it is commonplace to check a box for male or female (known as gender binary), married, divorced, widowed or single. We need to think outside of these outdated terms and become more inclusive in our language on intake and registration forms by including terms such as transgender, non-binary, gender non-conforming, cisgender, other, adding in partnered and changing marital status to relationship status.  

Gender: Binary, non-binary, or non-conforming? 

Gender binary is based on a person’s physical anatomy or gender assigned at birth. A person who identifies as non-binary is someone who does not identify with the sex assigned at birth and whose gender identity is not necessarily male or female.  

Gender non-conformity is how a person’s gender identity, role or outward expression differs from societal or cultural norms. Gender dysphoria is a term used to describe the discomfort or distress due to the discrepancy or incongruency of one’s gender identity and the sex assigned at birth.  

The transgender spectrum 

Experts estimated that there are approximately more than 2 million people in the United States who identify as transgender. This number represents all racial, religious and ethnic backgrounds. That number may be grossly underestimated, however. Many transgender persons may simply identify as cisgender and not report that they are transgender. Often, this is due to stigma, discrimination and systemic inequality.  

In a recent study, many transpersons reported they had experienced some form of intimate partner violence. Approximately 47% reported being sexually assaulted in their lifetime.  

It is important to understand that there is a spectrum of identifying as transgender. Some persons live in their desired gender but do not have any gender affirmation surgery or procedures, some have partial or complete gender affirmation surgeries, some take gender-affirming hormones while others identify as transgender but have no plans to undergo any gender-affirming procedures, surgeries or take hormones.

Transgender women are assigned males at birth (AMAB) but whose identity or expression is female. This is also known as male-to-female (MTF). Transgender males are assigned female at birth (AFAB) who identify and live as a male also known as female-to-male (FTM).  

Related: Expanding the Rainbow: Understanding the needs of the LGBTQIA patient 

Important terms: Misgendering 

While it may be difficult to assimilate all these new terms into practice at one time, one term that is of the utmost importance to learn is regarding misgendering. This is when a person intentionally or unintentionally uses a term or language to describe a person that does not align with that person’s affirmed gender. This is often a deliberate act based on political, religious, or personal beliefs and is considered an act of discrimination. It can occur when someone makes an assumption based on another person’s outward appearance.  

Every time you misgender a patient, you are inflicting harm. It threatens a person’s sense of safety and invalidates them. Patients may not return to your care if they are misgendered. It is vital that all personnel understand the significance of avoiding misgendering a patient. The best advice is that if this does occur, simply acknowledge the mistake, correct yourself and move on.  

Primary care for transgender patients: Gaining trust 

It may take time for the transgender person to gain your trust. Many have been discriminated against by previous clinicians or have had negative experiences with the health care system.  

Introducing yourself with your chosen pronouns is a good place to start. This sets the tone for the visit and lets the patient know you are affirming. Using gender-neutral language and open-ended questions without any assumptions or judgment goes a long way in establishing a healthy patient-clinician relationship.  

Part of the conversation with the patient should include asking them if there are any anatomical terms that they may find offensive or triggering. For example, breast, penis and vagina are gender-loaded terms. Instead, use front hole, back hole, chest, internal genitals or external genitals when referring to body parts.   

Taking a sexual history can be sensitive, so be sure to use terms that are gender neutral. ‘People who menstruate’ or ‘people who produce sperm’ may suffice instead of male, female, or pregnant women. Taking an organ inventory records what reproductive organs were present at birth and what organs the patient currently has.  

This helps with identifying what screening tests need to be done based on what reproductive organs may or may not be present. Failure to ask these questions causes the clinician to lose the opportunity to connect with the patient by offering affirmative care and appropriate screenings.  

Primary care for transgender patients: Performing a physical exam 

There are specific considerations for the physical exam of the transgender patient. “Screen what you have” is a good rule of thumb. Physical exam should be relevant to the genitalia that is currently present and should only be done if it is pertinent to routine screening or the problem visit pertaining to these body parts. Many times, patients will defer sensitive exams until they get to know the clinician a little better or until they able to psychologically prepare themselves for the exam.  

Offering to have a care partner during the exam is beneficial to the patient. Be sure to explain to the patient what intimate exams will entail to help them understand the procedure.  

Navigating gender identity in young children 

Children as young as 3 or 4 years of age are identifying as gender diverse or transgender. Gender constancy is the cognitive stage of development around age 5-7 where children realize that their assigned sex at birth is fixed. NPs need to be skilled at helping the patient and family navigate this journey and encourage families to accept how the child identifies.  

For some children, this may just be a time of exploration but for others, it is important for the family to be supportive of the child during this period. It is essential that they advocate on the child’s behalf at schools, social activities, churches, or any other social event for others to honor the child’s chosen names, pronouns and expression. 

Additionally, the NP is a vital resource in helping the family grieve the loss of the child they knew but help them to embrace the identity that the child has chosen. It is important to stress that everyone use the child’s chosen name and avoid using the birth name. This is also known as their “dead” name. Using the birth name can be detrimental to the psychological well-being of the child and can worsen gender dysphoria.  

Intimate partner violence among the LGBTQIA+ community 

There is significant evidence of intimate partner violence (IPV) among the LGBTQIA+ community, notably among transgender patients. IPV can include physical, emotional and/or psychological abuse. Often, victims fear leaving their abusers. Encouraging an open dialogue with patients about IPV is important in helping to gain their trust. Be sure to refer to mental health clinicians who are well versed and accepting of this population of patients.  

Identification documents for transgender patients 

Identification documents pose a significant issue for many transgender persons. Depending on the state where they live, they may not be legally able to amend their birth certificate to reflect their gender identity. Without appropriate documents, they are unable to safely travel, register for schools or obtain necessary public services.  

Lastly, it is important for clinicians caring for this population of patients to build a referral network of specialty clinicians. This includes those educated and well-versed in the care of the gender-diverse patient. Reassure patients that any referrals will be to other clinicians who will be affirming and offer a safe place for the patient to be evaluated and treated.  

References 

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Editor’s note: this post was originally published on June 14, 2024.

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