Let's Talk About Gender-affirming Care

Most physicians haven't been taught how to care for transgender or non-binary patients, or even how to communicate with them. But the skills are teachable, says one expert.

While attention to transgender and non-binary issues is ramping up in our general culture, knowledge and protocols for treating these populations in the healthcare space is lagging.

Fundamentally, most physicians haven't been taught how to communicate with patients about gender identity, much less how to meet their medical needs.

For insights, HealthLeaders spoke with Alex S. Keuroghlian, MD, MPH, director of education and training programs at The Fenway Institute at Fenway Health in Boston. He is also an assistant professor of psychiatry at Harvard Medical School.

HealthLeaders: There is a lot of variation in terminology when it comes to services related to gender identity. What is the best way to describe healthcare for transgender individuals?

Keuroghlian: The term we use generally for this kind of care is gender-affirming care. So we talk about gender-affirming medical care, gender-affirming behavioral healthcare, and gender-affirming surgical care.

In terms of what that involves, there are several components, which include social affirmation, legal affirmation, psychological affirmation, medical affirmation, and surgical affirmation.

HealthLeaders: What are the questions to ask in determining a patient's gender identity?

Keuroghlian: You have to have a systematic way in which gender identity data are being collected and used accordingly by all clinicians and staff. Patients should be asked at registration or the front desk what their current gender identity is and their sex assigned at birth.

It's crucial to ask both questions—it's called the two-step process—because a lot of transgender people are otherwise just going to identify themselves as a man or a woman.

But when we ask about sex assigned at birth, we have more information to tailor care accordingly. For example, we will do preventive cancer screening based on the organs retained in someone's body, not just the sex listed on their insurance card.

The electronic health record should collect this information so that people have to provide it only once. If they're continually misgendered, you risk losing them [as patients].

However, you want to check in with some regularity about people's names, pronouns, sexual orientation, and gender identity because those things can evolve throughout a person's life.

HealthLeaders: What else is important to know about communicating with transgender people?

Keuroghlian: People need training in sensitive, effective communication across the board. This includes being taught not to make assumptions about people's gender identity or pronouns. This goes for everyone, from clinical to nonclinical staff, including the front desk, financial services and billing, the security guards, and everyone in between.

Affirming and effective communication expresses cultural humility and empathy.

HealthLeaders: Gender-affirming healthcare isn't part of most physicians' standard medical training. Do you foresee this changing?

Keuroglian: These are very teachable skills that all clinical teams can do. But obviously, medical and nursing curricula need to be modernized to teach them. It's not happening yet, but I am seeing a shift among young people—even people coming up five years behind me as more recent trainees—who are really passionate about this.

So I'm optimistic that something is going to shift because there's been an extremely swift sea change in how much of a priority this is and how passionate young clinicians are about this area. They view [gender affirmation] as the civil rights movement of our time. This is going to happen.