Doctors and therapists are struggling to give transgender patients the best medical care because of a lack of expertise and experience, according to a new study from Appalachian State University in North Carolina.
The study, published this month in Sage, examined interviews with healthcare workers around the country, finding that medical providers are facing “vast amounts” of uncertainty when treating trans patients. Current guidelines carry little scientific evidence to show they work, writes the author, and the medical community’s narrow definition of what it means to be trans only exacerbates the issue.
“My research begins by asking what happens when there is no scientific evidence and little clinical experience to base medical decisions,” said the report’s author stef shuster (whose legal name is written in lowercase letters), an assistant professor of sociology at Appalachian State University. “This particular feature of trans medicine introduces the potential for providers to bring bias or limited knowledge into their work with trans people.”
Transgender is the umbrella term used to describe people who don’t identify with their biological, or so-called “assigned” sex. According to the American Psychological Association, a person who is trans has an “internal sense” of being a man or a woman, or something outside of these categories.
Often, trans people will seek to change their physical appearance and biology to resemble the identified gender, known as sex or gender reassignment surgery. It’s not a straightforward process, and generally requires multiple meetings with both doctors and therapists. Transgender medicine covers both physical care, such as estrogen or testosterone hormone therapy, as well as mental healthcare, to help a trans person transition both physically and socially.
When determining whether a person is a candidate for medical treatment, doctors, therapists and other health professionals typically use a set of clinical guidelines created by the World Professional Association for Transgender Health (WPATH), a nonprofit that promotes transgender healthcare. The guidelines lay out a series of steps, starting with one or more visits with a therapist, who decides whether sex reassignment surgery is the correct course of treatment.
If the therapist concludes that the person is indeed transgender, the trans person is sent to a doctor to receive treatment such as hormone therapy or surgery, including reshaping the breasts or the genitals to resemble the identified gender.
The process has many challenges, according to the study. The fact that a trans person’s fate is placed entirely in a therapist’s hands is morally questionable and controversial, writes shuster. Transgender medicine has also been built around the idea that to transition means to switch from male to female or vice versa. But that’s changing, shuster says.
“More recently, trans people’s understandings of their selves and bodies have become more fluid, and ‘cross’-gender transitioning is not always the ultimate goal,” writes shuster, who asked to be identified with the pronoun “they” rather than “he” or “she”. “The nuance in gender identification that trans people bring to the clinic exacerbates providers’ uncertainty.”
The study interviewed 23 doctors and psychologists who have chosen to work in transgender medicine. Many had entered the field because they personally knew someone who had trouble finding a provider to treat them. Only two of the participants worked exclusively with trans people, while just one identified as transgender.
According to the study, uncertainty about how best to treat a trans patient was something that was regularly experienced by all of the respondents. To cope with this uncertainty, providers used current guidelines to help inform their decisions.
The study found that some providers closely followed guidelines, while others were more flexible and interpreted them on a case-by-case basis.
Those new to the profession and those with a decade or more experience tended to be more rigid, expecting trans people to be “100% certain” about their desire to undergo sex reassignment surgery. One reason for this, writes shuster, is that more experienced providers may be slower to accept changing notions of what it means to be trans, while those new to their profession lacked the experience to confidently chart their own course.
One respondent named Sarah, a therapist in private practice, said she closely followed guidelines to ensure a patient didn’t come to regret their decision to transition later on.
“I can’t have you wake up on a surgeon’s table and say, ‘Who are you and what are you doing to my body?’ That has happened,” she said. “So I am really good about wanting to be holistic with people, and saying, please just let me be your therapist.”
This absolute power to decide the course of another person’s future made some of the participants uncomfortable. Alexis, a social worker, said although she has refused to okay some people for sex reassignment surgery, the double standards in transgender medicine versus other areas of medicine doesn’t always sit right with her.
“It is a tough function to fulfill,” Alexis said. “In all other areas of mental health practice, I don’t really have to give permission to people to do things.”
The idea that a trans person has to be absolutely certain about their desire to transition doesn’t take into account the complicated and oftentimes changing nature of gender identity, writes shuster. For instance, some people might start hormone therapy but decide months later that the treatment isn’t right for them.
“Trans people are allowed little room to explore their identities on their own terms,” writes shuster.
It also gets more complicated when people identify as “gender fluid” rather than explicitly male or female. One participant, Brandon, a psychologist at a university clinic, said it’s much easier for a therapist to make a decision when the boundaries are clear and a person wants to transition from male to female or vice versa.
“In the land of non-binary gender folks, you have to wade through waves and waves of ambiguity,” he said. “You have to build way more of a relationship with the person and establish a whole lot more trust.”
Respondents that took a more flexible approach to the guidelines said they weighed up what was more harmful: to treat someone even when it isn’t clear they are ready for medical treatment, or to not treat someone at all.
“It seems far less harmful to give someone hormones long term and take some risk that it might kill them, where maybe before they were suicidal,” said Anna, a family practitioner at a community clinic. “It is not for me to say to any given person, ‘Well you are not quite suicidal so I don’t think it is worth the risk.’”
Shuster describes gender as a “socially-ascribed category” that cannot be simplified or standardized. More research is needed in the area of transgender medicine, shuster says, especially from the perspective of the medical community. Shuster also urges doctors and therapists to be less dogmatic and allow trans patients to have more ownership in the process.
“From a trans patient perspective, healthcare encounters might feel easier to negotiate if providers stopped emphasizing this narrow definition of ‘transgender’,” shuster says. “And opened up more dialogue for their trans patients to describe how they understand their own identities and bodies.”
