The following article is a part of conference coverage from the American Academy of PAs 2021 Conference (AAPA 2021), held virtually from May 23 to May 26, 2021. The team at the Clinical Advisor will be reporting on the latest news and research conducted by leading PAs. Check back for more from AAPA 2021
It’s well-documented that transgender individuals face discrimination both in broader society and within the health care system. This discrimination leads to health disparities, including a lack of access, postponed care, and harassment in medical settings from providers and staff, according to a poster presented at the American Academy of PAs 2021 Annual Conference (AAPA 2021).
These disparities are associated with subsequently higher rates of HIV/AIDS; disproportionate use and abuse of drugs, alcohol, and cigarettes; as well as the presence of cardiovascular disease, obesity, and certain cancers. Mental health conditions are of particular concern within this population, with 82% of transgender people experiencing suicidal thoughts and 40% attempting suicide — a rate 9 times that of the general US population.
In order to highlight both the healthcare-specific and social challenges that impact how the transgender community access primary health care in the United States, researchers from the Charles R. Drew University Physician Assistant Program in Los Angeles, California, conducted a systematic review of the current medical literature.
A search identified 607 potential studies published between 2015 and 2020, 22 of which were included in the final analysis. Results were categorized into 1 of 6 groups based on the identification of common barriers to health care access.
In a breakdown of the included studies, the presenters found that 10 identified “transphobia, discrimination, fear of stigma, fear of not being accepted, and/or fear of being outed” as a significant concern. In particular, transmasculine patients were twice as likely as transfeminine patients to delay necessary care due to discrimination.
Findings were also similar among transgender youth, with 25% reporting that they did not speak to their health care provider about gender or sexual preference “due to fear of disclosure to the parents.” Compared with transgender adults, transgender youth experience an additional set of unique barriers, including lack of familial approval and a fear of being outed to parents or caregivers.
An additional 10 studies cited “lack of knowledgeable/experienced/willing providers” as a barrier to transgender health care access. One common concern in this domain was a refusal by providers to initiate and continue hormone therapy.
Six studies cited “difficulty accessing health care” as a barrier. A small study conducted in New Jersey found that 50% of participants were outright refused services when health care was sought.
Five studies cited “embodied disruption” as a barrier — which occurs “when a provider does not acknowledge or incorrectly assumes the identity of a nonconforming LGBTQ individual.” According to the presenters, this can include misgendering the patient and using the incorrect name and/or pronouns. Transgender men in particular are more affected by this misgendering, with reports that they find themselves “less able to return to masculine normity” after being misgendered or misidentified.
An additional 6 studies cited barriers from the provider perspective, and 4 cited a lack of societal and/or familial support.
Overall, the lack of providers with knowledge, experience, and willingness to treat transgender individuals contributes significantly to health disparities in the transgender vs cisgender communities. Many providers are unfamiliar with commonly used terms within the community and are unable to speak to LGBTQ patients using sensitive, appropriate terminology. This, coupled with a generalized fear of “discrimination, maltreatment, and physical abuse” on the part of transgender patients has created a system in which transgender individuals are less likely to receive the care they need and deserve.
Three primary solutions for these barriers were identified: provider education, student education, and policy reform and community advocacy. Educating students is the first step towards creating educated providers; for providers currently practicing, specific knowledge and education on transgender issues should be provided. Through policy reform and community advocacy, transphobia and socioeconomic barriers can be addressed.
“We must pair discussions with the community, medical professionals and educators, and legislators, and offer tangible solutions for the transgender population in order to move towards an all-inclusive health care system and a more equitable society,” the presenters concluded.
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Lui B, Castorena G, Desinor J, Mueske N. Barriers to accessing primary care services in the transgender population: a systematic review. Presented at: American Academy of PA Conference; May 22-26, 2021. Poster 33.