BMJ article on gender dysphoria issues


A few weeks ago, the British Medical Journal carried two educational articles about management of gender dysphoria in the non-specialist setting (one written by a gender dysphoria specialist with input from patients, and one a collection of advice from transgender people). Transgender people can have some significant problems with healthcare both for their gender dysphoria care and for their general care, so, although this only affects a small minority of the population, this is an issue it’s important for me as a GP to be aware of.

I have a separate site where I keep the notes I make on any medical articles or educational modules I read, in order to refer back to them later. This time, however, I thought I might post them here; after all, transgender health care is an important topic to many people here. Here are the points covered by the articles:

  • When someone comes to you expressing problems with gender identity (‘you’, here, meaning GPs, not the general population), offer them referral to gender identity services ASAP. Waiting lists are horrendous, so, if a patient does want to explore the possibility of transitioning, the sooner they get on the waiting list to do so the better. As a GP, I’m very schooled in the approach of “let’s wait a bit and see how this goes with time”, and for a large proportion of the patients I see that is perfectly appropriate, but gender dysphoria is one of the situations where it isn’t. The gender identity services themselves will be the ones who can offer expert assessment and help patients reach an informed decision regarding transitioning. (As one of the patients in the second article pointed out, gender identity treatment has one of the highest satisfaction rates of any branch of medicine. Puts the desistance myth into perspective, doesn’t it?)
  • Take the trouble to find out what name and pronouns your patient wants to use, and use them. That, frankly, is just basic courtesy. However, be aware that, for safety reasons, a patient may need letters to be addressed to their old name for the time being (if they’re living with family members who are against the transition and unsupportive or even threatening over it). Use their new name and pronouns when discussing them with other healthcare personnel; it’s a way of respecting their gender even when they’re not there.
  • Transgender people who haven’t yet accessed proper treatment may be self-medicating with hormones purchased online. Ask about this and advise that it does carry risks and that ideally it should be stopped until the person is seen by the gender identity clinic. Of course, given the waiting lists, there’s a gulf here between ‘ideally’ and ‘bearably’. If a person can’t face stopping medication for the time it’ll take to get seen, advise them to let us know of side effects and to let healthcare practitioners they see know about the medication.*
  • Suggest informal on-line support groups while a patient is waiting to be seen. Tranzwiki.net was the example given.
  • Some surgical treatment can take place locally, such as hysterectomy/oophorectomy; however, do bear in mind that a person who has become visibly male may feel very awkward about attending a gynaecological clinic. One possibility suggested was that a patient in this situation could get a woman to accompany him to the clinic, if possible, so that he wouldn’t stand out as a solitary male in a sea of female patients.
  • Screening can raise unexpected problems. For one thing, gender-based automated systems in the NHS are not set up to deal with patients who’ve changed gender, and so they may not be called automatically for screening they should actually have (aortic aneurysm screening for MTF, cervical screening for FTM who still have a cervix in situ). Remember that the form that goes with the sample will need to clarify what’s going on so that the lab doesn’t simply assume that the cervical smear sample labelled as coming from Mr Fred Jones, M, to be a mistake. For another thing, the screening tools for things like risk of cardiovascular events or fractures include gender as one of the factors used to calculate risk, and the data on transgender people in this context simply doesn’t exist. It’s necessary to do some common-sense estimating and explain the uncertainties to the person in question.
  • On the topic of screening, the article also stated that AMAB women do not need routine mammography as, in the absence of progesterone, their risk of breast cancer is too low for it to be needed.
  • Conversely, an AFAB male who still has breasts should be advised to have mammography if in that age group, but may find it distressing to discuss the matter. The article ‘I am your transgender patient’ suggested that talking about ‘chest’ rather than ‘breasts’ might be easier for some men in this situation.
  • There isn’t any single rule or guideline for how transgender people feel about their gender, their identity, or their gender-specific body parts. They might be very distressed by some, quite comfortable with others. It’ll vary from person to person. This is one of the (many) situations in medical practice where you have to be sensitive to the person’s cues and willing to find out their wishes and to follow their lead.

 

*This, of course, raises the question of whether GPs in that situation should prescribe hormones themselves rather than leave the patient with the risks of buying hormones on-line. This wasn’t covered by the article. WPATH guidelines do touch on the possibility of ‘bridging’ prescriptions, but it’s a complicated issue that carries the risk of major medicolegal problems for the GP if they prescribe outside their area of expertise, and there are very good reasons why GPs would typically be unwilling to do this. This is beyond the scope of this particular article, which is why I haven’t gone into it further here.

Comments

  1. Siobhan says

    On the topic of screening, note that AMAB women do not need routine mammography; in the absence of progesterone, their risk of breast cancer is too low for it to be needed.

    Would that mean if progesterone is prescribed, that the need for routine screening returns?

    • Dr Sarah says

      That does seem to be the implication, but wasn’t specifically stated.

      I think I’ll actually edit the wording of this post to ‘the article says…’ as I am not personally qualified to be handing out advice on when transgender people should or shouldn’t be having mammography screening, and the current wording, now that I reread it, does sound like I’m giving advice.

  2. Crip Dyke, Right Reverend Feminist FuckToy of Death & Her Handmaiden says

    @Shiv:

    I’m interested in that answer as well – particularly since lifetime exposure seems to be important, but there are no studies I can find about how delayed puberty affects or doesn’t affect age at which mammogram first becomes medically useful.

    Further complicating this issue is the fact that there is significant disagreement (or at least there was a few years ago) about when women should begin regular mammography, given that the radiation exposure from mammography itself increases risk of cancer – and since mammography radiation is concentrated on the breast, specifically of breast cancer. Thus the benefits of early detection could (theoretically) be negated by a higher incidence of cancer overall. There’s been significant discussion about how other risk factors play into when women should begin receiving regular mammography and, IIUC, large agreement that the general population with no or minimal specific risk factors should start later than those with significant risk factors … but how much later was hotly debated last I checked.

    So how much delay, and delay from what baseline are both very important questions. I don’t want trans* women to lose out on the opportunity for early detection of cancers, but I also don’t want to increase cancer incidence among trans* women through unnecessary mammography.

    Any clarifications from Dr Sarah or other medical experts would be greatly appreciated.

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