By Ana Nazmi Glosson, Neurobiology, Physiology & Behavior ‘21
Author’s Note: I initially wrote this literature review for UWP 104F in Winter 2020. I chose to focus on a topic that was, and is, very dear to me. I believe that readers would benefit from an overview of transgender specific health, as it is a subsection of science that is often unknown or overlooked. I wrote this while personally researching TGD healthcare and the availability of transitional therapies, and realizing firsthand the barriers to access, and lack of available information.
Transgender and gender diverse (TGD) individuals are people whose gender identity does not match the biological sex they were assigned at birth. Transgender is an umbrella term for many gender identities, and individuals may identify as male, female, or outside the gender binary. This population faces more barriers to healthcare access than cisgender individuals, or people whose gender identity does match their sex assigned at birth. Lack of access to knowledgeable healthcare providers, as well as provider bias, creates an environment of hostility for a TGD patient. Transgender people have unique health needs that healthcare professionals must be educated on in order to properly serve this community. Emerging literature is beginning to identify health concerns among transgender people who have undergone hormone replacement therapy (HRT) that may require specialized treatment and attention. This review attempts to answer the following question: What does current research tell us about barriers and educational gaps in healthcare of transgender individuals, and what physiological differences in this population, compared to cisgender individuals, make this research important? Further studies are essential to properly providing healthcare to this population.
Key Concepts: Transgender and gender diverse, hormone replacement therapy, culturally competent healthcare.
Historically, TGD individuals have faced many barriers to healthcare access—and many of these barriers still exist [1-9]. This paper aims to review the specifics of these barriers and educational gaps. Current research suggests that a lack of education from physicians and provider biases against transgender people are primary reasons why transgender individuals—especially TGD youth— struggle to access safe and culturally component heathcare [3,5-7]. Transgender people are less likely to seek healthcare, and if they do seek it, they are less likely to receive proper, unbiased access with educated professionals [1,3]. This review also presents literature on unique physiological differences between transgender and cisgender individuals in order to properly express why clinical research is needed to increase baseline education [10-16]. The critical health differences between the TGD population and other groups means a team of doctors and specialists—primary care physician, gender specialist, surgeon, and endocrinologist—must collaborate to provide culturally competent care. TGD individuals may choose to medically transition and undergo gender-affirming therapies such as gender-affirming surgery (GAS) or hormone replacement therapy (HRT). Given the nature of this topic, it is important to note that much of the research in this review is from ground-breaking preliminary studies that have not yet been repeated with larger sample sizes beyond initial investigation.
Healthcare Access Among TGD Individuals
TGD individuals of all ages face challenges to healthcare on both a personal and institutional level. Increasing numbers of TGD people, including older adults, are openly living with their gender identity, meaning this is a critical area of research. TGD adults frequently struggle with insurance access; they are less likely to have insurance access compared to non-TGD LGBTQ+ individuals, and those that do have access are more likely to face healthcare discrimination [7,8]. One study found that individuals with Medicaid were more likely to be refused hormone replacement therapy, and more likely to lack a surgeon to perform gender-affirming surgery in their network, as compared to individuals with private insurance . TGD adults who are part of other disadvantaged communities, such as being an ethnic minority or having lower socioeconomic status, face additional obstacles and higher levels of healthcare refusal [1,8]. Older LGBT adults are far more likely to have physical and mental health struggles than their non-LGBT counterparts, but older TDG adults are the most likely to have those struggles within the LGBT community [9,17]. Older TGD adults are more likely to live alone and have a community of “chosen family” instead of partners or children, which adds a layer of complexity to difficult end-of-life care decisions and increases senior care costs [9,17]. These circumstances show the need for thoughtful and individualized care for TDG individuals of all ages, necessitating competent and knowledgeable providers to navigate these sensitive topics.
Adolescence is a very stressful time in people’s lives, and recent literature shows that young TGD individuals are especially vulnerable [3,5,11]. Surveying the adolescent population directly allows researchers to analyze experiences and suggestions from youth to further improve healthcare. Currently, there is not much information on transgender youth, though the field of research has begun to grow rapidly in the past few years. In everyday life, TGD individuals are often misgendered or referred to as names that they do not identify with anymore. In the context of medical care, this leads to individuals being less likely to seek continuing care. Even without malicious intent, these actions may be incredibly damaging to the TGD individual. In a medical setting, misgendering patients may foster unspoken feelings of distrust and alienation between the patient and their doctors. This is critical because transgender individuals are less likely to continue seeking routine and specialized healthcare if they feel uncomfortable in the medical environment [2,3]. In order for healthcare professionals to serve this population, practices must be as friendly as possible. Requesting and consistently using the individual’s pronouns and preferred name is a critical first step [2-3,5]. Surveyed youth suggested that healthcare providers should ask all individuals these questions, instead of only those known or assumed to be LGBTQ+ . This will lead to the subpopulation not being immediately singled out in a healthcare environment, as well as creating a welcoming space for patients who may not otherwise volunteer this information. Another suggestion was healthcare providers using gender-neutral decor in exam rooms . In settings such as a gynecologist office, traditionally feminime or masculine imagery and furnishings can further alienate TGD individuals and reduce the likelihood of patient continuation. The language used in medical forms should be adjusted to encompass diverse gender expressions. Given the fact that many TGD individuals identify outside of the gender binary, medical records should allow patients to write in their identity rather than check one of two boxes . The gender binary is essentially the rigid classification system of two genders, male or female, a system which is commonly rejected by members of the LGBTQ+ community and their allies. Since gender identity and the language that individuals use to express their personal sense of self is incredibly varied, giving patients more freedom to define and communicate their gender identity would allow them a greater sense of expression. This may also require reform of electronic healthcare systems to include this information, which is currently not common practice. In one study, the vast majority (79%) of TGD youth indicate they would appreciate the professional record of preferred name and pronouns .
A common method of surveying the adolescent population is in-depth interviews of a small sample size. These thorough accounts of real experiences are very useful, as researchers can gain a more holistic insight into the individual’s life and experiences. The downside of this research approach is the small sample size, which may lead to results that are not as applicable to larger audiences as would be the case with a larger sample size. In order to best reach this population, researchers target LGBTQ+ programs, but for many reasons, a large subset of the TGD population cannot safely participate in those programs, and therefore are not included in reviews such as this. Voices of closeted LGBTQ+ community members in general are rarely heard, meaning this subset of the population is almost always left out.
Research also suggests that preferences regarding the inclusion of gender identity information in medical records differ greatly if the patient is closeted or “out” . There are factors that should be taken into account with medical records disclosing transgender identity. For instance, a TGD minor may privately disclose their gender identity or preferred pronouns to their healthcare provider. If this TGD youth was not “out” to their parents, and the healthcare provider made a note, their parents might find this while viewing their medical records. This could potentially be damaging or even dangerous to the patient, so healthcare providers should be careful with handling such delicate information. Additionally, TGD care—especially for patients that are in the process of transitioning—involves many aspects of healthcare; a team of culturally competent therapists, physicians, specialists, nurses, and staff must all be properly informed to contribute to a holistically supportive team.
Sexual Health Needs
Research into sexual health needs of young transgender people demonstrates TGD youth have unique sexual health needs that are not currently being met by their healthcare providers. Healthcare providers tend to be less knowledgeable about TGD-specific health issues, which differ from cisgender individuals [3,13,15]. Distinct aspects of TGD individuals include hormone replacement therapy (HRT), gender-affirming surgery (GAS), reversible puberty blockers, and same-sex STI transmission. Compared to previous generations, youth today are more likely to come out as transgender at a younger age, but many healthcare providers are not properly relaying healthcare information to their patients . When providers fail to relay crucial information to their patients, it poses risk to the patients that could otherwise be avoided. For instance, a doctor who is unknowledgeable on STI transmission among two people that were assigned the same sex at birth, or even a doctor with personal prejudices against TGD patients, might not inform patients of essential sexual health information, thus putting the patients at higher risk. Sexual education information for teenagers is lacking, and this issue is amplified for TGD youth, many of whom receive absolutely no relevant information from professionals and alternatively turn to unvetted online sources. Healthcare providers need to stay up to date on the current literature for LGBTQ+ patients and have an obligation to confirm their patients receive adequate and age-appropriate information on topics of sexual health.
Transgender men or non-binary individuals who have been prescribed testosterone, a gender-affirming hormone replacement therapy, may suddenly experience an ovulatory event after a long period of time . Testosterone can stop ovulation by suppressing the hypothalamic-pituitary-adrenal axis, but this research study is the first to show that after an extended period of time, such as several years, some individuals may “overcome” these suppressed hormones and suddenly ovulate . This is important for healthcare professionals to be aware of because their patients may not be on contraceptives and will likely not expect this after suppressed ovulation. Unplanned pregnancy may result among patients who partake in sexual intercourse with sperm-producing individuals. Healthcare providers have an obligation to inform their patients of medical issues such as this, as pregnancy for a transitioning TGD individual can be an extremely emotionally stressful event, especially in the face of body and gender dysphoria.
An emerging branch of literature involves TGD patients and gynecological care. TGD patients are less likely to seek this type of care, and when they do, healthcare providers may have personal biases against treating transgender patients [4,6-7]. Transgender men or transmasculine individuals were found less likely to seek cervical cancer screenings, the main preventative test against cervical cancer. This is because of a variety of barriers on both a personal level and a wider institutional level. On a personal level, traumatic experiences with past healthcare, misgendering, and overall gender dysphoria contribute to transgender men not seeking cervical cancer screenings . Institutionally, research suggests incompetent provider education is a primary barrier to accessing satisfactory healthcare. This leads to a reduced number of transgender men or transmasculine individuals continuing cervical cancer screening .. Healthcare professionals should focus on ways to retain transgender men as patients throughout their transition and changing gender identity, as well as providing culturally competent healthcare to this population.
In a study on gynecological health of transmasculine people, healthcare professionals were surveyed on their willingness to provide healthcare to TGD individuals. It was found that personal biases and attitudes against TGD individuals were the greatest barriers . This contradicts other studies, which indicate healthcare providers’ lack of knowledge to be the biggest obstacle to accessing safe healthcare. Professional training should account for transphobic beliefs among healthcare professionals .
Much of the research on TGD populations are groundbreaking pilot studies, and conducting more large scale clinical studies and research is highly recommended for improving healthcare for transgender individuals [2,5,17]. Another recommendation is to standardize inclusive and informed education on transgender topics in medical school curricula and continuing education programs [3,5,8]. Informed and supportive healthcare professionals are absolutely vital in addressing health and continued patient retention among TGD individuals. More research must be done to determine the extent of additional training needed to properly serve this population.
HRT and Physiological Differences
Literature has begun to explore and emphasize that physiological differences exist between transgender individuals who are undergoing gender-affirming hormone replacement therapy (HRT) and cisgender individuals [11-17]. Hormone replacement therapy is suggested to be gender-affirming to a patient with gender dysphoria by helping their body match their preferred gender identity, and has been found to be correlated with better body- and self-perception, as well as lower sexual distress . This is incredibly important in increasing the holistic wellness of a transgender patient. Limited available research suggests that transitioned TGD individuals are at greater risk for certain cardiovascular diseases, such as heart attacks, compared to the general population . When researching the impact of HRT on adolescents, one pilot study found key body composition differences in regards to cardiovascular health, suggesting this population has unique cardiometabolic needs that differ from both cisgender males and cisgender females [11,16]. Similarly, in regards to resting state network, individuals on HRT were found to have “intermediate” levels of physiological values unique and distinct from cisgender male or female individuals [11,16]. For the purpose of this paper, we can think of resting state networks as networks and patterns of activity between spatially separated areas in the brain, which are helpful in analysing organization, when the brain is not processing a specific task.. This information is preliminary—and it is important to keep up with developing research—but it suggests the extreme importance of larger repeat studies. Questions for further research include long-term effects of HRT on adolescents. Additionally, research should be conducted on the distinct physiological values of individuals on HRT. In particular, do these values (the intermediate state) change the longer the individual is on HRT? If a patient were to stop HRT, would this “intermediate” state revert to values similar to their gender assigned at birth?
Another question to consider would be whether or not this intermediate state is reversible if the patient were to stop HRT for a period of time. However, such a question would bring up many ethical concerns for the psychological well-being of the study participants, as well as physical concerns of abruptly stopping medical therapy. One longitudinal pilot study found that transgender individuals on HRT had altered resting state functional connectivity in emotional, cognition, and sensorimotor ways after undergoing gender-affirming surgery . These studies suggest that the brains of TGD individuals have the ability to form altered synaptic connections in a way that is different from cisgender people. Much more research is required in order to pinpoint any major connections and the implications of treating this population. These medical differences could be very important in areas such as proper drug dosage. Healthcare professionals must recognize these differences, and continue to push for more research to ensure transgender patients receive the competent care they need. Much of this research contributes to some sense of a gender binary, given that this “intermediate” state is defined as being between “the two” genders; furthermore, a TGD individual may not aspire to follow a binary gender, and providers should be thoughtful and individualized in the language they use with patients. The majority of these studies were composed of very few individuals. These results suggest that healthcare professionals must stay informed with research findings in order to keep their patients updated.
Transgender individuals face discrimination in everyday life, as well as in the medical world. This is a large problem because transgender patients have specific healthcare needs that differ from cisgender patients and must be approached and treated differently. Many of these studies are pilot studies and were only published in the last several years. Several recent studies have attempted to classify barriers transgender individuals face, specific health differences, and what steps healthcare providers need to be taking. As research in transgender healthcare continues, it is important to note that not all transgender people can be grouped under one umbrella. Subpopulations exist within the TGD community, each with their own healthcare concerns, physiological health differences, and types of care they seek and receive. In order to better treat these populations, healthcare professionals cannot treat every transgender person with identical care. This emerging research, especially on topics of physiological differences, should not be used to discourage TGD individuals from their necessary transitional therapies. Rather, a more comprehensive understanding should help healthcare providers give their patients stronger, evidence-backed information about their medical choices. In addition, there are barriers that this discussion barely touched on, such as cost, insurance issues, and overall accessibility. Many more studies are required to identify the best ways to combat transgender barriers to healthcare access in order to address the physiological differences between TGD and cisgender individuals.
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