1. Unique needs of transgender individuals. Most groups have specialized and unique needs, and transgender people are no different.
2. Cultural considerations, which again are distinct and unique to the population.
3. Appropriate language to use within the clinic to increase the comfort of the patient and as an educational tool for HCPs and other staff.
4. Special considerations for the transgender population.

Regarding marginalized identity, this is a population that has suffered pronounced marginalization within our society, including bias, hate, microaggressions, and misinformation. For example, some states have passed or are considering legislation that would make it illegal to treat transgender people younger than 18 years of age—despite treatment being under the auspices of best medical practices or guideline recommendations.^1,2 These legislative attempts further the spread of misinformation and hateful language through the healthcare system and society. In turn, this affects the mental health of transgender people and how they navigate the world. It is really important for HCPs to consider this marginalized experience when formulating plans for how to best care for transgender patients.

It is critical to note that this marginalization has led to frequent and well-documented denial-of-care episodes. Transgender people have very frequently reported being denied care by HCPs, with the denial being quite explicit in such statements as: “I don’t know how to care for people like you,” “we don’t care for your kind here,” and “I’m sorry; we just can’t care for you.” Now that denial of care is codified into law, HCPs may now say, “We can’t care for you; it’s illegal.” HCPs should consider what these episodes may do to a transgender patient’s mental health along with their impact on how these patients feel about HCPs in general. Would a transgender patient perceive an HCP as an ally or an enemy?

Turning to disease burden, I want to emphasize that the transgender experience is not a disease, but rather a normal variant of the human experience. However, there is a distinct and well-documented burden of disease that comes with being in a marginalized population. In the transgender population, this includes:

• Frequent office visits and the need to take time off work for those visits.
• The need to take numerous medications, often from an early age, and sometimes even travel to other states to access medications.
• Even at a young age, transgender individuals may undergo multiple surgeries that are often invasive and require prolonged recovery times, causing disruption in their lives.
• Comorbidities that go along with the transgender experience, such as a higher risk for HIV infection in some individuals.^3,4 

Finally, economic hardships can shape the transgender experience. Unfortunately, there are high rates of unemployment and underemployment in the transgender population, along with high rates of homelessness, largely due to stigmatization.⁵ Furthermore, the cost of medical care contributes to the economic hardship experienced by transgender individuals. Many states are starting to mandate insurance coverage for gender-affirming hormone therapy and surgery, but other states are moving in the opposite direction—forcing people to pay out-of-pocket for complex, expensive medical procedures and ongoing medications.⁶ These needed therapies can cost hundreds of thousands of dollars.

There is also an administrative burden associated with changing documentation (eg, birth certificates) to accurately reflect gender identity. Sometimes the federal and state rules conflict over whether documents can be changed, meaning that the individual will have federal documentation that says one thing and state documentation that says another. Because many states do not allow the assigned sex at birth to be changed on a birth certificate, this can disrupt even normal bureaucratic procedures such as obtaining or renewing a driver’s license.

As I mentioned, these 3 factors—marginalized identity, disease burden, and economic hardship—can also intersect.⁵ For example, transgender people may delay seeking care due to previous negative experiences in our healthcare system and subsequently be diagnosed with more advanced disease because of the delay. In addition, economic hardship can contribute to the disease burden experienced by this population; as mentioned above, some transgender individuals are at higher risk of HIV infection, which can be due to turning to survival sex work when they are unable to secure employment.

Transgender patients must deal with all these challenges, and that heavy burden is on their shoulders when they come into the clinic and will affect how they interact with HCPs. Thus, it is important for HCPs to consider the weight of these challenges when providing care to these patients. We all exist in the same society and ecosystem, and many of the systems and language that HCPs use daily—such as, “What is the sex of the patient?”—create an unnecessary barrier to the care of the patient or even harm the patient.

This is a photograph that I took outside of a subway station in Manhattan. One day, out of the blue, this graffiti appeared that said, “Trans power,” and I thought, “Wow, we’ve really come a long way.” It was not Transgender Day of Remembrance or LGBTQ+ Pride Month. Somebody had just decided to paint “Trans power” and I thought that was great. Then, within a week, I was walking past again and saw that someone else had scribbled homophobic slurs over “Trans power.”

Unfortunately, even in this day and age, homophobia exists in an overt, virulent form that we all know about but also in a more passive form. I imagine that the person who wrote those homophobic slurs may be younger and may not fully understand the consequences of what they wrote. They may even consider it “just a joke,” but this has the same harmful effects. I noticed it and, given that this is in New York City where hundreds of thousands of people walk down this street every year, at least some percentage will be transgender and will have read this.

How will those homophobic slurs make them feel about themselves? About their place in the world? About their place in a city where they thought they were safer? How many of those people are on their way to their doctor, and what feelings do they bring to their doctor’s office as a result of seeing this? What happens when they encounter a roadblock in the office? Suppose the front desk misgenders them or rejects their insurance card because it does not agree with the name they use on another form of documentation?

We have data from several large surveys of transgender people. Here, I will highlight findings from Injustice at Every Turn, a pivotal report published in 2011 by the National Center for Transgender Equality and the National LGBTQ Task Force.³ This study included the responses of 6450 transgender and gender-nonconforming participants.

The numbers were startling: 28% reported verbal harassment in medical settings and 19% have experienced outright refusal of care. This is at the hands of HCPs, not someone on the street or behind the counter at a store.

Among participants, 41% have attempted suicide. HCPs should think about that statistic when in the exam room with transgender patients. The rate for suicide attempts in the general population was only 1.6% at the time of the report—dramatically lower than 41% for transgender respondents. This is approaching one half of all transgender individuals who have been pushed to such a limit that they have attempted suicide, not just thoughtabout suicide.

Why do transgender people attempt suicide? Survey participants reported that 26% had lost a job because of their gender identity and 50% had been harassed at work. One out of 10 have been sexually assaulted and 26% have been physically assaulted.

I want HCPs to think about how this would affect your life and imagine what transgender people’s lives must be like as they simply navigate going to work and the grocery store. Transgender people have shared with me that when they go to buy food at the grocery store, people tear off their dresses or reach underneath to feel them. Experiences like this happen every single day to transgender individuals. Then, when a transgender person who experiences this daily comes to clinic, HCPs wonder why they are in tears and cannot even give a complete history.

These statistics go on and on: 19% have experienced homelessness at some point in their life and 26% have experienced physical assault or violence. Violence often happens on the street. I have heard many stories over the years in which a transgender individual is simply walking down the street when a passing person just hits them just for no reason. Does the victim report the assault to the police? No, because transgender individuals do not feel safe with the police, and they have just cause to not feel safe. Among survey participants, 29% reported experiencing police harassment or disrespect and 46% reported feeling uncomfortable seeking assistance from police.

Of course, the numbers are worse for people who have intersectional identities. Transgender women of color experience higher rates of all these terrible statistics. Furthermore, as mentioned, transgender women of color have a very high rate of HIV infection. The 2019-2020 National HIV Behavioral Surveillance Report found that, among 1608 transgender women across 7 US cities, the HIV prevalence rates were 62% among Black vs 17% among White women.⁷ New York City had among the highest rates at 52%. I want readers to sit with and think about these numbers for a moment.

I also want to contrast these numbers with the experience of our colleagues in the Netherlands, who did a lot of early and rigorous research on transgender care and have been providing transgender care for a long time.⁸ In the much more inclusive culture of the Netherlands,⁹ the suicide risk in transgender individuals is lower than in the United States based on available evidence.^3,10,11In other words, the suicide statistics in the United States do not correlate with the experience of being transgender, rather they correlate with the experience of being transgender in the United States—specifically, in an environment that does not support, understand, or accept transgender individuals.

Everybody has biases—preconceived views that favor toward or against individuals, groups, or ideas.¹² Some biases are explicit, where individuals are aware of their attitudes and prejudices toward certain groups. We live in a society that regularly manifests racism, bigotry, and homophobia in so many different ways and perpetuates these biases through the news and other media.

But not all biases are conscious or explicit.¹³ Some we soak up, like a sponge in dirty water, even if we do not want to be biased. These are implicit biases, which are an unconscious imprint of certain conceptions about a group of people that are not related to any actual character or physical traits. These biases can be either positive or negative. We do not have any active role in forming implicit biases, and we cannot help that they are there. However, we must know about implicit biases to neutralize them.

One way to recognize implicit biases is to take a quiz such as the Implicit Association Test (IAT), which tests implicit biases based on different categories (eg, religion, gender, disability, skin tone, race, transgender vs cisgender).¹⁴ I had an interesting experience with implicit bias testing. I identify as a lesbian and am of European heritage. I assumed that I would have a positive bias toward LGBTQ+ people and some implicit biases against other groups. However, when I took the IAT, I was surprised to find that although I did not have as many biases as I expected against some of the other groups, I had some negative biases against my own group.

This personal example illustrates my point that because we never know what the test might uncover, it is worth taking the test. The results do not condemn you for having implicit biases. It instead gives you the knowledge you need to consciously work around biases you didn’t even know you had. If you do not know they are there, those implicit biases will act out.

As an HCP, if you feel unprepared to care for anybody for any reason—be it that you live in a state that legally forbids care or for some other personal reason—you still have an ethical responsibility to refer the patient to an appropriate alternate resource. It is unethical, in my opinion, to leave a patient coming to you for help out in the cold. If you feel truly that you cannot give them that help, offer them a reasonable alternative. If that means sending them out of state, that is what you will have to do.

Recall that, statistically speaking, transgender people have had many negative experiences with HCPs. Although they may not be as scared of you as they are of the police, they will likely still be scared. To begin building a therapeutic relationship with a transgender patient, it helps to understand the distinct cultural characteristics of the transgender, nonbinary, and LGBTQ+ communities.

People outside of those communities are generally most familiar with caricatures and the campier side of LGBTQ+ culture. To the right is a picture depicting the character Dr. Frank N. Furter from a theatrical production of The Rocky Horror Show. This character may be seen as a funny cliché, but some transgender people would probably find it to be an offensive image; others might not. There is a long and textured history of negative or diminutive stereotypes like Dr. Frank N. Furter—the happy, funny, campy gay person or the over-the-top transgender person. These types of characters are beloved by many but may be quite harmful and triggering to others and are not useful when you are an HCP sitting in front of a transwoman who is an accomplished attorney and may not like these symbols from popular culture. Do be aware of that cultural background. Fortunately, authentic transgender representation in television and film is becoming more common, with transgender or nonbinary actors increasingly playing transgender or nonbinary roles, and even cisgender roles, in recent years.

To connect with transgender and LGBTQ+ patients, it would also be helpful for HCPs to be aware of some deep history and distinct cultural touchstones that are honored, respected, and celebrated by many in the transgender and LGBTQ+ communities. A key event is the Stonewall riots or uprising in June 1969—a pivotal moment in the gay rights movement and the reason that LGBTQ+ Pride Month is held in June.¹⁵ It is interesting that we refer to “gay” rights because the riots were actually started by 2 transgender women, whom we will discuss below.

The AIDS epidemic is a second example of an important historic topic in these communities and is highlighted here in the left picture, which shows the AIDS memorial quilt remembering all those who died of AIDS. Similar to the Stonewall riots, Americans generally consider AIDS to be something that affects gay men, but in the 1970s and 1980s, the people whom we would now call transgender women were often categorized as gay men. The AIDS epidemic is in the living memory of a whole population—people who woke up every day wondering which of their friends would die that day or if they themselves would die that day. I want to mention that many of the people who took care of those hospitalized with AIDS were called lesbians at the time, but we would now consider them to be transmasculine. I cannot emphasize enough how pervasive and how much of an impact the AIDS epidemic had, and continues to have, on the transgender and LBGTQ+ communities.

Another important historic topic is that of marriage and bathroom equality. In 2015, the US Supreme Court found that states can neither deny marriage licenses nor refuse to recognize lawful marriages performed in other states for same-sex couples.¹⁶ Marriage equality is wonderful, but the 2022 overturning of Roe v. Wade has worried many that marriage equality will also be affected.¹⁷ There is also a recent history and ongoing developments around “bathroom bills” aimed at preventing transgender people from using bathrooms that do not match sex assigned at birth.¹

Turning now to the middle picture, this mural depicts just a few of the role models in the LGBTQ+ community. These are not role models from movies, but the role models who people look up to as being influential in the LGBTQ+ rights movement. The leftmost and rightmost figures in this mural are the 2 transwomen I mentioned earlier who instigated the important Stonewall riots: Marsha P. Johnson and Sylvia Rivera. As hard as life can be now for transgender people, we should reflect on what their lives were like leading up to the Stonewall riots in 1969. These 2 transgender individuals laid the groundwork for everybody else, and the debt that is owed to them is high. Another role model not shown here is Janet Mock, a gifted writer, director, and executive producer who is a transgender woman. She was one of the head writers for the television show “Pose” and the first transgender person to sign a production deal with a major studio.¹⁸ Her legacy has paved the way for other transgender artists in the television and film industries.

As we discussed, it is very important to consider how minority stress might factor into your interactions with these patients.¹⁹ Understanding what your patient might have brought to the table can enable you to clinically support your patient as they navigate those stresses and also put the patient’s mind at ease about your intentions.

I consider it critical to transmit an atmosphere of acceptance at all times. It helps put people at ease when staff have something as simple as pronoun badges. These transmit the message that everyone in patient care considers pronouns to be important. A poster at the front desk of the rainbow flag that invites people to share their pronouns can show that LGBTQ+ inclusivity is supported in the practice. These small things go a long way toward making people feel comfortable.

On this slide is an introduction to key LGBTQ+ terminology, including “The Gender Unicorn” infographic, a well-known simple explanation of this. I will also add the caveat that language continually evolves, so there may be nuances not captured here or that may emerge over time, or you may even learn something new from your transgender patients. But as an overview²⁰:

• Sex assigned at birth is what was provided to an individual based only on an HCP’s split-second assessment of the newborn’s external genitalia. Most of the time the individual’s gender identity matches the sex assigned at birth. The older term natal sex is no longer preferred, perhaps because it implies a definitiveness to sex.

• Gender is what an individual feels inside and it is very hard to describe, much like how it is very hard to describe or define “love.” Gender is not a construct—it is a real thing, but it can be very fuzzy on the edges. Gender is not observable and is instead defined completely by the person themselves. It is there, imprinted, irrefutable, and based on what the person says—no one else can define it or change it. Gender is also separate from sex. We think that gender develops much later than sex assigned at birth and tends to finish forming by approximately 3 years of age.²¹ It is an internalized sense of oneself as either male or female, sometimes neither of those things, sometimes a sense of both of those things, sometimes some other thing entirely. Some people have even, more recently, had a sense of themselves being transgender, which is a new phenomenon.
• Sexual orientation is whom a person is attracted to. We use terms like “gay,” “straight,” “lesbian,” “bisexual,” “pansexual,” and “asexual.” Many in the LGBTQ+ community, including myself, do not love any of those terms because they make certain assumptions about someone’s sex or gender. When interacting with patients, it is best to steer clear of sexual orientation labels unless the patient uses the labels. If they define themselves as gay or straight or a lesbian, by all means, use that term. However, when collecting a general history, I would stay away from specific labels and instead would use phrases like, “has sex with people with penises” or “has sex with people with vaginas” or both.
• Pronouns are the alternate ways we describe each other when we do not want to use each other’s names. Pronouns can be things like she/her, they/them, he/him, or ze/zim—ze/zim is a newer pronoun that is nongendered. People can choose whichever pronouns they want and care about them however much they want. The important takeaway is that HCPs should ask and not assume, even if they think a person’s pronoun is obvious. Furthermore, once known, the patient’s pronouns should be used consistently in the electronic medical record and across all documentation. Finally, to make a transgender or nonbinary patient comfortable with sharing their pronouns, you can share your own pronouns, display pronouns on name badges, and place signage in your clinic stating the importance of honoring pronouns.

Again, mistakes happen, and most people will understand if it happens once. If it is happening a lot or all the time, then the HCP may need to re-evaluate their own views and biases and make adjustments.

Physical exams of the genitals or sex organs can be quite triggering for a transgender individual. In these instances, I explain what the exam entails beforehand. I usually try to offer to do the exams of the genital or sex organs in a separate visit to allow the patient time to prepare mentally. I also ask the patient if they prefer to have a different HCP do the exam. Although I have established a rapport with the patient, they may feel embarrassed to have me do the exam, as if I will see them differently if I know what is under the curtain, and the goal is to have the patient feel as much in control as possible. If these approaches are not suitable to the patient, I try to find an alternative approach. For instance, instead of doing a traditional cell swab with human papillomavirus (HPV) testing, I may be able to offer an HPV self-swab where a patient is given a cytobrush and takes the sample themself.

The exam itself should use a trauma-informed approach. This includes maintaining as much modesty as possible, talking the patient through the exam or procedure, and asking for their permission before touching them. I like to give the patient a play-by-play depending on where I am touching. If I am doing a breast exam, I will say, “I’m going to touch the breasts now.” Note that I use “the breasts” and not “your breasts,” because it can be very triggering for people who are identified as male to even have breasts. It can be helpful to separate the person from the organ itself.

To screen for depression, I recommend something as simple as the Patient Health Questionnaire-2 tool.²⁴ This can be done at the same time as vital signs. If any positives come up, the staff doing the vitals can pass that along to the HCP to explore further with the patient. The risks of suicide and depression are just too high not to do this. I have personally had more than 1 transgender patient attempt suicide and it is not something any HCP wants for any of their patients.

HCPs also should be prepared to offer referrals to transgender-competent social work or mental health providers, if available. However, it can be very hard to find referral sources sometimes. If local resources are not available, HCPs should be prepared to offer national resources. For example, HCPs can offer the phone number to Trans Lifeline (1-877-565-8860), a US suicide prevention hotline for transgender people, and have that phone number printed on cards for patients.

Training to increase awareness is a great opportunity to establish a practice environment that bolsters your ability to provide optimal care for transgender patients. Furthermore, in my experience, most people want this information because they do not want to upset patients or feel unprepared.

None of us practices alone, and what happens at the front desk affects what happens in the exam room. For example, if a patient has an undue amount of difficulty registering at the front desk because their insurance card gender or sex marker does not match the marker on their state or federal identification, that will affect how the patient feels when they finally see the HCP. This is one example of why diversity, equity, and inclusion (DEI) training should be an important part of all onboarding and annual compliance training at healthcare institutions.

Basic transgender and nonbinary competency training should be added within each practice, for example, by reviewing what is already being done by human resources and supplementing from there. Supplemental training can foster a basic contemplative understanding of and appreciation for the use of pronouns and variations in gender identity among staff, along with cultural considerations. For example, it would be important for security personnel to understand the historic mistrust of police by transgender people. It makes a big difference when people improve their understanding of these issues.

HCPs could also consider leveraging Continuing Medical Education (CME) for themselves and staff. Providers, particularly in small practices, are leaders whose actions are models for everybody else. Because CME is already required for licensed HCPs, this approach is a win–win where staff will get their required credits along with their DEI training on transgender and nonbinary competencies.

For instance, in addition to fostering a therapeutic relationship with the patient, honoring a patient’s preferred pronouns and their preferred name when doing documentation, if the patient consents, will encourage their use down the line by the next HCP who interacts with that patient. The next HCP will not have to ask the patient or do a lot of work to use the patient’s preferred pronouns and name because it’s already in their medical record. Including preferred pronouns in medical records also has the advantage of helping other HCPs avoid making mistakes, particularly if someone’s physical or outward appearance does not match stereotypical gender presentation. The more consistent HCPs are with using a patient’s preferred pronouns and name, the less likely there is to be a mistake.

Another means of informal education is through the observance of some of the major events that I mentioned earlier, such as the Transgender Day of Remembrance celebrated on November 20 or LGBTQ+ Pride Month in June. It takes only a few minutes at a morning meeting to acknowledge these days. The more integrated these events are into your everyday routines, the more normal they can be for everybody in the practice.