UC Med Students Learn to Care for Transgender Patients

Gender dysphoria, gender-affirming hormone therapy and puberty blockers are topics medical students at the University of Cincinnati are gaining expertise in to better assist the transgender patients they expect to encounter as future physicians.

Aaron Marshall, PhD, along with Sarah Pickle, MD, and Shauna Lawlis, MD, have developed and implemented a curriculum for students which will include didactic sessions on transgender medicine and management of transition, a mock patient encounter with a gender dysphoric patient, a description of medical and surgical interventions for transgender patients, and discussion of potential complications of gender-affirming hormone therapy.

The curriculum also includes discussions of health disparities faced by transgender patients along with defining property terminology related to sex, gender identity and gender expression and sexuality. Marshall, Pickle and Lawlis have submitted a publication describing the curriculum with the Association of American Medical Colleges (AAMC). About 70 percent of medical schools in the United States and Canada have reported having zero coverage of gender transitioning.

"Serving our community by educating our students with best practices in transgender medicine is really our focus,” explains Pickle, an assistant professor in the Department of Family and Community Medicine and course director for the longitudinal primary care clerkship. "The paper is basically a how-to guide for schools that are interested in expanding their transgender medicine curricula.”

About 700,000 adults in the United States identify as transgender. 

Pickle says gender dysphoria is the diagnosis that many patients experience and it is defined when the sex they were assigned at birth does not match up with how they identify their own gender.

"Someone born male may identify as female or someone on the feminine spectrum, and they may experience a lot sadness, anxiety and a disconnect between the sex they were assigned at birth and to who they know they are. Those patients may experience gender dysphoria,” says Pickle.

"Many patients have been experiencing this disconnect for a long time. The medical term, gender dysphoria, helps clinicians guide gender-affirming medications, provide guidance for the need for future surgeries and allows insurance companies to be part of this effort,” says Pickle.

"Our medical students will be interacting with transgender, gender queer and gender non-conforming patients and so we wanted to be able to equip them with not only the background of the endocrine system and the physiology of medications we use for gender affirmation, but what are the best practices to use in patient settings,” says Pickle. 

"We know half of transgender patients don’t get medical care because they are worried about how their providers will react, and we know 20 percent of transgender patients won’t get care because they will be rejected by their medical providers,” says Pickle. "We don’t want this generation of medical students to be those providers.”

Gaining Understanding into Transgender Medicine

The new curriculum was first used to train students in the class of 2019 at UC and about 73 percent of students reported feeling more prepared to assist transgender patients, says Marshall, an assistant professor in the Department of Medical Education. Twenty-six percent of students using the curriculum reported feeling at least equally prepared to aid transgender patients.

Marshall says there has long been an LGBT panel discussion integrated into medical school curriculum that allowed individuals from each population group to come and speak to medical student about their experiences. Those panels tended to focus on health care disparities, taking a proper sexual history and addressing individuals appropriately without offense, but Marshall says he knew there was more to transgender medicine which required understanding the endocrine system and impact of gender-affirming medications.

As part of hormone replacement therapy, sex hormones—androgens for transgender men and estrogens for transgender women—are given for the purpose of synchronizing a person’s secondary sexual characteristics with their gender identity. But for transgender youth, physicians may administer puberty blockers, medications that allow them to grow but prevents them from developing secondary sex characteristics, says Lawlis, a third-year fellow in adolescent medicine at Cincinnati Children’s Hospital Medical Center.

Lawlis is also part of video developed as part of the curriculum that allows students to see a mock encounter between a physician and a transgender patient. 

From a Patient Perspective

Roberta Grosser, a transgender activist and employee at Cincinnati Children’s Hospital Medical Center, has assisted in training medical students in transgender medicine by sharing her story at UC. Grosser, a veteran of the U.S. Army, says efforts by the College of Medicine are to be applauded.

She says transgender patients still encounter medical staff who often know little about how to care for them and sometimes offer ridicule instead of support, explains Grosser, who worries transgender youth suffer the most trying to find medical care in a climate that can be hostile.

"You can usually tell that the patient is a transgender person, but make them feel at home and make them feel welcomed,” says Grosser. "If you have a receptionist, make sure they also treat them respect. When I first came out in 2003 and I had to go to a doctor’s office I heard all these scary stories about they will talk about you under your breathe or they will snicker.”

That initial visit turned out not to be as scary as Grosser feared, but there have been other encounters with physicians, psychiatrists and medical benefits staff that haven’t gone nearly as well. Her first trip to the Cincinnati VA back in 2003 left Grosser feeling belittled and rejected and she didn’t get the help she needed.

"I ended up going to the VA in Dayton and they had a clinic that knew how to work with transgender people and that’s when it all began,” says Grosser, noting she met with an endocrinologist. "I wanted to start transitioning from male to female. They said one of the things you have to do is see a psychologist and so many psychiatrists. 

"There was a list of psychologists and psychiatrists. For transgender people there was no insurance to assist. Everything came out of pocket,” says Grosser. "The reason for the psychiatrists and psychologists is because for you to get your surgery they want to make sure this is what you really want. Once they do the surgery from male-to-female there is no going back.”

Grosser made her transition from male-to-female in 2004 after finding a surgeon in Pennsylvania skilled in transgender medicine. Initially, she looked at doctors in Colorado and Canada, before finding a physician who was closer to Cincinnati. She paid for her surgery and cost of travel by taking out a loan on her home.

She began hormone therapy afterward. Some transgender women needed to have surgery on the Adam’s apple to adjust their voices so the voice would be more feminine or undergo cosmetic breast surgery. "I didn’t have to do any of that since the hormones seemed to be doing what I needed,” says Grosser.

But with hormone therapy Grosser learned there are long-term risks. "You are only supposed to stay on the hormones for five or six years,” says Grosser. "It can cause cancer if you are on them too long.”

Despite the worries, Grosser remains on hormone therapy because it allows her to retain the feminine characteristics she has long wanted. She also is using the Cincinnati VA for care which is much more supportive of transgender people more than a decade after her first encounter.

Grosser says her transition still means she encounters some struggles such as her wish for a passport which properly identifies her. Some individuals refuse to accept Grosser, but she seems quite able to take care of herself.

"When I went to get my [military] identification card changed I had issues at Wright Patterson Air Force base in Dayton,” says Grosser. "I had to pull rank with the young private first class (Pfc.) at the counter.”

Grosser says the officer did not want to understand or help her change her ID from male to female. "You don’t have to like the person but you have to respect the rank,” says Grosser.  "I said, Pfc. I am a sergeant first class you will stand at ease. I said you will be respectful to me. ‘Stand up.’ Then his supervisor came up to the counter and everything changed.

"Sometimes you have to stick up for yourself,” says Grosser.

She says she hopes medical students leave their sessions on transgender medicine with a few thoughts. "Please learn and have knowledge and great bedside manner,” says Grosser. "Know how to work with the people you are going to be treating. Have a heart. Don’t think that they know what they are doing because a lot of young people don’t.”