In an effort to create an all-inclusive environment for your clinic, we’ve covered how to best approach men’s health and women’s health this term. However, there are gender expressions beyond strictly male or female, a population of patients that would fall into the category of Transgender and Gender Nonbinary People. Transgender and gender nonbinary care is something that is foreign to many healthcare practitioners. According to UCSF Transgender Care at the University of California - San Francisco, ‘Transgender people encounter a range of barriers to accessing primary health care. Many postpone seeking medical care due to prior disrespect or discrimination, and a large percentage report having to teach their providers about their own healthcare.’ Although there are no clinical trials and research performed on this population from a TCM standpoint, we can still do our due diligence by being well equipped with the tools and knowledge to meet the healthcare needs of these patients. I recently spoke with Dr. Todd Canon of South Austin Medical Clinic about how he approaches these patients and the best practices to keep in mind.
Q: In what ways do you like to approach your transgender or gender nonbinary patients?
A: For me as a practitioner I personally like to ask about patient pronoun preferences and for there to be a consistent place for that to be documented. Likewise, it’s a good idea to have a consistent place in the chart to document if a patient is transgender. For example, in our charts it’s in the past medical history section and there is a particular template that you can open up where you can choose if this person if queer, transgender female, transgender male, etc.
Also when I’m in communication with staff about patients, I always try to use the pronouns that the patient prefers because sometimes I slip up as well. If I use the wrong pronouns and realize it at the time, I will always correct it. If it occurs to me later, I will send a message to whomever I was speaking to correcting my mistake. So for me it’s having the comfort level with my staff to do that and understanding that they won’t be offended, but instead know I’m just trying to help them out.
I always explain to patients, especially new transgender patients, that we all want to use their preferred pronouns but sometimes we might slip and to please politely correct us if we do. By in large it’s been well received. Overall if the patient can sense that the practitioner is trying and that their heart is in the right place, that’s what matters.
Q: Do you see transgender patients of all ages?
A: I don’t see any patients under 18 who are wanting to go through a transition, mainly because I’m not comfortable managing hormones in a person whose body is changing that dramatically. Because you are trying to mimic what nature does through puberty, you want to make sure that they are getting a full opportunity for their body to grow and develop. Hormones affect so many things that we don’t always think about that there are too many risk factors for them to be seen by anyone except a specialist in that specific field in my opinion. For those patients I send them to a specialist at UT Austin who I met at a transgender health conference. Doctors who prescribe to transgender patients under 18 are not very common. She is one of the only, if not the only, doctor in the Austin area that treats this population.
Q: What kind of information do you want to communicate with the patient before starting on hormone therapy?
A: If you are prescribing an estrogen, you confer to them the risks that individuals with breasts have, such as the risk of breast cancer and increase of blot clot formation. I also often give a testosterone blocker along with estrogen, the most common one is Spironolactone. It’s not only a testosterone blocker but also an anti-hypertensive, diuretic, and heart failure medication. So when I’m prescribing it as a testosterone blocker I need to educate patients about the side effects of being a diuretic as well as having altered levels of potassium and reduced blood pressure.
As far as testosterone, you’ll be looking at increased cardiovascular risks, elevated cholesterol, elevated liver tests, acne, elevated hematocrit counts, mood changes, anger, etc. In contrast to transgender females, there is no estrogen blocker that I give to transgender males receiving testosterone.
Another thing it’s important to be vigilant about is talking about STD risks because the risk is higher in the transgender population, like it is for gay men. I’ve often been so caught up with focusing on the hormones and getting it right that I miss the boat on that. I also prescribe a lot of PrEP at my office for all patients.
Q: Do you personalize hormonal therapy for each patient?
A: I think you should allow people to age, for example cis women go through menopause where their hormones change so if I’m treating a patient near that age, I might not use the same targets for estrogen that I would for a 30-year-old. Testosterone levels also decrease with age so I may not prescribe as high of dose for transgender men over 60. Now there are patients I also have that don’t want to go all the way and want to preset as more gender-queer, non-binary, or androgynous. For them I have to meet them where they are at and may have to prescribe just enough of each hormone to look not quite like one or the other.
Q: Is having a good network of colleagues and professionals in the area beneficial when treating this population?
A: Yes, there are other doctors I know in town that sometimes I will lob questions to that have a number of transgender patients. There’s also another great online resource with UCSF medical school. They have a big transgender health program and online resource for clinicians. I believe they even have a call-in option for clinicians with questions.
For more information about Dr. Canon and his practice, visit www.southaustinmed.com
For other local transgender or LGBT healthcare support, visit www.kindclinic.org
For helpful guidelines on treating transgender or gender nonbinary patients, visit https://transcare.ucsf.edu/guidelines