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Published On November 16, 2017

POLICY

A World in Transition

Physicians are rarely trained to care for transgender patients. New efforts aim to bridge that gap. 

Surgeon Jess Ting, who performed more than 100 gender reassignment surgeries during the past year, can tell you exactly how many hours of training he received in transgender medicine during his general surgical training in the 1990s: Zero. “I don’t think I heard the word transgender once,” he says.

The statistics have improved only slightly over recent decades; a 2011 survey found that medical schools typically spend just five hours covering issues relating to LGBTQ health. Transgender patients are at a higher risk for some problems—HIV, mental distress, smoking and addition—that are covered in other parts of the medical school curriculum. But they also have needs that are unique.

Ting is director of surgery at the Center for Transgender Medicine and Surgery at Mount Sinai Hospital, in New York City, and has spearheaded an effort to offer specialized training. He and his colleagues at Mount Sinai’s Icahn School of Medicine recently launched the nation’s first fellowships to focus on transgender care—in this case, for surgical and psychiatric services.

Surgeons experienced in transgender surgery are especially needed, says Ting. Mount Sinai began to offer surgical services through the Center in March 2016, and within a few months, about 200 patients were on the waiting list. “We didn’t publicize it. We didn’t even have a website for the first year,” he says. That waiting list has now stretched to about 500.

The first surgical fellow, Bella Avanessian, says that training under Ting provides immersion in a field that is hard to study in any other way. Procedures required by transgender people include plastic surgery to the face, chest and genitals. “Gender reassignment surgery, especially, requires a lot of technical prowess,” says Avanessian. “In the hands of someone who hasn’t been properly trained, it could be dangerous.”

The need for psychiatrists trained to help transgender patients may be even greater. While not every patient opts for surgery, all of them live in a world that can be hostile to their mental health. A comprehensive 2016 survey of transgender people in the United States found that 40% of respondents had attempted suicide at some point, and almost the same number had experienced serious mental distress during the prior month, compared with about 5% in the general population for both categories.

Psychiatrist Hansel Arroyo, who runs the Mount Sinai fellowship’s psychiatric program, says transgender people often encounter obstacles when looking for mental health care. Some providers say outright that they’re unwilling or unable to treat transgender patients; others present more subtle barriers, such as office personnel who won’t call these patients by their preferred name or pronoun. “We don’t need many reasons to avoid seeing the doctor,” Arroyo says. “So those people don’t go in, and they live with their issues, which can put lives at risk.”

Endocrinologists are also critical to transgender patients, who typically seek hormone replacement therapy. A study published in January, based on a survey of physicians and program directors of the Endocrine Society, found that almost 80% of responding physicians had treated a transgender patient, but just over 80% had never received any special training to do so. Almost all of the program director respondents agreed that there’s a need for specialized fellowship training in transgender medicine, in addition to other options, such as presentations at society meetings or online training classes.

Online training is particularly important for physicians in rural areas, where transgender patients may lack access to specialists and are more likely to rely on their primary care providers. To increase such offerings, the Fenway Institute in Boston, which runs the National LGBT Health Education Center, launched TransECHO, a program that offers both online training and online networking with physicians experienced in transgender care. The program has been fully subscribed since it launched in October 2016.

Ting and Arroyo say they expect the demand for transgender care to increase, driven by several factors. First, more insurance companies are covering gender reassignment surgery as “medically necessary” for transgender people, putting the expensive procedures within reach of a much broader swath of the community. What’s more, the growing visibility of transgender people in public life has encouraged many others to pursue long-deferred dreams of transitioning. “The oldest patient we’ve operated on was a 77-year-old transgender woman,” Ting says. “This was something she’d wanted since she was five.”