By Annette M. Boyle
FORT BELVOIR, VA — When the DoD lifted the ban on transgender individuals serving in the armed forces last year, it set an aggressive goal of June 2017 for proficiency in treating personnel with gender dysphoria. With only a month to go, a recent research letter calls into question the preparation for serving transgender servicemembers received by clinicians on the frontline of care.
The proportion of transgender individuals in the U.S. military is twice as high as in the general population, according to the JAMA Internal Medicine letter published online in March. Estimates place the number of transgender servicemembers at about 13,000 and approximately 200 are expected to seek treatment related to gender dysphoria each year.1
Researchers electronically surveyed 204 clinicians participating in the 2016 Uniformed Services Academy of Family Physicians annual meeting on their readiness to care for patients with gender dysphoria. Family medicine physicians provide the bulk of primary care for both servicemembers and their families seen at military treatment facilities.
Of the 180 respondents who met criteria for inclusion, more than one-third (37%) reported having already cared for a patient with gender dysphoria. Only 5%, however, had received more than three hours of training on transgender care and nearly three-quarters (74.3%) had not received any training in gender dysphoria during their medical education.
According to lead author David Klein, “each military service has been tasked to train their servicemembers,” so they can fill in the gaps left by medical education programs that did not discuss gender dysphoria and the unique healthcare issues experienced by transgender individuals.
Based on the results of the survey, many clinicians said they still felt uncertain about their ability to provide care specific to transgender individuals. Readiness to prescribe cross-hormone therapy, in particular, appeared relatively rare among the family physicians surveyed, with 87.1% indicating that they had not “received sufficient education to provide” the therapy which prepares patients for gender transition. In addition, 52.9% said that “they would not personally prescribe cross-sex hormones to an adult patient, even if they were provided with additional education or the direct assistance of an experienced clinician,” the authors reported.
The lack of exposure to transgender individuals and to medical training in their care might have colored the responses, however. The researchers found that, while medical training in transgender care more than doubled the likelihood that physicians would prescribe cross-sex hormone therapy to an eligible adult patient, it did not affect their expectations that they would offer “nonjudgmental” care, which 76.1% said they could do already. More than half (50.4%) believed that seeing and treating openly transgender patients would make them more comfortable treating transgender servicemembers.
“Our findings showed that, while the majority of military family physicians believed that they could provide nonjudgmental care to transgender patients, the preponderance had not been adequately trained in transgender care issues. These findings are consistent with data from civilian providers, underscoring the importance of including transgender care training in our medical schools and residency programs,” Klein told U. S. Medicine.
The Uniformed Services University of the Health Sciences is adding transgender training to its curriculum. In addition, Klein said he would like the DoD to encourage civilian programs — where most military physicians train—to do the same.
Didactic, small group, panel and simulated patient experience training, as well as simple exposure to transgender patients, could all help make medical students, residents and current physicians more confident in their ability to appropriately treat gender dysphoria, he said.
More training is critical to enabling the DoD to reach its goal for proficiency in caring for this population noted the authors. “Given that education in transgender care was significantly associated with greater likelihood of prescribing hormone therapy and that prior research shows that additional medical instruction on transgender care contributes to greater competency, it will be vital to augment the training of military physicians to ensure skill and sensitivity in treating patients” with gender dysphoria, they wrote.
Klein noted that physicians can take immediate steps to make transgender patients more comfortable, adding that a few changes can have a big impact.
“Physicians should make known that their clinical environment is a safe and confidential place to discuss issues related to sexuality and gender,” he said. “This can be accomplished during the clinical interview as well as through subtle changes to the work space, such as forms, displays, etc.”
Assuring patients that they will not be judged for seeking care or discussing gender dysphoria is essential, and “proper referrals should be streamlined, if needed,” Klein added.
Both medical training and establishing a nonjudgmental environment could have a significant effect on the quality of care received by transgender servicemembers. As Jamie L. Henry, MD, a transgender military internist at Walter Reed National Military Medical Center in Bethesda, MD, observed in an invited commentary on the research letter, “in the absence of openness, gender dysphoria could be misdiagnosed as anything from generalized anxiety disorder to bipolar disorder to addiction.” Beyond the issues of hormone therapy, Henry noted that care for transgender individuals needs to address preservation of fertility and issues of isolation as a result of gender identity.2
Transgender Service: By the Numbers
RAND research provided the Pentagon the most rigorous and impartial estimates available of the costs and implications of allowing transgender men and women to serve openly.
1,320 to 6,630 estimated transgender men and women now serving in active duty out of 1.3 million
25 to 130 active component service members with deployment restrictions due to transition-related medical treatments
18 other countries already allow transgender people to serve in the military
- Czech Republic
- New Zealand
- United Kingdom
Source: Transgender Troops: Fit to Serve Transgender Troops: Fit to Serve, RAND Corporation, Aug. 18, 2016
- Schvey NA, Blubaugh I, Morettini A, Klein DA. Military Family Physicians’ Readiness for Treating Patients With Gender Dysphoria. JAMA Intern Med. 2017 Mar 13. doi: 10.1001/jamainternmed.2017.0136. [Epub ahead of print]
- Henry JL. A Transgender Military Internist’s Perspective on Readiness for Treating Patients With Gender Dysphoria. JAMA Intern Med. 2017 Mar 13. doi: 10.1001/jamainternmed.2017.0140. [Epub ahead of print]