Should all family physicians provide gender-affirming primary care?

Case

Emmanuel (assigned female at birth, dead name Emily), a 22-year-old transmasculine patient, has recently moved to Canada from Venezuela to study psychology. In Venezuela he had been subjected to discrimination most of his teenage life while living as a gay woman. He did not have strong family support. He connected with others online and became aware that he was, in fact, transgender and that living in Venezuela as a transgender man would be even more difficult and dangerous. Since coming to Canada he has done as much social transitioning as he could and has been supported by fellow students at university. He is now trying to access primary care for general health issues such as contraception and would like to begin discussing the use of gender-affirming hormones. The health centre at his university has indicated it is not able to provide gender-affirming care and has given him a list of possible providers who might be able to help. When Emmanuel tried to contact them, he was told the wait to see these providers was likely 2 years. Should the health centre be expected to provide gender-affirming primary care for Emmanuel?

Current state of gender-affirming primary care

Transgender and gender-diverse Canadians tend to have more illnesses and greater health service use than the rest of the population.³ They also tend to have less access to primary care and more unmet health care needs.^2,4 The number of TGD people with unmet general and mental health needs has only worsened during the COVID-19 pandemic.⁵ This includes access to assessment for gender dysphoria, hormone therapy, and referral for transition-related surgery.⁶ For those living outside urban centres, access is even more challenging.^7-9 Availability of valuable virtual care in parts of our country is under threat owing to changes in funding for virtual appointments.^8,10 Delays in accessing care can have devastating effects on the well-being of TGD patients.^11,12

Family doctors are community-responsive providers of high-quality, comprehensive care,¹³ but are we ready to provide gender-affirming primary care? Most family physicians are comfortable prescribing estrogen and progesterone to cisgender female patients and discussing risks associated with taking estrogen and with smoking. We order bone mineral density tests for cisgender women who have been taking medroxyprogesterone acetate for extended periods of time. We routinely prescribe spironolactone to those in need of a potassium-sparing diuretic, and we treat hypogonadal and hypoandrogenic cisgender males in their 60s and 70s with testosterone. Family doctors already adapt their skills to perform Papanicolaou tests for cisgender women with vaginal atrophy. We are skilled counsellors for cisgender women who request breast reduction or augmentation surgery and hysterectomy. We provide counselling to patients for fertility issues, body dysmorphia, and even the removal of unwanted facial hair. The tools for gender-affirming care already exist within most family doctors’ scopes of practice.

It is our opinion that gender-affirming primary care should be recognized as a competency that all family physicians have, as it encompasses knowledge and skills that are within the scope of family medicine. It is attitudes and fear of doing harm that limit this essential care being provided to TGD patients. Physician-cited barriers to providing care to TGD patients, such as inadequate knowledge or feelings that this care is specialized, create additional challenges for patients trying to access primary health care.¹⁴ Family doctors have a responsibility to provide safe and welcoming environments for TGD patients¹⁵; this is part of a broader issue of respect and inclusivity. Using proper pronouns, providing gender-neutral spaces, and using gender-neutral language, where appropriate, are essential to providing equitable patient-centred care. This involves education for everyone who works in primary care settings.

Training for gender-affirming primary care

The World Professional Association for Transgender Health’s Standards of Care for the Health of Transgender and Gender Diverse People, version 8, published in 2022, strongly recommend an emphasis on education in the provision of care for TGD people (Table 1).^16,17

Medical educators are working hard to catch up with patients who are currently seen in family practice offices, constantly updating curricula to ensure that competent care for 2SLGBTQ+ patients is embedded in medical school education. One of the greatest challenges in medical education in Canada today is ensuring the curriculum reflects the needs of students to provide comprehensive, inclusive care that covers an increasingly complex range of health issues facing patients. Determining how best to implement curricula regarding TGD health—and deciding whether to implement such content at all—is left to individual undergraduate medical education institutions, which face barriers in these efforts: lack of training opportunities, absent faculty expertise and training, and a packed curriculum.¹⁸

Practising health care providers regularly access information online, learning informally to provide treatments that patients request.¹⁹ We routinely identify new priority competencies and adapt our practices to our patient populations. Excellent resources have been developed to guide family doctors in the primary care of TGD patients (Table 2).

The future of gender-affirming primary care

“Gender-affirming care is primary care!” This message has been used by the Halifax Sexual Health Centre to inform policy and practice in Nova Scotia, and it won the centre the “Best theme” award at the 2022 Halifax Pride parade. It is time for family physicians across Canada to embrace their responsibility to provide gender-affirming primary care to patients. This is not a call to action for family doctors to take on more work. Much of the work we do already encompasses the needs of TGD patients. Any additional requirements are well within our skill sets. The personal and professional satisfaction to be achieved by showing empathy to, understanding, and providing primary care to TGD patients is immeasurable.

Will family physicians make mistakes and at times use incorrect pronouns or use terms that can be hurtful to TGD patients? Yes, of course, we will. We will apologize and hope not to do it again. But that does not mean we should not try. We must be comfortable with learning from patients, even if that contrasts with how most medical education occurs. We should incorporate the principles of providing safe, inclusive care without feeling that we need to send TGD patients to specialized clinics, especially patients who have been in our practices for many years. Family doctors can provide gender-affirming primary care, and patients will benefit immensely. Emmanuel and others with similar experiences deserve as much.