Harrison has an informal test that he runs on primary care physicians when he meets them for the first time: the eye contact test. When he arrives at the appointment and tells them that he’s transgender, he watches their eyes for a reaction. He’s looking for signs of shock — have they ever met a trans person before? Do they get nervous, or start talking at him, rather than with him?
Trying to find an accepting clinician, especially where he lives in the mountains of North Carolina, can be tough. He’s been ghosted before — doctors tell him to follow up over an online patient portal or to call back later, which he does, only to never hear back again.
“It’s literally like dating,” said Harrison, a paramedic-firefighter, ski patrolman, and high school swim coach. (Harrison asked that STAT use only his first name to protect his safety and privacy.)
Even when he can find a primary care clinician who accepts his gender identity, they aren’t always educated on how to provide affirming care, like prescriptions for testosterone. And as a health-care worker, Harrison is meticulous about his medication. When he moved to North Carolina, he stopped taking hormones for six months because he couldn’t find someone who was both willing and knowledgeable enough to prescribe it with a professional understanding of the correct dosage.
“I work in the medical field, so I’m not willing to take a medication that [a clinician] is uneducated on,” he said. “I’m uneducated on it, so I need help.”
Gender-affirming care is under attack across the U.S. In restrictive states where it’s banned for minors and facing restrictions even for adults, care can be difficult to access. In cities and states with more expansive policies, the demand for gender-affirming care can be so high that there are months-long wait times for patients to see clinicians. People who take testosterone, a controlled substance that needs to be prescribed in person now that the pandemic public health emergency is over, may be especially at risk of losing access to medication because of such delays. Hormone therapy with testosterone or estrogen is used to change someone’s bodily features. Testosterone can increase body hair growth, deepen a person’s voice, and more.
Experts say that primary care physicians are well-positioned to fill the gaps in all types of gender-affirming care: providing information on social and legal transition and on safety in practices like chest binding, along with prescribing hormones and making surgery referrals. But while some primary care practices across the country already do this, many clinicians feel uniformed on how to best provide such care.
“We make gender-affirming care specialty care, and that automatically creates barriers in terms of access and a bottleneck,” said Alex Keuroghlian, director of the division of education and training at The Fenway Institute, an organization focused on LGBTQ research and policy.
Educating physicians on gender-affirming care
More primary care clinics across the country are beginning to take on the task of integrating gender-affirming practices, said Keuroghlian, who is also the principal investigator of the National LGBTQIA+ Health Education Center, which trains federally qualified health centers to do just that. Keuroghlian says that the first steps to educate a practice are often taken by a champion within an organization.
That’s what happened across town from Keuroghlian in Boston, at Brigham and Women’s Hospital. Raquel Selcer, a first-year medicine-pediatrics resident, noticed that all gender-affirming care was run through the hospital’s Center for Transgender Health, one of the city’s newest health centers for all things trans health care. Patients at the center must typically wait around three months for an appointment to receive hormones, said Ole-Petter Hamnvik, the center’s director of education. To keep people from waiting even longer, he’ll often finagle the schedule, fitting people in early or late outside of clinic hours.
At the University of California Irvine, where Selcer went to medical school, more primary care practices were providing trans care. With the help of Hamnvik and others, Selcer created a pilot program to educate physicians on how to provide gender-affirming care.
“I’m trying to really reinforce for primary care doctors that you can do this. We manage a lot of other medications that are more high-risk or more complicated, and for which there are more options,” Selcer said.
Becoming a gender-affirming practice involves buy-in from top to bottom, said Selcer, whose primary home clinic site is at Brigham and Women’s Family Care Associates. They launched the pilot there first, training all staff members on how to respect patients’ pronouns and create a welcoming, safe space. Then Selcer provided educational materials on the medical basics of trans care to the clinicians, and held a question and answer session during which clinicians could ask any and all questions in order to feel comfortable providing such care. In the hospital’s electronic consultation system, Selcer and the team added an official track on gender-affirming care so that physicians can consult Hamnvik with questions.
“It’s a lot faster for me to answer a pretty straightforward question in this format than it is to see the patients,” said Hamnvik, who currently prescribes almost all gender-affirming hormones at the hospital. “And as part of that, there’s a bit of teaching that happens.”
Selcer and their team are quick to note that the pilot is not the first of its kind. Keuroghlian’s National LGBTQIA+ Health Education Center, the World Professional Association for Transgender Health, and others provide educational programming to practices looking to integrate this care. And in the Boston area, medical systems like Fenway Health have long integrated gender-affirming services into their primary care practices.
But as need continues to increase, the team hopes to help primary care clinicians feel more comfortable providing gender-affirming care by offering them training from colleagues they already know and trust.
Despite what Harrison and other patients may worry about, figuring out the proper dosage of hormones is not the hardest part of becoming a gender-affirming practice, experts say.
“We all went to med school and we learn about new medications all the time,” said Colleen Monaghan, the medical director at Family Care Associates.
Instead, primary care physicians often need more education on basic gender issues, such as the difference between gender identity and sexuality, or about topics that are steeped in misinformation online, like experiencing regret after transition.
Most physicians receive little to no training about transgender health in medical school. “They’re playing catch-up after the fact. They shouldn’t have to,” Keuroghlian said. “If they had this adequately in their formative training years, it would be a no-brainer in their primary care practice.”
Creating safe spaces for trans patients
Medical schools and residency programs have slowly begun to adapt and add more curricula on transgender health, in a movement mostly led by students and trainees like Selcer.
“I do strongly believe that gender-affirming care fits within the purview of primary care — and also I just wanted more training in that area,” Selcer said. “I have a vested interest in making the training that I want to see possible.”
It’s unclear how attacks on trans people across the country may affect both medical training on gender-affirming care and its integration into primary care. Hamnvik, who reads applications for the endocrinology fellowship program, has already noticed more hesitancy from trainees in focusing on that subspecialty.
“I do think that [the anti-trans attacks] will impede incremental mainstreaming of gender-affirming care within primary care, and is likely to result in this care being relatively confined to specialty care if offered at all within those states,” Keuroghlian said.
Even if providers can’t provide certain aspects of gender-affirming care like hormones, experts say that the basic education can make a big difference for trans patients. Using the correct pronouns and offering gender-inclusive bathrooms can make a trans patient feel safe and less likely to delay regular primary care appointments.
“It doesn’t have to be a huge overhaul. You just have to make the effort,” said Shanna Kattari, an associate professor at the School of Social Work at the University of Michigan. “If we don’t create these spaces, we are contributing to mental health concerns.”
In the meantime, trans people across the country keep searching for care. After connecting with a local North Carolina university’s LGBTQ center, Harrison was able to find a practice with clinicians who would be willing to see trans patients. He waited months for an appointment with one of those doctors, but experience told him not to hold his breath on getting hormone prescriptions from the practice. In the interim, he signed up with Folx Health, a telemedicine startup, for testosterone.
When the appointment at the local clinic finally came, Harrison found he was right — the doctor told Harrison that he was willing to help with hormones, but didn’t know what to do.
Harrison stuck with Folx for hormones, but says his primary care doctor helps him to coordinate blood tests to monitor their effects. It’s a patchwork system of providers, but for now, one that he feels safe within.