Through explanation, research and personal stories, Hartford HealthCare’s first gender health conference helped care providers better understand the needs of transgender and gender diverse patients.
Hosted by the system’s new Center for Gender Health, “Building Gender Literacy: Gender Affirmative Care across the Lifespan” included presentations by specialists involved in the Center on gender-affirming hormone therapy, infectious disease and reconstructive surgery.
“The LGBTQ+ population has unique healthcare needs and it’s critical that healthcare providers have at least a basic understanding of those needs and how to meet them,” said Laura Saunders, PsyD, ABPP, director of the new Center for Gender Health.
Priya Phulwani, MD, a Hartford HealthCare adult endocrinologist and pediatric endocrinologist director of Connecticut Children’s Hospital’s Gender Program, explained the “incongruence between the affirmed gender that the patient sees themselves as and gender assigned at birth often leads to gender dysphoria in adolescents.”
“The current diagnostic criteria do have some controversies – they are currently located in the manual for mental ‘disorders’ and state the need for at least six months of ‘distress’ clinically, socially or in other important areas of life,” Dr. Phulwani said. “Distress can range from an intense need to ‘do away’ with sex features, have sex features of another gender, transform into another gender or have society treat them as another gender.”
The diagnosis of gender dysphoria in prepubescent children, she explained, includes meeting five of the below criteria. The child may have a strong preference for:
- Opposite gender clothing.
- Cross-gender roles in fantasy play.
- Toys, games and activities of the other gender, rejecting those associated with the assigned sex.
- Playmates of the other gender.
- Strong dislike of one’s sexual anatomy.
- Strong desire for primary/secondary sex characteristics of another gender.
The last two correlate with a higher incidence of gender dysphoria that persists into adolescence, Dr. Phulwani said.
Research shows that one third of young children will continue to experience gender dysphoria in adolescence. However, if gender dysphoria is still present after puberty has begun, she said more than 95 percent of youth will persist with identifying with their affirmed gender rather than that assigned at birth..
Overall, .5 to 1.3 percent of the population will identify with a gender other than that assigned at their birth, she said.
Denying these feelings in a child or adolescent, Dr. Phulwani continued, can be emotionally harmful.
“If hormone transition is desired by youth with persistent, insistent and consistent gender dysphoria, the potential risk of not treating is worsening depression, anxiety and even self-harm and suicide,” she said.
Questions about gender identity can be woven into provider-patient conversation, she suggested.
“Make it part of your adolescent questions that should be asked in confidence – Do you smoke or vape nicotine? Are you sexually active? Are you happy with your gender?” Dr. Phulwani said, adding that follow-up questions for youth who do not identify as cisgender could include whether they have told their parents and if they feel safe doing so.
Addressing safety in the LGBTQ population, said Patrick Cahill, MD, medical director of Hartford HealthCare’s Community Care Center, also includes monitoring sexually-transmitted diseases, which are not yet tracked based on gender identity even with increased risk of infection for LGBTQ+ people, especially youth.
“There are higher rates of risky sexual behavior, leading to as much as twice as many cases of gonorrhea, chlamydia and HIV for these youth versus heterosexual men,” Dr. Cahill said.
While less than half a percent of American adults have HIV, he said the rate is nine percent for transgender people. Up to 14 percent of transgender women have HIV, compared to three percent of transgender men. The number jumps to 26 percent in transgender Hispanic women and 44 percent in transgender Black women.
Dr. Cahill advocated for the use of antiretroviral preexposure prohylaxis (PrEP) in high-risk populations to stem the rate of HIV, and improved accessibility to testing.
Conference speakers also touched upon the role of reconstructive surgery – such as breast and genital reconstruction and facial shaping – in gender affirmation. A one-hour panel discussion featured five people with lived experience who underwent social and/or surgical gender affirmation or transition and offered suggestions for providers to effectively and compassionately discuss the physical and emotional needs of their transgender patients.
“The insight this panel provided was invaluable, and unlike anything we could offer through research or even our own experiences in the office. They live it – the good and the bad – and they were very candid and articulate about how things can be better,” Dr. Saunders said.