Care of Transgender Patients: A General Practice Quality Improvement Approach

Abstract

Primary care must ensure high quality lifelong care is offered to trans and gender minority patients who are known to have poor health and adverse healthcare experiences. This quality improvement project aimed to interrogate and audit the data of trans and gender minority patients in one primary care population in England. A new data collection instrument was created examining pathways of care, assessments and interventions undertaken, monitoring, and complications. General practitioners identified a sample from the patient population and then performed an audit to examine against an established standard of care. No appropriate primary care audit standard was found. There was inconsistency between multiple UK gender identity clinics’ (GIC) individual recommended schedules of care and between specialty guidelines. Using an international, secondary care, evidence-informed guideline, it appeared that up to two-thirds of patients did not receive all recommended monitoring standards, largely due to inconsistencies between GIC and international guidance. It is imperative that an evidence-based primary care guideline is devised alongside measurable standards. Given the findings of long waits, high rates of medical complexity, and some undesired treatment outcomes (including a fifth of patients stopping hormones of whom more than half cited regret or detransition experiences), this small but population-based quality improvement approach should be replicated and expanded upon at scale.

Health Care Experiences of Patients Discontinuing or Reversing Prior Gender-Affirming Treatments

“… 2 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 By contrast, there is little clinical guidance when patients stop, or seek to reverse, gender-affirming medical interventions, referred to as detransition. 14 Medical detransition involves ceasing or switching gender-affirming hormone therapy and/or surgical reconstruction or reversal. 15 After medical detransition, individuals may continue identifying as transgender or nonbinary, or they may reidentify with their birth sex (eg, female or male).…”

“…Of these 12, 4 patients were rereferred to the clinic, suggesting interest in resuming medical transition following detransition (eg, retransition). Individuals report detransitioning for reasons such as mental and/or physical health concerns, 15 , 17 , 21 , 22 fertility preservation, 17 change in political beliefs, 15 shifting gender identity 14 , 15 , 16 , 17 , 21 , 24 or understanding of one’s sexuality, 15 , 21 social challenges living as a transgender person, 17 , 21 pressure from a romantic partner or family member, 17 employment discrimination, 17 postoperative surgical pain, 25 and career-related or financial concerns, 17 , 25 among others. Some report regretting their initial gender transition, whereas others experienced it as an opportunity to explore and clarify their gender identity.…”

“…One international survey of 237 self-identified detransitioners found 49% wanted information on stopping or changing hormones, and 15% required information on surgical reversals. 14 However, 31% of the sample had not medically transitioned. Authors have called for qualitative research into detransition to understand this population’s everyday lives and their clinical needs.…”

A Content Analysis of Osteopaths’ Attitudes for a More Inclusive Clinical Practice towards Transgender People

“…Indeed, there is currently a developing interest from different research groups involved in research in healthcare experiences for sexual and gender minority people. Various researchers have focused on these LGBT populations using a variety of different types of studies, such as audits [ 57 ], observational studies [ 58 ], qualitative research [ 59 ], mixed-methods designs [ 60 ], and a current protocol for a systematic review [ 61 ], to monitor the improvement in health, well-being, and healthcare experiences for sexual and gender minority people. This research is likely to contribute to the better understanding of any issues as well as further opportunities to address them.…”

“…Nevertheless, we know from recent research findings that the failure to gather data on LGBTQIA+ identification in healthcare (including osteopathic) practice and education is part of a more significant issue that restricts addressing LGBTQIA+ health inequities [ 57 ]. For example, a recently published survey revealed that American medical education institutions undervalued sexual orientation and gender identity in demographic collection procedures, with osteopathic programs reporting less inclusive best practices in several areas than allopathic programs.…”