Participant characteristics

Participants consisted of family medicine physicians (n = 5), physician assistants (n = 3), nurse practitioners (n = 2), endocrinologists (n = 2), and an adolescent medicine physician (n = 1). Their practices consisted of primary care patients at a local LGBT health center (n = 8), specialty care at a large academic medical center (n = 4), and private practice (n = 1). Eleven participants identified as women and two as men. The majority identified as White (n = 9), and the remaining identified as Black (n = 3) and Latina (n = 1). No participant identified as transgender. Ages ranged from 31 – 58 (mean 46.7 years) and had been providing health care to patients from 2.5 to 29 years (mean 17 years). Many had master’s degrees in public health (n = 4) or PhDs (n = 2) in addition to their health care degrees. A summary of participant characteristics can be found in Table 1.

Table 1 Participant and interview characteristics

Themes

Five themes and 13 subthemes were constructed from the data. The major themes included: (1) Knowledge Acquisition: Formal and Informal Pathways to Competency; (2) Perceived Challenges and Barriers: I didn’t know what I was doing; (3) Power to Deny: Prescriptive Authority and Gatekeeping; (4) Stigma: This is really strange, and I can’t really understand it; (5) Reflections: Strategies for Success, Rewards, and Personal Motivations. An overview of the relationship between the study’s research questions, themes, subthemes, and meaning units can be found in Table 2. Four out of the five themes were identified in every interview, and all subthemes were identified by the 5th interview providing evidence that saturation was achieved (see additional file 4) The authors’ prior qualitative (KS & TP) and clinical expertise (OD, JT, RM, TP) affirmed that the depth of participants’ description of their experiences with transgender people and meaning saturation were also met. A summary of each theme is provided below.

Table 2 Overview of the relationship between research questions, themes, subthemes, and meaning units

Theme 1. Knowledge acquisition: Formal and informal pathways to competency

Knowledge about transgender health care was acquired in one of two ways: formal and informal pathways.

Formal pathways to competency

Formal pathways to knowledge acquisition included exposure to skills or knowledge related to transgender health care, or transgender people, during residency or volunteering at a clinic. One participant stated:

I volunteered on Saturdays’cause I work during the week…I didn’t know anything about trans, anything, and it seemed like a good opportunity for me to learn and grow and challenge some of my own assumptions about gender and about who transgender people were and what it meant to be trans. (PA-200).

The majority learned through attending training at their place of employment, e.g., we had one staff meeting where she did sort of a trans medical care 101 and she talked about hormones and surgery and labs and that kind of stuff (PA-200). Many participants discussed exposure to skills or knowledge tangentially related to transgender care that helped bridge their learning. For example, an adolescent medicine physician already had a deep understanding of hormones, saying you really have to know hormones to a tee (MD-239) which increased her comfort prescribing hormone therapy. Others were exposed to sexual minority patients or topics during formal schooling, which sometimes applied to transgender people usually there are like two lectures on GLBT issues and that’s called inclusiveness…there’s not really much medical information (MD-220). Most participants did not have formal training about transgender health care during their education.

Informal pathways to competency

All but one clinician discussed obtaining knowledge through informal pathways. This included learning through a combination of peer mentorship and self-instruction via experimentation or through books, conferences, online protocols (predominantly the World Professional Association for Transgender Health and the Endocrine Society guidelines), or other online searching methods. One participant reflected on their education as a self-learning process. She stated, I’ve spent hours on self-research. I’ve read every book, all the latest books that have been written by the medical community (PA-212). Another talked about using trial and error, I tend to transition people over to patches, you know, over the age of 50 or 55, but there’s not a real standard for that. It just, it seems to make sense (MD-224). Expert mentorship was important and most frequently sought within a place of employment; as this clinician said [I go to] the person who knows the most about transgender [care]. It’s just the quickest and the easiest to go to…someone who has more experience in dealing with transgender care (MD-210). Absence of workplace mentorship drove some to consult external colleagues. A few discussed learning by using the patient’s experience as a guide after conferring with a mentor or online resource. One participant said when she [my patient] came to see me, she said I prefer the injectable, and I said, great let me look it up, looks like it’s fine, you know? What’s the amount you were on before? (PA-227). Every clinician over the age of 50, and nearly every clinician with more than ten years of experience, discussed being self-taught. Conversely, every clinician with less than ten years of experience noted mentorship as instrumental to their learning.

Theme 2. Perceived challenges and barriers: “I didn’t know what I was doing.”

Challenges and barriers to care included not knowing how to care for transgender people, feeling that scientific guidance was limited, fear of providing non-standardized care, and managing multiple needs.

“People don’t know how to treat:” Knowledge gaps in providing care

When recalling their first interaction with a transgender patient, clinicians consistently discussed becoming aware of their knowledge gaps, including not knowing what to do or whom to ask. Some would refer out to another clinician, specifically to initiate hormone therapy. Clinicians lacked knowledge about medications and dosing, endocrinology, the appropriate medical history, gender-affirming surgical options, social issues (e.g., how to write a medical letter to enable a patient to change a sex marker on a driver’s license), and language (e.g., pronouns, definitions). Two clinicians shared stories about times when their knowledge gaps contributed to patient harm, such as failing to consider that a transgender patient used their penis during sex, resulting in a weeks-long delay in diagnosing syphilis.

Although every nurse practitioner and physician assistant disclosed personal knowledge gaps, medical doctors usually attributed their gaps to external factors such as limited evidence or limitations in their patient panels. For example, a physician stated, the right [hormone] therapy is not precisely known…there aren’t great comparative studies (MD-224). Another explained uncertainty about who should receive treatment this way: there are more issues of really who should be treated, and are we doing the right thing, and how do you be sure…we don’t as medicine, we just don’t understand what it really is (MD-223). Clinicians also felt whichever gender or age group they cared for most often determined the knowledge they possessed. Consequently, they lacked knowledge about the medical needs of people in other age groups or with other gender identities. This skewing of patient panels contributed to needing more time to become knowledgeable and confident about treating diverse transgender people. When mental health or other specialized care needs arose, sourcing referrals presented a challenge due to a scarcity of knowledgeable clinicians. Clinicians noted that finding mental health professionals that are experienced in transgender care is really difficult, especially…if the patient doesn’t have cash to kill (MD-207).

“She was not comfortable”: Establishing a patient-clinician relationship

Establishing strong patient-clinician partnerships was key to gaining proficiency in caring for transgender people. However, there were two main barriers: mutual distrust and meeting expectations. For the former, clinicians talked about patients not feeling comfortable divulging certain things such as a complete sexual history due to, e.g., want[ing] to please you [the clinician] (PA-227) or due to lack of shared identity. On the other hand, clinicians also felt patients would, e.g., tell you what they think they need to tell you to get hormones, (MD-220) take a higher dose of hormones, or turn around and sell what you’re giving them because they have street value (MD-224). These instances reaffirmed clinician distrust of patients. However, clinicians also disclosed how they perpetuated distrust, including making stigmatizing remarks such as I don’t mean to beat a dead horse, but I’m like, are you really only having one partner? And what exactly are you doing? (NP-218).

Conflict due to differing expectations also precluded the formation of strong partnerships. Some clinicians felt transgender patients all want hormones, and they ask for the hormones by name (MD-239) and want their transition to be instantaneous (MD-210), which conflicted with what clinicians’ thought was realistic. Dispelling the lore about how well they [hormones] should work and what works best (MD-224) and tell[ing] the patient that it [transition] takes time (MD-239) felt contentious to clinicians. For example, some patients preferred a particular medication based on the belief it would produce better results, while clinicians were concerned about the associated risks.

Theme 3. Power to deny: Prescriptive authority and gatekeeping

Medical gatekeeping refers to the practice of a clinician deciding whether a patient receives the care and services they are seeking. Clinicians discussed gatekeeping and the power to make decisions – usually regarding prescribing hormones, less frequently about providing primary care. Clinicians often did not apply gatekeeping practices to patients who were already using hormone therapy. All but one clinician over the age of 50 discussed gatekeeping practices they had performed. In contrast, the majority of those under the age of 50 talked more about their position of power as a gatekeeper and efforts to reduce gatekeeping.

Gatekeeping: The stigma, discomfort, and fear underlying denial of hormone therapy

The most frequent gatekeeping practice was requiring a letter of support from a mental health professional or proof of engagement in mental health services before prescribing hormone therapy. Additional practices included requiring a homogenous transgender narrative; smoking cessation; initiations of social transition (e.g., dressing in specific clothes); financial, emotional, and physical stability; and a commitment to undergoing surgery and achieving standard-range sex hormone levels.

Clinicians attributed gatekeeping practices to personal discomfort with the concept of a transgender person and limited treatment knowledge. Discomfort providing hormones to non-binary patients was common; that is, people whose gender identities are outside the binary of female or male. As one clinician stated:

I wouldn’t say you’re fucked up, but I would say, I don’t prescribe hormones in this situation. I’m okay setting that limit. It’s…my limit for my behavior. I guess I feel…if you don’t want to be in either gender, why do you need hormones? (MD-220).

Denial of care was justified by lack of knowledge, e.g., if I don’t know what I’m doing, I’m not going to see this person because I won’t be able to treat him appropriately (MD-210).

Workplace climate affected gatekeeping. One clinician reported not prescribing hormones because doing so became very out of favor, and you couldn’t even say the word, so to speak, in this institution (MD-223). Other clinicians described refusing treatment based either on lack of trust, or conversely, total confidence in the judgment of collaborating mental-health clinicians. For example, one clinician required patients to get mental-health care within their own institution because they found it very difficult to trust whoever this [unknown] therapist was (MD-223). Another clinician stated they can’t undermine them [psychologist colleagues]. And for whatever reason, they’re telling me that I should wait, and that’s where my comfort level is (PA-212).

Fear of personal and professional consequences perpetuated gatekeeping practices. Specifically, clinicians feared malpractice litigation based on medication side effects, irreversibility of treatments, and perceived violations of the Hippocratic oath or accepted standards of care. One clinician reported being more concerned about testosterone [than estrogen] because it’s not very reversible (MD-220). Another clinician was more concerned about estrogen, stating: the complications. You die from it. You give someone high-dose estrogens then they’re going to have a thrombotic event (MD-223). While several clinicians expressed fear of precipitating thrombotic events, none reported cases among their patients. Some clinicians were afraid of general harm, especially with youth: the feeling of oh, my God, if we screw this kid up (MD-215). Only one clinician noted the huge impact [of hormones] on their [patients’] quality of life (MD-224), which counteracted their concern about treatment risks.

Some clinicians expressed concern about the lack of data to support gender-affirming care, stating, e.g., Show me the papers. Show me the data. Show me the research that says you should be doing this for patients (MD-214). One participant felt many clinicians were concerned about their license. This participant noted that they would not provide care without on-the-job guidance, stating I think in the end, I feel like my license is still on the line for doing something that technically I’m not quote-unquote trained to do (MD-210). The person who trained clinicians on transgender care wielded tremendous power in how prescribing decisions were made and the workplace culture around it. One clinician recollected being berated by a colleague with a shared patient, who said, what the hell do you think you’re doing giving this guy estrogen…I’ll make trouble for you if you persist in this (MD-214). Some felt that gatekeeping practices, particularly the letter of support, helped quell these fears by providing medicolegal protection.

Exceptions to the gatekeeping rule

Clinicians’ willingness to continue therapy for patients already taking hormones was much greater than their willingness to initiate hormone therapy without gatekeeping practices. One stated, a lot of the trans patients that I’ve had come to me already on hormones. And at that point, even if I do have some discomfort, I’m sort of inclined to grandfather them in (MD-207). Patients typically were in this category by using non-prescription hormones. Two of the three clinicians willing to initiate hormone therapy for new patients without gatekeeping were physician assistants and attributed this practice to a harm reduction approach: if they did not prescribe hormones, the patient would obtain them through risker methods.

Power to prescribe or deny

About half of the participants reflected on the power to prescribe or deny hormone therapy, including variations in how the standards of care were interpreted. For example, one stated, some people feel like the mental health requirement is a requirement, and some people feel like it’s a suggestion…so while there are standards, I think they’re interpretable standards (PA-200). Several clinicians talked about making decisions to prescribe based on whether it was right for the patient rather than on clinical guidelines.

Theme 4. Stigma: “This is really strange, and I can’t really understand it.”

Only three clinicians did not describe stigmatizing beliefs or make stigmatizing statements, indicating that patient-clinician relationships were primarily characterized by stigma. Four subthemes arose around stigma: negative stereotypes about transgender people, transgender people’s concern with physical appearance, discomfort and discriminatory practices towards transgender people, and stigma towards people with nonbinary identities or expression.

Negative stereotypes: “They’re really homosexuals that are afraid to admit it.”

Clinicians demonstrated three central stereotypes about transgender people: sexually promiscuous, closeted homosexuals, and difficult patients. Clinicians discussed concerns about sexual practices that put transgender people at higher emotional and physical risk with stigmatizing language such as “sexually promiscuous.” One clinician asserted that transgender people perform in drag shows for attention, stating, I think it’s being accepted in that group of people who are observing them…and they’re looking for it in the wrong places obviously (MD-212). A few clinicians conflated gender identity and sexual orientation and talked about transgender people being homosexuals that are really afraid to admit it (MD-223). A clinician referenced their transgender patients as difficult patients, particularly trans women who have had pretty rough experiences, and are pretty rough people…[with] a higher incidence of personality disorders (MD-220). Clinicians frequently made negative generalizations about transgender people as patients, like they are a little more scattered (MD-210), kind of crazy (MD-214), or they can be difficult patients (MD-220) that are a lot harder to deal with (MD-207).

Physical appearance: “It’s this obsession.”

Clinicians made negative comments about transgender women’s physical features, such as they are always so awkward…they don’t fully pass [i.e., are not always perceived as a cisgender person]or they never quite get the mannerisms of women, and it always looks artificial. You can spot them a mile away (MD-223). At the same time, clinicians were judgmental of the women’s relationship with their physical appearances, expressing sentiments like it’s this obsession like it’s never going to be okay (MD-207), and as a psychological problem…[that] raises this flag in me (MD-207). Only one clinician talked about the difference that economic privilege, specifically access to expensive surgeries, can make for a transgender woman who wishes to change her appearance. The notion of obsession with appearance was never discussed in the context of transgender men. Providers felt that transgender men’s physical appearances were “generally much better, more believable” (MD-214), even “scary how good they…completely pass” (MD-223).

“This is really strange, and I can’t really understand it.”

Clinicians commonly expressed disbelief that a transgender person could ever find happiness, as exemplified by the remark, I just looked at him and felt to myself, “Are you really happier?”…I don’t know what the answer is. Sometimes I feel like saying to somebody, “Can’t you grow out of this a little bit?” (MD-223). Yet another clinician talked about having to convince colleagues that transgender people were real people with authentic identities. Mistreatment of transgender people based on underlying stigmatizing beliefs was only discussed as something witnessed, not practiced. Mistreatment included seeing a lot of laughing and snickering [at transgender patients], and people would walk in just to see them like it was a sideshow type of thing. The doctors would flip a coin over who had to take them [a transgender patient] (PA-212).

“Go all the way.”

Clinicians believed that a transgender person’s goal should be to become invisible as a transgender person. For example, one clinician noted, if you want to transition, go all the way and transition…the best thing for a trans person is to transition as fully as possible as soon as possible (MD-220). One clinician expressed disapproval of transgender people choosing a name that doesn’t really necessarily go in one direction or the other (NP-218). In addition, clinicians expressed a lack of understanding of non-binary identities, exemplified by statements such as it’s often a stage…[and] it’s a social statement, and you don’t treat things with medications that are social statements (MD-220).

Theme 5. Reflections: Strategies for success, rewards, and personal motivations

Every clinician discussed: strategies that increased their proficiency in caring for transgender people; reflections on how their ideologies, identities, and background impacted the care they provided; or sentiments about why they provided care and how they benefited from caring for this patient population.

Becoming proficient: Strategies for success

Clinicians shared several individual and structural strategies for building trusting patient-clinician partnerships. Strategies included attempting to reduce hierarchical power dynamics through partnering with patients by do[ing] things together step by step (MD-214) and creating a safe space by initiating the visit with what their [the patients] goals are. What they would like to accomplish (PA-212). Some discussed the importance of using time, especially during the extended initial visit, to listen to patients and learn a little bit about what these people are facing (MD-224) in other aspects of their life, i.e., [to] focus on the patient as a human being, as a person (MD-239). Yet another tactic was being humble and transparent, such as telling patients I don’t have any standardized basis for how to do this, but I will be happy to work with you (MD-214).

Clinicians also talked about the importance of communicating honestly, realistically, and prioritizing the patient’s goals. Tell[ing] them [patients] basically what they can expect (PA-212) was an important tool that experienced clinicians did to align their patient’s expectations with what hormone therapy could produce. Experience also contributed to improved communication and a better understanding of the barriers and concerns around accessing gender-affirming care as one clinician learned: very few people persist in saying they don’t [want gender-affirming surgery] when you figure out how to ask the question right, as in if it was free and safe and you weren’t afraid of general anesthesia…It’s a good protective mechanism to say you don’t want something you can’t have (MD-220).

Some clinicians described the need to engage in self-reflexive processes to overcome barriers in developing proficiency such as to face their own fears and get comfortable treating different types of people that they had not seen in their training (PA-227). Many talked about experiences of initial discomfort or anxiety when caring for a transgender or nonbinary patient, related to not knowing what am I supposed to do? (PA-212), being so fearful of failure (MD-239) and not doing it right (MD-220). One clinician talked extensively about the goals of therapy as sort of fundamentally different than some of the other things that we do…instead of looking at lab tests to be sure their hemoglobin A1C is better…you’re asking them how they feel (MD-224). Empowering patients to drive medication dosing based on their own risk tolerance signaled an important shift from clinician-driven care to person-centered care. Some clinicians acknowledged the need to look at your own biases, what you bring to the table (MD-239) to provide care successfully. This included the need to resist the societal push to be a beautiful woman (PA-200) when that was not the patient’s goal and the prejudice of over-testing transgender patients for sexually transmitted infections due to assuming that their behavior is riskier (NP-218).

Structural strategies included curating a workplace environment that facilitated supportive and inclusive care. This included hiring a diverse and culturally competent staff including transgender people; promoting a nonjudgmental culture; reducing restrictions on medications and limitations on visit durations; and putting systems in place to support patient care, such as electronic medical record templates for clinicians to easily write a letter of support for a patient to obtain a passport or driver’s license. Mentors were important for providing resources, supporting less experienced clinicians, and reviewing medical notes to ensure they had asked the right questions (NP-218). Mentorship and experience were felt to increase clinician comfort more than formal training or certification in transgender care. Lastly, having a knowledgeable and trustworthy referral system, such as the ability to work very closely with the psych clinic here (MD-223), was crucial in removing barriers for both the clinician and patient.

Why I provide care

Most clinicians organically discussed their motivations and the benefits of providing transgender care without being prompted. Although a few perceived transgender people as interesting or fringy, on the edge alternativeness (MD-215), most were motivated to provide care by a desire and commitment to those who can’t just go anywhere and get healthcare, who have problems or barriers in healthcare (PA-212). Two clinicians told a story of being changed after their first experience with a transgender patient: whatever views I may have had or never had…all I see in front of me is someone who is sick, and I just need to treat them (MD-210). Other reflections included the satisfaction that came after building a trusting relationship with a patient, the joy of seeing the transition of how the person changes, like how they’re happier (MD-210) after they transition, and the knowledge that they supported a patient to achieve in most cases a lifetime goal for themselves (PA-212). One clinician talked about the rewards as one of those things where you feel like it’s mutual (PA-227). Another spoke about it increasing their compassion and desire to promote equality and rights (NP-218) for the greater transgender community.

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