Historically, transgender persons have faced discrimination and harassment on the basis of their gender identity, both in their personal lives and within the context of the healthcare system.^{(4,7,10,17)
‍}

Perceived stigma may prevent transgender patients from disclosing their gender identity to their healthcare provider, which deprives the provider from information that may be pertinent to clinical decision-making and/or diagnosis.
Compared to their cisgender counterparts, transgender patients may be more likely to delay seeking preventive health services (i.e., Papanicolaou (Pap) test, prostate cancer screening), and less likely to receive urgent medical care.
Minority stress theory posits that the continual, lifelong stress that results from being a member of a minority group with a stigmatized social identity can potentially lead to an adverse sequelae of chronic health outcomes.

Healthcare providers should educate themselves on transgender issues and should strive to provide culturally competent, nonjudgmental, compassionate healthcare. ^{(6,7,8,9,12,13,14)
‍}

The codes of ethics of both the American Nurses Association and the International Council of Nurses acknowledge the importance of providing respectful nursing care to all patients, regardless of gender identity status.
The World Professional Association for Transgender Care (WPATH) offers up-to-date guidelines for transgender healthcare

In recent years, new legislation has been passed that attempts to protect the healthcare rights of transgender persons. ^{(4,6,7,10,12,13,18)
‍}

In 2014, the US federal government lifted the ban on Medicare coverage for gender reassignment surgery.
In the UK, the Equality Act (Sexual Orientation) Regulations 2007 prohibit discrimination on the basis of sexual orientation or gender identity status in the provision of all goods and services, including medical care. Additionally, equal access to healthcare is guaranteed for transgender patients by the National Health Service (NHS) Constitution.

The Gay and Lesbian Medical Association (GLMA) has developed a set of recommendations for issues that transgender patients should discuss with their medical providers. These issues include access to health care, health history, hormones, cardiovascular health, cancer, STIs and safer sex, alcohol and tobacco use, depression, injectable silicone, and fitness.

A growing body of research recognizes the health disparities that exist between transgender patients and cisgender patients. ^{(4,7,8,12,13,14)
‍}

Compared to cisgender patients, transgender patients report poorer physical and mental health, and are significantly more likely to have a disability.

Transgender patients face a number of unique challenges and inequities within the healthcare system. ^{(4,,9,10,12,13,18,20)
‍}

Transgender patients often experience difficulties accessing the healthcare system; 19% of transgender individuals report that they have been refused medical care due to their gender status.
In the US, persons who identify as transgender are more likely to be uninsured than both the general population and other members of the LGBT community. Many health insurance policies include discriminatory exclusions for transgender-related care.
50% of transgender patients report having to “teach” their healthcare provider about transgender medical issues.

Individuals who identify as transgender may seek surgery (e.g., hysterectomy, vaginoplasty, breast augmentation) or hormone therapies (e.g., estrogen, testosterone) to achieve greater congruence between their gender identity and physical appearance.
‍

Current evidence suggests that hormone therapy is safe when correctly monitored, and that risk of cancer is not elevated in transgender patients receiving hormone therapy.
Transgender patients are at increased risk for heart disease, possibly due to the effects of hormone therapy.
The American Medical Association considers gender-transition services, such as hormone therapy, to be medically necessary.
Transgender individuals who seek surgery, hormone therapy, or other medical treatment for gender dysphoria often face out-of-pocket healthcare costs that are prohibitively expensive. As a result, many transgender patients resort to obtaining hormones and other treatments via the black market.

Transgender persons, and transgender women in particular, are at high risk of HIV infection; the CDC reports that the highest percentage of new HIV cases currently occur among individuals who identify as transgender.^{(1,21,22)
‍}

Transgender patients experience HIV at nearly four times the rate of cisgender patients.
African-American and Hispanic transgender patients are at a particularly elevated risk for HIV and other STDs.
Transgender patients with HIV often experience hurdles receiving appropriate HIV treatment, due to lack of access to healthcare and increased rates of poverty among this population.

Mental health issues are of particular concern among the LGBT population. ^{(5,7,9,10,16,18,20,21,22)
‍}

Almost 80% of transgender persons responding to a recent survey indicate that they have contemplated suicide, while 41% have actually attempted suicide.
High rates of depression, anxiety, and suicidality are likely related to stigma and discrimination faced by transgender persons.
Identifying as transgender is not a mental health disorder, and transgender patients should be treated medically rather than psychiatrically. However, transgender patients often benefit from speaking with a mental health professional about the impact of discrimination, stigma, and lack of social support on their mental health.
Patients who identify as transgender have increased rates of substance abuse compared to their cisgender peers; transgender patients should receive appropriate screening and treatment for substance abuse.

For more information on health issues of LGBT patients, refer to the Gay and Lesbian Medical Association or the Joint Commission’s LGBT Field Guide.

References

Centers for Disease Control (2015). HIV among gay and bisexual men. Retrieved from http://www.cdc.gov/nchhstp/newsroom/docs/CDC-MSM508.pdf
Centers for Disease Control (2013). Viral hepatitis: Information for gay and bisexual men. Retrieved from http://www.cdc.gov/hepatitis/Populations/PDFs/HepGay-FactSheet.pdf
Daniel, H., & Butkus, R. (2015). Lesbian, gay, and transgender health disparities: Executive summary of a policy position paper from the American college of physicians. Annals of internal medicine, 163(2), 136-148.
Denton, F.N., Rostofsky, S.S., & Danner, F. (2014). Stigma-related stressors, coping selfefficacy, and physical health in lesbian, gay, and bisexual individuals. Journal of Counseling Psychology, 61(3), 383-391. doi: 10.1037/a0036707.
Fish, J. (2007). Briefing 2: Improving access to health and social care for lesbian, gay, bisexual and trans (LGBT) people. Retrieved from http://dh.gov.uk/publications
Fredriksen-Goldsen, K.I., Kim, H.J., Barkan, S.E., Muracao, A., & Hoy-Ellis, C.P. (2013). Health disparities among lesbian, gay, and bisexual older adults: Results from a population-based study. American Journal of Public Health, 103(10), 1802-1809.
Garland-Forshee, R.Y., Fiala, S.C., Ngo, D.L., & Moseley, K. (2014). Sexual orientation and sex differences in adult chronic conditions, health risk factors, and protective health practices, Oregon, 2005-2008. Preventing Chronic Disease, 11, 1545-1563.
Hein, L.C., & Levitt, N. (2014). Caring for transgender patients. Retrieved from http://nursingmadeincrediblyeasy.com
Hillman, J., & Hinrichsen, G.A. (2014). Promoting an affirming, competent practice with older lesbian and gay adults. Professional Psychology: Research and Practice, 45(4), 269277.
Johnson, S.R. (2008). Gynecologic issues for lesbians. Global Library of Women’s Medicine [Online publication]. Retrieved from http://www.glowm.com/section_view/heading/Gynecologic%20Issues%20for%20Lesbia ns/item/430
Levitt, N. (2015). Clinical nursing care for transgender patients with cancer. Clinical Nursing Journal of Oncology Nursing, 19(3), 362-369.
Lim, F.A. (2014). Addressing health care disparities in the lesbian, gay, bisexual, and transgender populations: A review of best practices. American Journal of Nursing, 114(6), 24-35.
Merryfeather, L., & Bruce, A. (2014). The invisibility of gender diversity: Understanding transgender and transsexuality in nursing literature. Nursing Forum, 49(2), 110-123.
National Cancer Institute (2015). Anal cancer prevention: Information for health professionals. Retrieved from http://www.cancer.gov/types/anal/hp/anal-prevention-pdq
O’Byrne, P., & Watts, J. (2014). Include, differentiate, and manage: Gay male youth, stigma, and healthcare utilization. Nursing Inquiry, 21(1), 20-29.
Roche, K., & Keith, C. (2014). How stigma affects healthcare access for transgender sex workers. British Journal of Nursing, 23(21), 1147-1152.
Sabin, J.A., Riskind, R.G., & Nosek, B.A. (2015). Health care providers’ implicit and explicit attitudes toward lesbian and gay men. American Journal of Public Health, 105(9), 1831-1841.
Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Human sexuality and sexual dysfunctions. Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed., pp. 564-574). Philadelphia, PA: Wolters Kluwer Text
Safer, J.D., & Weinand, J.D. (2015). Hormone therapy in transgender adults is safe with provider supervision: A review of hormone therapy sequelae for transgender individuals. Journal of Clinical and Translational Endocrinology, 2, 55-60. doi: 10.1016/j.jcte.2015.02.003
National Center for Transgender Equality (n.d.). National transgender discrimination survey. Retrieved from http://www.transequality.org/issues/national-transgender-discrimination-survey
National Center for Transgender Equality (n.d.). Health & HIV. Retrieved from http://www.transequality.org/issues/health-hiv
Vanderbilt University Medical Center (2012). Key transgender health concerns. Retrieved from https://medschool.vanderbilt.edu/lgbti/key-transgender-health-concerns

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