Barriers in LGBTQ Care: Exploring Highlights from Day 2 of the 2021 ACOG Annual Meeting

Minority patient populations face a unique set of social and economic barriers to healthcare, including transgender, transmasculine, and nonbinary patient communities. And Day 2 of the 2021 ACOG Annual Clinical and Scientific Meeting brought to light some of the challenges these communities have to endure daily. Here are a few sessions exploring these barriers and investigating how OB-GYNs can enhance their care of these communities.

Care Considerations for Pregnancy in Transmasculine & Nonbinary Patients

For transmasculine people, meaning transgender men and nonbinary people whose biological sex assigned at birth was female, the pregnancy process can be challenging. These patients often avoid seeking OB-GYN care for fear of facing stigma and discrimination.

In a session on transmasculine patients and pregnancy, Dr. Beth Cronin, an Assistant Clinical Professor of OBGYN at Brown University/Women & Infants Hospital, highlighted three key barriers to care for this patient population: lack of insurance, lack of transgender training in healthcare settings, and the fear of being outed to their employers. She emphasized that these patients likely have specific needs focused on fertility, contraception, pregnancy, and abortion.

At the root of the session, Dr. Cronin urged OB-GYNs to have better conversations with their patients. Some of those conversations are highlighted below:

• Do you have the desire to be pregnant? This question is often overlooked, but it’s important that patients understand their options for both pregnancy care and abortion care.
• Have you considered fertility treatments? A patient’s eggs can be cryopreserved, either on their own or after fertilization.
• What medications are you taking? Review patients’ medications that may have an impact on fertility. Patients may have to stop taking testosterone for ovulating to resume in addition to taking prenatal vitamins and tracking their cycle.
• Would your insurance cover any pregnancy procedures? Insurance often fails to cover trans-specific health services, so providing financial connections and identifying pro-bono folks to help cover the costs of these procedures can be beneficial.

Dr. Cronin also recommended a few considerations for OB-GYNs caring for transmasculine patients looking to get pregnant and shared a few strategies for helping them overcome barriers.

For instance, the psychological experience of pregnancy can be challenging for many patients. With little to no role models of gender variant parenting, patients often experience loneliness and isolation, and some suffer from postpartum depression. That’s why Dr. Cronin recommends having open and honest conversations with patients about their experiences and seeking out resources for postpartum depression that are more inclusive.

But improving inclusion and quality of care for transmasculine patients goes beyond these conversations, according to Dr. Cronin, and what’s happening directly within practices may be reinforcing some of the discrimination transmasculine patients fear.

Dr. Cronin emphasized the importance of a few considerations to help eliminate any negative stigma from your practice:

• Do you and your staff receive transgender training? According to Dr. Cronin, a least a third of transmasculine patients have had a negative experience in a healthcare office. And even if you’re having these open conversations and providing the best care you can, if your front staff isn’t providing that same level of care, these patients will continue to feel mistreated and discriminated against.
• What does your office look like? What does your signage say? Do you have gender-neutral bathrooms? Improving these things can help transmasculine patients feel more comfortable in your office and more willing to come back for follow-up appointments.
• What types of resources are you providing? Resources are important to help them answer questions and provide support, but oftentimes, these resources are gendered and not inclusive. Ensure that the resources you’re recommending are non-discriminatory and inclusive, such as Fenway Health.

Guiding transmasculine patients through pregnancy can present a unique set of barriers, but having informative conversations and creating an inclusive environment can help improve care and eliminate discrimination for this patient population.

Reducing Health Disparities in the Transgender Population: Improving Health Equity & Determinants of Healthcare Delivery

How can OB-GYNs optimize their practices and help improve health disparities in the transgender community? Dr. Courtney Marsh, an Associate Professor and Reproductive Endocrinology and Infertility Division Director of the Center for Advanced Reproductive Medicine at The University of Kansas, discusses health disparities in the transgender community and shares strategies to develop gender-affirming, culturally sensitive methods of incorporating health screening and health maintenance to improve transgender health outcomes.

Dr. Marsh began her session by highlighting some of the key differences in health risks among the transgender community, including a 34-fold increase in HIV for transgender youth, a 6-fold increase in suicide for transgender youth, and an increased risk of cancer due to hormone therapy.

But before getting deeper into health risks, Dr. Marsh emphasized that social determinants could increase these threats, such as the risk of homelessness and stress, a lack of access to care, healthcare professional bias or lack of knowledge among healthcare professionals, a high cost of care, a lack of social support, and a high risk of violence and/or abuse.

Health risks in this patient population are also impacted by barriers to healthcare, some of which include an ICD-10 diagnosis of gender dysphoria by healthcare professionals, which can be discriminatory; coverage denial for gender-conforming surgery or any related procedures; and verbal harassment.

Dr. Marsh encourages a few actions OB-GYNs can take to help implement inclusive changes in office practices and health system settings to reduce disparities in transgender care. She recommends the following:

• Educate yourself and encourage education for your staff: Dr. Marsh emphasizes that it’s not on the burden of the patient to teach; OB-GYNs and practice staff need to educate themselves to provide comprehensive care. The World Professional Association for Transgender Health is a valuable resource for this.
• Affirm transgender care: This can be done by utilizing appropriate pronouns and being respectful of the name the patient prefers to be called and how they prefer to identify. Don’t forget to make sure that your front staff is doing the same. Stick to anatomical terms, and be careful with the language you use.
• Make changes in your office: Include an option in your patient intake form to allow them to indicate their preferred pronoun. Ensure that your bathrooms are gender-neutral and that your signage is inclusive.

According to Dr. Marsh, keeping these considerations in mind can help lead OB-GYNs down the path to a more inclusive, supportive healthcare environment and reduce disparities in transgender care.