How to Provide a Safe Healthcare Space for Transgender Patients

Podcast Transcript

Dr. James K. Stoller:

Hello, and welcome to MedEd Thread, a Cleveland Clinic Education Institute podcast that explores the latest innovations in medical education and amplifies the tremendous work of our educators across the enterprise.

Dr. Tony Tizzano:

Hello, welcome to today's episode of MedEd Threat, an Education Institute podcast exploring healthcare for transgender and gender-diverse individuals. I'm your host, Dr. Tony Tizzano, director of student and learner health, here at Cleveland Clinic in Cleveland, Ohio. Today I'm very pleased to have Dr. Cecile Ferrando, associate professor of obstetrics and gynecology, director of the clinic's urogynecology and transgender fellowship programs, and director of transgender surgical services here to join us. Cecile, welcome to the podcast.

Dr. Cecile Ferrando:

Thanks for having me, Tony.

Dr. Tony Tizzano:

To get us started, could you tell us a little bit about yourself, your educational background, what brought you to Cleveland, and your role here at Cleveland Clinic?

Dr. Cecile Ferrando:

I'm a urogynecologist by training. I did my OB/GYN residency in Boston and was lured to Cleveland, Ohio because of the fantastic urogynecology fellowship that's here at Cleveland Clinic. I came in 2012 and did a three-year fellowship and then stayed on as a staff. So I've been here for nine years. A few years into my practice, we saw a massive need to provide access to transgender and gender-diverse people seeking gender-affirming care. So we started our transgender surgery and medicine program out of our LGBTQ+ center and it's evolved since then. So we offer comprehensive care for all patients seeking gender-affirming services, and it's been a very successful program and we've been able to take care of a lot of people. 

Dr. Tony Tizzano:

Yeah. And I'm so proud that we have it, but Cecile, to get started, you know, tell us how do we frame the importance of giving appropriate consideration to healthcare for transgender and gender-diverse individuals?

Dr. Cecile Ferrando:

There's really been historic lack of access, marginalization, discrimination for this patient population and for these people. There are almost as many transgender individuals as there are type 1 diabetics in the United States. There are almost 1.5 million people who identify as transgender or gender diverse. That's a lot of people. And so historically, these patients have had difficulty finding care, people who would open their doors. This is mostly a result of either feeling uncomfortable with knowledge and education about transgender care, but then it's also been deep-rooted in- in bias as well.

Dr. Tony Tizzano:

So there's different facets to this and I can see where, you know, a generation ago and even my generation of physicians hasn't really gotten formal training in this area. And if you don't stay up to date and seek out information in this area, it- it passes you by. So I suspect that your interest in this didn't come out of thin air. So what are some of the things that pushed you in this direction and- and made you sensitive to do something that many people aren't sensitive to?

Dr. Cecile Ferrando:

I'm gonna date myself but I graduated from college in 2003. And before going to medical school, I took a research position in New York City where I had access to transgender people. We weren't using the term transgender at that time, but I was encountering homeless youth as part of my job and what I very quickly recognized was that many of them were transgender. And again, we weren't using that terminology at that time, but I learned a lot about these people and became familiar with a lot of their struggles and realized very quickly that I wanted to start my early medical career with a very focused goal of being able to take care of this patient population eventually. And so I had a lot of this exposure as a very young pre-physician and established my goals early on.

Dr. Tony Tizzano:

Okay. You know, at the very root of all this too, I- I wonder if there's not a gap in our understanding of just the terminology. And for the purposes of our conversation today, you know, when we refer to somebody as being transgender, we're looking at gender diverse, transgender, genderqueer, while acknowledging there's still a spectrum of variations and preferred technology. Can you help us through some of that?

Dr. Cecile Ferrando:

Yeah. So, again, in this is, you know, speaking of- of what it was like 20 years ago, we didn't have a lot of terms. A lot of these individuals were referred to as cross-dressers or transsexuals as are very antiquated ways of referring to people who are gender diverse. So I think it's important to have a basic understanding of what this is. So, you know, to be transgender is to be an individual whose gender identity doesn't align with one's biologic sex. And when we're talking about sex, we're talking about our chromosomes and the things that lead to our biology, our external genitalia, our internal genitalia. So individuals who are transgendered have a misalignment between the two.

Gender identity is how we view ourselves within this world and that isn't based upon our sex. Our gender is a social construct. It's how society or culture has dictated what it means to be a man, what it means to be a woman, right? So our gender identity can sometimes be in conflict with that a bit. And then our gender expression is what we reveal to the world. And so not all of these things are always aligned.

And I think an important term to understand because we say it all the time, and I may even say it today is the term cisgender, which is the counterpart to transgender. Cisgender individuals whose gender identity aligns with their biological sex. And that's the majority of the population. 

Dr. Tony Tizzano:

Yeah. And it's always easy to be in the majority, but we really have to pay attention, as you mentioned, you know, 1.5 million people. And those are the people who perhaps say something. I mean, I wonder what the number really is at the end of the day, but thanks for helping us all become familiar with this because I think it's appropriate for us to learn this to be able to care for our patients. What do you see as some of the barriers for transgender individuals trying to access health care?

Dr. Cecile Ferrando:

Finding clinicians who are knowledgeable. You know, there are a few surveys that have been done, cross-sectional studies looking at physician and other types of caregiver knowledge of not gender-affirming care. You know, care that patients need in order to transition or self-affirm themselves, but just medical care preventative care. And interestingly, this number has evolved over time too. The number of clinicians who are willing to care for patients is not proportional with the percentage of those who feel like they have enough education to actually care for them. So while three quarters of clinicians may be more than willing to see an individual who identifies as transgender, less than half of them feel actually equipped to do it. And so I think that that's the biggest problem. So there's a problem with self-confidence and the ability to actually offer patients care.

Then obviously, there's the percentage of clinicians who have their own biases, which then further the marginalization that patients feel because they simply don't feel safe in their offices.

Dr. Tony Tizzano:

Do you think it's a good thing to say, "You know, I- I welcome you to my practice. I wanna tell you right up front that I don't consider myself expert, but I developed some outlines, so I don't miss." Can you be that straightforward? I mean, I would do it for obstetric patients. As I go back, I'm now saying, wow, a lot has happened in seven years. I need a checklist to make sure that I don't miss anything. And how do you think that's perceived? 

Dr. Cecile Ferrando:

Oh, I think that's perceived really well. I call it respectful curiosity. I think that's the best way to take care of this patient group, right? Be respectful, but be curious. And then you wanna add a little bit of transparency and honesty. So I think telling patients, "I may get this wrong, but I also want to just be really thorough. So if I make a mistake, please let me know." Just saying that affirms that they're in an all right space with you. So I think that it's important to do it that way. 

I also think this so-called inventory that you might be referring to, right? A checklist of all the things you should ask is really important. You know, I have a tremendous amount of experience taking care of transgender patients. I've seen, you know, thousands of patients at this point, but I use a scaffold also, I use an inventory also. And I sit with my patients and I send them to go through a few things, including, you know, doing an... what we call the organ inventory, understanding what organs they may or may not have, who the patient is, what their transition history is, whether they've had hormones, whether they've had surgery, and I go through each individual thing. And sometimes I even misspeak, but then you just say, "I apologize, I may have misunderstood. Can you explain it to me better." But I think that goes a long way. I don't think patients are expecting every person to be an expert in gender-affirming care, but the expectation is that they're going to be looked at in a very holistic way and in a very honest way.

Dr. Tony Tizzano:

Yeah, I couldn't say that better. You know, I feel that one of the things that the clinic always puts out there is that we're a team, we work in teams. And I look at the amount of information that we have and the speed with which it's increasing and doubling, and there's no way for any one person to be spot on unless you're so specific in your interests. And you know, finding that person to help navigate all the other providers for our LGBTQ patients, I think it's really important if we do nothing more to- to get them in hands that are capable while we're trying to learn. So, you know, what are the steps to begin to bridge this gap in our practices? It's one thing to be here at the clinic where everyone is aware, you know, more than a practice in rural Ohio. You know, how do we get that group to look at this with a open mind and a more focused lens and make the appropriate judgments and referrals?

Dr. Cecile Ferrando:

So that's where, you know, recruiting champions for offices is the most important part. And it can be anybody, right? It doesn't have to be somebody who's clinical. It can be an administrative person who works within an office. Every office space should have somebody who really understands this aspect of care that is culturally competent in gender diversity, understands the language and the terminology and continues to improve on the processes within the office and educate new members, old members, provide updates, and to be that individual who navigates patients. I think that if we were intentional about making sure that we had individuals like this in all types of practices, urban, rural, I think it would really help patients feel like they could, you know, approach those practices and feel safe.

Dr. Tony Tizzano:

So when the, you know, trans individual Google's our hometown, and looks for someone who has interest or expertise in this area, you're gonna find nothing. So you land on someone's doorstep. You know, how are these patients made to feel when they come? Do you think it's open arms, or do you think there's a problem? 

Dr. Cecile Ferrando:

Oh, I think there's a problem. You know, I think that patients now what's happened is that there's clustering for care. So patients travel to clinics that are specifically targeting transgender individuals and providing gender-affirming specific care, which means that those clinics have long waits, that the more patients you have, the more difficult it is to get back to patients even if you have the best of staff. So these clinics are you know, overpopulated, so to speak. So there is actually a need for other practices to step up and to help take care of these patients. So I think that not creating these welcoming spaces which require such small effort can be really detrimental. Some patients cannot go to these other clinics, and so they don't get the care that they need. And we're not just talking about gender-affirming care, right? We're just talking about preventative health care.

Dr. Tony Tizzano:

Yeah. I think, again, it's sometimes incumbent upon us as physicians to make sure the team is, you know, on point and, you know, touching base with the front desk. You know, I had the privilege of taking care of my first transgender patient and he needed a pelvic ultrasound for bleeding. And I went down to radiology and unfortunately the person I knew who was going to do the ultrasound wasn't there that day. And so I lost track of it. But no sooner had they had their procedure done, their study done, as I got a phone call and said, "I can't tell you how pleased I was. The respect I was shown and the sensitivity." And I just about had a lump in my throat when they were saying 'cause I was so concerned. So you know, it takes so little effort to try and of course, if you don't think they didn't get feedback, you'd be wrong. I made it a point of visiting them personally and thanking them.

So, you know, there are special considerations also that we may not think about around fertility and pregnancy and contraception, that you think, "Oh, that's not an issue for them." What sort of issues do we need to know about?

Dr. Cecile Ferrando:

Well, first and foremost, transgender people get pregnant. (laughs) Some desire pregnancy and it's intentional and others do not. I think there is a misconception that those individuals on gender-affirming hormones are unable to get pregnant, meaning most commonly transmasculine individuals, those are individuals assigned female at birth, but identifies male, many of them are on testosterone. There's this misconception that because they don't have their menses that they're not ovulating and "can I get pregnant because of the testosterone?" That is not true. It is not a contraceptive. It reduces the conception rate, but it is not zero. And so it's not an effective form of birth control. So I think that's important and making sure that we assess patients' desires to become pregnant versus not, and not make assumptions about what their needs are without directly asking them. 

There's also the misconception that gender-affirming hormones like estrogens and testosterone, render patients infertile. That's not true either. We've studied this and we know that they're able to have fertility while on hormones but also if hormones are stopped, fertility is significantly improved. So patients can be advised of this if they want to start families. So I think that those are the biggest sort of misconceptions, but I also think that putting, uh, definitions to what a family looks like I think we do that with a lot of bias also, and forget that families look different for different people and that we should remain open-minded about those things too. 

Dr. Tony Tizzano:

Yeah, I can't agree more with that. And I sometimes think that perhaps television has done more to help open our minds (laughs) than some of the things that we would consider in the realm of formal learning. So for the individual with interest, you know, if any, should there be certain guides to preventative care for the transgender individual? Or is it based on the organs you have?

Dr. Cecile Ferrando:

Yeah, we've looked at this and we've certainly published some guidelines. But one of the things you'll notice that in, certainly in any of the guidelines that I've contributed to, we've made it really clear that most of our guidelines are extrapolations based upon cisgender guidelines, taking into consideration original, you know, biologic sex, followed by any type of gender-affirming treatment. So was somebody born biologically male or female? Have they undergone exogenous hormone therapy that changes risk stratification, it can change certain things like the density of breast tissue. You know, and I'm referring to breast cancer screening. And then what organs does somebody have? A biologic female who identifies as a man may or may not have a cervix for Pap smear screening, if they've had a hysterectomy for gender affirmation or another indication. So get, not making any assumptions is probably the most important thing. 

So it first starts with understanding someone's biologic sex and just simply asking them, "You know, you are presenting... You know, tell me who you are? What is your preferred name? What are your preferred pronouns? Tell me about your biologic sex. What have you done in terms of your transition? And then let me specifically ask you about certain organs just to be sure." And then extrapolating from what we know from the cisgender population when it comes to things like breast cancer screening, cervical cancer screening, prostate screening.

Dr. Tony Tizzano:

Yeah. And as you articulate that, I can't imagine how we can't start there. You know, we could start with any patient without knowing these things that we take to be the foundation of the care we're about to administer. So, just shifting a tad to mental health issues and for example, intimate partner violence, you know, what are the differences there that we need to be aware of?

Dr. Cecile Ferrando:

Just like sex minorities, gender minorities are at bit higher risk if we look at epidemiologic data. And, you know, again, this is self-reported data for the most part, so you have to understand that in self-reported data, there are often underestimations of the true prevalence of these things. But I think that you shouldn't make an assumption that all transgender people have experienced intimate partner violence. That would be a very bad assumption, but I think remembering to ask about it. And, you know, we've looked at this across all patients, and as clinicians, even OB/GYNs, we sometimes forget to do this or we make assumptions about people feeling safe at home. It's probably the number one thing that is missed on (laughs) board examinations or when we do clinical, you know, OSCEs for our medical students, but this patient population, the prevalence is higher because of that discrimination and marginalization. And so it's important to- to first create that space so that you may then ask them and screen for it.

Dr. Tony Tizzano:

Yeah, I think it's important. In my entire life, I've been involved with a domestic violence agency and worked around sexual assault at our local hospital and part and parcel of my intake is simply: Are you safe at home? And are you safe with your partner?

Dr. Cecile Ferrando:

I would say that with this patient population, what I've learned also is that I have been very specific about asking about psychological abuse, because there are some also assumptions that abuse is either sexual in nature or physical violence. But transgender individuals will very commonly report other types of abuse that have occurred across sort of their lifespan whether it be with partners, family members, et cetera. And so I always specifically ask about that because that definitely can affect a patient's frame of mind, understanding where they're coming from when they come into your office. So it's good to also be specific. 

Dr. Tony Tizzano:

And finally, in your role in the surgical environment, you know, what sorts of services are offered here at the clinic for transitioning individuals?

Dr. Cecile Ferrando:

So we have it all. I'm proud to say that. (laughs) We have a very comprehensive program. The most important is preventative health services for individuals who are transgendered by a team of people who really understand their needs, in the context of them being transgender and seeking gender-affirming care. But when it comes to gender-affirming care, there's medical care, so that includes gender formation or affirming hormone therapy, so providing hormones to help with transition process, androgens or testosterone for transmasculine people, estrogens and anti-androgens for transfeminine people. We also have a wonderful mental health care service line for all of our patients. That has been a very successful program and we've had great leadership in that area. And we offer all of the surgeries. So there are chest surgeries for both masculinizing and feminizing procedures, genital surgeries for both as well. And then facial reconstruction. And so we again have a comprehensive team between our gynecology, urology and plastic surgery departments.

Dr. Tony Tizzano:

Fabulous. You touched on things I hadn't really thought about. So what lies on the horizon? If you had your magic wand, what would you, what would you have next?

Dr. Cecile Ferrando:

You know, it doesn't have to be that big of an innovation. I think that we would be providing the biggest service to our patients if we had better aggregate data that was accurate, that we really were able to capture patients over the long term to show how they're thriving in the supportive medical environments that we're creating. And so being able to capture outcomes in the long term is something that's been missing. We really rely on that in medicine, right? Not just immediate outcomes, not just two year, four year, five year, but we would like to know how patients are doing 20, 30 years out from gender-affirming medicine, or the services that they're receiving, whether they be surgical or medical. I think that not to sort of ensure that we are caring for them properly, doing the right thing so to speak, but more so so that we can learn what else we should be doing adjunctively to improve their outcomes even more or to support them.

Dr. Tony Tizzano:

Excellent. Well, Cecile, this has been a very insightful and certainly thoughtful and thought-provoking look at what I think is a very important topic. Are there some questions I should have asked or things that you'd like our audience to know that I may have missed?

Dr. Cecile Ferrando:

In a time where the rights of our patients are being threatened a bit, and also where there is concern that we won't be able to provide as much care as we once have been able to provide over the last 10 years, I always say, you know, don't close the door, open it wider. Meaning we might not be able to provide the full spectrum of gender-affirming care in every hospital system or every state currently. And, you know, who knows what will evolve over time. But to make sure that our patients feel that they can still get very good affirming, preventative health care is going to be what's will keep them healthy, right? And what will maintain the trust that has been built over the last decade in the healthcare system. So I just say open the door wider in the face of adversity and welcome patients and any chance that you get.

Dr. Tony Tizzano:

Well said. I hope that that last comment resonates with every one of us. Certainly resonates with me and I hope it's resonated with our listeners. That is extraordinarily important. 

Well, thank you so much, Cecile. This has been a fascinating and enlightening episode of MedEd Thread. To our listeners, thank you very much for joining and we look forward to seeing you on our next podcast. Have a wonderful day.

Dr. Cecile Ferrando:

Thank you.

Dr. James K. Stoller:

This concludes this episode of MedEd Thread, a Cleveland Clinic Education Institute podcast. Be sure to subscribe to hear new episodes via iTunes, Google Play, SoundCloud, Stitcher, Spotify, or wherever you get your podcasts. Until next time, thanks for listening to MedEd Thread, and please join us again soon.