Considerations on medical training for gender-affirming care: Motivations and perspectives

Abstract

Background: Many transgender individuals lack access to needed medical care, partially due to a lack of providers with experience in gender-affirming healthcare.

Aims: The purpose of this study was to identify professional motivators for medical providers seeking out training in gender-affirming care and to define which training experiences were most beneficial to their career development. By identifying experienced providers’ recommendations on which training modalities are most relevant to their practice, we aim to suggest future directions for medical education initiatives to effectively expand the transgender care workforce.

Methods: A voluntary cross-sectional electronic survey was distributed through professional listservs and publicly-available referral lists to interdisciplinary providers who self-identified as having experience in providing care to transgender individuals.

Results: One hundred and fifty-three (n?=?153) physicians, physician assistants, or advance-practice nurses responded to the survey. The majority (96.7%) were located in the United States, representing 37 states. The two most common motivators for seeking out training in gender-affirming care were filling a need in the community (73.0%) and/or having met a transgender-identified person in a clinical setting who requested care (63.8%). While many providers gained skills independently (57.3%), the two most commonly-available training opportunities were professional conferences (57.3%) and mentorship (41.3%). Respondents were most likely to recommend that others in their field be trained via structured clinical experience (e.g., a rotation or longitudinal exposure during training), rather than additional didactic training.

Discussion: This study identifies key high-yield training methodologies which could improve access to quality gender-affirming healthcare. Through integration of structured clinical experiences during training, direct clinical mentorship, and professional development at conferences on gender-affirming care, the workforce of welcoming and prepared healthcare providers for transgender patients will increase. This will lead to a tremendous improvement on access to gender-affirming care in our communities.     

Synergistic effects of pain and alcohol use in relation to depressive and anxiety symptoms among Latinos in primary care

Although past work has shown that alcohol use co-occurs with anxiety/depression among Latinos, little work has examined the variables that qualify such associations. The present investigation sought to address whether pain severity (i.e. pain intensity and/or pain-related disability, respectively) moderated relations between hazardous drinking and depressive/anxious arousal symptoms among an economically disadvantaged Latino sample recruited from a primary care medical setting. Participants included 253 adult Latinos (M_age = 38.5 years, SD = 10.8; 86.6% female) who attended a community-based primary care clinic. There was a significant interaction of hazardous drinking with pain intensity in relation to depressive symptoms and significant interactions of hazardous drinking and pain-related disability in relation to depressive and anxious arousal symptoms. Hazardous drinking was associated with more severe depressive/anxious arousal symptoms only when pain intensity/disability was high. This is the first study to demonstrate the moderating role of pain intensity and disability in associations between hazardous drinking and anxiety/depression among Latinos in a primary care medical setting.     

Exploring the Base for Family Therapy Edited by Nathan W. Ackerman,Frances L. Beatman,and Stanford N. Sherman

General systems theory and group psychoanalytic psychology are utilized to present a typology of consultation requests that face the liaison psychiatrist in a general medical ward. These theories are also used to suggest interventions that enable the liaison psychiatrist to accomplish the dual purpose of providing useful consultations to the medical staff and training them in the psychological care of their patients without becoming trapped in the contradictory demands of the pressured medical-ward setting. Examples of psychosocial-medical rounds are presented illustrating three different kinds of consultation requests and specific intervention strategies.     

Report of the Working Group on Governance and Administration

Prepared by the Working Group on Governance and Administration from the November 1995 Georgetown conference sponsored by the Association of Medical School Psychologists, this paper delineates the various trends in health care that may impact upon organizational structures for psychologists within academic medical centers. Ten variables that describe various functional issues within academic medical centers or health science centers are defined. Finally, seven organizational guidelines and recommendations pertaining to governance of psychological services are detailed.     

Patient and Family Descriptions of Ethical Concerns

Abstract

Ethically challenging situations routinely arise in the course of illness and healthcare. However, very few studies have surveyed patients and family members about their experiences with ethically challenging situations. To address this gap in the literature, we surveyed patients and family members at three hospitals. We conducted a content analysis of their responses to open-ended questions about their most memorable experience with an ethical concern for them or their family member. Participants (N?=?196) described 219 unique ethical experiences that spanned many of the prevailing themes of bioethics, including the patient-physician relationship, end-of-life care, decision-making capacity, healthcare costs, and genetic testing. Participants focused on relational issues in the course of experiencing illness and receiving medical care and concerns regarding the patient-physician encounters. Many concerns arose outside of a healthcare setting. These data indicate areas for improvement for healthcare providers but some concerns may be better addressed outside of the traditional healthcare setting.     

Communication Differences Between Physicians and Their Patients in an Oncology Setting

The physician-patient relationship has critical importance in the quality of medical care, especially in the oncology setting. Of particular interest over the past two decades has been the communication between physicians and their patients. It is understood that communication is related to patient and physician satisfaction as well as other medical outcomes. However, despite this interest and attention, investigators have only recently begun to assess the communication between physicians and patients from the patient's point of view. Additionally, previous investigations have primarily relied upon retrospective reports of the interaction from patients or physicians. The current investigation assessed physician–patient communication in an oncology setting, both as it was occurring and following the interaction. The units of analysis included participant ratings as well as those of trained observers. Findings revealed that physicians and patients disagree as to the valence of the messages which transpired. Additionally, results suggest that it is the patients who distort the messages in the positive direction. Research and clinical implications of this disagreement and positivity bias are discussed.     

The Five Senses of Haiti

The Five Senses of Haiti discusses a series of medical mission trips by physicians and medical students to the Central Plateau of Haiti delivering care in the outpatient setting. Practitioners describe their experiences through the use of their five senses to draw contrast between modern health care and medical practice in the developing world. Physicians in a resource poor setting are left without the usual diagnostic armamentarium and the safeguards and distractions of the modern hospital setting. This deficit creates an opportunity to devote time and focus to individual patients. Practicing medicine in this context clinicians use a heightened sense of awareness and increase their reliance on physical exam findings. Global medicine creates an opportunity for medical students to learn and physicians out of training to practice overlooked physical exam skills in the modern era. Physical exam findings and patient care yield diagnoses and fosters the bonds of the doctor-patient relationship.     

An Empirically Supported Framework for Addressing Pediatric Nonalcoholic Fatty Liver Disease in Outpatient Care

In the wake of the pediatric obesity epidemic, the prevalence of nonalcoholic fatty liver disease (NAFLD) has been rising. Standard care for pediatric NAFLD includes dietary and physical activity guidelines, but such recommendations are difficult for families to implement. Clinicians in medical settings may be called upon to address NAFLD; cognitive behavioral techniques that have been effectively used for pediatric obesity are likely applicable. However, given the unique circumstances surrounding NAFLD, it may be helpful also to incorporate community-based and telehealth strategies when assisting families. This treatment development report offers a framework for integrating cognitive behavioral techniques within a community-based, telehealth approach to treating NAFLD within a medical setting. A series of illustrative cases is presented to depict exemplary considerations for implementing this intervention.     

Integrating Care for Persons, Not Only Diseases

Integrated care is geared toward enhancing usual care and decision-making for common combinations of medical and mental health conditions, including the behavioral health and behavioral change aspects. Yet even with comprehensive and well-integrated care for health conditions and well-coordinated teamwork in place, some patients do not engage or respond to care in the way clinicians would like or predict. This troubles patients and clinicians alike and may be chalked up informally to things like medical complexity (multiple co-existing conditions), mental health conditions (that complicate care), or simply the case being considered complex or difficult. It also raises the question of how to address person-specific factors that interfere with care of whatever conditions the patient may have, and invites behavioral health clinicians in medical settings to look beyond care of conditions to the care of persons, and to look beyond disease-specific care management protocols to master generic practices of care management across whatever conditions the person may have. This person-centered emphasis is intrinsic to the concept of the “patient-centered medical home” which has burst into animated discussion and demonstration among providers, health plans, government plans, employer purchasers, and professional associations across public and private entities. This represents an opportunity for collaborative care clinicians to help shape the national state of the art in medical home and includes a range of person-oriented (rather than disease-oriented) practices for care management, including working systematically with complex patients and difficult patient–clinician relationships.     

“I knew that I wasn’t cis,I knew that,but I didn’t know exactly”: Gender identity development,expression and affirmation in youth who access gender affirming medical care

Abstract

Background: Research about gender identity development is still in its infancy, especially among youth who experience gender dysphoria and are accessing gender-affirming medical care.

Aims: This article contributes to the literature on how gender identity and gender dysphoria is experienced, expressed and addressed by youth who have started, or are just about to start, a gender-affirming medical intervention.

Methods: The project draws from qualitative interviews with 36 trans children and youth of different ages and stages of puberty. The data were collected in three specialized Canadian clinics that offer gender-affirming care and they were analyzed through inductive thematic analysis.

Results: Two interlinked dimensions of the youth’s lives allow meaning-making of their gender identity: 1) internal or personal and 2) interactional or social processes. Careful analysis reveals three gender identity development pathways that may be taken by youth, from early questioning to the affirmation of their gender identity. A discussion of current models of gender identity development and their limitations concludes the article.     

Health Care Reform and Psychologists in Medical Schools: Stress, Challenge, and Change

Psychologists from 45 academic health science centers throughout the United States and Canada gathered at Georgetown University for a national conference November 2–5, 1995 organized by the Association of Medical School Psychologists. This paper introduces the proceedings of that conference described in the next four articles in this issue of the Journal of Clinical Psychology in Medical Settings[Volume 4, number 1]. Papers prepared by the working groups focus upon clinical services, education and training, research, and governance and administration within the academic medical setting.     

The Impact of Gender on Productivity and Satisfaction Among Medical School Psychologists

The impact of gender on productivity and satisfaction was examined among a random sample of 293 psychologists employed as faculty members in medical schools. Forty-one percent of the respondents were female. Males were older than females, had worked in a medical school longer, had higher academic ranks, held more administrative positions, were more likely to be tenured, and earned higher salaries. When years of employment as a psychologist were statistically controlled, there were no gender differences in productivity, as measured by publications, presentations, and grant awards; however, gender differences in salary remained. Females were less satisfied than males with regard to salary, promotion opportunities, and overall respect. Results are discussed within the context of the changing gender composition within psychology and the changing demands within the health care system.     

The experiences of gender diverse and trans children and youth considering and initiating medical interventions in Canadian gender-affirming speciality clinics

Abstract

Background: Canadian specialty clinics offering gender-affirming care to trans and gender diverse children and youth have observed a significant increase in referrals in recent years, but there is a lack of information about the experiences of young people receiving care. Furthermore, treatment protocols governing access to gender-affirming medical interventions remain a topic of debate.

Aims: This qualitative research aims to develop a deeper understanding of experiences of trans youth seeking and receiving gender-affirming care at Canadian specialty clinics, including their goals in accessing care, feelings about care and medical interventions they have undergone, and whether they have any regrets about these interventions.

Methods: The study uses an adapted Grounded Theory methodology from social determinants of health perspective. Thirty-five trans and gender diverse young people aged 9 to 17?years were recruited to participate in semi-structured interviews through the specialty clinics where they had received or were waiting for gender-affirming medical interventions such as puberty blockers, hormone therapy, and surgery.

Results: Young people felt positively overall about the care they had received and the medical interventions they had undergone, with many recounting an improvement in their well-being since starting care. Most commonly shared frustrations concerned delays in accessing interventions due to clinic waiting lists or treatment protocols. Some youth described unwanted medication side-effects and others said they had questioned their transition trajectory at certain moments in the past, but none regretted their choice to undergo the interventions.

Discussion: The results suggest that trans youth and gender diverse children are benefiting from medical gender-affirming care they receive at specialty clinics, providing valuable insight into their decision-making processes in seeking care and specific interventions. Providers might consider adjusting aspects of treatment protocols (such as age restrictions, puberty stage, or mental health assessments) or applying them on a more flexible, case-by-case basis to reduce barriers to access.     

The Future of Psychology in Family Medicine

Psychology has been integral to the field of family medicine since its inception as a medical specialty in the 1960s. Psychologists and other behavioral scientists contribute to family medicine in teaching clinical skills, in defining research questions, in developing research methodology, and in creating integrated physical/mental health care delivery systems. Future developments in the field of psychology in family medicine are likely to emphasize development and evaluation of screening measures which identify mental health problems in primary care, development of early intervention for those mental health problems, and more precise measurement of process and quality of care and health outcomes. Psychologists have an important role to fulfill in educating physicians on alternatives to pharmacologic and medical interventions for common presenting problems in primary care. However, current economic forces shaping the practice of medicine may work against further enhancing the efficacy of the physician in dealing with psychosocial issues. The future role of psychology in family medicine is not yet delineated, and while the move toward parity of reimbursement for mental and physical health care delivery may enhance this collaboration, there is a need to continue to evaluate how the psychological well-being of patients is influenced in the evolution of new models of care delivery.     

The Care-Based Ethic of Nazi Medicine and the Moral Importance of What We Care About

This article reports on an inquiry into ideas used to justify the shift of medical ethos in Germany prior to and during the Nazi era, specifically the principles of care advocated by Erwin Liek and Karl Kötschau, the era's most influential medical theorists, who argued that commitments to care of individual sick persons (Fürsorge) had to give way to a preventive care that respects emerging needs of the entire society (Vorsorge). The article examines both the socio-cultural factors that shaped, and the far-reaching effects of, this manipulation of care. It argues that we should be attentive to the meaning and requirements of the care revealed in this debate, the ancient Greek idea of care as a concerned moral option.     

The Starting Early Starting Smart Integrated Services Model: Improving Access to Behavioral Health Services in the Pediatric Health Care Setting for At-Risk Families with Young Children

We evaluated the Starting Early Starting Smart (SESS) national initiative to integrate behavioral health services (parenting, mental health, and drug treatment) into the pediatric health care setting for families with young children. Data are presented from five pediatric care (PC) sites, drawing from families at risk due to demographic and behavioral health factors, with infants less than 12 months of age (n = 612). Families were randomly assigned to either the SESS program or a standard care Comparison group. We utilized longitudinal analyses to estimate differences in utilization rates for parenting, mental health, and drug treatment over 6 follow-up time points (3, 6, 9, 12, 15 and 18 months). Our findings indicate that SESS caregiver participants were 4.6 times (p < 0.001; CI = 3.33–6.26) more likely to receive parenting services, 2.1 times (p < 0.001; CI = 1.48–2.86) more likely to receive outpatient mental health treatment, and 1.8 times (p = 0.025; CI = 1.08–3.14) more likely to receive drug treatment than Comparison group participants. Our results demonstrate the success of the SESS program in coordinating and improving access to behavioral health services for high-risk caregivers within the pediatric health care setting and highlight the importance of continuing to focus public health policy on the behavioral health care needs of families with young children.     

Medical Psychology Services in Dutch General Hospitals: State of the Art Developments and Recommendations for the Future

In this article an overview is presented of the emergence of medical psychology in the care of somatically ill patients. The situation in the Netherlands can be considered as prototypical. For 60 years, clinical psychologists have been working in general, teaching and academic hospitals. Nowadays, they are an integrated non-medical specialism working in the medical setting of hospitals in the Netherlands, and are a full-member of the medical board. This paper discusses several topics: the position of the general hospital in the health care system in the Netherlands, the emergence of medical psychology in Dutch hospitals, the role of the professional association of medical psychologists, and the characteristics of patients seen by clinical psychologists. Following the discussion about the situation of medical psychology in other countries, recommendations are formulated for the further development of medical psychology in the Netherlands as well as in other countries.