The first thing she heard after waking up from surgery was “Sir, I need you to remain calm.” She was there for a gender-affirming orchiectomy, and the person who uttered these words assumed her gender based on the name of the procedure. This situation could have been easily avoided by a more thorough look at the patient’s chart and history. While this act of misgendering was made unintentionally, it is not necessarily benign.

Similar experiences of misgendering and gender dysphoria still frequently occur within the health care setting. Approximately 33% of trans individuals have reported at least 1 negative experience with their health care provider related to their gender identity, and 23% reportedly avoid seeking health care due to fear of mistreatment.¹ With more health care systems, providers, and insurance companies now offering coverage for gender-affirming care, the number of transgender and gender-diverse (TGD) people seeking to establish and undergo care is projected to increase.

As a result, the demand for health care providers and physicians who are competent, sensitive, and well-trained in providing TGD-specific care in urology is also anticipated to increase. However, medical school and residency curriculums historically have provided limited training and education on TGD specific health. Available studies have reported that around 74% of medical students have received less than 2 hours of training on transgender health throughout their education.² It is imperative that we address these discrepancies, but where do we start? How do we close this educational gap?

What Standards Should Be Implemented in Medical Curriculums to Ensure the Future Progress and Safety for These Patients?

In the absence of formal educational guidelines, some recommendations for learning objectives in medical student curriculums include:

1. Historical barriers to care for TGD patients. Experiences of prejudice, discrimination, and trauma in health care and society, socioeconomic barriers, inappropriate pathologizing of gender incongruence, and dysphoria are just some of the barriers TGD individuals continue to face. Understanding these experiences would help trainees provide culturally informed care that can decrease the risk of re-traumatization within health care.
2. Gender identification terminology on sex, gender, and orientation. Terminology is ever-changing, and it is important to stay up to date on proper and respective language to improve care.
3. Pronouns and name. Asking and addressing a patient by their name and pronouns is one of the most important ways for physicians to first establish rapport and build trust with patients. It is crucial for trainees to have an understanding of the different pronouns used by persons to self-identify as well as the negative impact “dead-naming”—when one refers to a TGD person by a name they did not ask you to use or by a name they used prior to transitioning, usually the name they were assigned at birth and with which they no longer identify.
4. Gender transition (social, medical, and/or surgical). Transitioning is not a single step nor a single experience. Understanding the various steps one may or may not go through to affirm their gender identity and/or expression helps ensure optimal care is being provided. While hormonal (medical) treatments are primarily managed by a patient’s primary care physicians and/or endocrinologist, intended and unintended effects of feminizing and masculinizing hormonal therapies impact urological examinations and management. Every person’s transition process is unique, and they should receive care tailored to their individual experience.
5. Current standards of care on criteria for gender-affirming medical and surgical treatments for adults and adolescents. The guidelines provided by the WPATH (World Professional Association for Transgender Health)³ and the Endocrine Society^4,5 are designed to promote optimal TGD patient care, not limit access to care.
6. Elements of establishing a gender-affirming environment. Knowledge of how to promote safe and culturally informed care for TGD patients to avoid inducing gender dysphoria is an essential competency, as well as how to ask the important questions respectfully.
7. Elements of a trauma-informed care approach in urology. A urology-focused history and examination can be particularly intrusive for TGD patients, especially during the vulnerable moments accompanying examination and discussion of genitourinary and reproductive organs. It is therefore critical to understand how to perform a patient encounter and examination that avoids re-traumatization in a patient population already at such a high risk.

What Should Training for Health Care Professionals Providing Care for TGD Patients Entail?

The WPATH has put forth recommendations on cultural-knowledge training focused on treating and caring for TGD patients with dignity. For health care institutions and professionals, recommendations include training during orientation and as part of annual or continuing education, as well as training within each of the competency areas for the health care professional’s specialty.³ Implementing these strategies to ensure that these competencies are being met requires more attention and consideration. Should we incorporate standardized assessments and certifications for learners? Should we also allot an increased proportion of curricular resources and time to ensure adequate training? Collectively, clear and consensual learning objectives need to be defined in order to promote the highest quality of care for our patients.

Where Can Health Care Professionals and Patients Find More Information and Resources for TGD Care?

1. The World Professional Association for Transgender Health (https://www.wpath.org/):³ Information on clinical guidance for health professionals to assist TGD people with safe and effective pathways for social, medical, and surgical treatment for those experiencing gender dysphoria or discordance is provided within their Standards of Care, Version 8.
2. The Endocrine Society Clinical Practice Guidelines (https://www.endocrine.org/advocacy/position-statements/transgender-health):⁵ Provides standards of care for supporting TGD individuals, including information on pubertal suppression, hormones, and surgery and also standardizes terminology used by health care professionals.
3. The National Center for Transgender Equality (https://transequality.org/):⁶ Provides information for health care providers and patients on resources for rights to health care, mental health and social support, safe housing, insurance coverage, transition-related financial support, and employment.
4. The Center for Excellence in Transgender Health (https://prevention.ucsf.edu/transhealth):⁷ Resources available include online learning courses for health care professionals, manuals and clinical practice guidelines, and fact sheets and summaries on providing optimal evidence-based care for TGD patients.