Q&A: What gender-affirming care is, and how it’s provided at Ohio State

June 2024 Editor’s Note: Nima Baradaran, MD, no longer treats patients at the Ohio State Wexner Medical Center, but his expertise shared in this article is still relevant and accurate.

In many ways, patients who identify as transgender share the same medical needs as their peers who are cisgender (people whose gender identity matches the one they were assigned at birth). Routine screenings, tests and checkups are necessary for a healthy mind and body.

But the prospect of seeing a doctor — even for basic care — may feel daunting for trans-identifying individuals who have faced societal stigma or discrimination.

Too often, those fears are validated. Nearly half of transgender people reported experiencing mistreatment from a medical provider, including refusal of care and verbal abuse, according to a 2021 study from the Center for American Progress. One in 3 respondents said they’ve had to teach their doctors about transgender people.

“Even though this patient population is a minority by the numbers, they are still a significant demographic who deserve high-quality care,” says Ryan Nesemeier, MD, a facial plastic and reconstructive surgeon at The Ohio State University Wexner Medical Center. “Creating spaces where patients feel safe and affirmed in their decision to seek care is paramount in establishing trust.”

The Ohio State Wexner Medical Center strives to deliver gender-affirming care with an inclusive, multidisciplinary approach. In recent years, the health system has expanded the range of surgical options and opened a dedicated primary care clinic for transgender patients.

In advance of the Transgender Day of Visibility (March 31), Nesemeier shared thoughts alongside Ohio State Wexner Medical Center urologist Nima Baradaran, MD; Andrew Keaster, MD, an internal medicine physician and co-founder of the Ohio State Transgender Primary Care Clinic; and Amy Moore, MD, chair of the Ohio State Wexner Medical Center’s Department of Plastic and Reconstructive Surgery. Here are highlights from the conversation:

What does it mean when health care professionals say “gender-affirming care”?

Dr. Keaster: To me, it’s two related but distinct entities. The first is having a primary care home where patients feel they can safely access care from a doctor who will listen, respect and affirm them for anything related to their medical care. The second is the provision of care related to a transition. This could entail signing forms to help them update legal and identity documents, such as for a driver's license. It can also be hormone therapy or referrals for surgical services.

Dr. Baradaran: Patients who see discrepancy between their gender identity and the sex they were assigned at birth can suffer significant emotional distress. The goal of gender-affirming care is to reduce this discrepancy as much as possible with medical or surgical interventions. We try to provide unbiased care in an inclusive environment that most trans folks have been deprived of.

Dr. Moore: I think gender-affirming care is about recognizing that people are human and embracing individuals who want to feel more of who they are. We can provide medical treatment and surgical procedures that can be life-altering.

What are your top priorities when working with patients who are transgender?

Dr. Nesemeier: My first concern is making sure the patient feels comfortable and safe. Many trans-identifying and non-binary patients have had negative experiences in health care settings, making them wary of new providers, staff and facilities. Sharing deeply personal aspects of their life with a stranger can be anxiety-provoking. I try to lead with compassion, establish common ground and work to understand how I can use my abilities to help them achieve their goals.

Dr. Keaster: I’m cognizant of what I say, how I introduce myself, how I interact. It all comes from self-reflection. We all make mistakes. As we learn, not only do we correct ourselves, but we become advocates. So, when I’m talking to our trainees, part of our education is cultural humility and how we use inclusive language, sensitivity and respect. That has been a big mission at both the Ohio State Wexner Medical Center and The Ohio State University College of Medicine.

In what ways has gender-affirming care evolved?

Dr. Baradaran: Gender-affirming care has been around for decades, but what has really changed is the visibility and the fact that academic institutions are taking a lead. A lot of gender-affirming care has been provided in isolation without widespread published research. Our mission is to deliver quality patient care, but also to train future leaders and report our research to improve outcomes.

Dr. Moore: When I was in school two decades ago, transgender care and surgical training for gender-affirming procedures were not part of our education. What I think is so great about the field of plastic surgery is that it’s innovative and patient-centric. Over a short span of time, we have approached an area of need that is now part of our training. It’s an opportunity to apply our skills and surgical principles to elevate care.

Dr. Keaster: Patients often find us via word of mouth. But over the past decade, we went from few doctors knowing about or providing gender-affirming care to it really being on the radar — well beyond your “rogue” community doctors. And it's not offered just in small, isolated practices; it’s in your larger medical centers. This awakening and the availability of services have come a long way.

When it comes to services that cis patients also regularly receive, are there different considerations for someone who’s transgender?

Dr. Baradaran: The majority of care is gender-neutral. But if somebody has had complex surgery or has very specific hormone requirements or we’re talking about gender-specific cancers — screening for prostate cancer in a trans female who has had vaginoplasty, for example — long-term follow-up care is needed. Complications can happen, but also “normal” things could be perceived as abnormal by people who aren’t familiar with the concept of gender affirmation … the urologic and sexual functions that play a huge role in patients’ wellbeing.

Dr. Nesemeier: Every person has unique anatomic challenges. The difference with trans and non-binary patients is that many of the services I perform can have a much bigger impact on their quality of life and ability to function in society — securing a job, obtaining housing, impacting their overall safety in public and visive lifespan. But, on the other hand, there is also more medical gatekeeping regarding the care of these patients. It is common for insurance companies to require mental health evaluation (sometimes with two separate providers) before covering certain gender-affirming treatments or procedures. This stigmatizes trans-identifying patients, and often leads to significant delays in care. Although mental health care is important, mood disorders aren’t unique to gender-diverse people.

What do you see as the greatest misconceptions about gender-affirming care?

Dr. Nesemeier: The most damaging misconception I hear is that people will regret their decision to undergo gender-affirming care/surgery and want to “de-transition.” In actuality, the overall rates of this are extremely low. This sentiment is, however, common in our society, especially when it comes to transgender youth. Most trans and gender-diverse people have an internal sense of who they are very early in life. Receiving treatments, such as hormone blockers, earlier in development can have a significant positive impact on their quality of life, and potentially prevent the need for many more invasive interventions in the future.

Another misconception is that there is a true “binary” (or only two options) of “biological sex.” Every person possesses masculine and feminine qualities; finding harmony within those is an individual process. There is no single “male” or “female” experience, and the notion of a binary continues to create harm — not only for gender-diverse people, but for everyone.

Why is it important to offer gender-affirming services and clinics?

Dr. Baradaran: Ohio State is unique. It’s a big institution, and we have many departments, so it’s easier to coordinate care under one umbrella and collaborate. We’re sensitive to a variety of patients and the needs that might be neglected or overlooked in a place where their insurance status might be more important.

Dr. Keaster: I’m very proud we have a transgender primary care clinic, but it can be a double-edged sword because patients must self-identify in order to see us in this particular clinic within the Ohio State Wexner Medical Center. Ultimately in health care, we should get to a point where all physicians — no matter where they practice — know how to navigate a transition for patients. Housing everything together in a center at Ohio State allows us to bring in more medical and nursing students to get that experience.

What's the message you'd like patients who are transgender to know when seeking care?

Dr. Moore: We are committed to their health, and we want to provide innovative procedures based off science and data. We have this at Ohio State. I understand some may be a bit fearful of how they’ll be received, but we are dedicated as an institution to providing elevated medical care, not just surgical care.

Dr. Baradaran: I met a patient who told me she’s extremely skeptical to go to any doctor. That is in most part the health care system’s fault because we haven’t gained the trust of the trans community. My message is that the culture has changed, and the providers’ approach has changed. We strive to regain their trust so their basic health care needs are no longer neglected.

Dr. Nesemeier: I want to convey to my patients that I see them. I am their ally in getting the care they need to achieve their goals, which are unique to every patient, and are irrespective of gender identity. I’m proud to work at an institution putting the time and resources behind building a true multidisciplinary team to provide this care to the most marginalized people in our society.