Access to health care is not a privilege, but a basic right. Yet for many marginalized populations, and the transgender and non-binary (TGNB) community in particular, barriers to basic health care are pervasive. These include lack of knowledgeable and competent providers, experiences of prejudice, discrimination and trauma in health care settings, and cultural barriers.¹ As a result, many TGNB individuals, people whose gender identities and/or gender expressions do not align with their sex assigned at birth may not seek routine health care or delay necessary care.²

According to the Report of the 2015 U.S. Transgender Survey, representing nearly 28,000 respondents:³

• One-third of those who saw a health care provider in the past year reported having at least one negative experience related to being transgender, such as being refused treatment, verbally harassed, physically or sexually assaulted, or having to teach the provider about transgender people in order to get appropriate care, with higher rates for people of color and people with disabilities
• In the past year, 23% of respondents did not see a doctor when they needed to because of fear of being mistreated as a transgender person, and 33% did not see a doctor when needed because they could not afford it

Seeking urologic care presents unique challenges for TGNB individuals, as many aspects of urology are inherently “gendered” based on genitourinary anatomy and urologic evaluation often involves sensitive exams. Using “male” and “female” labels linked to reproductive anatomy may trigger gender dysphoria (ie psychological distress resulting from incongruence between one’s sex assigned at birth and gender identity). Genital exams can be traumatic for many transgender individuals, 47% of whom have experienced sexual assault at some point in their life.³ As a result, adopting a trauma-informed care (TIC) approach for all TGNB patients is appropriate. Trauma doesn’t introduce itself when you walk in the room, but you have to assume that it is there, in some form, with every patient that you interact with. Acknowledging this, learning to recognize trauma, and integrating practices to prevent re-traumatization are basic principles of TIC.⁴ In a qualitative study describing experiences of urologic care among individuals assigned male at birth, one trans woman said, “The doctor seemed unaware…of the trauma that comes with being a trans woman and being around and being attacked on the street.”⁵ Providers may include the following TIC techniques during physical exams:

• Preparing the patient for what will happen during the exam
• Providing warning before physical touch
• Involving the patient in their physical exam
• Performing the exam in the patient’s preferred position (i.e. do not have trans women or transfeminine people stand for genital exams)
• Asking if you may use anatomical language
• Providing chaperones for sensitive exams

The Substance Abuse and Mental Health Services Administration’s Concept of Trauma and Guidance for a Trauma-Informed Approach provides additional guidance for TIC implementation.⁴

Another patient in the same qualitative study shared, “When it comes to medicine, there needs to be both sensitivity and competence. I don’t care how nice you are if you don’t know what you’re doing [when caring for transgender patients].” Providing competent urologic care to TGNB individuals is multifaceted, and includes:

• Awareness that TGNB patients may most often seek care for general urology issues (eg kidney stones, gross hematuria, urinary tract infections) rather than care directly related to their gender identity or transition;
• Understanding each patients’ anatomy, including an accurate record of which organs a patient may or may not have in an “organ inventory” (ie recording the presence of a prostate after vaginoplasty);
• Familiarity with basic principles of gender affirming genital surgery; and
• Understanding that not all TGNB patients will elect the same medical and surgical transition (ie erectile function may remain important to transfeminine patients and receptive vaginal intercourse may remain important to transmasculine patients).

Urologic trainees have historically received minimal to no education in transgender specific care,^6,7 however resources such as the AUA Core Curriculum and AUA Update Series now include TGNB health and may fill educational gaps.

Figure 1.

When accessing urologic care, patients interact with staff at the front desk, over the telephone and through electronic health records. Many nurses, nursing assistants, and medical assistants graduate without training in transgender care. Each of these interactions provides opportunities for misgendering (calling a patient by their birth sex rather than their gender identity in pronouns and prefixes), dead-naming (using a patient’s birth name rather than chosen name), or other harmful microaggressions. As one patient shared, “What happens at the front door is figuratively speaking...the foundation block of what’s going to happen next. And if you start out being misgendered then the entire thing is going to put you on eggshells.”⁵ Using chosen names and pronouns should extend into chart notes and written communication, as these are shared with patients and other providers, and this act of respect will strengthen the trust between the patient and provider. This may require extra attention in electronic medical records when some fields may be auto-filled. Training for all staff members in how to appropriately address and care for TGNB patients is a basic first step in improving quality of care, and would ideally be a part of an ongoing effort with accountability and self-reflection. Fortunately, many clinic staff and health care providers have a high level of compassion toward this community and are eager for knowledge.⁸ Figure 1 provides additional suggestions for creating a safe, affirming experience in the urology clinic for TGNB patients.

In summary, practicing trauma-informed care, undertaking education in TGNB-specific urologic needs and transgender health, diligence with using correct names and pronouns in direct and indirect communication, and providing a gender-affirming clinical space are steps that all urologic providers can take towards reducing health disparities among TGNB people.