Military Family Physicians' Readiness for Treating Patients With Gender Dysphoria

In June 2016, the Pentagon lifted the ban on transgender personnel serving openly in the US military. As a result of the historic policy change, many military health care beneficiaries will likely seek services for gender dysphoria (GD). Transgender individuals are overrepresented by 2:1 in the military vs in the general population, and it is estimated that nearly 13 000 transgender individuals currently serve in the US military, 200 of whom will seek GD-related treatment each year.¹ Approximately 1700 uniformed staff and resident family physicians serve in the US Army, Navy, and Air Force on active duty status. Given that family medicine physicians are responsible for the primary care of most of the active duty force and their family members seen in military treatment facilities (based on TRICARE Prime enrollment data), they will have an important role in treating service members and other beneficiaries with GD. The Department of Defense has stipulated that proficiency in transgender-related issues must be attained by June, 2017; however, the extent to which military clinicians currently feel competent caring for patients with GD is unknown. Most civilian practitioners receive no formal training on transgender-related services,^2,3 and patients with GD cite fear of stigma and clinicians’ lack of cultural competence and sensitivity as barriers to care.^4,5 Thus, the current study assessed military physicians’ readiness to treat patients with GD.

Clinicians participating in the 2016 Uniformed Services Academy of Family Physicians annual meeting (n = 300), open to family physicians and other professionals, were invited to complete a pro bono survey electronically during or after the meeting. Of the 204 (68.0%) who participated, medical students and those who did not indicate training status (n = 24) were excluded. Sex/gender was determined by self-report. Analyses included descriptive statistics and logistic regressions. The study was approved by the institutional review board of the Uniformed Services University of the Health Sciences. Responding to the survey questions constituted consent to participate.

Participants were primarily white (85.5%) and male (62.8%) practicing in academic medical settings (54.0%). See Table 1 for participant demographics. Since earning their licenses, 37.3% of the clinicians had cared for a patient with GD. However, a preponderance of the sample (94.9%) received 3 or fewer hours of training on transgender care during their medical education; 74.3% did not receive any training at all. Eighty-seven percent of the sample reported that they had not received sufficient education to provide cross-hormone therapy for patients ready for gender transition, and 52.9% of the sample reported that they would not personally prescribe cross-sex hormones to an adult patient, even if they were provided with additional education or the direct assistance of an experienced clinician. Most of the sample (76.1%) felt that they could provide “nonjudgmental” care to a patient with GD, and half (50.9%) agreed that exposure to openly transgender service members would increase their comfort in caring for transgender patients. Adjusting for sex, race, years of experience, and practice setting, greater medical training in transgender care was not associated with perceived ability to provide nonjudgmental care to patients with GD (odds ratio [OR], 2.31; 95% CI, 0.97-5.52) but was significantly associated with the likelihood of prescribing cross-hormone therapy to an eligible patient (OR, 2.35; 95% CI, 1.23-4.48) (Table 2).

Most clinicians did not receive any formal training on transgender care during their medical education, had not treated a patient with known GD, and had not received sufficient training to prescribe cross-hormone therapy. Given that education in transgender care was significantly associated with greater likelihood of prescribing hormone therapy and that prior research shows that additional medical instruction on transgender care contributes to greater competency,⁶ it will be vital to augment the training of military physicians to ensure skill and sensitivity in treating patients with GD.

Corresponding Author: David Klein, MD, MPH, Department of Family Medicine, Fort Belvoir Community Hospital, 9300 DeWitt Loop, Fort Belvoir, VA 22060 (david.a.klein26.mil@mail.mil).

Published Online: March 13, 2017. doi:10.1001/jamainternmed.2017.0136

Author Contributions: Drs Schvey and Klein had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Schvey, Morettini, Klein.

Acquisition, analysis, or interpretation of data: Schvey, Blubaugh, Klein.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: Schvey, Klein.

Statistical analysis: Schvey, Blubaugh, Klein.

Administrative, technical, or material support: Morettini.

Supervision: Klein.

Conflict of Interest Disclosures: None reported.

Disclaimer: The opinions and assertions expressed herein are those of the authors and are not to be construed as reflecting the views of USUHS, the US Air Force, the US Army, US Navy, the US military at large, or the US Department of Defense.

Additional Contributions: We thank the Clinical Investigations Committee of the Uniformed Services Academy of Family Physicians for assistance with data collection.