Letters to the Editor  |   January 2015
Improving Osteopathic Medical Training in Providing Health Care to Lesbian, Gay, Bisexual, and Transgender Patients
Author Notes
  •  *Laura Arrowsmith, DO Tulsa, Oklahoma
Article Information
Medical Education / Obstetrics and Gynecology / Professional Issues / Psychiatry / Curriculum
Letters to the Editor   |   January 2015
Improving Osteopathic Medical Training in Providing Health Care to Lesbian, Gay, Bisexual, and Transgender Patients
The Journal of the American Osteopathic Association, January 2015, Vol. 115, 6-7. doi:
The Journal of the American Osteopathic Association, January 2015, Vol. 115, 6-7. doi:
Web of Science® Times Cited: 1
To the Editor: 
I read with great interest the editorial by Melanie A. Gold, DO, in the October 2014 issue of The Journal of the American Osteopathic Association .1 
As an osteopathic physician who also happens to be a transgender woman, I find it appalling that in many parts of the United States, it is incredibly difficult for transgender people to find access to health care. Anecdotally, nearly all of the trans-gender people I know, which is a relatively large number, have stated that they have been told, often multiple times, "We don't treat your kind of people." This experience is not unusual, as large surveys of the transgender population have found.2It has happened to me on more than 1 occasion. Half of us reported that when we did manage to find a physician who would accept us, we had to teach the physician how to care for us.3 
Part of our oath4 and duty as physicians is to care for all of our patients, not just patients we necessarily understand or agree with. I'm sure each one of us has treated patients whom we don't particularly like, or patients whose political, religious, or personal views are different from our own. But we treat them anyway. 
It seems as if those who refuse to treat transgender patients use their lack of training in this medical condition as a justification for their discrimination. A lack of knowledge could rationalize this response if it weren't for the vast amount of medical information about transgender health care that is easily accessible. But of course lack of knowledge is probably not the real issue. 
Statistics vary, but it is likely that 1 in 1000 people is transgender.5 So it is likely that many physicians will treat or already have treated a transgender patient whether they know it or not. Some transgender patients have learned that the only way to receive medical care or to be treated respectfully is to not disclose their transgender status to health care providers. 
Things are changing, though. Transgender people are being featured openly in movies, television shows, documentaries, books, and magazines. And, importantly, we are being shown authentically, not as objects of amusement or ridicule. We are beginning to stand up and openly express who we are despite the discrimination, rejection, misunderstanding, and, sometimes, violence we face. 
Although not yet clarified in the judicial system, there are many legal and federal policy experts who believe that the Affordable Care Act includes sections that pertain to medical care and health care discrimination against transgender patients (personal communication, H.G. Tobin, Esq, 2014). Furthermore, they believe that it is not only discriminatory but illegal to refuse to provide health care to a transgender patient if the physician also provides equivalent care for a cisgender (nontransgender) patient. For example, if you have provided hormone replacement therapy for a pregnant woman, then it is discriminatory to refuse to provide it for a transgender woman. The first legal cases alleging physician discrimination have been filed (written communication, Office of Civil Rights, 2012). 
All current medical research continues to confirm that transgender is not caused by a mental illness, nor is it a choice; rather, transgender is a congenital medical condition that deserves attention and proper care.6-14 It is not difficult to learn about and certainly is within the scope of all primary care physicians. 
As the American Osteopathic Association's code of ethics states: 
[T]he physician should not refuse to accept patients for reasons of discrimination, including, but not limited to, the patient's race, creed, color, sex, national origin, sexual orientation, gender identity, or handicap…. 
It is critical that the American Osteopathic Association support the incorporation of transgender health care education into every medical school curriculum. The American Medical Association, the American Psychiatric Association, the American Psychological Association, the American Psychoanalytic Association, and the National Association of Social Workers, among numerous other professional medical and mental health organizations, have issued policy statements saying that transgender is a medical condition that is best treated with supportive mental health, medical, hormonal, and surgical care. 
It is time for transgender health care to be a mandatory part of medical education. We are a vital and important part of the human population. We deserve medical care, too. (doi:10.7556/jaoa.2015.001) 
Laura Arrowsmith, DO 
Tulsa, Oklahoma 
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When Health Care Isn't Caring: Lambda Legal's Survey of Discrimination Against LGBT People and People with HIV. New York, NY: LambdaLegal; 2010. Accessed November 13, 2014. [PubMed] [PubMed]
Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011. Accessed November 13, 2014.
Osteopathic oath. American Osteopathic Association website. Accessed November 13, 2014.
Olyslager F, Conway L. On the calculation of the prevalence of transsexualism. Paper presented at: World Professional Association for Transgender Health Symposium; September 6, 2007; Chicago, IL.
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Hare L, Bernard P, Sánchez FJ, et al.  . Androgen receptor repeat length polymorphism associated with male-to-female transsexualism. Biol Psychiatry. 2009; 65(1): 93-96. doi:10.1016/j.biopsych.2008.08.033. [CrossRef] [PubMed]
Hengstschläger M, van Trotsenburg M, Repa C, Marton E, Huber JC, Bernaschek G. Sex chromosome abberrations and transsexualism. Fertil Steril. 2003; 79(3): 639-640. [CrossRef] [PubMed]
Kruijver FP1, Zhou JN, Pool CW, Hofman MA, Gooren LJ, Swaab DF. Male-to-female transsexuals have female neuron numbers in a limbic nucleus. J Clin Endocrinol Metab. 2000; 85(5): 2034-2041. [CrossRef] [PubMed]
Meyer-Bahlburg HFL. Transsexualism ("gender identity disorder") – a CNS-limited form of intersexuality? In: Hormonal and Genetic Basis of Sexual Differentiation Disorders and Hot Topics in Endocrinology: Proceedings of the 2nd World Conference. New York, NY; 2011.
Swaab DF. Sexual differentation of the human brain: relevance for gender identity, transsexualism and sexual orientation. Gynecol Endocrinol. 2004; 19(6): 301-312. [CrossRef] [PubMed]
AOA code of ethics. American Osteopathic Association website. Accessed November 7, 2014.