Intro
I was very fortunate to be invited to a webinar hosted by an LGBTQ+ specialist medical massage therapist, discussing specific considerations for manual therapists, equitable treatment approaches, and how to create a safe space for the LGBTQ+ community in practice.
Concrete Experience →
The webinar was fantastic, and highlighted the struggles faced by LGBTQ+ people when trying to access healthcare, the significant health inequalities produced by these (particularly for trans people), and more specific clinical considerations.
These included a number of social and service-based factors, such as 64% of GPs self-reporting that they do not have adequate training in transition related healthcare, 24% of trans people fearing discrimination in accessing healthcare, increased rates of depression, anxiety, PTSD, and suicide attempts amongst the trans population, and average waiting times for Gender Identity clinics across the UK being 36-60 months pre-COVID.
There were also a number of specific clinical considerations, such as:
- Increasing incidences of micro-dosing black market hormones due to poor access to transition related healthcare
- Tissues for phalloplasty often being taken from latissimus dorsi, and the musculoskeletal consequences from this
- Chest binding in trans women being associated with costochondritis, cardiorespiratory complications, panic attacks, and worsening of scolioses
- Potential consequences of oestrogen therapies including anterior pelvic tilting (after 2-3 years), worsening of scolioses, association with osteoporosis and fibromyalgia, and increased incidence of breast cancer.
- Potential consequences of testosterone therapies including increased tone and mass of muscle tissue (particularly upper traps and SCMs), development of prostate tissue (after 2-3 years), and risk of side effects if therapists touch the site testosterone gel is administered to (usually over left deltoids and posterior shoulder)
Reflective Observation ↓
I really wasn't aware of the severity of the problem with regards to people of the LGBTQ+ community accessing appropriate healthcare, particularly with regards to the lack of knowledge amongst professionals, fear of discrimination, and the mental health ramifications of all of these factors. I toying with the idea for some time of buying ally pins to wear on my name badge at work, but hadn't done so for fear of offending the more conservative cohort of our practice's population. Now I see how important it is to create a safe space for LGBTQ+ people in practice, and to be open about inclusivity. The pins are currently out for delivery!
I don't have much experience of seeing trans people in clinic, but can recall one particular trans man who came to see me several times and we ended up building good rapport. We spoke about skin being taken from the medial surface of his forearm for the purpose of his gender affirming surgery, but I wasn't aware at all that he may have had tissue taken from his latissimus. I wonder now if this may have had any influence on his upper back pain. Sadly I won't see him again as I no longer work in the same catchment, but will take this knowledge forward as a consideration for any future patients I meet who may have had surgery using latissimus tissue.
A particular gap in knowledge surrounded hormone treatment, and a lack of access leading to black market demand. I had no idea that hormones could cause the development of prostate tissue, or that there was a significant increase in incidence of breast cancer
Active Experimentation ↑
I started wondering if this might be an idea for a research project: to explore whether or not trans people are being invited for appropriate cancer screening, and if not, how could appropriate flags be placed on their records to do so. I will discuss this further with the research co-ordinator at AECC to see if this could be a viable study.
Abstract Conceptualisation ←
Particularly learning about hormone therapies got me thinking about screening. Was this another health equality that trans people were facing? GP records act as a data hub for a patient, and all of their demographic details are extracted from this point to be used across other domains of the NHS, one of which is national screening.
If a trans person chose to change their sex on their GP record to indicate their gender, this may alter their inclusion/exclusion criteria for national screening programs. For example, a trans male may still have breast tissue, but as their GP record states that their sex is male, they may no longer be invited for breast screening as part of the National Screening initiative. The same would go for cervical screening. Prostate screening is not part of the National Screening initiative per se, but I wonder if this is a consideration that medical professionals are taking, for example when ordering blood tests or considering hyperplasia symptoms later in life.