AUA Session Highlights the General Urologist’s Role in Gender-Affirming Care

“May I never see in the patient anything but a fellow creature in pain,” reads part of the Oath of Maimonides. This quote was used to open a session from the final day of the American Urological Association (AUA) 2024 Annual Meeting focusing on what urologists should know about caring for transgender patients or those seeking gender-affirming care, presented by Polina Reyblat, MD, chief of the urology department at Kaiser Permanente Los Angeles Medical Center.

Transgender individuals make up less than 1% of the US population. To put it into a urological perspective, Reyblat noted this is about how many patients have urethral strictures in the US.

Touching on health economics, a third of transgender or nonbinary patients live in poverty, and they have 6 times higher unemployment rates compared with the general US population, alongside a 10-fold increase in suicide attempt rates. This is reflected in survey results from 2022, where 28% of transgender or gender-diverse patients said they did not visit a health care provider when needed because they could not afford to, with 33% of patients saying the same back in 2015. These survey results also showed that 48% of transgender or gender-diverse patients had at least 1 negative health care experience related to their gender identity, growing from 33% in 2015. Additionally, 24% of patients said they did not seek out health care in the prior 12 months out of fear of this discriminatory treatment, similar to 23% in 2015.

However, Reyblat noted that significant strides are being made in medical education, with recent surveys revealing that about half of urology residents nationwide—particularly those in coastal regions, reflecting insurance coverage patterns—have had exposure to transgender patient care, although this training remains largely absent for many urologists.

“Additionally, urology is inherently gendered; we work with gender organs, and reproductive anatomy is very male and female,” Reyblat added. “Since genital exams can be traumatic, and a lot of patients had sexual trauma before, I want to emphasize the trauma-informed care to avoid active retraumatization of our patients.”

Symbols of the gender spectrum | Image credit: Olga Tsikarishvili – stock.adobe.com

Trauma-informed urology care involves 4 main components:

• Realizing the widespread impact of trauma and understanding paths for trauma recovery
• Recognizing trauma signs and symptoms in patients, families, and health care staff
• Integrating knowledge of trauma into policies, procedures, and practice
• Actively avoiding retraumatization

Urologists can incorporate certain practices into their routine to avoid retraumatization, and assuming all transgender or gender-diverse patients have a form of trauma can help instill these practices. Some habits that can benefit all patients include preparing them for what the visit will entail, getting consent before making physical contact, and making sure the patient is an active participant during their physical exam.

Urologists should also be mindful to perform physical exams in the patient’s preferred position. For example, urologists should avoid examining transgender women in a standing position, and avoid using stirrups or positioning transgender men into a lithotomy or birthing pose during pelvic exams. They can also ask patients if it is OK to use anatomic language when necessary, and allow chaperones to be present at the patient’s request.

It’s also important to note that urology care for transgender patients goes well beyond just top or bottom surgeries; in the pyramid of the transgender care spectrum, undergoing surgery is at the very top at the smallest point. Urologists typically follow transgender patients before, during, and after the transition process. As the care spectrum moves up the pyramid, other conversations include potential hormone therapy as well as interest in surgery.

The conversations don’t always entirely revolve around the transition process either. Transgender patients can present with unrelated urologic issues just like everybody else, such as overactive bladder, urethral strictures, erectile dysfunction, kidney stones, and so on. They can also experience genitourinary-specific complications like meatal stenosis, stream deviation, and urinary tract infections, among others.

It’s also important to educate patients on their risk of certain conditions, such as how transgender women are still susceptible to prostate cancer after surgery. Reyblat explained that many transgender women are not aware that the prostate stays in place, emphasizing the importance of prostate cancer screening when these patients are eligible, as the cancer can be more advanced by the time it is identified due to delayed screening. Because of this, a proposed screening workflow for transgender women involves having the expectation of a lower prostate-specific antigen levels because of their long-term estrogen use, but conducting an MRI of the prostate in cases of elevated levels.

“In conclusion, I want to say that gender-affirming surgery is an effective treatment, but it's not a cure to gender dysphoria, and we continue with the patients and help support them throughout their journey,” Reyblat closed. “So, back to my original statement, let's help our patients.”

Reference

Reyblat P. State-of-the-art: transgender care for the general urologist. Presented at: AUA 2024 Annual Meeting; May 3-6, 2024; San Antonio, TX. https://aua2021.app.swapcard.com/event/2024-annual-meeting-san-antonio/planning/UGxhbm5pbmdfMTczMDU0Nw==