This Doctor Prescribes Respectful Care to the Trans Community

When Robbie Goldstein, A05, M12, GBS12, finished his M.D. at Tufts University School of Medicine and started his infectious disease residency, he wanted his career to focus on HIV care and prevention. “I thought that I would work mostly with gay and bisexual men,” he said. But Goldstein, who also has a Ph.D. from the Graduate School of Biomedical Sciences, soon learned that the people impacted most disproportionately by HIV are actually transgender women.

According to the CDC, 42% of transgender women have HIV, and the rate increases to 62% if they are Black. “I started to think, If this is the community that’s highest at risk, what can I do to support that community?” Goldstein said.

His work led him to help create Massachusetts General Hospital’s Transgender Health Program. As medical director, he guides the clinic in providing respectful care to a population that has long been disenfranchised by the health care system.

It started in 2014 with a conversation. Goldstein sat at a table with MGH doctors, nurses, researchers, and other staff, including transgender people and people with transgender family members. They decided that the hospital not only needed a space—a dedicated clinic—for trans patients, but that it needed to educate everyone at MGH, from the doctor performing knee surgery to the valet parking a patient’s car, about interacting with trans and nonbinary people. “We had to actually change hearts and minds across the hospital so that everyone saw it as their responsibility to provide affirming care to the trans community,” Goldstein said.

The hospital created a webinar that is now part of the onboarding for all new hires. It also held small group sessions where employees could ask Goldstein and other knowledgeable staff about what it means to be transgender or nonbinary. Everyone has questions, Goldstein said, but it shouldn’t be up to patients to educate health care workers during impromptu conversations.

“The time to ask those questions is not when you're the nurse in the recovery unit and someone's waking up from anesthesia, or you're the primary care doc doing someone's physical,” he said.

But there are questions that are always appropriate, and necessary, Goldstein said. “Much of gender-affirming care really comes down to just asking: What is your name, what are your pronouns, what is your gender identity?” When the clinician mirrors those words back, “that opens the door for patients to be more open with us.”

Clinicians need to recognize that patients are more than their anatomy, Goldstein said. “A transgender woman does not become a woman when she starts hormones or has surgery. She's a woman from the moment she identifies as a woman.” If that same transgender woman has a prostate, the clinician needs to screen for prostate cancer, but can talk about it in a way that still affirms the patient’s gender.

“It doesn’t affect my exam in any way,” he said. “What it does is create a safe space to build on the doctor/patient relationship.”

While they worked to change the hospital culture, Goldstein and his colleagues reached out to clinicians from internal medicine, pediatrics, psychiatry, surgery, urology, OB/GYN, and other practices around the hospital, who signed on as providers. In September of 2018, the program started seeing patients—and there was a flood of them. Many were not transfers from other hospitals or providers, but people who had not been in primary care for years, if ever. Goldstein suspects that was in part because of past discrimination.

“About 50% of trans people nationally say that they've actually been denied care when they went into the health care setting,” Goldstein said. One national survey of transgender and nonbinary people found that 28% reported being harassed in medical settings.

The program has enrolled about 1,000 patients, ages 5 to 80, and provides help with everything from hormones to surgery to the legal process of name change. But Goldstein’s team also conducts routine physicals and treats runny noses.

“We're here to be your primary care doc, which means if you don't want to talk about gender in that visit, we don't have to,” Goldstein said. “It's likely not relevant to the last time you got a tetanus shot.”

Eventually, the program hopes to engage community members in research, to answer questions about the long-term benefits of hormones and other gender-affirming care on mental and physical health.

But even in a few short years, Goldstein has seen the program change lives. One of his first patients was a transgender woman who was newly diagnosed with HIV. Today, he said, “her HIV is undetectable. She's on gender-affirming hormones. She's going through gender-affirming surgery.” And in part from the social services the team connected her to and the stability provided by her medical care, “she went from being marginally housed to having a place to live every night.”

“There are real impacts of us being able to provide this type of specialty care,” Goldstein said, “for a community that has been vulnerable for a very long time.”