SAN DIEGO -- Despite advances in civil rights in the gay and lesbian community, transgender patients still face discrimination and disparities in the health system, an expert on gay healthcare said here.

Transgender people routinely avoid using healthcare resources because of the way physicians may have treated them in the past, or because of fear of being treated differently, said Joe Freund, MD, a family physician in Des Moines, Iowa, who cares for a large base of gay, lesbian, bisexual, and transgender (GLBT) patients.

"I've got trans[gender] patients who refuse to go to the emergency room unless they're basically unconscious because of doctors screaming out of the room when they discovered something they didn't think they were going to find," Freund said at the American Academy of Family Physicians (AAFP) scientific assembly. "People are poorly treated at times."

Transgender patients often have difficulty finding physicians who are accepting of their condition, willing to treat them, and knowledgeable about the nuances that come with their care.

"Some practices really don't know very many GLBT folk," Freund said. "What that may create is discomfort that is felt immediately by the patient."

Transgender people are more likely to lack insurance coverage or have inadequate insurance. They also are routinely denied coverage because their gender identity and resulting treatments are deemed pre-existing conditions.

"Hopefully, this will be addressed -- both access issue and exclusion -- when the [Affordable Care Act] comes on board," Freund said.

Jennifer Burnett, MD, a family practitioner in Selma, Calif., said that between one in 500 and one in 1,000 individuals in the U.S. are transgender, but it's hard to find a more exact number because so many refuse to seek routine healthcare care or simply can't find it. Burnett presented a poster at the AAFP on a treatment protocol for male-to-female transsexual.

Healthcare disparities in the transgender population is particularly prevalent in the mental health field with up to a third of suicide attempts by teens reported as related to sexual orientation or gender identity.

Roughly a third of GLBT people have reported attempting suicide at some point in their lives, Freund said, although that number drops for transgender people after sex reassignment surgery (BMC Psychiatry 2008).

"We've got a [sex reassignment] treatment that works," he said. "We just don't use it."

Medicare is currently examining whether or not it should cover sex-change surgery, and Freund called the pending decision "vital."

"It is a part of healthcare. It shouldn't be looked at as something that's optional," he told MedPage Today.

Furthermore, there are few GLBT-based clinical recommendations, Freund said.

Family physicians sometimes forget that transgender women still have a prostate that needs to be examined, and that transgender men are still susceptible to breast cancer, he said. GLBT patients face much higher risk for smoking, substance abuse, and sexually transmitted diseases.

Today's healthcare system is not properly set up to acknowledge GLBT issues, Freund said. Demographic information isn't collected so health data can be identified, although that is starting to change.

"We're getting more [training] in schools and residencies as time goes on," Freund said.

There is a growing base of resources on transgender health for providers, such as the Gay and Lesbian Medical Association and Fenway Health in Boston. The University of California at San Francisco recently started a Center of Excellence for Transgender Health.

Providers can ask transgender patients what pronoun their patient wants them to use or avoid the use of pronouns entirely, Freund said. Their office forms can be altered to account for GLBT-sensitive questions and information. Physicians should take a more complete history to catch the disparities that may exist.

"The more and more you ask about it, the more comfortable you are with it," Freund said.