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One in three transgender patients reports experiencing serious discrimination or bias when seeking medical care, even when that care is unrelated to their transgender status, according to a recent survey of nearly 30,000 people, released in December.

These negative experiences ― which ranged from verbal harassment, physical or sexual assault and refusal of treatment, to having to educate doctors about transgender people ― degrade the overall standard of care that transgender people receive, no matter what health care needs they may have. In fact, 23 percent of survey respondents said they skipped seeing a doctor, even though they needed to, for fear of mistreatment.

While some of these negative interactions in health care may stem from discriminatory attitudes on the part of medical care professionals, a survey published this week, this one among endocrinologists, reveals that doctors feel they lack the training they need to feel confident when treating transgender patients.

The online survey, which was sent to members of the Endocrine Society, is the first to measure American doctors’ confidence levels and willingness to treat transgender patients, explained lead author Caroline Davidge-Pitts, an endocrinologist who specializes in transgender and intersex medicine at the Mayo Clinic.

Survey reveals the severe lack of training in transgender health care

The anonymous survey found that while 80 percent of hormone doctors have treated a transgender patient, 81 percent of them also said they had never received any training on the care of transgender patients.

Among program directors, 72 percent said they provide some kind of education on transgender health topics, and 94 percent said this training is important. However, the program directors said they struggled to educate their fellows on these issues because they don’t have enough experienced faculty to teach the subject.

Davidge-Pitts hypothesized that some negative experiences between a transgender patient and caregiver come down to a doctor’s low confidence and competence in transgender health care, due to a lack of education or awareness. But she thinks that as transgender health care, which encompasses medicine, mental health, primary care and surgery, becomes a more common concentration in U.S. medical schools and health care facilities, transgender patients will start to report more positive interactions with medical experts.

Only about half of the 104 program directors of endocrinology fellowships responded to the survey, as did only 411 of the 6,992 doctors affiliated with the Endocrine Society. This could indicate a willingness only among transgender-friendly doctors to respond.

“There may be a slight positive bias with that, but I still think [the results] show promise,” said Davidge-Pitts. “What concerned me more was how many of our providers in the endocrinology world are seeing transgender patients with very little education behind them.”

Of the minority of doctors who said they did receive training, only 4 percent said they got it during medical school, while only 7 percent said they were trained during their residency. The majority of teachers who received specialization got it during their endocrinology fellowship (58 percent), while 53 percent learned more at local, national or international meetings.

One way to bridge the education gap, said Davidge-Pitts, would be an online course that could provide a standard curriculum to programs across the country about how to address transgender health care needs.

Lack of specific training is no excuse for discrimination

“When transgender people have a negative experience, it can just turn them away from any preventive care, or seeking care at all,” said M. Dru Levasseur, director of the Transgender Rights Project at Lambda Legal, a national LGBT nonprofit legal organization. “A lot of people wait for emergency care because they’re so afraid of going to the doctor.”

Lambda Legal was the first to cite the Affordable Care Act’s non-discrimination provisions in a federal lawsuit for the right to health care, regardless of sex or gender identity on behalf of transgender patients. The group’s client, Naya Taylor, had decided to resume hormone medication to treat her gender dysphoria, but her primary care doctor in rural Illinois told her she did not have enough experience to prescribe the medication to her. Taylor was eventually told by the clinic that it “does not have to treat people like you.”

Lambda Legal filed the lawsuit in 2014, but then dropped the case a few months later when Taylor died after a heart attack. They have since filed similar lawsuits, the most recent of which was against a New Jersey hospital for denying a transgender man a routine hysterectomy. But what Taylor’s case demonstrates, explained Levasseur, is that doctors should not be able to claim ignorance or a lack of expertise to deny hormone medication to transgender patients.

“I do think that medical schools need to provide better training so that physicians can be culturally and clinically competent,” Levasseur said. “But all the information they would need to care for a transgender person are available online for everybody, and there’s really no excuse for doctors to turn transgender people away from treatment.”

“It’s so important for people who are trained in endocrinology to know that part of their responsibility for the population they’re going to serve is to transgender people,” Levasseur concluded.