Trans individuals may report greater levels of dental fear and increased barriers when accessing healthcare services, say Katie Horisk, Emma Underwood, Michael Petch and Adele Johnson.

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Abstract

It is essential to raise awareness of the health and social needs of trans individuals. This article presents the barriers that trans people may encounter when accessing healthcare services and offers practical recommendations on how holistic care may be achieved.

Introduction

It is highly important to raise awareness in the dental profession of the issues surrounding the management of trans patients. The umbrella term 'trans' describes individuals whose gender is not the same as the sex they were assigned at birth. This encompasses a wide variety of terms including transgender, non-binary, gender-fluid and agender.1

The Government Equalities Office (2018) estimates that approximately 200,000-500,000 trans people are living in the UK.2 Therefore, as dentists, it is probable that in all settings we will provide care for these patients. Additionally, there has been an increase in the paediatric population, with referrals to the paediatric Gender Identity Development Service in the UK increasing from 697 in 2014/2015 to 2728 in 2019/2020.3,4

It has been reported that trans individuals can experience greater levels of dental fear and increased barriers when accessing healthcare services. In the United States, the National Transgender Discrimination Survey highlighted several factors which impact on trans patients' experience of healthcare services. These included refusal to provide them with healthcare, harassment and patient delay in seeking care due to the fear of discrimination.5 This has also been described by The Trevor Project, with 78% of transgender and non-binary youth reporting discrimination due to their gender identity.6

Further research in the UK, highlighted by the Stonewall LGBT in Britain - trans report (2018), stated that 41% of trans individuals felt that healthcare staff failed to acknowledge their specific health needs.7 A lack of recognition and understanding of individual requirements when accessing services can lead to emotional distress. Additional factors found to impact on patient care include staff expressing their negative views towards trans individuals and healthcare professionals focusing on trans status when it is irrelevant to the reason for attendance.8 Increasingly, these patients may also be the target of bullying, with 40% of LGBT+ pupils reporting homophobic, biphobic or transphobic cyberbullying.3

There are a number of wider factors to consider in the holistic management of trans patients. Trans people report higher rates of mental health issues, disability or being neurodiverse.9 Other research shows that facets such as being trans, non-heterosexuality, left-handedness and being double-jointed tend to cluster together.10 All of these may require levels of adaptation in our services. There is a need for caution when correlating autism and trans identities,11 as this can lead people to believe there is a causal relationship, which is often weaponised against trans autistic individuals to minimise their sense of self.

The eight recommendations listed are to aid us as healthcare professionals in appreciating the individual requirements of these patients and to provide a holistic approach to their health and social needs.

Recommendations for managing trans patients

  1. 1.

    Training - equality, diversity and inclusion training should reflect on the needs and experiences of trans patients, including the maintenance of their privacy and confidentiality.5 Staff training and continued educational opportunities will result in increased knowledge and understanding of managing this potentially vulnerable population without judgement12

  2. 2.

    Policy - dental clinics should have a clear policy which communicates a zero-tolerance approach to transphobia. This refers to discrimination, bullying and harassment based on gender identity7

  3. 3.

    Undergraduate education - collective action to promote the inclusion of teaching in dental schools would increase awareness and knowledge of the emotional, social and physical needs of trans patients. This has been highlighted by trans patients as a priority when seeking treatment13

  4. 4.

    Teaching - the Stonewall report recommends training programmes and that Royal Colleges review their course content to ensure LGBT+ health inequalities and needs are included in compulsory teaching7

  5. 5.

    Open setting - create a welcoming environment by considering the display of LGBT+-friendly signs; for example, the rainbow badge initiative introduced by various NHS trusts. Such symbols establish an open and non-judgemental setting, putting the patient at ease while encouraging communication and establishing rapport

  6. 6.

    Pronouns - ensure that the patient's name and pronouns are documented in the clinical records and that these are consistently used by all team members, including reception staff.12 A simple question, such as 'can I ask what pronouns you use?', will demonstrate respect. This can be universally applied to all of our patients. Pronouns used may include 'he' and 'she'; however, some may use gender-neutral pronouns, such as 'they', 'them' and 'theirs'14

  7. 7.

    Communication - communicate sensitively as disclosure can be difficult for patients. Ensure sufficient time is devoted to listening to the patient and addressing any concerns they may have. Following a disclosure, the information should be kept confidential. If it is relevant to share this information (for example, to ensure a service you are referring to is aware of patient-specific needs) do this with the patient's consent12

  8. 8.

    Safeguarding - in the paediatric population, a heightened awareness of safeguarding risks which present more commonly in the transgender adolescent is essential. These include self-harm, suicide, problems at home or school and the potential for bullying.3

There is limited dental literature on the management of trans patients; therefore, we hope the listed recommendations will aid clinicians when providing care in their areas. There are a wide range of trans support services in the UK (Table 1), some of which can provide staff training. Ensuring clinicians and healthcare services are sensitive and competent in treating trans patients will result in trans people feeling safe, respected and cared for holistically.15

Table 1 Useful UK resources for healthcare staff and patients requiring support
Full size table

This article was originally published in the BDJ on 12 March 2021 (Volume 230 pages 283-284).