Clinical laboratories could significantly improve healthcare for the transgender community by using both sex and gender identity to make decisions about clinical testing, and by determining normal lab values for healthy transgender patients. A review published today in AACC’s Clinical Chemistry journal emphasizes these as critical steps on the road to eliminating the many hurdles that transgender individuals face when seeking quality healthcare.
Surveys show that 25%-30% of transgender people delay or avoid healthcare due to fear of discrimination, 15%-20% have been refused care by medical professionals, and 25%-30% have experienced harassment or violence in a healthcare setting. In addition to this widespread overt discrimination, many healthcare protocols do not account for sex/gender incongruence and little medical research exists on the effect of gender-affirming hormone therapy and surgery on physiology. In particular, these issues hinder the ability of transgender patients to get accurate clinical laboratory test results—which in turn can lead to incorrect diagnoses and treatments. One serious example of this is a case in which PSA screening was correctly ordered for a transwoman, but a large national reference laboratory failed to flag the elevated results indicating prostate cancer because her sex was listed as female. As a result, her tumor was not caught until much later, when it had already advanced to stage 3.
In this review, a team of researchers led by Dina N. Greene, PhD, of the University of Washington in Seattle recommend best practices for clinical laboratories to help ensure that transgender patients receive equitable care. One of the most important steps labs can take is to base decisions on a patient’s birth sex and gender identity. However, labs frequently don’t receive both of these pieces of information. Labs should therefore develop institution-wide protocols for identifying transgender patients that highlight the different electronic medical record systems where sex and gender identity both need to be listed. As an additional precaution, when sex-specific tests such as those for PSA or pregnancy are seemingly ordered for a patient of the opposite sex, labs should not cancel these tests and should always properly flag the results.
A critical need also exists for labs to develop precise reference intervals for transgender patients taking hormone therapy. Reference intervals are the range of normal test values appropriate for a patient population and are crucial for correctly interpreting test results. Sex-specific reference intervals are used for hormone-related tests in addition to several indispensable primary care tests, such as those for cholesterol, liver and kidney function, and red and white blood cell levels. Until such reference intervals are established for the transgender population, lab professionals should use hormone therapy status and clinical judgment to assess abnormal test results in transgender individuals.
“Understanding gender incongruence, the clinical changes associated with gender transition, and systemic barriers that maintain a gender/sex binary are key to providing adequate healthcare to the transgender community,” said Greene. “Transgender appropriate reference interval studies are virtually absent from within the medical literature and should be explored. The laboratory has an important role in improving the physiological understanding, electronic medical system recognition, and overall social awareness of the transgender community.”