Abstract
Objective:
To examine how specialist-to-pediatric primary care provider (PPCP) consultative support may impact PPCP comfort in providing gender-affirming care.
Methods:
PPCPs in West Virginia completed an electronic survey. T-tests compared comfort providing gender-affirming care and rank-sum tests compared the practicality of four consultative support modalities by time in practice and specialty.
Results:
Of 51 participants, 47.1% had been in practice for <10 years and 59.6% were trained in pediatrics. PPCPs with <10 years in practice and those trained in pediatrics were more comfortable providing gender-affirming care than those in practice >10 years and those trained in family medicine. PPCPs felt that telemedicine was more practical than tele-education, although they reported all consultative support modalities would increase comfort providing this care.
Conclusions:
Access to consultative support can increase PPCP comfort providing gender-affirming care, although certain modalities may be more effective for PPCPs with varying levels of experience and specialty training.
Keywords: telehealth, transgender, pediatrics, vulnerable populations
Introduction
Recent school-based studies suggest that as many as 7–9% of adolescents in both rural and urban areas identify as gender diverse, or endorse a gender identity that differs from their sex assigned at birth.1,2 This group of youth has been shown to experience significant mental health disparities, including rates of depression, anxiety, and suicidality that are far higher than their peers.3 Fortunately, an increasing body of literature suggests that both affirming environments and access to gender-affirming medical care are associated with improved mental health outcomes among this group.4–12
Unfortunately, many gender diverse youth (GDY) experience barriers to accessing gender-affirming care. One such barrier is the limited number of providers who have received education and training in caring for GDY.13,14 Historically, this has limited the provision of gender-affirming care to specialty care settings in large, tertiary pediatric hospitals, which are frequently located in major metropolitan areas, making them difficult to access, especially for youth living in rural communities.13,14
Because of these existing barriers, an increasing number of GDY and their families are seeking guidance and support from their pediatric primary care providers (PPCPs).15,16 Although existing research suggests that PPCPs often lack adequate training in this area,13,17 little is known about whether access to consultative support from specialists would help PPCPs feel more comfortable providing gender-affirming care in their practices. Thus, the purpose of this study was to (1) examine how access to consultative support impacts PPCP comfort providing gender-affirming care, (2) explore PPCPs' perspectives on four potential consultative support modalities, and (3) determine whether comfort and preferences differ by provider-level characteristics such as time in practice and specialty.
Methods
STUDY DESIGN AND RECRUITMENT
PPCPs across West Virginia (WV) completed a 76-item anonymous online survey distributed electronically through professional medical organizations in the winter of 2021 through the spring of 2022. This study was determined to be exempt by the West Virginia University IRB (Protocol #2110449675).
MEASURES
Demographics
Survey items included demographic characteristics, including, age, years in practice, gender identity, sex assigned at birth, provider level of training (resident, attending physician, advanced practice provider), and provider specialty (pediatrics, family medicine).
Comfort providing gender-affirming care with consultative support
To broadly assess the impact of access to consultative support on PPCP comfort providing various aspects of gender-affirming care, participants were provided with the statement stem, “If I had access to timely consultative support from a pediatric gender clinic specialist, I would feel more comfortable…” This was followed by seven different aspects of gender-affirming care provision pulled from current World Professional Association for Transgender Health Guidelines,18 including providing information and resources; advocating for affirming environments; referring to affirming behavioral health providers and for gender-affirming surgeries; and prescribing, monitoring, and refilling gender-affirming medications (see Table 3 for full item text). Responses were measured on a Likert Scale from 1 = strongly disagree to 5 = strongly agree.
Table 3.
T-Tests Comparing Comfort Providing Gender-Affirming Care with Consultative Support, by Years of Experience and Specialty
| OVERALL (N = 51), MEAN (SD) | YEARS OF EXPERIENCE (N = 51) |
SPECIALTY (N = 47) |
||||
|---|---|---|---|---|---|---|
| <10 YEARS (N = 24), MEAN (SD) | 10+ YEARS (N = 27), MEAN (SD) | t-TEST, SIG | PEDIATRICS (N = 28), MEAN (SD) | FAMILY MEDICINE (N = 19), MEAN (SD) | t-TEST, SIG | |
| If I had access to timely consultative support from a pediatric gender clinic specialist, I would feel more comfortable: | ||||||
| Providing information, resources, and support to gender diverse patients and families | ||||||
| 4.18 (1.05) | 4.38 (0.77) | 4.00 (1.24) | t = 1.28, p = 0.10 | 4.39 (0.92) | 3.89 (1.29) | t = 1.55, p = 0.06 |
| Advocating for affirming environments at home, school, and in clinical spaces for gender diverse patients | ||||||
| 3.88 (1.11) | 3.92 (1.02) | 3.85 (1.20) | t = 0.21, p = 0.42 | 4.11 (0.99) | 3.63 (1.30) | t = 1.42, p = 0.08 |
| Connecting gender diverse patients with affirming behavioral health providers when necessary | ||||||
| 4.20 (1.08) | 4.25 (1.03) | 4.15 (1.13) | t = 0.33, p = 0.37 | 4.32 (1.02) | 4.00 (1.25) | t = 0.97, p = 0.17 |
| Referring patients for gender-affirming surgeries | ||||||
| 3.43 (1.43) | 3.50 (1.44) | 3.37 (1.45) | t = 0.32, p = 0.38 | 3.68 (1.47) | 3.32 (1.35) | t = 0.86, p = 0.20 |
| Initiating GnRH agonists, estrogen, or testosterone for gender diverse patients in my clinic | ||||||
| 2.69 (1.59) | 3.25 (1.57) | 2.19 (1.47) | t = 2.50, p < 0.01* | 2.89 (1.59) | 2.74 (1.59) | t = 0.33, p = 0.37 |
| Monitoring medications like GnRH agonists, estrogen, or testosterone for gender diverse patients in my clinic | ||||||
| 3.04 (1.60) | 3.54 (1.41) | 2.59 (1.65) | t = 2.19, p = 0.02* | 3.46 (1.50) | 2.84 (1.57) | t = 1.37, p = 0.09 |
| Refilling GnRH agonists, estrogen, or testosterone for gender diverse patients in my clinic | ||||||
| 3.00 (1.57) | 4.54 (1.38) | 2.52 (1.60) | t = 2.43, p < 0.01* | 3.36 (1.50) | 2.89 (1.56) | t = 1.02, p = 0.16 |
p < 0.05, Items were scored on a Likert scale (Response options 1 = Strongly disagree, 5 = Strongly agree) and means were compared using t-tests.
GnRH, gonadotropin releasing hormone.
Consultation modalities
To help determine what consultation modalities providers felt would be most helpful in supporting participants in caring for GDY, we provided definitions of four potential specialist-to-primary care provider (PCP) consultative support modalities (Table 1) and asked participants to respond on a Likert scale (1 = strongly disagree, 5 = strongly agree) regarding whether each “would help [them] feel more comfortable supporting gender diverse youth in the primary care setting.” The four proposed modalities were chosen because each had been identified by PPCP participants in our prior qualitative study19 as being both a viable and desired method of providing specialist support to PPCPs interested in caring for GDY in the primary care setting.
Table 1.
Description of Each Proposed Consultative Support Modality
| Tele-education/ECHO | A model that virtually connects groups of community providers with a team of specialists for regular, real-time collaborative sessions incorporating both didactic education and opportunities for consultation. For example, a tele-education platform could involve a small group of primary care providers who meet monthly with a gender specialist to receive education and present cases for consultation. |
| Electronic consultation | A model that uses a shared EHR or another web-based platform to provide opportunities for timely PCP to specialist communication and consultation. For example, a PCP could enter a patient-specific management question via a prepopulated consultation template in the EHR that would be answered by a gender specialist within 24–48 h. |
| Telephone consultation | A model that uses telephone calls for consultation between PCPs and specialists. For example, a PCP could call an on-call line and request callback later that day from a gender specialist to discuss a specific management questions over the phone. |
| Telemedicine consultation | A model where your patient is seen by a gender specialist while they are in your clinic via audio-video telemedicine. |
EHR, electronic health record; PCP, primary care provider.
Finally, participants were asked to rank each of the four consultative support modalities in order of which they felt would be most (1) to least (4) practical for them to use.
DATA ANALYSIS
Descriptive statistics were used to characterize the sample and summarize responses to each survey item. T-tests were used to compare the mean responses to each of the comfort questions by years of experience (<10 years, 10+ years, chosen due to estimated introduction of medical school curricular content having occurred after 201120) and specialty (Pediatrics, Family Medicine, other). Finally, rank-sum tests were used to compare the rankings for each of the consultative modalities overall, as well as by years of experience and specialty. Due to sample size, comparisons by specialty were only completed for pediatrics and family medicine.
Results
DEMOGRAPHIC CHARACTERISTICS
A total of 51 providers completed the survey (Table 2). Most identified as female (62.8%), White (84.3%), and heterosexual (84.3%) and the mean age was 40 years (SD = 11.9). Roughly half had <10 (47.1%) and 10+ (54.9%) years of experience. Most respondents were physicians (92.2%), and of these, 59.6% indicated having received specialty training in pediatrics and 40.4% in family medicine. Providers reported seeing a mean of 5.3 GDY in their practice in the prior year.
Table 2.
Demographics of Survey Participants (n = 51)
| % (n) | |
|---|---|
| Gender identity | |
| Female | 62.7 (32) |
| Male | 33.3 (17) |
| Prefer not to say | 3.9 (2) |
| Sex at birth | |
| Female | 62.7 (32) |
| Male | 33.3 (17) |
| Prefer not to say | 3.9 (2) |
| Sexual orientation | |
| Heterosexual | 84.3 (43) |
| Not heterosexual | 5.9 (3) |
| Not sure/Prefer not to say | 9.8 (5) |
| Ethnicity | |
| Hispanic/Latino/a/x/e | 0 (0) |
| Not Hispanic/Latino/a/x/e | 92.2 (47) |
| Prefer not to say | 7.8 (4) |
| Race | |
| Asian | 5.9 (3) |
| Black | 2.0 (1) |
| White | 84.3 (43) |
| Other | 3.9 (2) |
| Prefer not to say | 3.9 (2) |
| Training background | |
| Pediatricsa | 54.9 (28) |
| Family medicine | 37.3 (19) |
| N/A | 7.8 (4) |
| Role | |
| MD | 68.6 (35) |
| Resident | 23.5 (12) |
| Other | 7.8 (4) |
| Practice type | |
| Private (solo or group) | 9.8 (5) |
| Academic/hospital-based | 66.7 (34) |
| Community/Federally Qualified Health Center | 15.7 (8) |
| Multiple | 3.9 (2) |
| Age (years, mean [SD]) | 40.0 (11.9) |
| Time in practice (years, mean [SD]) | 11.1 (9.3) |
| GDY seen in past year (mean [SD]) | 5.3 (8.2) |
Includes Internal Medicine/Pediatrics.
GDY, gender diverse youth; SD, standard deviation.
COMFORT PROVIDING GENDER-AFFIRMING CARE WITH CONSULTATIVE SUPPORT
For nearly every aspect of gender-affirming care, PPCPs in our study agreed, on average, that having access to consultative support would help them feel more comfortable providing this care (Table 3). Scores were highest for connecting GDY with affirming behavioral health providers (mean = 4.20 ± 1.08) and lowest for initiating gender-affirming medications (mean = 2.69 ± 1.59).
PPCPs with fewer than 10 years of experience and those trained in pediatrics were more likely to agree that access to consultative support would make them more comfortable providing each aspect of gender-affirming care compared to those with more than 10 years of experience and those trained in family medicine, respectively. Specifically, PPCPs with fewer than 10 years of experience were significantly more likely to agree that consultative support would help them feel more comfortable initiating (t = 2.50, p < 0.01), monitoring (t = 2.19, p = 0.02), and refilling (t = 2.43, p < 0.01) gender-affirming medications compared to PPCPs with 10 or more years of experience. No other significant differences in comfort emerged for the other aspects of gender-affirming care by years of experience, and there were no statistically significant differences in comfort by specialty.
CONSULTATION MODALITIES
Comfort
When asked whether each consultation method would help make them more comfortable providing gender-affirming care, scores were generally high (Table 4). Electronic consultation scored the highest (mean = 3.78 ± 1.17) and tele-education/Extension for Community Healthcare Outcomes (ECHO) scored the lowest (mean = 3.59 ± 1.17) on average, although there were no statistically significant differences between the consultation modalities with regard to comfort providing this care.
Table 4.
Comfort With and Ranking of Consultative Support Modalities for Gender-Affirming Care, by Years of Experience and Specialty
| OVERALL (N = 51), MEAN (SD) | YEARS OF EXPERIENCE (N = 51) |
SPECIALTY (N = 47) |
||||
|---|---|---|---|---|---|---|
| <10 YEARS (N = 24), MEAN (SD) | 10+ YEARS (N = 27), MEAN (SD) | t-TEST, SIG | PEDIATRICS (N = 28), MEAN (SD) | FAMILY MEDICINE (N = 19), MEAN (SD) | t-TEST, SIG | |
| Would help feel more comfortable providing gender-affirming care (1 = strongly disagree, 5 = strongly agree) | ||||||
| Tele-education/ECHO | ||||||
| 3.59 (1.24) | 3.88 (1.03) | 3.33 (1.36) | t = 1.59, p = 0.06 | 3.71 (1.12) | 3.32 (1.45) | t = 1.06, p = 0.15 |
| Electronic consultation | ||||||
| 3.78 (1.17) | 4.21 (0.72) | 3.41 (1.37) | t = 2.57, p < 0.01* | 3.96 (0.96) | 3.53 (1.43) | t = 1.26, p = 0.11 |
| Telephone consultation | ||||||
| 3.72 (1.25) | 4.00 (0.98) | 3.48 (1.42) | t = 1.50, p = 0.07 | 3.93 (1.09) | 3.37 (1.50) | t = 1.49, p = 0.07 |
| Telemedicine consultation | ||||||
| 3.71 (1.17) | 4.08 (0.78) | 3.37 (1.36) | t = 2.26, p = 0.01* | 3.93 (1.02) | 3.26 (1.37) | t = 1.91, p = 0.03* |
| Ranking (1 = highest, 4 = lowest) | ||||||
| Tele-education/ECHO | ||||||
| 2.71 (1.20) | 2.46 (1.28) | 2.92 (1.11) | t = −1.30, p = 0.19 | 2.75 (1.27) | 2.74 (1.24) | z = 0.13, p = 0.90 |
| Electronic consultation | ||||||
| 2.43 (1.06) | 2.42 (1.14) | 2.44 (1.01) | t = −0.16, p = 0.88 | 2.75 (1.00) | 1.89 (0.94) | z = 2.80, p < 0.01* |
| Telephone consultation | ||||||
| 2.59 (1.12) | 2.79 (0.98) | 2.41 (1.22) | t = 1.13, p = 0.26 | 2.50 (1.07) | 2.47 (1.17) | z = 0.05, p = 0.96 |
| Telemedicine consultation | ||||||
| 2.27 (1.08) | 2.33 (1.09) | 2.22 (1.09) | t = 0.39, p = 0.70 | 2.00 (1.02) | 2.89 (0.94) | z = −2.84, p < 0.01* |
p < 0.05, Comfort items were scored on a Likert scale (1 = Strongly disagree, 5 = Strongly agree) and mean scores were compared using t-tests; Mean rankings (1 = highest, 4 = lowest) were compared using rank sum tests.
ECHO, Extension for Community Healthcare Outcomes.
PPCPs with fewer than 10 years of experience and those who trained in pediatrics were more likely to agree that each consultation method would make them more comfortable providing gender-affirming care compared to those with more than 10 years of experience and those trained in family medicine, respectively. Specifically, PPCPs who had fewer than 10 years of experience rated both electronic consultation (t = 2.57, p < 0.01) and telemedicine consultation (t = 2.26, p = 0.01) significantly higher than did PPCPs who had 10 or more years of experience. Those trained in pediatrics were also more likely to agree that telephonic consultation would make them more comfortable providing care compared to those trained in family medicine (t = 1.91, p = 0.03).
Rankings
Overall, participants ranked telemedicine consultation (mean = 2.27 ± 1.08) as the most practical method and tele-education/ECHO (mean = 2.71 ± 1.20) as the least practical (Table 4). Telemedicine consultation ranked significantly higher on practicality than tele-education/ECHO (t = 1.91, p = 0.03), but no other statistically significant differences in rankings emerged between consultation methods. Although rankings did not differ significantly by years of experience, PPCPs trained in family medicine ranked e-consultation significantly higher than did participants trained in pediatrics (1.89 vs. 2.75, p < 0.01), while those trained in pediatrics ranked telemedicine consultation significantly higher than did those trained in family medicine (2.00 vs. 2.89, p < 0.01; Table 4).
Discussion
PPCPs are well positioned to support GDY given their ongoing relationships with both patients and their families.15–17 This is especially true in rural areas, where GDY are more likely to experience geographic and travel-related barriers, which limit opportunities to receive care in specialty settings.21–23 Our findings from this study suggest that both times, in practice and specialty, are important considerations when determining which platforms PPCPs perceive are most practical or most likely to increase their comfort providing this care.
Providers in our study indicated that consultative support would increase their comfort creating affirming environments for their patients by providing them with information, resources, and referrals, which are especially important given that the access to these affirming environments is associated with improved mental health. Even with consultative support, PPCPs generally felt less comfortable with all aspects of managing gender-affirming medications for GDY. This suggests that consultative support may be very useful in supporting PPCPs in creating affirming environments for GDY, but that additional interventions, such as improved medical education curricula, are likely needed to help PPCP's feel more comfortable managing gender-affirming medications.
Our finding that providers with fewer years of experience are more comfortable providing this care may be reflective of increasing medical education content in this area in recent years and an openness to seeking consultative support when it expands on prior received training as opposed to novel education. It is also possible that differences in graduate medical education curricula in this area across specialties may explain why pediatric providers reported more comfort than those trained in family medicine. These differences suggest a need to further explore differences in medical education curricula across specialties at all levels of training.
Overall, rural PPCPs reported feeling that all four proposed consultative support modalities could increase their comfort providing care to GDY, however, their perspectives regarding their practicality differed with telemedicine being viewed as the most practical and tele-education/ECHO least practical. These views regarding practicality are in line with similar findings from our prior qualitative study with PPCPs who noted concerns about the time commitment required to participate in an ECHO and difficulty blocking clinical time to participate.13 PPCPs in this prior study also reported logistical concerns related to coordinating unscheduled phone calls with specialists in telephonic consultation models and limited opportunities for verbal provider to provider communication with electronic consultation.13
In this study, we also found provider views regarding practicality differed by specialty, with PPCPs trained in pediatrics more likely to view telemedicine consultation as more practical, and family medicine physicians were more likely to view the e-consult as more practical. This may be because family medicine physicians, who likely have a smaller proportion of pediatric patients than pediatricians, felt that this was something they would use less frequently and thus desired the simplest or most efficient method. It is also possible that providers trained in pediatrics viewed having a more comprehensive evaluation through telemedicine consultation more important and worthwhile given that this group of patients may be some they could see more frequently.
Although these findings have the potential to inform the development of future specialist-PCP platforms to support the provision for care for GDY, they should be interpreted within the context of the following limitations. First, our sample size was small, which may have limited our power to detect significant differences, especially across specialties. Second, participants were recruited from one rural Appalachian state, and it is possible that their views may differ from PPCPs practicing in more urban areas or other parts of the country, or those who are not predominantly White, female, and heterosexual. Questions about comfort were also framed positively (“I would feel more comfortable…” and could have introduced bias. Study participants were also anonymous, which could result in bias from mischievous responders while also allowing PPCPs to share insights they would be otherwise unwilling or unable to share.
Finally, the survey was distributed before the introduction and passage of a law limiting the provision of gender-affirming care in WV in March of 2023, suggesting that additional investigation is likely needed to understand how this legislation may impact PPCP comfort providing this care in the future.
Conclusions
In conclusion, specialist-PCP consultative support modalities show great promise in increasing PPCP comfort caring for GDY in the primary care setting. This may be especially important for rural PPCPs, whose patients may be more likely to experience geographic and travel-related barriers to receiving this care in specialty settings. Increasing availability of these consultative support modalities has the potential to both improve access to care and health outcomes for this group of youth.
Acknowledgment
We thank Bronson Herr for editorial support.
Authors' Contributions
G.M.S.: conceptualization, writing—original draft preparation, reviewing, and editing. K.M.K.: conceptualization, methodology, and writing— review and editing. A.S.: methodology and writing—review and editing. N.F.K. and S.H.: formal analysis and writing—review and editing. L.M.C. and I.N.: writing—review and editing. J.N.: supervision and writing—review and editing.
Disclosure Statement
G.M.S. has received compensation from Pivotal Ventures for participation in an advisory board. Authors have no other conflicts of interest to disclose.
Funding Information
G.M.S. receives funding from the AHRQ (K08 HS029028-01, PI: G.M.S.). K.M.K. is supported by the National Institute of General Medical Sciences of the National Institutes of Health (2U54GMi04942-07; PI Hoddes).
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