摘要：Objectives. We investigated health care utilization, barriers to care, and hormone use among male-to-female transgender persons residing in New York City to determine whether current care is in accord with the World Professional Association for Transgender Health and the goals of Healthy People 2010 . Methods. We conducted interviews with 101 male-to-female transgender persons from 3 community health centers in 2007. Results. Most participants reported having health insurance (77%; n = 78) and seeing a general practitioner in the past year (81%; n = 82). Over 25% of participants perceived the cost of medical care, access to specialists, and a paucity of transgender-friendly and transgender-knowledgeable providers as barriers to care. Being under a physician's care was associated with high-risk behavior reduction, including smoking cessation ( P = .004) and obtaining needles from a licensed physician ( P = .002). Male-to-female transgender persons under a physician's care were more likely to obtain hormone therapies from a licensed physician ( P < .001). Conclusions. Utilization of health care providers by male-to-female transgender persons is associated with their reduction of some high-risk behaviors, but it does not result in adherence to standard of care recommendations for transgender individuals. Transgender persons (or transpersons) are individuals who feel an incongruity between their self-identified gender and their birth gender. The overarching goal of care for transgender persons, as articulated in the Standards of Care for Gender Identity Disorders of the World Professional Association for Transgender Health (formerly the Harry Benjamin Society), is “lasting personal comfort with the gendered self to maximize overall psychological well-being and self-fulfillment.” 1 Health care professionals can facilitate the real-life experience, hormone therapy, and surgery that are components of what is referred to as “triadic therapy” for transpersons. Many transpersons (including those who may not wish to pursue surgical interventions) seek hormone therapy to bring their appearance into alignment with their gender identity. 2 – 5 The Standards of Care for Gender Identity Disorders include a psychological and medical evaluation before hormone treatment, 1 with continued medical supervision during hormone use by a physician experienced in caring for transgender patients. 1 , 6 Despite these recommendations, available data suggest that many transpersons are uninsured and that, overall, a smaller proportion of transpersons than of the general population access medical care. According to a national survey, only 30% to 40% of transgender individuals utilize any regular medical care. 3 Indeed, transgender persons may have difficulty identifying competent and compassionate providers with transgender patient experience. Additional obstacles to expertly supervised care might include economic limitations, comorbidities resulting from substance abuse, and stigmatization. As a result of these barriers, transpersons may obtain hormones from nontraditional sources, including friends, street vendors, the Internet, and pharmacists (in the absence of a prescribing physician). The prevalence of unsupervised hormone use reportedly ranges from 29% to 63% within urban groups of male-to-female transgender persons, 5 , 7 , 8 posing significant health risks to transgender clients. One serious potential risk is that of HIV seroconversion from needle sharing or parenteral administration of hormones. Although no data exist on the incidence of HIV infection secondary to needle sharing, a review of US-based HIV prevention literature found an average HIV prevalence of 27.7% (range = 16%–68%) among male-to-female transpersons. 9 Hormone therapy regimens pose additional health risks to transgender clients, the most serious of which is hypercoagulabilty associated with estrogen administration. The incidence of thromboembolism among male-to-female transgender persons on estrogen therapy ranges from 0.4% to 2.6% per year. 10 , 11 Other documented side effects include depression, mood swings, hyperprolactinemia, elevated liver enzymes, migraines, and decreased insulin sensitivity. 6 , 12 A review of endocrine treatments at Johns Hopkins University found that many clients use high-dose hormone regimens and utilize multiple hormones concurrently without medical supervision in the belief that this will achieve faster results. 6 According to Healthy People 2010 , biases against gender identity differences must be addressed to ensure access to quality health care and related services, eliminate health disparities, and increase quality of life and years of healthy life for all Americans. 2 This goal requires the collection of accurate information among individuals marginalized by their gender identity. Although there are some data documenting the health care needs of transgender persons in the United States, 2 – 5 the medical literature does not provide sufficient data on transgender individuals' access to medical care, availability of culturally competent providers, and access to supervised hormonal regimens to assist the “transition” to their self-identified gender. Elucidation of this information may result in measures to improve the quality of medical care and increase healthful behaviors within this population, and it will show the health system's progress in reaching the goals set forth in Healthy People 2010 . Therefore, we investigated utilization of medical care within a sample of male-to-female transgender persons in New York City. Within our sample of transgendered persons, we evaluated potential barriers to care, types of health care providers utilized (general practitioner, endocrinologists, or mental health professionals), and sources and types of hormones utilized. We anticipated that persons with providers (general practitioners or mental health providers) would be more likely to report fewer barriers to care, fewer high-risk behaviors, and care that is provided in accordance with the current Standards of Care for Gender Identity Disorders . By assessing transgender patients' experiences with the health care system, we aimed to identify ways to improve their access to medical care and safe hormone therapy and aid in reaching Healthy People 2010 goals.
