The Spanish Society of Family and Community Medicine (semFYC) has analyzed the principal strategies to strengthen healthcare for binary and nonbinary transgender individuals in primary care. This care remains marked by structural barriers, professional unawareness, and experiences of discrimination that directly affect patients’ health and relationships with the health system.

These findings were presented at the symposium, “The trans population in your practice: a look at the Transaludes study,” held during the semFYC congress in Madrid, Spain. 

Lucía Expósito Legarza, family physician at the TransCan Unit (Care and Support Unit for Trans People) in Tenerife and a member of the semFYC LGBTIQ+ Health Working Group, delivered the central address on strengthening primary care for trans individuals.

The meeting, moderated by Alberto Cotillas Rodero, president of the Sociedad Madrileña de Medicina Familiar y Comunitaria and coordinator of its LGBTQ+ Health Working Group, highlighted primary care as a crucial space for both identifying unmet needs and reducing health inequalities. Expósito presented the results of the Transaludes study (2024), coordinated by the Carlos III Health Institute in Madrid. She clarified that she used the term “trans” as an umbrella concept to refer to diverse realities, aiming to facilitate comprehension without erasing the plurality of identities.

Depathologizing Approach

The discussion was based on the findings of the Transaludes study, which included more than 1800 participants.

The study was developed within a pathologizing and integrative framework. Trans individuals were actively involved at every stage of the project, from design to implementation and analysis.

The primary aim of this study was to identify unmet needs, structural barriers, and lived experiences related to healthcare access and delivery. The researchers sought to generate evidence that was not previously available in Spain.

Expósito highlighted the high rate of engagement in primary care in this population. According to Transaludes, 85% of the participants attended a family medicine consultation in the preceding year, which was slightly higher than that of individuals in the overall population.

However, when the reason for consultation was related to gender transition, the trend reversed. In these cases, transgender individuals attended hospital specialty services more frequently than primary care physicians. Expósito explained that this shift toward the hospital setting did not always reflect clinical needs but rather a perception of insufficient training or professional discomfort at the first level of care.

Consultation Barriers

Nearly half of transgender individuals do not disclose their gender identity during clinical consultations. More than 40% reported encountering professionals who struggled to provide care because of a lack of knowledge, discomfort, or absence of specific training. Furthermore, nearly 40% experienced unpleasant incidents related to clinical documentation, the name displayed in medical records, national identity documents, or treatment received from staff.

Expósito emphasized the widespread lack of awareness regarding the current legal framework and the rights of trans, binary, and nonbinary individuals to be addressed by their chosen names and pronouns, regardless of official documentation. The study noted that approximately half of the participants initiated or completed registry changes for name, sex, or both.

Nevertheless, a significant proportion of those who had not made such changes cited fear of rejection or administrative barriers as reasons. Despite legislative reforms in 2023, the process was still described as complex, with long waiting lists, slow bureaucratic procedures, and staff who were not always up to date on the latest developments. For nonbinary individuals, Expósito noted that Spain still lacks a specific registry marker, which increases their institutional invisibility.

The Transaludes study also quantified specific experiences during consultations. 1 in 4 individuals received invasive comments or questions regarding their bodies. 1 in 5 participants encountered clinicians who refused to use their names and pronouns. Up to 12% reported feeling pressured or coerced to make unnecessary referrals, procedures, or consultations.

According to Expósito, individuals with nonbinary identities are frequently referred almost automatically to mental health services — a defensive response to the absence of appropriate clinical tools.

Fatphobia is another axis of discrimination. In nearly 20% of cases, weight bias posed an obstacle to accessing gender-affirming treatments. The cumulative impact of these experiences helped explain why approximately 1 in 4 transgender individuals avoided healthcare settings.

Clinical Recommendations

The Diagnostic and Statistical Manual of Mental Disorders has removed the term “disorder” from its section on sexual disorders. The International Classification of Diseases has followed a similar path, removing it from the mental disorders section and placing it in the category of conditions related to sexual health.

However, Expósito questioned whether these changes had been translated into everyday clinical practice. The term that appears most frequently in medical records is still “gender incongruence,” a concept that implies “something is not aligned” and perpetuates the routine application of a psychiatric diagnostic code.

She recommended the 2021 guide for socio-healthcare for transgender individuals published by the State LGBTI+ Federation, which includes a dedicated section on good and bad practices. Among actions to avoid, she listed failing to respect names and pronouns, questioning gender identity, making assumptions about sexual orientation, anatomy, or sexual practices, and automatically referring patients to mental health.

Positive recommendations included using surnames in waiting room calls, respectfully inquiring about names and pronouns during consultations, guaranteeing confidentiality, and pursuing continuous education.

The need for training aligns directly with the role assigned to family physicians by the World Professional Association for Transgender Health Standards of Care. According to this international body, primary care is not only the first point of contact but also the appropriate setting for ongoing, gender-affirming healthcare.

Their responsibilities include comprehensive and continuous care, and when clinicians possess sufficient training, the prescription and monitoring of gender-affirming hormone therapy (GAHT). Although such treatment is typically initiated in endocrinology departments in Spain, Expósito argued that primary care physicians must understand these medications, their reversible and irreversible effects, potential adverse events, and the criteria for laboratory monitoring parameters.

Such competence would improve equity by sparing transgender individuals from the need to navigate hospital-based care for any concerns related to their transition.

Beyond Hormones

Healthcare for transgender individuals extends well beyond hormone therapy. Expósito addressed the need to support families with transgender children, recognize distress related to the development of secondary sexual characteristics, and possess basic familiarity with pubertal blockers.

She also emphasized the importance of understanding nonpharmacologic interventions, such as binding (concealing the breasts), tucking (concealing the penis and testicles), and taping (techniques to conceal breast volume, commonly used as alternatives to binders; adhesive tape is used instead of compression garments). This was complemented by knowledge of surgical options and access pathways, which varied significantly between autonomous communities in Spain.

The Transaludes study yielded a critical finding: 14% of participants did not wish to initiate GAHT, and 28% expressed no interest in surgical options. Expósito stressed that clinicians should never assume that a transgender person desires hormones or surgery or that a predetermined path or timeline exists.

Mental Health

Only slightly more than 50% of binary and nonbinary transgender individuals rated their health as positive compared with 85.3% of individuals in the population overall. This negative perception was most pronounced among nonbinary individuals, who are described as a profoundly invisible population within the healthcare system.

The most frequently detected conditions were anxiety, depression, eating disorders, and other mental health issues. More than 70% of the participants had received a mental health diagnosis within the preceding year. Depression was 17 times more prevalent, and anxiety was 11 times more prevalent than in the overall population.

Eating disorders are underdiagnosed and are often misinterpreted as expressions of gender dysphoria. Expósito warned against this oversimplification, which is prevalent in clinical practice.

Nearly 75% of respondents reported suicidal ideation, nearly 60% engaged in self-harm, and almost 40% attempted suicide. These figures underscore the pressing need for specialized mental health services.

A central message of Expósito’s presentation was that mental health problems in trans populations should be understood as consequences of structural violence and not as causes of gender diversity. She warned that misinterpreting this relationship could lead to ableist practices, wherein the presence of a mental disorder is used to justify withholding gender-affirming care.

She argued that transphobia is a form of structural violence with profound health consequences. The concept of minority stress, while not without criticism, helps explain the elevated prevalence of anxiety, depression, posttraumatic stress disorder, and social isolation. Evidence has increasingly framed structural violence as a trauma component.

According to Transaludes, more than 90% of the participants had experienced violence or discrimination during their lives; two-thirds had experienced it within the preceding year through offensive comments, insults, threats, or physical assault.

Sexual Health

Regarding sexual health, the study reported an HIV prevalence of 1.8% among the overall binary and nonbinary trans population, increasing to 5.6% among transfeminine individuals. These figures may be underestimated, as six out of 10 participants had never undergone HIV testing.

Despite a substantially higher prevalence than that of individuals in the overall population, knowledge of preventive measures was low. The study identified clear disparities in access to testing, screening, vaccination, contraception, fertility preservation, and reproductive services.

Professional Responsibility

Expósito reminded clinicians of the professional responsibilities of healthcare personnel to understand and enforce the legal framework, create safe clinical spaces, and deliver individualized care centered on each patient’s specific needs. Familiarity with local resources and referral pathways was identified as a key competency.

She highlighted the value of networking with LGBTI+ community organizations, a practice she credited with transforming her understanding of healthcare and improving the quality of the care she delivered.

Expósito observed that transgender individuals seek medical attention for reasons unrelated to their transitions. Therefore, primary care must be equipped to provide cancer screening, contraception, management of vaginal atrophy, and all other aspects of medical care to patients receiving testosterone or any other treatment, delivered competently, respectfully, and without assumption.

Expósito reported no relevant financial conflicts of interest.

This story was translated from Univadis Spain, part of the Medscape Professional Network.