Evidence suggests inflammatory bowel disease is equally prevalent in transgender and cisgender populations. However, it remains unclear whether gender-affirming care and the higher rates of trauma experienced by many transgender patients affect disease course.
As political pressure threatens access to gender-affirming hormone therapy (GAHT), patients with IBD who are transgender are increasingly caught in an uncertain care landscape. Major knowledge gaps remain around how hormone therapy may affect Crohn’s disease and ulcerative colitis, as well as the psychosocial challenges of being transgender and navigating gastrointestinal care.
Image: Rainbows in Gastro. Reprinted with permission.
“There is an urgent need to close many gaps in literature,” Victor Chedid, MD, MS, gastroenterologist and director of the IBD Pride Clinic at Mayo Clinic, told Healio. “More data and guidelines will help us better care for patients from the LGBTQ+ community, including transgender and gender-diverse populations who are living with inflammatory bowel disease.”
Among other important steps toward building trust with patients, having an inclusive and respectful space is critical to caring for patients who are transgender and have IBD, according to Kira Newman, MD, PhD, clinical assistant professor of internal medicine at Michigan Medicine.
Newman emphasized that individuals with IBD often spend a significant amount of time interacting with the health care system.
Kira Newman
For patients who are transgender, that “presents a lot of opportunities to come in contact with individuals who may have stigma against trans people or systems where they feel like they’re not seen or heard,” Newman, whose clinical research focuses on health care equity for LGBTQ+ people with digestive diseases, said.
Chedid has conducted studies with focus groups of patients in the LGBTQ+ community and found that many of them have experienced aggressive or dismissive care, which has eroded their trust in clinicians.
“Patients living with IBD need prompt care,” he said. “If somebody has a history of [experiencing] discrimination and stigma and a mistrust of health care, they might delay and only present to clinic when their disease is more severe.”
IBD care and flares
Newman and Chedid were investigators in a key retrospective, multicenter study published in Clinical Gastroenterology and Hepatology in 2023 that evaluated IBD flares among patients in the transgender community.
“We found there was no overall increase in IBD flares in the year after starting gender-affirming hormone therapy, which was a reassuring finding for providers and patients,” Chedid said.
Victor Chedid
He did note that patients with active IBD or inflammation when GAHT was initiated were more likely to experience a flare the following year.
“That speaks to the importance of including an IBD provider in the gender-affirming care of a patient, because at the time of initiation of gender-affirming care — especially gender-affirming hormones — it will be important to get the IBD in deep remission to reduce the risk of flaring,” Chedid said.
Chedid also recommends that clinicians be proactive and “consider noninvasive monitoring within the first 3 months of initiating hormones with stool-based testing, such as fecal calprotectin, and again at 6 months and 1 year.”
Newman concurs that clinicians should continue observing patients during this period.
“It appears that GAHT is safe and does not cause flares, but it is important to monitor anyone going through a major physiologic change, just like we would monitor people as they go through pregnancy or treatment for a major comorbid illness,” she said.
Newman also highlighted the importance of recognizing that GAHT is not one monolithic treatment and not every patient is taking the same formulation.
“If there is a liver-related injury we think is related to medication, [we should] assess all of a patient’s medications, including their GAHT,” Newman said.
She added that clinicians should be aware that GAHT also differs in dosage and duration of action. If patients experience complications, it may be important to confirm they are obtaining GAHT from a licensed practitioner.
Newman recommends asking where patients obtain their medications because, “while many transgender people are fortunate to be able to access clinics where they can get gender-affirming care, not everyone who is on GAHT is accessing that through a clinic.”
Another point of concern is how feminizing hormone therapy specifically may interact with IBD.
“Estradiol, especially if given orally, can increase the risk of venous thromboembolism, which is also a concern in patients with severe IBD,” Laura Targownik, MD, told Healio.
Targownik is a clinician researcher at Mount Sinai Hospital in Toronto and president of Rainbows in Gastro, an organization that advocates for the LGBTQ+ community in gastroenterology and hepatology spaces.
Laura Targownik
She said there are still questions about how those two risk factors for venous thromboembolism interact, particularly when a third risk factor is added, like hospitalization.
In those specific cases, Targownik said she believes temporarily pausing therapy could be a consideration to lower the risk for DVT. But in general, she emphasized that gastroenterologists should not think of GAHT as any less important than any other medication they may be on for any concomitant condition.
“Even though we recognize some medications prescribed for other conditions can theoretically cause GI symptoms or impact a patient’s IBD, we’re pretty circumspect about telling people to stop medications that other [clinicians] have prescribed,” Targownik said.
Alexander Michael Goldowsky, MD, attending gastroenterologist at Beth Israel Deaconess Medical Center and assistant professor at Harvard Medical School, cautions clinicians about “transgender broken arm syndrome,” a phenomenon where any condition a transgender individual is experiencing, up to and including a broken arm, is blamed on their GAHT.
Goldowsky advises clinicians to avoid making assumptions and automatically attributing concerns a patient who is transgender experiences to their gender-affirming care, particularly when so little is known about the relationship between GAHT and gut health.
Alexander Michael Goldowsky
He noted that he may have that conversation if a patient begins experiencing symptoms directly after starting GAHT, but even then, he would not necessarily recommend stopping their gender-affirming care.
“I’m going to use the tools in my toolbox as a gastroenterologist to treat whatever symptoms [they’re] having, because we know that folks who take GAHT do better overall, particularly from a mental health perspective,” he said.
Not all concerns surrounding IBD and gender-affirming care are specific to GAHT.
“For patients [with IBD] who are considering surgical interventions, there may be issues that come up in terms of feasibility or anatomic considerations, particularly for patients with rectal involvement of their IBD or perianal fistulas,” Targownik said.
Gastroenterologists have a role to play in determining how a patient’s IBD might impact surgical planning, and it is important for them to be collaborative in that effort.
“It’s a multidisciplinary conversation — involving obstetrics and gynecology, colorectal surgery and plastic surgery — to come up with the best decision,” Goldowsky said.
Building a welcoming practice
Patients who are transgender “can develop gastrointestinal issues like anyone else,” Targownik said, which means that gastroenterologists need to have an awareness of the “communication needs and values of this population.”
“One of the things we can do is not just think about how we want [our practice] to be a welcoming space, but really show that space is welcoming,” Newman said. “Whether that’s displaying statements of nondiscrimination, safety or patients’ rights in the clinic space or thinking about ways to minimize points of friction.”
These messages can also be included on intake forms and practice websites to create an inclusive culture at a clinic.
“I think it’s important — whatever your personal feelings are — to create a welcoming environment for all your patients, whatever their background might be, and that doesn’t necessarily mean going over the top and festooning your clinic with trans flags,” Targownik said.
“But it is worth advertising to your referral base that your practice is a welcome environment to LGBTQ+ patients with GI related health care needs,” she added.
Building a welcoming practice “starts at the front desk,” according to Goldowsky.
At his practice, patients are called to the exam room by their last name to avoid using a ‘deadname’ — the given name an individual who is transgender no longer uses after transitioning.
Newman recommends calling patients using a pager that gets buzzed to avoid concerns about not knowing a patient’s preferred name or pronouns.
“Medical record systems that allow people to include pronouns, chosen name, gender and sex-assigned at birth is important on an institutional level,” Newman said.
When institutions “can track and record things over time, [patients] don’t have to reintroduce themselves every time they meet a new provider.”
Goldowsky also emphasized the importance of practicing trauma-informed care as a gastroenterologist.
“We also recognize that trauma happens not just in transgender folks — it happens in everyone,” he said. “We know that it significantly impacts GI disease, particularly irritable bowel syndrome, so I encourage folks to complete training in it.”
Goldowsky recommends clinicians look to online modules from the Human Rights Campaign and The Fenway Institute for trauma-informed care training. Additionally, he advises practices to look into bringing in trauma-informed care speakers to run workshops.
Gastroenterologists perform examinations of intimate areas, which can be triggering for patients with medical or physical trauma.
“Since we’re a procedural subspecialty, I always make sure I know if someone has a trauma history, if they feel comfortable disclosing that,” Goldowsky said.
Building rapport with patients is key to building trust, Targownik said.
“Our responsibility as a physician is to the patient’s health,” she added. “We know that when you create a hostile environment — or even an uncertain environment — for your patients, they are going to lose trust in medical care and may not feel confident reaching out to you when they need you.”
In the endoscopy suite
Given that IBD is a known risk factor for colorectal cancer, patients with IBD often undergo more endoscopic procedures than those without the disease.
When it comes to procedures like colonoscopy, “there are special considerations for people who have dysphoria related to their genital conformation and who may be triggered by having to expose parts of their body that are discordant with their gender identity,” Targownik said.
Gastroenterologists can create an inclusive endoscopy suite by providing a place where patients feel comfortable preparing for procedures.
“We have patients go into a locker room to change before their procedures,” Chedid said. “We have options for patients to change in a male locker room, a female locker room, and a nongendered or gender-neutral space.”
“It can be really helpful to have a private place to change, not just a curtain, but somewhere with a door that closes and locks,” Newman said.
Targownik emphasized the importance of clarifying which items of clothing need to be removed and which can stay on, as well as transparency about procedures, including what areas need to be examined.
“I explain with a lot of detail and a lot of care in advance what I’m doing and why I’m doing it, and what parts of the body are going to be exposed,” she said. “For instance, during a colonoscopy, I’m going to make it clear to the patient that I do not need to directly expose their genitals in order to perform the procedure.”
Providing these explanations can alleviate patient anxiety.
“As doctors, we never want to have our patients think the reason we’re doing something is because we’re curious about them or their bodies in a way that doesn’t apply to their medical diagnosis or the care we need to provide,” Newman said.
Clinicians can also help by allowing patients to keep their support system with them, according to Newman.
“Let patients bring their person or their people with them to the visit, into the hospital or to the endoscopy appointment, and ask in an open-ended way who they have brought with them, rather than making an assumption about it,” she said.
When Goldowsky’s patients who are transgender are undergoing colonoscopies, he “makes sure that everyone in the room is aware of what pronouns the person uses and that the patient is draped for as long as possible.”
Due to the trauma patients who are transgender may have faced in health care systems in the past, respect is a key tenet to emphasize in practice.
“What I think [patients] are probably more afraid of is not the examination itself, but that they may be treated with disrespect,” Targownik said.
Chedid advocates for a holistic approach to gastroenterology care that considers a patient’s social and mental health, along with other aspects of their life.
“Patients who are from the transgender and gender-diverse community may have a dual burden on their health care because they are managing chronic GI conditions, like IBD, as well as identity-related stressors,” Chedid said. “This can amplify psychosocial strain and can impact care engagement.”
For more information:
Victor Chedid, MD, MS, serves as secretary and board member for Rainbows in Gastro. He can be reached at chedid.victor@mayo.edu.
Alexander Michael Goldowsky, MD, serves as treasurer and board member for Rainbows in Gastro. He can be reached at agoldows@bidmc.harvard.edu.
Kira Newman, MD, PhD, is vice president of Rainbows in Gastro. She can be reached at kinewman@med.umich.edu.
Laura Targownik, MD, is president of Rainbows in Gastro. She can be reached at laura.targownik@sinaihealth.ca.
Sources/Disclosures
Source:
Healio Interviews
References:
Disclosures:
Chedid reports consulting or advisory board roles with Johnson & Johnson and Takeda Pharmaceuticals and an industry grant from Pfizer for a study on LGBT health and IBD. Goldowsky reports no relevant financial disclosures. Newman reports consulting work for Takeda and receiving grant funding from Pfizer. Targownik reports consulting or advisory board roles with Canadian subsidiaries of AbbVie, Fresenius Kabi, Johnson & Johnson, Merck, Organon, Pfizer and Takeda.
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