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Willingness of clinicians to routinely care for transgender patients is still lacking, according to researchers.

In a survey of 163 family medicine physicians and general internists working in the Midwest, most stated that they would be willingly to care for a transgender patient, although nearly 15% said they would refuse, reported Deirdre Shires, PhD, MSW, MPH, of the Henry Ford Health System in Detroit and colleagues.

Also, over 21% of those responding to the survey said they would refuse to provide a Pap test for transgender men, the team reported in the .

"Support was not universal," the researchers wrote, adding: "Our findings, as well as the success of transgender speaker panels, point to the importance of integrating not only clinical but also personal exposure to transgender individuals into medical education."

For the analysis, the clinicians were asked several questions to gauge their empathy, level of transphobia, and personal exposure to transgender people, as well as to gather demographic information. To assess "transphobia," the researchers used an eight-question test, with a seven-point scale for each (ranging from "strongly agree" to "strongly disagree"). Questions included, "I believe that the male/female dichotomy is natural"; "I would be upset if someone I'd known for a long time revealed to me that they used to be another gender"; and "I believe that a person can never change their gender."

The majority of clinicians surveyed were residents (52.1%), followed by attending physicians (45.7%); very few of the respondents were advanced practitioners (2.1%). Fewer clinicians surveyed reported having conservative political views (16.4%) compared with moderate (36.4%) or liberal (47.1%) views, potentially modifying the findings, the researchers noted.

Age was indicative of a clinician's willingness to be a routine provider for a transgender individual -- the odds of willingness went down among older doctors (adjusted OR 0.96, 95% CI 0.91-0.99, P=0.039).

As for a clinician's willingness to provide a Pap test for a transgender man, family physicans had five-fold higher odds of being willing to do so, compared with internists (aOR 5.08, 95% CI 1.35-19.16, P=0.16). Clinicians who reported that they had met a transgender person raised their odds of willingness to provide a Pap test (aOR 4.11, 95% CI 1.13-14.96, P=0.32).

Similarly, those with higher transphobia scores were less likely to willingly provide a Pap test (aOR 0.54, 95% CI 0.32-0.91, P=0.20). Yet those expressing unwillingness to provide care to transgendered patients did not score as markedly more transphobic than those who said they were willing -- mean transphobia scores among the unwilling in the two scenarios were 3.8, compared with 3.0-3.1 for the willing providers.

Even though most clinicians surveyed stated that they were willing to provide routine care for transgender patients, nearly a third indicated that they did not feel capable of providing such care (68.6% yes versus 31.4% no). Similar numbers were reported when the clinicians were asked if their staff lacked knowledge about transgender care (32.1% lacked knowledge).

Overall, clinicians were generally split when asked if they lacked training on transgender health (47.9% yes versus 52.1% no) and whether they lacked familiarity with transition care guidelines (52.1% yes versus 47.9% no).

Although Shires' group said it was "encouraging" to find that the majority of doctors surveyed reported a willingness to provide routine care for transgender patients, the team said that "ideally, every clinician should be willing to provide routine care -- within the general scope of their practice -- to all patients, regardless of their gender identity or expression."

The researchers also noted that despite the high rates of willingness to provide care, fewer doctors reported being equipped to provide quality care to these patients: "The importance of incorporating best practices for appropriate care for transgender patients into medical education cannot be overstated," Shires and co-authors wrote.

In a in the journal, Alex Keuroghlian, MD, MPH, of the Fenway Institute in Boston, and colleagues outlined suggestions and scenarios to help clinicians interact and communicate with patients with nonbinary gender identities.

Among their tips: avoid gendered terminology when speaking with new patients, and "us[e] terms that apply to all genders and anatomies, like 'underwear' and 'chest.' Through these communication approaches, healthcare clinicians can remain responsive to rapidly expanding concepts and terminology for gender identification and expression within our society, and can offer more patient-centered care that moves beyond binary gender concepts."