Protocols pervade medical practice yet they stir much debate in medical education and health services research. Health professionals caring for transgender (trans) patients in the context of gender-affirming medicine are particularly reliant on medical protocols, which guide assessments related to hormones and surgeries. Gender-affirming medicine includes hormones (e.g., oestrogen, progesterone, antiandrogens, and testosterone), chest/breast surgery (e.g. breast augmentation and chest reconstruction surgeries), and genital surgery (e.g., orchiectomy, vaginoplasty, hysterectomy, metoidioplasty, and phalloplasty) . Trans people face numerous barriers to gender-affirming medicine. Medical education gaps are cited as a major barrier to healthcare for trans people [2,3,4]. A review of trans medical education programs found that when offered at all, these are limited to one-time awareness-based interventions and rarely include advanced clinical practice skills such as gender-affirming medicine . Finding clinicians who can compassionately provide gender-affirming medicine proves especially challenging, which may exacerbate mental health challenges in this population [1, 5]. While not all trans people seek gender-affirming medicine, those who do rely on health professionals with the knowledge and skills to use gender-affirming medicine assessment protocols.
The World Professional Association for Transgender Health (WPATH) standards of care  serves as a form of curriculum—teaching a standard of care in gender-affirming medicine [7, 8]. The WPATH standards of care provide the main protocols for assessing patient readiness for gender-affirming medicine . It is important to note that social science scholarship indicates several problems with these standards. First, they are misunderstood by health professionals due to the absence of formal education and training . Second, given that health professionals apply assessment criteria to determine when, or if, trans patients can access gender-affirming medicine, a relationship exists between the WPATH standards of care protocols and medical paternalism [7, 8]. These protocols contribute to poor patient-provider alliances because trans patients feel compelled to strategically present narratives according to assessment criteria in order to mitigate the risk of being denied gender-affirming medicine [8, 9]. Furthermore, it is argued that gender-affirming medicine protocols do not meet Oxford Centre for Evidence-Based Medicine criteria, despite claiming to be ‘evidence-based’ . In response to these concerns, an international movement calls for better practice to advance autonomy and self-determination for trans people .
Previous research shows that when encountering problems with gender-affirming medicine protocols, clinicians have informally learned how to adapt, tailor, and work around protocols, to achieve justice and equity for trans people [7, 10]. Furthermore, content knowledge related to trans people and gender-affirming medicine is currently lacking in formal medical school, residency, and continuing professional development curricula [2,3,4]. Numerous studies have shown positive associations between exposure to baseline knowledge about trans people and improvements in learners’ attitudes, yet pedagogical interventions focused on integrating advanced clinical skills are absent . In this report we discuss the creation of a free online education tool designed to fill this education and clinical skills gap titled: The Path to Patient-Centred Care (PPCC) . Our resource aims to teach clinicians how to offer patient-centred care to trans adults seeking gender-affirming medicine in Canada; however, its implications are relevant in all geographic locations where health professionals use the WPATH standards of care.
Our project studies gender-affirming medicine assessment learning and teaching in three distinct phases. Phase one study findings have been published elsewhere . In the first phase of our qualitative study we found that health professionals identified problems with strict gender-affirming medicine protocols. Study participants expressed discomfort with diagnosing patients with gender dysphoria because doing so rendered patients’ identities as mentally disordered . This finding is also consistent with one trans person’s experience presented in the PPCC resource shown in Fig. 1. In response, protocols were applied flexibly. In this report we outline the process of stage two: by applying design thinking, a solution-based approach to solving problems, we developed an online gender-affirming medicine education tool .