For the first time, the standard bearers of the dental field are asking themselves if we’re adequately prepared to meet the needs of transgender and transitioning people. The honest answer in most cases is we are not.

In fact, as the transgender population blooms—one recent estimate put it at 1.4 million people in the United States and around 25 million worldwide, though both are believed to be very conservative—and creates a greater need for health care providers, including dental professionals, who are experienced in managing their care, the social and institutional stigma against transgender people is resulting in discrimination within the health care field.

At least part of the problem can be attributed to ignorance. Little research has been conducted on the oral health implications of transitioning and the barriers to care. At this point, what little we do know about the transgender community is mostly being gleaned from the limited research on the larger LGTBQ community. Not that that should serve as an excuse. If anything, it should further illustrate just how slow we’ve all been to respond to what’s been a prevalent need for quite some time now.

The minority stress theory

One of the few studies focused on the transgender community that does exist was published in late 2017. An anonymous survey among transgender adults was conducted using both a web-based and paper survey. The researchers were attempting to evaluate the level of “dental fear” among transgender people and see if they could spot predictors for it.

“Dental fear” is a term that was coined to describe the anxiety and fear that can be felt in anticipation of or in reaction to dental care. People who have professional dental care regularly generally have fewer oral health problems. But, lots of studies have found that dental fear is one of the most common reasons people don’t maintain that care as they should, along with the cost of dental procedures.

This study found that across the spectrum of transgender identities and biological conditions due to hormonal interventions, the rate of dental fear was higher than at any other point over the last 40 years, though only marginally. “The reason for the slightly higher dental fear may be explained by the minority stress theory,” the researchers wrote.

The minority stress theory posits that when minority groups face chronic levels of increased stress, they develop a negative psychological response to trauma.

The National Transgender Discrimination Survey reports that 19% of people who identify as transgender have experienced refusal of health care, 28% have experienced harassment, and 50% felt a lack of provider knowledge regarding the caring of transgender individuals. Even more, 28% have postponed receiving health care due to fear of discrimination.

That’s the epitome of the minority stress theory.

Those results are riddled with any number of concerns. For one, 40% of transgender individuals have attempted suicide, in part because of that stress, which is roughly nine times the rate of attempted suicide among the US population overall. For our purposes here, let’s home in on why the lack of regular, professional dental care is particularly troubling for someone who is transitioning or transgender. Variations in hormone levels directly affect the oral cavity. So, patients who are undergoing hormone therapies should expect an overly severe inflammatory reaction, which can lead to greater incidences of gingivitis and periodontal disease.

If either isn’t promptly and properly treated, doors can swing wide open to a host of much larger concerns, including heart disease, various kinds of cancer, diabetes, and Alzheimer’s.

Change on the most basic level

The American Dental Association Commission on Dental Accreditation, in its Accreditation Standards for Dental Education Programs states that “programs must create an environment that ensures an in-depth exchange of ideas and beliefs across gender, racial, ethnic, cultural, and socioeconomic lines” and that “graduates must be competent in managing a diverse patient population and have the interpersonal and communications skills to function successfully in a multicultural work environment.” Despite these statements, education about the care of sexual and gender minority patients has been found to be lacking in predoctoral dental education. The result is a profession of dental providers who may be uncomfortable with the delivery of care specific to transgender patients.

That’s an excerpt from an article titled “Should Dental Care Make a Transition?” that appeared in The Journal of the American Dental Association in February 2018. Where exactly does it leave us? Adrift, that’s where. Are we supposed to wait while curriculums are overhauled? That could take years. And that’s presuming that it’s already begun, which it hasn’t.

For a study that was published earlier this year, oral and maxillofacial surgery residents in accredited training programs across the US were surveyed between July 1, 2017 and January 30, 2018. The results showed that they “had limited exposure to the care of transgender people, but they perceived that such exposure should be an important component of their training.” In other words, medical school and academic hospitals still exist in a bubble.

Institutions are slow to change, even when lives are at stake. So this change is going to need to begin in grassroots fashion, with each one of us consciously meeting our patients where they are, without judgement or preconceptions. It’ll be awkward and mistakes are bound to be made, but that shouldn’t deter us. In a recent survey, transgender and gender-nonconforming people, as well as support networks, said that respectful mistakes are readily corrected with goodwill. Basically, the effort is what matters most—for now.

All of this begins with trust. And, as with every other kind of relationship, that will grow from simply greeting each other with all the respect, kindness, and empathy that should entail. It’s really that simple.