The Biopsychosocial Model and Transgender Healthcare
When counseling patients' physicians often rely on the biomedical model, which has been the dominant model for Western medicine since the 19th century. The biomedical model focuses on health status, and achieving freedom from compromised health. By focusing on decreasing chronic conditions, it creates a common language and understanding between the physician and patient. Such commonality of focus and language is harder for many transgender patients because of the fact that many patients have very personalized transition goals, and, due to the lack of information regarding long-term outcomes in transgender patients. Other important factors that limit the utility of the biomedical model for transgender care is because some care providers lack of understanding about not only what it is to be transgender, but also, how being transgender can affect- and be affected by, different aspects of the patient's' social world and health. The disconnect that results can for many patients foster distrust towards the healthcare system.
We propose a new model for transgender healthcare, which is rooted in the Biopsychosocial Model first proposed by George L. Engel and Jon Romano in 1977. Engel and Romano's model focuses on the development of illness from the complex interactions across and within biological, psychological, and social systems (Figure 1).[75,76] Engel emphasized that the biomedical approach is flawed because the body is not the only contributor to illness, or wellness.[76,77] Instead, an individual's own psychological (mood, personality, behavior, etc.) and social (cultural, familial, socioeconomic, etc.) domains also significantly impact underlying biological (genetic, biochemical, etc.) factors, to determine how illness and health are caused and treated. Engel also emphasized the need for two-way dialogue between the patient and doctor in order to find the most effective treatments.
We note that the process of gender transition affects (and is affected by) both biological and social continua. For example, gender affirming hormone therapy and surgery are a part of gender transition for many transgender/gender non-conforming people, as is a significant change in an individual's gender and social roles. A common theme in the World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) Guidelines is that a cornerstone of care for the transgender patient is to facilitate and adapt to positive change in mental health, social domains, and for some, physical/body related domains.
What is perhaps less obvious from the biopsychosocial model is that for people undergoing gender transition, certain subdomains of the biological and social continua change significantly, and often over a relatively short period of time. It is useful for healthcare providers to consider how changes in sex hormones, body appearance, dress, personal pronouns, partner, family, and professional relations can occur during gender transition, and that such changes affect health and illness. In essence, a provider can consider how each subdomain of Engel's biopsychosocial model is affected by the nature, and stage, of gender transition.
We propose a model for healthcare of the transgender and gender non-conforming individual that accounts for the complex interplay between the individual's gender transition, biological and social systems (Figure 2A).
Gender transition and the biopsychosocial model. (A) Model for healthcare of the transgender and gender non-conforming individual that accounts for the complex interplay between the individual's gender transition, biological and social systems; (B) cancer risk at any given time is influenced by the multiple levels of organization that Engel describes in the biopsychosocial model.
In the context of cancer screening, the model we propose reminds us that cancer risk at any given time is influenced by the multiple levels of organization that Engel describes in the biopsychosocial model, and other factors (Figure 2B). For example, the age at which an individual commenced transition with use of GAHT, and what stages of transition they have completed, influence factors, which are predictors of cancer screening needs and cancer risk (Figure 2B).
When we consider transgender health from the perspective of the model shown in Figure 2, three key points become clear: first, that gender transition constitutes different changes for different people (i.e., it is highly individual); second, patients can be in different states of transition across different domains at any given time; and third, an individual's present state of gender transition independently influences- and is influenced by, each of the concentric levels of organization within the biological, psychological and social continua.
Transl Androl Urol. 2020;9(6):2771-2785. © 2020 AME Publishing Company