WTBS 13 Transgender Patients: How to Foster a Safer Emergency Department Environment

He, she, they, him, her, hir: What’s in a name?

I have always been interested in communication issues in the emergency department (ED) and have written about this subject many times. I believe that establishing a rapport quickly in challenging situations is one of our most important skills as emergency care providers. I try to be progressive, inclusive, and respectful of all. Yet over time the world has evolved more quickly than I have; my daughters sometimes point out that my language is not really as politically correct and courteous as I intend it to be. I have found myself tongue-tied on duty as I try to remember what I should say when caring for a transgender patient, mix up the legal name on their chart and the name they use, guess at preferred pronouns and mess them up, and generally detract from what I’m trying to do.

This issue can be complex and controversial, as the well-publicized dust-up at the University of Toronto involving a professor who doesn’t want to be compelled to use gender-inclusive pronouns shows.

To me this issue can be viewed more practically; it’s not just about rights, it’s also about being a good and effective physician. If I can establish a rapport and earn a patient’s trust it makes my job easier and their care safer. That is more than enough to justify the effort required, but beyond that I recognize that patients bring their world experiences into the ED with them. If they have been abused, discriminated against, disrespected, or even assaulted because of their beliefs or who they are, simply treating them courteously can sometimes be more important and lasting in its impact than, say, a cast for a fracture or a course of antibiotics.

For help in this area I turned to a colleague, Dr. Nadia Primiani, who is comfortable with and well versed in these issues. She presented rounds on this topic to our staff and helped me redraft a chapter I’d written on communication skills in the ED for medical students to make it more inclusive and up to date. Then I asked her to write a guest blog on the topic! So here is Dr. Primiani’s advice on how to make your ED a more welcoming and safe place for some of our most vulnerable patients.

—Dr. Howard Ovens, July 2017

Breaking down barriers to health care for transgender patients

The ED in which I work once treated a trans man who asked to be called Steve* and to be referred to using the pronoun “he.” Though the nursing staff and physicians respected this and acknowledged Steve’s gender identity, his ED experience took a negative turn when an X-ray was ordered. The person who came to take him for imaging insisted on using Steve’s given name at birth and referred to him as “she,” despite Steve’s repeated request that he not be mis-gendered. This unfortunate incident led to an angry, loud interaction. This event also led me to start talking about trans issues with my colleagues.

My interest in marginalized populations began many years ago when I visited Vancouver and its Downtown Eastside. This led me to pursue my residency at St. Paul’s Hospital in Vancouver, which serves several vulnerable populations. This includes patients who are homeless, have addictions, have mental illnesses, or are lesbian, gay, bisexual, transgender, queer, intersex, or two-spirited (LGBTQI2S). Since then I have continued to advocate for these populations and I was recently invited to present rounds to my emergency group on the care of transgender patients in our ED. I was reminded how little we are taught about the LGBTQI2S population in our medical training, yet these patients are among those who have been marginalized the most.

At first I did not know what to expect when talking to my peers about this subject. But my colleagues were keenly interested in learning about gender-affirming surgeries, hormone use, and language to use in their interactions with trans patients. It’s not that they had been blatantly dismissive or insensitive previously, but they had found their own discomfort with asking sensitive questions had been obvious to their patients. Given some tools and a better understanding of their patients, they were able to overcome that discomfort and start a conversation like any other.

In this blog I will pass along some of the things I’ve learned from my patients and colleagues over the years. Since I am a cisgender white female, I wish to acknowledge my privilege. My intention is for this blog to be informative, but it is by no means representative of all TGGNC patients and their experiences; I hope it starts discussions within emergency departments to help improve the care of these patients.

Who are our TGGNC clients?

Most articles on LGBTQI2S issues focus on patients who identify as gay or lesbian. Transgender and gender-non-conforming (TGGNC) individuals are typically lumped into these data despite having unique challenges and health concerns. TGGNC patients are everywhere and though proper statistics are limited, TGGNC individuals are estimated to make up roughly 0.5% of the population.[1]

A small study from Ontario, Canada, showed that 21% of trans patients avoided the ED due to previous negative experiences they had had in that setting.[2] More than half reported having to educate their providers about trans issues and 52% reported having had trans-specific negative experiences in the ED. Reasons for avoiding the ED included experiences with hurtful language, providers’ lack of knowledge about trans health, and a fear of unwanted examinations based on previous encounters.

Along with having negative experiences when accessing health care, TGGNC people are statistically more likely to work in the “underground economy” (e.g., sex work, selling drugs), be incarcerated, and use alcohol or illicit substances to cope with the mistreatment they have experienced.[3] They are four times more likely to be infected with HIV and many have survived physical (61%) and sexual (64%) assaults.[4]

Gender is an internal experience and has no definite clinical categories. In other words, identifying as trans is a personal experience that falls outside the criteria physicians have historically used to define sex and gender (i.e., genitalia and secondary sexual characteristics). Similarly, there is no end point to transitioning. Therefore, identifying as trans does not depend on whether you have undergone surgery or are on hormone therapy. The only way to find out how patients identify is to ask them.

In a recent study [5] on patient-centred approaches to gender identity, the take-home message was that “patients are saying that you’ll make us feel more comfortable if you ask—and ask everyone, so that normalizes the questions.”[6]

This brings me to a few practical points.

What are some terms we should know?

To begin, it is helpful to discuss terminology. By definition, identifying as cisgender relates to when one’s perceived gender matches their biological sex/assigned sex at birth. TGGNC encompasses a variety of gender identities, including trans. Trans refers to a state of incongruence between one’s gender identity and the gender assigned to them at birth (usually based on phenotype and sometimes on chromosomal make-up). This includes people who are not cisgender, individuals who are non-binary, and trans men and trans women (e.g., Chaz Bono and Laverne Cox, respectively). The term non-binary is an umbrella term for anyone who does not identify with a static male or female gender. These can include genderqueer (someone who identifies as other than male or female, is a combination of the two, or is on a continuum between the two), bigender (someone whose identity encompasses two genders), gender fluid (someone whose gender identity shifts over time), and polygender (someone who identifies with multiple genders, either simultaneously or not).).

To clarify some other terminology, a trans woman is someone who identifies as a woman but was previously assigned as male. Biologically she may have a penis, testicles, a prostate, and so on. One does not have to undergo surgery or take hormones to be trans. However, some patients choose to take cross-gender hormones or undergo gender-affirming surgeries, such as breast augmentation and/or vaginoplasty while on estrogen in the example of a trans woman.

What are some practice implications for transgender patient care in the ED?

I recently saw a patient in the ED who presented with suicidality and depression. A medical student working with me approached the patient and asked for their name. My student did not expect the patient to state their name was Michael*, as the patient presented phenotypically as a woman in feminine clothes and the name on the chart was Mary*. This prompted my student to ask what pronoun to use, and the patient asked to be referred to as “he.” This led to an exemplary interaction and the patient appeared to be comfortable and respected with the remainder of the encounter.

It is important when approaching any patient to remain open and neutral. For example, asking a patient the name and the gender pronoun(s) they use gives the patient the opportunity to express their identity. Once a patient tells you their name and gender it is important to continue using them. Refusing to acknowledge their gender identity and choice of language harms the therapeutic relationship, is discriminatory, and insults the patient. Furthermore, this may add to any trauma they have already experienced and possibly foster increased thoughts of suicide and self-harm.

Some pronouns that may be used include binary ones such as he/she. Other non-binary terms include they/their and hir. One could start their interview by saying, “Hello, my name is Dr. Smith. What name would you like me to use when referring to you?” and then “What is your gender identity?” From there you can ask what pronoun they prefer to be applied to them, if that is not clear. When speaking to those around you, be sure to use the name and pronoun the patient has asked you to use. If you notice people mis-gendering the patient, gently remind them of the patient’s preferred name and pronouns.

It is difficult to tell care providers they should ask everyone they see to state their gender, as we can sometimes get a strange look from cisgender patients. For those who have never questioned their identity or been discriminated against, it may seem strange and uncomfortable to have this conversation. However, it used to be strange to take a sexual history and delve into our patients’ private lives; over time we have normalized this part of our history taking. We can similarly change ideas and behaviours around gender.

If we apply neutral language to all our patients, then those who do not identify with their assigned gender will feel more comfortable disclosing their identity and not feel ostracized. Given that not all patients will present with obvious gender identity concerns, it is important to start with open questions. When a patient gives me a strange look (I have had many), I say, “We ask all our patients this question. Does this mean you prefer the pronoun ___?” Making these questions standard among all care providers will normalize this aspect of care and benefit all patients.

Keep your questions relevant, keep your transgender patient informed

When taking a history it is important to identify the patient’s trans identity and inform others only if it is relevant to the patient’s care and their presenting complaint. Furthermore, when asking questions about past medical and surgical histories, include areas related to transitioning only if they are relevant to their chief complaint. For example, the status of a trans woman’s transition is not relevant if they present with an ingrown toenail. Conversely, if a trans man presents with acute pain in the lower left quadrant, you will have to gather a history around gender-affirming surgeries. As mentioned previously, transitioning can include taking hormones or undergoing surgery, but not everyone who identifies as trans will pursue these courses of treatment.

Be mindful of explaining why questions regarding their transition are important to the patient’s care. It is okay to start with open-ended questions that are a little vague before clarifying. For example, “You mentioned you have never had any surgeries. Does this include gender-affirming surgeries?” or “I am trying to find out what is causing your abdominal pain. May I confirm that you have not had any surgeries affecting your abdomen or genitals, and therefore you still have a uterus and ovaries?” If you are taking a history and your patient gives you a look of confusion or offence, pause and say, “If there is specific language you would prefer I use for different body parts, please let me know.”

As with any patient, prior to conducting an exam be mindful of the possibility of previous trauma. Always ask if the patient would like to have a support person in the room with them. Explain what will be done during the exam and why it is relevant. If at any point the patient seems uncomfortable, stop and ask how they would like to proceed.

Speaking about history taking, a colleague once told me about a patient who was a trans man married to a trans woman. The patient came in with acute pelvic pain and my colleague had to take a history around previous surgeries. The patient was quite open about discussing his hormone treatment and that he had not had any gender-affirming surgeries. My colleague then inquired about pregnancy risk. This took the couple by surprise, despite my colleague explaining the thought behind it. For the patient, the thought of pregnancy—which was the epitome of femaleness for him—was too distressing to discuss. He had not had surgery and therefore biologically could still get pregnant, yet he could not fathom the idea given that he identified as male. My colleague later told me they learned a few things from this encounter. First, some patients want to educate you; let them, even if they’re preaching to the choir. Second, as a doctor you have power and privilege (especially as a cisgender white male physician in this case), so you need to acknowledge that power and its oppressive capacity. Finally, stay compassionate and focused on the clinical issue, otherwise things can gets missed amid the tough politics.

Establishing a rapport with the patient and being mindful of possible previous negative experiences will help you navigate the interview with greater ease.

Pay attention to general practices for transgender patients

Regarding the ED as a whole, it is important that everyone who will interact with the patient knows the name and pronoun they use. Remember that the gender and name on the patient’s health card or chart may not reflect their true gender. Ensuring there is a space on the patient’s chart to document the name and pronoun(s) they use allows everyone who will come in contact with the patient to address them appropriately.

In the case of Michael, the patient who presented with suicidality, I had to place him on a form. When I brought the psychiatric assessment form to him, I said, “I recognize that you go by the name of Michael and identify as male. Unfortunately, for legal purposes I had to write your name given at birth on this form.” Acknowledging how the situation could potentially make the patient feel awkward and again recognizing his true gender allowed the patient to feel seen and respected.

Another interface in the ED to consider is washrooms. Ensure washroom signs are gender inclusive so they don’t become barriers. Having both male and female symbols on a door does not encompass gender inclusivity. Some creative solutions in health institutions include having single-stall washrooms labelled as “Washroom” or describing the equipment in a washroom (“This washroom has a toilet, urinal, sink, and change table”) instead of calling it, for example, the “Men’s Washroom.”

A big part of our job is to advocate for our patients. I hope this blog helps you understand where some of our most vulnerable populations are coming from and improves your familiarity and comfort with issues around gender.

Together we can make our EDs safe places for these patients to access care that is informed and non-judgmental.

—Dr. Nadia Primiani is an emergency physician on staff at Sinai Health System, Toronto, Ontario, Canada

*Names have been changed to protect patient privacy.

EM Cases main episode podcast on Patient Communication

References

1. Flores AR, Herman JL, Gates GJ, Brown TNT. How many adults identify as transgender in the United States? Los Angeles, CA: the Williams Institute, 2016.
2. Bauer GR, Scheim AI, Deutsch MB, Massarella C. Reported emergency department avoidance, use and experiences of transgender persons in Ontario, Canada: results from a respondent-driven sampling survey. Ann Emerg Med. 2014;63:713-720.e1.
3. Chisolm-Straker M, Jardine L, Bennouna C, Morency-Brassard N, Coy L, Egemba MO, et al. Transgender and Gender Nonconforming in Emergency Departments: A Qualitative Report of Patient Experiences. Transgender Health. 2017;2(1):8-16. doi:10.1089/trgh.2016.0026.
4. Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice At Every Turn: A Report of the National Transgender Discrimination Survey. Washington, D.C.: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.
5. Haider AH,Schneider EB,Kodadek LM, Adler RR, Ranjit A, Torain M, et al. Emergency Department Query for Patient-Centered Approaches to Sexual Orientation and Gender Identity: The EQUALITY Study. JAMA Intern Med. 2017;177(6):819-828. doi: 10.1001/jamainternmed.2017.0906.
6. Hoffman, J. “Gay and Transgender Patients to Doctors: We’ll Tell. Jusk Ask.” New York Times. May 29, 2017. https://www.nytimes.com/2017/05/29/health/lgbt-patients-doctors.html?mcubz=0. Accessed June 19, 2017.