I was working a regular shift at MacNeal Hospital in Illinois, where I am an emergency physician and medical director. I walked into a patient’s room ready to treat a 16-year-old presenting with severe psychiatric distress.
There was nothing in this patient’s chart to indicate that they did not identify as an adolescent male – as indicated by the gender marker on the chart. As I began my initial intake and questions, I quickly realized that this patient used female pronouns while her parents were very obviously using male pronouns. I really had to stop and think about my approach and what was most important: the patient in front of me and how she felt. I shifted my language to affirm what she had made clear – that she identified as female. While her parents didn’t shift their language, they didn’t attempt to correct me either. We seemed to create a non-verbal understanding that we were going to agree to disagree.
While I continue my journey to learn from my experiences with transgender and non-binary patients, I realize an important first step is signaling to them that I am an affirming provider and that they are safe to share their authentic selves with me. I do this by pinning a rainbow pin to my scrubs or coat during each shift. This lets them know right away that they can trust me, which allows me to the get the answers I need to provide them with the right care.
Training our Clinical Teams
If it feels like you are treating more transgender, non-binary, and other gender-diverse patients, it’s because you are. With recent federal guidance mandating nondiscrimination in the provision of healthcare based on gender identity, more gender-diverse patients are out to their healthcare providers than ever before. As societal recognition and acceptance have skyrocketed in the last decade, children and adults are recognizing that not only is there a name for the incongruence they feel between their assigned sex at birth (ASAB) and their gender identity, but they aren’t alone in those feelings.
At the same time, the bar is being continually raised for what it means to provide optimal care for gender-diverse patients. Advanced providers are graduating with specific training for treating trans patients, and physician residencies are following suit. Measures of patient satisfaction and outcomes captured by Press Ganey, CMS, and Joint Commission include gender identity within patient demographics. For seasoned clinicians like myself, we need to proactively pursue training in the area of gender to meet the needs of our gender-diverse patients.
Yet the resources needed for education and training of practicing clinicians lag woefully behind. As Clinical Education Chair at Vituity, I continue to seek resources to bring this critical education to our teams throughout the organization.
During Vituity’s annual Spring Symposium, a multi-day continuing education program, Diane Bruessow, PA, and faculty in the Yale PA Online program, led a CME session that was met with rave reviews. The session covered the medically necessary and effective care of gender-diverse patients across their lifespans. Among the key takeaways was a five-step approach to creating an inclusive experience for transgender and non-binary patients:
1.) Practice Both Cultural Competence and Cultural Humility
“Previously, healthcare professionals relied upon the construct of cultural competence which proposes an end-point to learning about categories of people,” says Bruessow. “However, this contributed to further stereotypes and bias. Cultural humility provides an alternative where each patient is approached with the mindset that our patient has information about themselves that is only possible to know if we ask them. This approach explicitly avoids making assumptions, which is critical to ensuring successful patient satisfaction and outcomes.”
Cultural humility acknowledges that we will never truly understand the full extent of experiences outside of our own. But it also allows us, as clinicians, to establish a relationship of mutual learning with our patients. At its core, cultural humility recognizes that even in sameness there is difference and reminds us to approach each patient as a complex individual – with a truly patient-centered framework.
To begin practicing cultural humility, providers should focus on listening with interest and curiosity, checking their personal biases in any given moment, and recognize the impacts of their presence as an authority figure. It is especially important for gender-diverse patients to receive affirmations of their identity from a person in an authoritative role. An affirming experience with a healthcare provider could be the only support a gender-variant patient is receiving.
To bridge the gap between ourselves and our patients, we must recognize that we don’t know what we don’t know. In the case of our gender-diverse patients, cultural humility is displayed when we ask our patients how they would like to be addressed, and then consistently affirm their identity.
2.) Understand and Prioritize the Use of Affirming Language
Creating a respectful, affirming experience for transgender and non-binary (TGNB) patients begins with employing the language our patients use to communicate who they are through their chosen name and pronouns. Yet, even with the best of intentions, this is where many clinicians stumble and it can feel challenging as terminology continues to evolve. Bruessow believes this continual evolution in terminology is a good thing because, as the language evolves, it becomes even more encompassing of the variety of gender identities and expressions.
Clinical language is no exception. Until the American Psychiatry Association changed the designation in 2013, being transgender or non-binary meant a diagnosis with DSM-4 Gender Identity Disorder diagnosis. At that time, the condition was renamed to remove the stigma associated with the term “disorder” and DSM-5 Gender Dysphoria was introduced as the preferred diagnosis.
Bruessow notes gender dysphoria still isn’t quite right. “Most transgender people I know aren’t dysphoric about who they are – quite the opposite, actually. They know exactly who they are.” Instead, she favors the ICD-11 designation of gender incongruence as a less pathologizing descriptor that recognizes incongruence between assigned sex at birth (ASAB) and gender identity. Gender incongruence gets closer to defining gender in terms of diversity rather than diagnosis because gender differences are common, culturally diverse, and normal variations that are not inherently pathological or negative.
Bruessow wants clinicians to know that it’s better to try to get it right than to hesitate. She explains, “If you become aware that you have misgendered a patient, apologize briefly, correct your error, and move on. Do say you are sorry. Don’t dwell.”
There are a variety of wonderful resources to explore on the meaning behind the terminology surrounding gender identity and expression that clinicians should become familiar with. Don’t hesitate to continue honing your language now. Patients will be responsive to your efforts.
“If you become aware that you have misgendered a patient, apologize briefly, correct your error, and move on. Do say you are sorry. Don’t dwell.”
Diane Bruessow, PA
3.) Stop Assuming
Of course, assumptions are a slippery slope, and this holds true when we consider the medical needs of our patients – especially the gender-diverse population. It is critical that we be aware of what gender is used as a proxy for and then remove those associated assumptions.
To illustrate, Bruessow provided a trauma case scenario of a John Doe requiring emergent blood products before the discovery that he was assigned female at birth. Hospital policy would have inadvertently delivered Rh-incompatible blood products based on the assumption that a male will not have a uterus.
To be more proactive, Bruessow recommends conducting an anatomy inventory. Instead of assuming anatomy based on what is in a patient’s chart, or based on their appearance, respectfully ask the patient about their existing anatomy. If they are non-verbal, conduct a thorough organ inventory before assuming an appropriate treatment method.
There is also a flip side to the positive experience of recognizing a patient’s gender identity that we as clinicians should also be aware of. It is a phenomenon referred to as the Broken Arm Syndrome. This term has been coined within the transgender community to describe when healthcare providers assume that all medical issues result from a person being trans – everything from mental health problems to the common cold, or even a broken arm. Personal stories are documented on social media using hashtags like #transhealthfail. “It is crucial to avoid errors of omission or commission in our provision of care when it can be avoided by simply inquiring,” said Bruessow.
4.) Support Transgender and Non-Binary Children and Their Families
Retrospective studies have found that most transgender adults were aware of their gender before puberty. While awareness of gender identity can occur at any age, most children recognize their own gender identity between the ages of 3 and 6. This remains true for a majority of transgender and non-binary youth and adults. The only difference is that, at the same time, they recognize that their ASAB isn’t aligned with who they feel they are and how they want to express themselves.
Many transgender youth experience family rejections, bullying and harassment in schools, homelessness and poverty, and feel unsafe in public spaces, including the doctor’s office and hospitals, and often with dire consequences.
Previous studies show that nearly half of the transgender population have attempted suicide by the age of 24.
Bruessow shared a story of a family she knew with a 6-year-old child experiencing gender variance. Unfortunately, when visiting their pediatrician, their child was mis-gendered and referred to by the wrong name on multiple occasions throughout the visit. On the ride home, the child attempted to unbuckle their seatbelt and jump out of the moving car stating they no longer wanted to live.
As heart-wrenching as this story is, there is good news coming out of several recent studies which found that when TGNB youth are affirmed by their families and supported by their communities, depression and anxiety are observed at levels consistent with the general population.
Even when the patient may seem medically healthy, affirming care from a provider can be a matter of life and death. “Parents and caregivers are looking to healthcare professionals for guidance on how to respond to what is happening with their child. What we say matters, and modeling affirmation can make all the difference in how that child and the whole family moves forward,” said Bruessow.
“What we say matters, and modeling affirmation can make all the difference in how that child and the whole family moves forward.”
Diane Bruessow, PA
5.) Improve Systems and Processes
Administrators have an essential role as well. Most modern EMR (electronic medical record) meaningful use criteria include gender identity and assigned sex at birth within the patient demographics. However, EMR setup can be problematic because this information, along with chosen names and pronouns, are often buried and require multiple clicks to access. Instead, this information should be front and center on the clinical page.
We can have the best intentions of walking in and treating the whole patient, but not having this crucial information front and center means we blow it before we’ve even really gotten started.
Additionally, updating the intake process goes a long way in setting the stage for more effective and inclusive treatment. When the CDC moved from asking solely about sex to asking two additional questions – gender identity and assigned sex at birth (ASAB), the percentage of transgender patients identified increased by over 60%.
There is far more to be done outside of these tangible examples, such as advocating for patient satisfaction and health outcomes by patient ASAB and gender identity, and training staff at every level on the use of gender-neutral language in the provision of care.
Continuing Inclusive Care for Transgender Patients
We all chose medicine to take care of people, and lifelong learning is a hallmark of our profession and a commitment we make when we take our oath.
There is now a body of data on TGNB health that translates well into practice and supports system improvements. And we can engage the assistance of others (colleagues, companies, and hospitals) who have already informed their systems and practices. As we implement our learnings to create even more inclusive care practices, we should engage in shared medical decision-making with our patients, and work closely with our teams and employee resource groups, especially to build process improvements.
I am proud that Vituity has taken the important first step of prioritizing the training and resources that better equip our clinicians to deliver inclusive care for gender-diverse populations. We are committed to continuing the pursuit of education to better serve each of our patients.
To learn more about compassionate conversations, explore this popular framework created by Dr. Swati Mehta that includes a 6H approach for building quality connections with your patients.
More Resources to Reference and Explore:
- Book: A Clinician’s Guide to Gender-Affirming Care
- Online Resources: For Providers and Hospital Administrators
- Podcast: Mayo Clinic Talks: Transgender Patient Care
- CDC: Recommended Practices for Healthcare Settings