Patients who identify as transgender often are reluctant to seek needed care, either because they have experienced negative interactions with providers in the past, or they fear they will be unwelcome or perhaps “judged” in a traditional healthcare environment. There also is evidence that providers themselves often feel uncertain regarding how to manage encounters appropriately with patients who present with gender identities that are different from what they were assigned at birth.
Like so many other problems, such barriers certainly have implications in the ED, where patients often ultimately present when they can ignore their symptoms no longer. Experts note that how staff manage these encounters can have profound implications, not just with respect to the specific clinical situations for which these patients are seeking emergency care, but also on how they interact with the healthcare system going forward.
Transgender healthcare has its complexities, to be sure, but clinician leaders in this area explain that there are basic steps hospital and ED leaders can take to ensure that both clinical and non-clinical personnel clearly understand how to address and interact with transgender patients so they receive the care and treatment they require in a gender-affirming environment.
Address Provider Insensitivity
Consider the experience of Samantha Gridley, a medical student at Vanderbilt University School of Medicine, who recalls one of her first clinical encounters with a transgender patient while she was seeing patients on the general surgery service.
“This patient was seen in the ED, and we were consulted because the emergency physician gathered that the patient was going to need abdominal surgery,” she explains.
In a blog post about the encounter, Gridley writes that she was “dumbstruck” by the insensitivity of the chief resident in the ED who reviewed the patient’s medical record, but only commented on the fact that he was transgender and had undergone a bilateral mastectomy. Using crude language, the physician joked about the patient’s “protected secret,” prompting laughter from colleagues. Then, after entering the patient’s room, Gridley relates that the physician was cordial, but seemed unconcerned about the patient’s obvious reluctance to interact with healthcare providers. The patient had 10 abscesses on his abdomen, and he admitted that he had tried to drain them himself using a pen.
“Seeing how someone can be treated so poorly just because of the pronouns they choose and the way they want someone to call them ... it was just kind of earth-shattering for me that someone could be treated in such a way,” Gridley explains.
Endeavoring to gain the patient’s trust after the troubling encounter, Gridley asked the patient about his life. She learned that he had been shot and beaten after “coming out,” and Gridley concluded that the fearful and anxious patient was exhibiting signs of PTSD.
Before the patient was discharged, Gridley set up appointments for him with an LGBT-friendly primary care physician (PCP) and a free counseling center in the area. She also later reported the behavior of the chief resident.
Gridley has since taken a strong interest in transgender health, recognizing that there is a clear need for education and training in this area. She recently coauthored a new study looking into the barriers to gender-affirming healthcare for transgender youth, which she completed with colleagues at Seattle Children’s Hospital.1 She also is among the first to take advantage of a new certificate program in LGBT health offered at Vanderbilt.
Use Gender-affirming Language
Jesse Ehrenfeld, MD, MPH, one of Gridley’s mentors and the director of the program for LBGTI health at Vanderbilt University School of Medicine, stresses that a key point in caring for transgender patients is to remember that they are humans.
“We lose sight of the fact that regardless of the person in front of us, our job as healthcare providers is to do the best thing for the patient who needs our services,” he explains. “While there is a lot of misunderstanding, fear, and uncertainty — and people aren’t always sure what words to use or exactly what to do — at the end of the day the thing that serves our patients best is compassion and wanting to do the right thing.”
Beyond the fundamentals, there are some practical best practices that Ehrenfeld encourages frontline providers and administrators to adopt. For example, he notes that clinicians should ask patients what their preferred name is and what pronouns they like to use.
“If a nurse or physician is not sure what to say, the most important thing you can do is ask the patient,” he explains. “Patients appreciate so much that you care enough to pause and ask the question. I see that over and over again, and that has been a really important guiding principle in my own work and for our institution.”
While it is important to construct a clear, regimented method for carrying out the intake process, it must happen through an “open, affirming lens” for all patients, Gridley observes. For example, when she was working on her research pertaining to transgender health at Seattle Children’s Hospital, Gridley notes that the institution compiled a set of proposed instructions for the hospital’s intake process that are designed to ensure providers receive the information they need while also respecting the preferred gender of patients.
The approach involved asking patients for their legal name as well as their preferred name, and then asking for preferred pronouns, Gridley explains, noting that a preferred name alone doesn’t necessarily tell you what a person’s gender identity is. Clinicians then ask what a patient’s birth-assigned sex is.
“Using that language is important because this question can be easily butchered in the intake process,” Gridley adds. “It is just important that you use affirming, understanding language. ‘Birth–assigned sex’ or ‘sex assigned at birth’ is very appropriate terminology.”
Gridley stresses that a patient’s gender identity can change over time.
“If a patient comes to the ED every couple of weeks or every couple of months, and they keep using the ED for primary care, it is important not to assume these issues remain static just because you asked [these questions] one time,” she says. “Gender identity may or may not necessarily be fluid for that person, but he or she may not have come out the first couple of times, and [a person’s preferred gender] might change if you keep asking.”
At Seattle Children’s Hospital, clinicians are instructed to ask return patients about their preferred names and pronouns every three to six months, Gridley notes.
“It is a good opportunity for the patient to say things have changed, but it is also just good [for the clinician] to practice asking these questions, even if there isn’t a change,” she says. “It just opens the door to letting people know they are in an affirming place ... it normalizes people of all gender identities.”
Determine Transition Status
Understanding where a transgender patient is in their personal transition also is pertinent from a clinical standpoint, Ehrenfeld notes.
“There are some unique healthcare concerns of transgender people, and they often are driven by where someone is with respect to their transition,” he says. “For example, many transgender people take hormones to affirm their gender identity, but not all, so it is important to understand if someone is taking hormones, what the side effects are, and how they can be used or not used safely.”
This is of particular concern, given the barriers many transgender patients experience when they attempt to obtain hormones. Some resort to purchasing these drugs on the street and may take them in a way that is not safe, Ehrenfeld explains.
“Identifying and understanding what those challenges are and talking to patients about what they are doing so that we can understand how to best help them is critically important,” he says.
For instance, Ehrenfeld recalls the case of a transgender woman he encountered after she had suffered a stroke.
“She was taking one of her friend’s birth control pills while smoking, so there was a confluence of things that were happening for this particular patient that led her to suffer a stroke and come to the hospital,” he says. “She did very well, and we actually were able to get her plugged into care, and we helped her understand how we could assist her in accessing hormones for her identity and how to [take those drugs] in a safe way.”
Implement Patient Support Systems
With the establishment of a “Trans Buddy” navigator program, Vanderbilt also has taken a big step toward easing the anxiety and fear that keep many transgender patients from seeking quality care when they have an urgent or emergent need.
“We started it [18 months ago], because we recognized that there continues to be friction points when transgender patients come in and out of our healthcare system, whether it is a routine office visit, a visit to the ED, or some other acute care episode,” Ehrenfeld says. “We have a trained peer advocate who is credentialed through our hospital volunteer services. They go through a day-and-a-half long training program, and then they are credentialed as a Trans Buddy volunteer.”
These volunteers are available any time of the day or night to assist transgender patients who need added support or guidance. The patient determines what level of assistance he or she needs, Ehrenfeld explains.
“If the patient wants the ‘Buddy’ to be there in the waiting room and hang out, that is fine. If the patient wants the ‘Buddy’ to accompany them all the way through the visit and during the provider encounter, they will do that. If they are in the ED and they just need someone to help them navigate through what is going on with a difficult situation, they will come into the hospital and be with the patient,” he says. “The program has been very successful, but the single place where we get the most requests from patients for services is from the ED.”
Reinforce Training, Education
Most EDs will not see a transgender patient every day, so it is important for hospital and departmental leaders to create mechanisms for continued education, training, and awareness around gender identity issues, Ehrenfeld recommends.
“Having opportunities where people can discuss these issues, express their concerns, and understand where the knowledge gaps are is important,” he says. “That has to happen across the entire department. It can’t just be the physicians and nurse practitioners. It has to include the support staff, techs, and registration clerks because we are a team. Patients don’t just see a piece of the team, they experience their interactions with the entire team.”
Further, leaders must continually reinforce and refine training to reflect new evidence.
“Our knowledge is changing, and our understanding of what best practices are is a moving target because the data have been so poor for so long,” Ehrenfeld says. “Data capture has been less than ideal around documenting transgender identity in health records.”
Ehrenfeld senses that instances of blanket discrimination against transgender patients have declined in the healthcare arena, but he observes that there still is uncertainty among providers.
“People are just afraid of the unknown. They don’t want to make a mistake, and whenever we are encountered with something that is unique or difficult, it just makes people anxious,” he says. “The ED is unique because we have such stress in our baseline work environment that when we have this additional uncertainty of not knowing how to address the patient or what to write in the chart or exactly what to do, those things lead to most of the problems that we see rather than a fundamental lack of desire to take care of people.”
Review Policies, Forms
Ehrenfeld’s advice to hospital and ED administrators who want to make sure they are providing a gender-affirming environment is to first examine their policies to make sure their departments are inviting for transgender patients.
“Are the forms that you have patients fill out inclusive of gender identity? Most places don’t have affirming language when someone is checking them in,” he observes. “That is starting to change, but it is an easy place to start because it signals to the patient when they arrive that it is a form that includes them and that they are welcome there.”
In fact, even after Vanderbilt made changes to its non-discrimination policies to be more inclusive of gender identity, administrators realized some old language remained in some patient waiting rooms.
“We weren’t visibly displaying [the new policies], so we corrected that, but it was a bit of a misstep,” Ehrenfeld admits. “Making sure that you have good policies, and that those policies are displayed so that they are recognized by patients in the community, is a really easy and important first step to making things more welcoming and inclusive.”
Also, Ehrenfeld recommends EDs develop referral sources so transgender patients can access primary or specialty care in their communities.
“Understanding in your local community who is an endocrinologist, who is PCP, who is a psychiatrist or psychologist who has the expertise, knowledge, and a willingness to help these patients is an important thing to know before you actually need these referral networks,” he says.
Resources for training in LBGTI health are available through the Fenway Institute in Boston (http://bit.ly/293wV0w). Also, Ehrenfeld co-edited a new guide that includes model language, registration forms, and other materials for presenting a welcoming environment to transgender patients: Lesbian, Gay, Bisexual and Transgender Healthcare: A Clinical Guide to Preventive and Specialist Care (Springer, 2016).
REFERENCE
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Gridley S, Crouch J, Evans Y, et al. Youth and caregiver perspectives on barriers to gender-affirming health care for transgender youth. J Adolesc Health 2016; DOI: http://dx.doi.org/10.1016/j.jadohealth.2016.03.017.
SOURCES
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Jesse Ehrenfeld, MD, MPH, Director, Program for LGBTI Health, Vanderbilt University School of Medicine, Nashville, TN. Email: [email protected].
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Samantha Gridley, Medical Student, Vanderbilt University School of Medicine, Nashville, TN. Email: [email protected].
