Recently, I had my first experience caring for a transgender patient in the emergency department. The patient's chief complaint was testicular pain. After assessing the vital signs and triage orders, I noticed the patient's sex was listed in the medical record as female. My initial inclination was to assume that this was an error, or that the patient had been mistakenly registered under an incorrect name. However, closer inspection of the triage note stated the patient identified as a transgender female. In fact, the patient had been registered appropriately.
Although I had previously attended several sessions on caring for lesbian, gay, bisexual, and transgender (LGBT) patients, I found myself overcome with anxiety. I became hyper-focused on “saying the right thing” so as not to offend my patient. Upon entering the room, my heart started to race. I introduced myself and began with my usual opening schema: “Tell me, what brought you in today?”
Fortunately, our conversation ensued as any other patient interview. I asked about her medical and surgical history, allergies, and medication use. The patient disclosed that she was transgender and shared with me her preferred name and pronouns. I asked for permission to share this information with my nurse and attending physician. In bold lettering at the top of my note, I wrote, “The patient's preferred pronouns are she/her and her preferred name is”¦” When ordering an ultrasound, I informed the technician of the patient's preferred name and pronouns. After a suspected diagnosis of torsion was ruled out, the patient was discharged.
Though our interaction was over, I reflected heavily on her visit: Why did I feel so anxious? What could I have done differently to make her feel more at ease?
In the United States, it is now estimated that 700,000 American adults identify as transgender. The term “transgender” describes an individual whose gender identity differs from the sex marked on their birth certificate. Gender identity is defined as a person's internal, personal sense of their gender, be it man, woman, or perhaps something outside of that binary. Individuals may be gender fluid, meaning they do not identify as having a fixed gender. Collectively, these identities are referred to simply as “trans.”
Many transgender individuals have had negative health care experiences, rooted in stigma, rejection, or ignorance from their providers. Sadly, such negativity is not limited to the health care space. In 2013, a disproportionate 72% of LGBT homicide victims had identified as transgender women; 41% of transgender individuals reported having attempted suicide, compared to 1.6% of the general population. Transgender people are 4 times more likely to live in poverty, and they experience unemployment at twice the rate of the general population. These numbers spike even higher among transgender people of color. These are only some of the barriers this community faces in accessing reliable health care. I was surprised to learn this population is now becoming increasingly reliant on the emergency department (ED) for their health care needs.
As an emergency medicine physician, I enjoy the incredible, rich diversity of the patients we care for. My patients inspire me to be a better physician by challenging me to understand their needs, motivations, and fears on a deeper level. During our short time together, my patient described her transition as “lifesaving”—and I now better understand why this was true for her. Laverne Cox, famous advocate for trans individuals, once stated, “It is revolutionary for any trans person to choose to be seen and visible in a world that tells us we should not exist.”
I sought to understand how to best care for trans patients. Here are several key lessons I've learned.
Avoid overemphasis on surgeries and/or patient anatomy. An inordinate focus on biological composition dehumanizes and ultimately minimizes the trans experience. As medical professionals, it may be relevant to ask about reassignment surgery or hormone therapy. However, probing out of curiosity is, simply put, inappropriate. In the majority of situations, one's gender identity is irrelevant.
Structure interviews with open-ended questions. This allows patients to share and disclose their identity as they deem appropriate. Ask known trans patients, “Which pronouns do you prefer and what may I call you?” Document this in the medical record and share this information with the patient's care team. However, remember there is no universal trans experience. Each person's transition is unique; each will come to you with a varying level of trust. Allow your patients to disclose as much or as little as they feel. Do not disclose a person's transgender status to anybody who does not need the information for care.
Be an advocate. If you find that a coworker or fellow staff member makes inappropriate comments, challenge their stance in a non-confrontational way. Ask, “What do you mean by this?” to unpack their thinking, or speak to the individual in private. It may feel awkward at first, but it is important to adopt this habit. Given the complex diversity of patients we care for, it is crucial that we continuously work to ensure our ED remains an open and inclusive space for all patients at all times.
It is important to continuously reflect on our experiences and allow ourselves to grow into the competent, compassionate physicians our patients deserve.