Ever forward: caring for patients who are transgender and gender-expansive

We are re-featuring this piece today in recognition of International Transgender Awareness Week 2024.

 

Five years ago I was asked to share some insights into the fundamentals of caring for transgender patients from my perspective as a nurse, lawyer, and leader in the efforts to advance LGBTQ+ equity and inclusion in the United States military and in healthcare. At the time, I served as the founding clinical program director of the Johns Hopkins Center for Transgender Health, now renamed the Center for Transgender and Gender Expansive Health to better reflect the population served across the lifespan. 

 

Before I was a nurse and a lawyer, I was an officer in the U.S. Navy. When I accepted that my own gender identity didn’t align with the sex I was assigned at birth, it put me on a very different path. While I had to put away my uniform, it didn’t end the obligations I undertook when I swore my oath when I was first inducted into the Naval Academy and then when I was commissioned in 1985. The obligations of fulfilling that oath–that I would support and defend the Constitution and bear true faith and allegiance to it–require me to act when people are denied access to healthcare or endure the negative impacts of the social determinants of health simply because of others’ willful ignorance and bigotry. Those harms offend the notion that all of us are protected equally and entitled to the same rights and obligations in our society.  

 

My personal and professional experience gives me unique insight and expertise about caring for transgender and gender-expansive patients. Five years on, the fundamental information remains essential. In 2023, it’s even more important to be able to give supportive and affirming care when the context in which we provide that care has changed. This year alone, almost 500 anti-LGBTQ+ bills have been introduced at the state and federal levels. These efforts reflect the toxic mix of religiosity, politics, and non-evidence-based policies that negatively impact the health of individuals and communities, particularly transgender youth who already face great vulnerability.  

 

I hope you find this post helpful in improving your skills as you work with your transgender patients and interact with your transgender colleagues. 

 

Treating all patients with dignity and respect 

We all strive to provide the highest quality care to our patients. We want them to feel welcome in our practice and to be comfortable with us. We know that building a trusting relationship between the patient, their family, and the practitioner is essential to giving holistic, patient- and family-centered care. However, for many transgender and gender-expansive patients, the healthcare system and healthcare practitioners have failed them. Our lack of cultural awareness and clinical competence contributes to the health disparities faced by this marginalized and stigmatized community. 

 

A 2021 Center for American Progress study reported that transgender people face increased risks for depression and suicidality as a likely consequence of stigma and marginalization. Approximately 80% of transgender respondents report being treated with less courtesy and respect than straight/cisgender people. The Williams Institute reported that transgender people are four times more likely to be victims of violent crime. Black and Latina transgender women disproportionally are victims.   

 

A downward slope leading to health disparities for transgender people 

The slope that ends in health disparities and health inequities for transgender communities often begins with our own unconscious bias. Unconscious bias is a human defense mechanism that leads us to respond unconsciously to situations and people based on our own experiences, behaviors, attitudes, training (or lack thereof), identity, and culture. The failure to recognize that we have biases leads to actions based on myths and stereotypes. If we don’t acknowledge the existence of our biases, don’t demonstrate a willingness to challenge our certainties, and refuse to accept evidence-based science that runs counter to our assumptions, we then act with a willful ignorance. This willful ignorance, in turn, fosters health disparities and health inequities. 

 

Most of us, regardless of our discipline or practice setting, have received almost no training about caring for transgender patients. Healthcare practitioners may think that they don’t see transgender patients in their practice setting. Folks forget that transgender people catch the flu, break their ankles, have heart attacks, get cancer, and suffer strokes too. 

 

Further, many of us may react defensively when cultural competency is addressed. “I give all my patients the same care. I treat them all the same.” Unfortunately, the reality is an unconscious default—all patients are treated as if they were heterosexual (straight) and cisgender (that means not transgender). This default is called cisheteronormativism. This is the pervasive belief that everyone is straight and cisgender within a binary structure of gender and that’s the way it is supposed to be. Being straight and cisgender is favored in this bias and those who are not chose to be that way and should be considered “abnormal” and less worthy. We act on our unconscious bias and on assumptions—because we haven’t bothered to ask about sex and gender. The topics make us uncomfortable. But every patient has a sexual orientation and a gender identity. And how can we really provide holistic and patient-centered care if we don’t know who our patients are?  

 

What can we do? 

Here are 12 things that every practitioner working with transgender patients (that’s all of us) needs to know:  

 

1. Don’t be a jerk.

It really is that simple. Be authentic and treat every patient with the dignity and respect you would want when you or your loved one seeks care. 

 

2. Apologize when you screw it up.

It’s gonna happen. You’re human. You might use the wrong name, the wrong pronoun, or ask a question using all the wrong words. When it happens, make a genuine apology. People will generally cut you a world of slack if they sense you are truly apologetic and working on doing things right. Don’t give a “Washington” apology: “I’m sorry that what I said offended you.” That translates to, “I have nothing to apologize for and you’re an overly sensitive snowflake.” Try this: “I’m sorry for [whatever it is you just said], I’ll be more thoughtful.” Then pay attention and don’t make the same mistake twice. 

 

3. Don’t make assumptions about someone’s gender or gender identity based on what you see or how they sound.  

Don’t reflexively use terms like “Sir” or “Ma’am” to show respect. Don’t call someone “Mr.” or “Miss/Ms./Mrs.” based on your perception of their gender expression. Show respect in the tone of your voice and your non-verbal communications. 

 

4. Use the appropriate name and pronoun. 

ASK the patient how they would like to be addressed and what pronoun to use. When they tell you what to use, THEN USE THEM. Many transgender patients don’t have identification documents that match their legal name or the name on their medical records. Call people by the name they use. Don’t ask people for their “real name.” That can be offensive. You can ask for the name on their driver’s license or other identification or their legal name if you need to locate a chart. Using a transgender person’s former name is called deadnaming. It can be very psychologically distressing to be called by that former name and in some situations, it can place a transgender person in physical jeopardy by “outing” them. Remember that not every patient identifies as male or female—they may identify as nonbinary or genderqueer or by some other term. Over one million people in the United States identify as nonbinary. They may ask you to use a gender-neutral pronoun or use “they” as a singular pronoun. (Use of “they” as a singular pronoun is not new or radical–it’s been a part of the English language since Shakespeare!) A way to approach this is to introduce yourself like this: “Hi, I am Paula and I’ll be your nurse today. My pronouns are she and her. How would you like me to address you and what pronouns do you use?” Understand that this is part of a large cultural shift and many of us and many of our patients will need time to adjust to this phrasing. 

 

5. Use correct terminology.

“Transgender” is an adjective, not a noun or a verb. It’s “transgender” NOT “transgendered.” People don’t get straightened or gayed or lesbianed. Transgender people do not get transgendered. 

 

6. Don’t use outdated language.

Don’t use	Appropriate terminology
Sex change	Transition, Gender confirming (affirming) surgery, gender reassignment surgery
Hermaphrodite	Intersex
Transvestite	Cross-dresser
Transsexualism / Transgenderism	None. Using those terms is always offensive

 

7. Ask an appropriate question, at the appropriate time, in an appropriate way.

As clinicians, we need to take good histories and complete appropriate physical exams depending on the setting and the patient’s concerns. Nevertheless, questions about, or an unnecessary focus on, a patient’s genitalia when it is not relevant is inappropriate. The way to ask about sexual orientation and gender identity (SOGI) is in a straightforward, manner like asking any other demographic information: “What’s your sexual orientation / How do you describe your sexual orientation?” Allow the person to use their terms or description rather than giving them a label to choose. 

 

8. Gender identity is a two-step question: 

“What’s your gender identity / How do you describe your gender identity?” Allow the person to use their terms or description rather than giving them a label to choose. “What sex were you assigned at birth?” 

 

9. Questions not to ask (as phrased): 

“Are you pre-op or post-op?” This assumes every transgender person needs surgery. 

“When did you choose to be transgender?” This assumes gender identity is a choice. 

If you start a sentence with “I don’t mean any disrespect but . . .” think twice before finishing, because what comes next is almost always disrespectful. Turn it around: “I want to be respectful, but I don’t understand, can you explain to me . . .” 

 

10. Change the mindset from “gendered” medicine to “If you got the parts, we need to check them.”

We often order diagnostics or perform health screenings based on the gender marker in the record, rather than in a person-centered manner.  Base decision on the anatomy and history of the patient. As an example, if a patient has a prostate, and it needs to be checked, check it. While this may apply mostly to cisgender men, it will also apply to transgender women and nonbinary people assigned male at birth. 

 

11. Avoid “Transgender Broken Arm Syndrome.”

This happens when clinicians forget that transgender people are people who can experience illness or injury like anybody else. This syndrome reduces transgender people to a single dimension and focuses on their identity rather than the clinical presentation. It manifests as becoming so anxious and flustered by a transgender patient that one forgets basic competency. We know how to treat a broken arm – there is nothing different when a transgender person breaks theirs. Further, do not focus on whether the person has had genital gender-affirming surgery unless it is relevant. Lastly, do not ascribe causation for every clinical presentation to a transgender person’s use of hormones.  

 

12. Be an advocate for your patient. 

We live in a time when there is much willful ignorance, intentional misrepresentation of data, and intellectual dishonesty about the science that underpins providing evidence-based, medically necessary, gender-affirming care in public discourse. As professionals, we must ensure that policy makers, legislators and jurists make decisions based on the evidence and the science and not on emotion and fear mongering. Our code of ethics demands it and our patients deserve it. 

 

If you have any questions about caring for transgender and gender expansive patients, call me at 443-927-8552 or email me at pneira2@jhmi.edu. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.