Fundamentals for Caring for Transgender Patients

I’ve been a nurse for over 20 years, certified in emergency nursing. I’m also a lawyer and was a leader in the efforts to increase LGBTQ inclusion in the United States military by repealing the Don’t Ask, Don’t Tell policy and changing the regulations on transgender military service.

Before I was a nurse and a lawyer, I was an officer in the United States Navy. I graduated from the Naval Academy in 1985 and served in Operation Desert Storm. Unfortunately, I had to sacrifice my naval career when I accepted that my gender identity didn’t align with the sex I was assigned at birth. Having transitioned in the 1990s, I understand many of the challenges facing transgender people.

My background as a patient, a nurse, a lawyer, and an officer provides me with a unique insight and expertise about caring for the transgender patient. 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 settings and to be comfortable with us. We know that building a trusting relationship between the patient, their family, and the practitioner is essential to providing holistic, patient- and family-centered care. However, for many transgender patients, the health care system and health care practitioners have failed them. Our lack of cultural and clinical competence contributes to the health disparities faced by this marginalized and stigmatized community.

The 2015 U.S. Trans Survey, the largest survey ever completed on transgender people in the U.S., reported that 33% of transgender patients had a negative experience because of their gender identity within the past year when interacting with a health care practitioner. 24% reported that their health care providers knew “almost nothing” about transgender health care. 23% delayed seeking necessary care in the past year out of fear of discrimination based on their gender identity.

A downward slope leading to health disparities for transgender people

The slope that ends in health disparities and health inequities for the transgender community 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 this unconscious bias leads to actions based on myths and stereotypes. If we don’t acknowledge the existence of our bias, 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. 65% of Americans report that they don’t know a transgender person. Health care 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 and cisgender (that means not transgender). 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?

A few of the fundamental take-aways or pearls that every practitioner working with transgender patients (THAT’S ALL OF US!) should know are:

1. Don’t be a jerk.

It really is that simple. Treat every patient with the dignity and respect you would want when you or your loved one is a patient.

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 did 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 non-binary or genderqueer or by some other term. They may ask you to use a gender-neutral pronoun or use “they” as a singular pronoun. (While it may bug English teachers, it’s OK to do!) 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 the 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.

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 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.

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?”

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 . . .”

Paula Neira serves as the Clinical Program Director of the Johns Hopkins Center for Transgender Health and is part of the Office of Diversity and Inclusion team at Johns Hopkins Medicine. Beyond helping our patients, she’s also a resource for you. If you have any questions about the Johns Hopkins program or about caring for transgender patients, you can reach Paula Neira at 443-287-7161 or via email at pneira2@jhmi.edu.