You Are Safe With Me

My patient was 19 when he came to my primary care clinic for gender-affirming medical treatment, after transitioning socially. In our first visit, he shared how disconnected he felt with his assigned gender at birth and how significantly his mental health and wellness improved as he was able to express his gender and present and live as a man. His transition to that point had offered many benefits and his excitement about starting hormonal treatment to further support his transition was palpable, though I could also sense underlying apprehension. 

In no other area of my work do I see or experience as much joy as when practicing gender-affirming care.  As a primary care provider, much of what I do involves counseling patients on how to prevent disease or responding when these measures fail. While I try to keep patients’ wellness at the center of everything I do, to practice thoughtfully with kindness and offer comfort, our work together rarely results in true joy. 

In contrast, there’s a great deal of joy in gender-affirming care, or the care we give to affirm and support a person’s gender identity. The diagnosis “gender dysphoria” belies this and is insufficient on its own to fully encompass what people experience when their gender identify is incongruent with their assigned gender at birth. That said, it’s important to recognize that the dysphoria and often trauma that transgender people experience exists and is, at its root, derived from the failure of family, friends, and society at large to respect their gender identity and expression. Many of my patients have understood their gender identify for years and have lived much of that time being told in various ways that they’re wrong, both in their understanding of themselves and in their conviction that living consistent with their gender identify and expression is appropriate and healthy.   

It’s not hard to imagine why this causes terrible distress and why, as these failures also occur within the medical community, seeking medical care including gender-affirming care, can be frightening and overwhelming. As healthcare professionals we must create a safe space for patients. We can’t expect a person to share very personal information about themselves if we haven’t demonstrated that their care will be approached respectfully, thoughtfully, and without judgement. This is important for all patients, but especially important for transgender patients, many of whom have already experienced care that falls far short of these standards. 

And doing so is easier than you might think. 

First, remember that your transgender patients know more about themselves than you. A lot more. This includes their experience with gender, their transition goals, and what feels safe and healthy to them. Beyond this, my patients often come to a first visit for gender-affirming care knowing a great deal about treatment options and have already learned from a supportive community of other transgender people. My role as a clinician is to work to understand their experience and goals, counsel on treatment options available, and develop a plan together that will meet those goals. This is a very satisfying way to practice. 

Second, remember that language matters. The language we use during a visit and in the medical record must respect and affirm our patients’ gender identity and expression. A patient’s name and pronouns aren’t “preferred;” they just are. Additionally, language should be non-pathologizing and person-first. Ironically, the diagnosis “gender dysphoria” suggest pathology. Though it’s often necessary to include this in the medical record in order to access insurance coverage for gender-affirming care, we can mitigate the stigma associated with the idea of a gender dysphoria as a disorder by considering more broadly how gender identify, expression, and incongruence have impacted individual patients, and including this in both our discussions and documentation. 

Finally, I try to remember that while mistakes do happen, redirective feedback from our patients is exceptionally valuable and provides opportunities to offer better care. If I use language that is incorrect for an individual person or even unintentionally use a term that’s stigmatizing to them, I’m grateful for the chance to correct myself. When this happens, it can be very scary for patients to speak up, and it’s my responsibility to welcome feedback and respond respectfully and appreciatively when corrected. 

My patients are so generous, sharing their experience with gender, working with me to develop plans that meet their transition goals, and sharing their joy as they realize another part of their transition. When my 19-year-old patient ultimately started testosterone, he sent me a message that succinctly and poignantly summarizes this joy and the challenges to getting to care: “You’ve made my reality a dream come true, and I didn’t think this was going to happen.” While participating in all aspects of gender-affirming care is a privilege, witnessing this joy is uniquely special.   

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