Reducing Adult Transgender Barriers to Care in the Emergency Department

Strategies to Improve Policies and Practices

Abstract

The Research to Practice column is intended to improve the research critique skills of the advanced practice registered nurse (APRN) and the emergency department (ED) registered nurse (RN) and to assist with translating research into practice. In this column, we review a recent qualitative research study by M. Allison, S. Marshall, G. Stewart, M. Joiner, C. Nash, and M. Stewart (2021) titled “Experiences of Transgender and Gender Nonbinary Patients in the Emergency Department and Recommendations for Health Care Policy, Education, and Practice” with discussion of how their findings can be applied to inform providers how to deliver appropriate care of transgender patients within the ED.

MR. W., A 28-YEAR-OLD BLACK MAN, presented to the emergency department (ED) complaining of lower abdominal pain steadily worsening over the last 3 days. He endorsed fever, chills, nausea, weakness, and dysuria but denied headaches, vomiting, diarrhea, chest pain, shortness of breath, hematuria, or discharge from his genitalia. The patient described his symptoms as flu-like and similar to a bad urinary tract infection (UTI). He also complained of reduced oral intake for the past 3 days with general malaise. He stated that his symptoms were worsening, which is why he presented to the ED. His past medical history included alcohol abuse, recreational cocaine use, obesity, and UTIs. He selected male on his electronic registration information where the only sexual orientation and gender identity (SOGI) questions were binary, male, or female. He was triaged by a registered nurse (RN) within 30 min of registration.

His triage vital signs included a temperature of 39 °C, respiratory rate of 19, pulse of 75, blood pressure of 110/65, oxygen saturation of 95% on room air, and body mass index of 35.4. He rated his abdominal pain as 5/10. He was assigned an Emergency Severity Index core of Level 4 indicating a low acuity medical condition and was instructed to wait in the lobby to be called back to a room as soon as one was available. Mr. W. waited 1 hr in the lobby before being called back to the fast-track area of the ED. Although waiting, his abdominal pain increased. After being brought to the examination room, he waited another 30 min before the nurse practitioner (NP) entered his room. He remained in his clothing for the examination.

When the NP arrived, she took a more thorough medical history and noted his abdominal pain, fever, and painful urination started 3 days ago after eating out with friends and drinking margaritas. His abdominal pain was initially diffuse but over the past few days had migrated to the suprapubic region and lower left side. Although complaining of nausea, he denied vomiting, diarrhea, bloody stools, or urinary frequency or urgency. He stated that acetaminophen reduced his discomfort somewhat and eating and drinking made him feel worse. He denied having a primary care provider because he was uninsured.

Mr. W. endorsed a past medical history of a childhood tonsillectomy and stated that he received two SARS-CoV-2 vaccines. He denied any regular medication use but stated that he usually had three to five alcoholic drinks per day, used cocaine occasionally with friends, and denied tobacco or other recreational drug use. He indicated that he was currently living with friends, worked as a bartender, was sexually active with males and females, denied the use of barrier protection, and did not have any known drug allergies. He was unsure about his family medical history but thought that some family members had diabetes and high blood pressure.

Upon physical examination, Mr. W. was alert, oriented, and appeared uncomfortable but not in acute distress. Repeat vital signs were temperature of 39 °C, respiratory rate of 21, pulse 82, blood pressure of 125/83, oxygen saturation of 95% on room air, and pain 6/10. His skin was warm, dry, and normal for his ethnicity with no rashes or lesions. His abdomen was soft, nondistended, with hypoactive bowel sounds, and moderate tenderness localized to the suprapubic area and left lower quadrant without rebound, guarding, or costovertebral angle tenderness. The patient refused the genitourinary examination.

Given the differential diagnoses of UTI, pyelonephritis, sexually transmitted infection, or nephrolithiasis, the NP ordered a urinalysis with culture and sensitivity, chlamydia, gonorrhea, and trichomoniasis urine screen (due to Mr. W.'s history of unprotected sex), a complete blood count (CBC), and complete metabolic panel to evaluate for infection, liver and kidney function, and electrolyte status. As Mr. W. appeared to the NP as a cisgender male and his electronic health record (EHR) reflected that he was male, a pregnancy test was not ordered. The NP ordered 4 mg of ondansetron, 30 mg of intravenous (IV) ketorolac, and 1 L of IV normal saline to treat his nausea, pain, and suspected dehydration.

REVIEW OF THE ARTICLE

Study Purpose

The purpose of the study by ^{Allison et al. (2021)} was to examine the ED experiences of transgender/nonbinary (NB) individuals presenting for care in southern urban and rural EDs. A second purpose was to explore transgender/NB patient suggestions, based on their experiences, for improving health care provider education and health system policies and practices (^{Allison et al., 2021}).

Study Design and Methods

The authors used a semistructured, interview-based, qualitative research design to explore the study purposes. Initial data were collected by graduate research assistants, participating in a service-learning public health project course on health disparities (^{Allison et al., 2021}). Members of the transgender/NB community partnered with course instructors to recruit participants, teach students about health access concerns, and design the questions asked during the data collection interviews (^{Allison et al., 2021}). All interviews were standardized and recorded. The questions were developed by the researchers in collaboration with members of the transgender/NB community who reported having had a prior ED visit (^{Allison et al., 2021}). One of the authors trained graduate students, who served as study interviewers, in how to conduct the interviews, summarize participant responses, and document exemplar quotes for data collection and analysis (^{Allison et al., 2021}). Study participants were recruited by word of mouth from individuals within the transgender/NB community and through referral by a physician who provided care within the transgender/NB community throughout the state (^{Allison et al., 2021}). A total of nine transgender/NB individuals participated in the interviews.

Data Analysis and Results

Of the nine participants, 78% identified as transgender, 56% as White, 89% as non-Hispanic, 22% as Black, 11% as multiracial, and only 1% as American Indian or Alaska Native (^{Allison et al., 2021}). Most (89%) were younger than 50 years and were insured, 78% had some college education, and 33% of participants reported earning less than $10,000 per year (^{Allison et al., 2021}). Eight individuals reported ED experiences within three urban hospitals and one discussed their experience in a rural hospital (^{Allison et al., 2021}). Data analysis included deductive coding in which interview transcripts were first scanned by one investigator applying content-related codes to interview items using a deductive approach. A second investigator also reviewed each interview to confirm initial coding results. Next, two other investigators conducted a content analysis of each transcript together, using an inductive approach to derive content themes (^{Allison et al., 2021}). Any coding discrepancies were resolved by a third reviewer (^{Allison et al., 2021}). The results of the analysis identified four main themes that the participants reported affected their ED experiences. These included systems and structural issues, interactions with clinicians/staff influence care received, perceptions of clinician knowledge and education, and impact of experience on future health and health care access (^{Allison et al., 2021}) as shown in Table 1.

Table 1. - Themes and examples described by participants in the study by ^{Allison et al. (2021)}

Theme	Examples
Systems and Structural Issues	Incorrect name/gender in EHR No place to list correct pronouns/chosen name on intake forms SOGI questions absent from EHR Dead name used instead of chosen name
Interactions with Clinicians/Staff-Influenced Care Received	Clinicians and staff asked inappropriate questions Being misgendered during ED visit Nonessential personnel entering room, staff gawking, and staff watching patients from hallway Staff appeared repulsed and did not appropriately interact with patients once transgender status revealed One participant admitted to hospital without being examined or touched by provider in ED
Perceptions of Clinician Knowledge and Education	Patients believed that ED providers possessed knowledge necessary to deliver emergent care but knew little about transgender/NB people, their health needs, and proper treatment of transgender/NB patients One individual asked to remove his chest binder without a stated reason and asked irrelevant questions about his genitalia Some participants felt that they had to teach providers about transgender/NB health concerns
Impact of Experience on Future Health and Health Care Access	Negative experiences in the ED caused patients to avoid or delay needed care afterward Several individuals reported worrying about being misgendered, mistreated, misunderstood, or referred to by the wrong name Approximately half of the participants stated that they would not be willing to return to the ED they had visited Some patients stated that they were likely to return to an urban ED because of potentially superior medical care, although respect for them as individuals was not necessarily any better Patients underscored need for staff to communicate in ways that make transgender/NB patients feel comfortable

Note. ED = emergency department; EHR = electronic health record; NB = nonbinary; SOGI = sexual orientation and gender identity.

Study Strengths, Limitations, and Conclusions

Strengths

The main strength of this study is that it was the first conducted to determine the experiences of the transgender/NB population receiving care within southern EDs. The findings highlight the systemic and clinical discrimination faced by transgender/NB individuals when attempting to access emergent care. The results of ^{Allison et al. (2021)} were also consistent with another study of ED experiences of transgender/NB individuals conducted in the Northeast (^{Samuels, Tape, Garber, Bowman, & Choo, 2018}). These congruent findings are important since the study by ^{Allison et al. (2021)} was conducted in the Southeast where the authors concluded that there are more cultural barriers to acceptance such as religion, less inclusive beliefs, and lower comfort associated with sexual and gender minorities.

Limitations

The main limitations to this study are its small sample size, biased sampling methods, and lack of generalization of findings. Another limitation is that although the interviewers were graduate students who were provided some training and followed an interview guide, there was no discussion of their background or qualifications (^{Allison et al., 2021}). In other words, they may have missed relevant information in synthesizing and recording participant answers to questions. An additional limitation is that the investigators designed the interview questions but did not include them in the publication, which limits replication of the study as well as study conclusions. Finally, because the interviewers summarized the responses, data quality may have been impacted as interviews were not transcribed verbatim (^{Allison et al., 2021}).

Conclusions

The authors concluded that their findings were the first to describe the experiences of transgender/NB persons who accessed emergent care in the South. The negative experiences and discrimination encountered by these transgender/NB patients suggest that there is a need to improve ED practitioner knowledge of transgender/NB emergency care practices. The recommendations of ^{Allison et al. (2021)} include improving policies and procedures to safeguard patient privacy and calling the patients by their chosen name rather than their legal name while they are in the waiting room. In addition, updating EHRs to include SOGI questions that reflect chosen name, sexual orientation, gender identity, pronouns, and sex assigned at birth may reduce discrimination and improve the patient experience in the ED (^{Allison et al., 2021}). Moreover, the findings suggest that the lack of SOGI choices within EHR intake and registration forms in the ED can cause confusion and conflict with ED staff, and incorrect pronoun usage can result in patients' perceptions of disrespect and violation of privacy (^{Allison et al., 2021}). The absence of SOGI information may also cause a missed opportunity for clinicians to identify hormone medications during reconciliation or to perform necessary and appropriate health screenings.

AUTHORS' DISCUSSION

Transgender/NB individuals experience significant health care disparities over their life span. Moreover, they frequently encounter stigma and discrimination when accessing health care in the ED. Nurse practitioners can improve care delivery to these individuals by examining personal or professional discriminatory practices or beliefs, improving one's health literacy through evidence-based research, asking patients how they would like to be addressed, and using their preferred pronouns and names. Deliberately referring to a patient's legal name instead of his or her chosen name can be construed as a form of harassment and may violate a transgender patient's right to privacy and dignity (^{Lambda Legal, 2016}).

As transgender/NB patients have unique health needs when they seek emergent care, efforts should be made within entities to identify implicit and explicit bias within policies, staff, and systems to reduce harm and improve outcomes. These strategies include posting inclusive signage and instituting gender-neutral restrooms, implementing annual workforce training to promote clinical and cultural competence, and integrating SOGI data into the EHR. Without SOGI information, transgender/NB patients and their specific health needs cannot be identified, their health disparities cannot be addressed, and necessary health care services may not be delivered (^{Centers for Disease Control and Prevention, 2022}). Moreover, using SOGI questions within the EHR provides an opportunity to promote patient–provider communication, presents opportunities for screening and treatment, and increases the visibility of transgender/NB patients in the ED (^{Grasso, McDowell, Goldhammer, & Keuroghlian, 2019}).

In 2011, both the Institute of Medicine (IOM) and The Joint Commission recommended collecting and documenting SOGI demographic information within health care settings as it was deemed crucial to providing patient-centered care for sexual and gender minorities (^{Grasso et al., 2019}). Moreover, ^{Grasso et al. (2019)} underscored the use of SOGI data as a way for health care institutions to track, monitor, and address health care disparities in sexual and gender minority populations. Likewise, in March of 2016, the Health Resources and Services Administration (HRSA) began requiring all federally funded health centers to report SOGI data yearly in the Uniform Data System (^{Grasso et al., 2019}). In response to this requirement, the National LGBT Health Education Center stated that reporting SOGI data has the potential to be significant in determining health outcomes, providing culturally competent care, and contributing to the overall reduction of health disparities (^{National LGBT Health Education Center, 2016}).

Despite these findings, most health care institutions do not have data fields in their EHRs that include the range of SOGI information; therefore, the data captured are not uniform across EHR systems (^{Streed, Grasso, Reisner, & Mayer, 2020}). ^{Kodadek et al. (2019)} found that patients and providers have opposing perspectives regarding the importance of SOGI data in the emergent setting. Specifically, patients perceived the collection of SOGI data as important in most clinical experiences and essential to their identity in promoting therapeutic relationships with their providers. Conversely, most ED providers in the study did not perceive SOGI information to be clinically relevant in most cases as similar care was provided regardless of SOGI information (^{Kodadek et al., 2019}). The differing perceptions between patients and providers regarding SOGI information is problematic because it may prevent patients from seeking needed care thereby negatively impacting the patient–provider relationship among medically vulnerable populations (^{Kodadek et al., 2019}). This potential bias can lead to all patients being treated as heterosexual and cisgender, thereby ignoring the specific and unique health care needs of individuals outside of heteronormative groups (^{Kodadek et al., 2019}). For example, if EHRs use only binary classifications for sex and gender, a transgender woman who has a prostate may not receive a needed prostate evaluation if the EHR does not include a reproductive organ inventory, which would drive physical examination templates derived from patient history. ^{Hsiang et al. (2022)} propose that mandatory diversity and inclusion training for ED providers with continual feedback from content experts is critical to help drive institutional policy change and modify provider perspectives.

The recommendation of ^{Allison et al. (2021)} for the integration of SOGI information in the EHR is significant because it can reduce confusion among ED staff, promote inclusivity and respect, and likely reduce barriers to care for transgender/NB individuals within the emergent setting. This suggests integrating SOGI fields into ED EHRs to improve the quality of transgender/NB patient care in the ED by increasing visibility and raising awareness among providers. Ensuring that SOGI data are captured and visible throughout all departments within an institution will help support continuity of care and support clinical decision making.

CASE REVISITED

In reviewing Mr. W.'s urinalysis, the NP noted positive nitrites, positive leukocyte esterase, occult red blood cell count, and a specific gravity of 1.030. His gonorrhea and chlamydia tests were pending but the wet mount did not show white blood cell count of trichomonas. His CBC showed a slightly elevated white blood cell count of 12.5 mm³ and a serum creatinine of 1.4. All other laboratory test results were within normal limits (WNL). As the NP suspected that the patient had pyelonephritis and was dehydrated, she ordered 1-g of IV ceftriaxone and another 1 L of normal saline. After the administration of the antibiotic and second liter of normal saline, the NP returned to check on Mr. W. He stated that he was feeling better, his pain was a 3/10 after the ketorolac, and he was no longer nauseous. The NP informed Mr. W. that he had a UTI, noted that his temperature was trending downward at 100.8, and the rest of his vitals were WNL. She stated that she would be discharging him home after his IV fluids were finished and he was able to tolerate oral fluids. She provided home care instructions, including increased hydration, and gave him prescriptions for an antibiotic and antiemetic with instructions to return to the ED if his abdominal pain worsened or if he could not control his fever. When asked how he was going to get home, Mr. W. responded that his friend would pick him up and stated that he would wait in the lobby. Mr. W. received his discharge instructions and written prescriptions from the RN and was discharged to the waiting room. The NP completed charting on the patient, finished her shift, and left the hospital at 18:45 hr.

At 20:30 hr, a patient in the lobby approached the nursing desk and informed the staff that someone had passed out in the men's restroom. Two medics went to check, noted that an unresponsive Black man in his late 20s or early 30s slumped to the side of a toilet, with fast, shallow breathing, a rapid, thready pulse, wearing a hospital wristband. One medic stayed with the patient whereas the other retrieved a stretcher, notified a provider, and alerted the charge nurse. An NP who just came on shift returned with the medic; evaluated the patient; noted a rigid, hard abdomen; and immediately accompanied the patient and medics to the radiology department for a noncontrast computed tomography (CT) of the head to rule out a stroke and a contrast CT of the abdomen and pelvis. Two large bore IV catheters were also inserted and sepsis protocol was initiated. While in the radiology department, the NP was informed that the head CT was WNL but the abdominal CT revealed a ruptured ectopic pregnancy. The NP informed her attending, consulted Obstetrics/Gynecology, and the patient was prepared for emergent surgery. By this point, the patient was responsive and was able to answer the NP's questions. The NP ordered IV pain and nausea medications, explained what had happened, and was present when the surgeon came to meet the patient. The patient was taken to surgery and was subsequently admitted to the intensive care unit for 5 days. The left fallopian tube and ovary required a salpingo oophorectomy.

Had SOGI information been collected during the intake and registration process, the patient's status as a transgender male would have been noted as well as the fact that his assigned sex at birth was female. This would have resulted in a pregnancy test being ordered, which would have indicated the patient's positive pregnancy status at the beginning of the visit thus expanding the differentials for his abdominal pain and resulting in a different plan of care. He would have still needed surgery, but his fallopian tube and ovary could have potentially been saved and the life-threatening emergency of a ruptured ectopic pregnancy requiring surgery and an extended hospital stay with associated costs may have been prevented. In this scenario, not having SOGI information within the EHR resulted in a devastating reproductive outcome for the patient and could have been fatal had he not been discovered in the hospital lobby restroom by another patient.

CONCLUSION

Transgender/NB patients encounter significant health care disparities compared with the general population including higher incidents of sexually transmitted infections, substance use disorders, mental health problems, and suicide. Moreover, when they come to the ED for emergent evaluation, they often encounter care providers who lack knowledge of transgender health needs and face stigma and heteronormative systems and structures that are barriers to care. Integrating SOGI information into patients' EHRs is recommended by the IOM, The Joint Commission, and HRSA, and is critical to improving transgender/NB patients' quality of and access to health care services and ensuring culturally competent care.