As emergency department visits go, this one was pretty standard. A patient named Diego Sanchez had broken his wrist. He described his pain to the physician. “We discussed the relevant body part — my wrist,” he recalled. Then the doctor treated it.
What makes this encounter memorable to Mr. Sanchez? The fact that it was all so ordinary. “We didn't talk about anything else,” said Mr. Sanchez, the director of policy for PFLAG National in Washington, DC, and an openly transgender man.
“Simple steps can make a medical visit seem routine and typical for transgender patients,” he said. Yet research in the past few years suggest that emergency treatment of transgender individuals has had a troubling track record, at least in some emergency departments.
A recent Canadian study on the ED visits of about 400 transgender patients showed that more than half had “trans-specific negative ED experiences.” The results for this patient population, which was about equally divided between transgender men and transgender women in Ontario, indicate that many avoid the ED predominantly because of fear of discrimination. (Ann Emerg Med 2014;63:713.) Thirteen percent of those seen at U.S. EDs felt they had received unequal treatment, and 16 percent reported being harassed or disrespected, according to a canvass conducted by the National Center for Transgender Equality and the National Gay and Lesbian Task Force. (Injustice at Every Turn: A Report of the National Transgender Discrimination Survey, 2011; http://bit.ly/1dy3LIy.)
Section 1557 of the Affordable Care Act strictly prohibits gender bias, and that small clause has been interpreted by the U.S. Department of Health and Human Services to include discrimination based on gender identity, including prejudice toward patients over failure to conform to stereotypical views of masculine and feminine attributes.
In what is believed to be the first case to test that particular form of discrimination, a transgender man who alleged mistreatment in a Minnesota ED is suing the health system where he received care. The courts have upheld his right to use this medically-specific cause of action. (Rumble v Fairview, Minnesota Law Review; March 2015; http://bit.ly/1LIkJhE.)
Jakob Rumble, who began transitioning when he was 15, presented to the ED at Fairview Southdale Hospital in Edina with “inflamed reproductive organs,” according to the Star Tribune in Minneapolis. (March 20, 2015; http://strib.mn/1FcVHm5.) A registrar clerk gave him an ID bracelet that said he was female, despite his explanations about being transgender, and the EP treating him conducted a history in a “hostile and aggressive manner,” including asking if “he had ever had sex with objects,” according to the StarTribune report.
Mr. Rumble's lawsuit said the EP conducted a “rough” genital exam that was characterized as “assaultive” by the judge permitting the case to proceed, the news article said. The hospital and EP's employer, Emergency Physicians Professional Association, declined comment because of the pending litigation when approached by the Star Tribune.
Many emergency physicians perceive their specialty as one that is far less judgmental and much more sensitive than many other professions, so why would special considerations need to be emphasized? “I have had the pleasure of challenging colleagues on that perspective,” said Joel Moll, MD, the emergency residency director and an assistant professor of emergency medicine at Virginia Commonwealth University in Richmond.
He cited a traditional inquiry about “sexual preference,” but noted that being transgender is not a preference but an orientation. No credible evidence supports calling sexual orientation a choice either, and most people in the lesbian, gay, bisexual, and transgender (LGBT) community feel it is not, he explained. So an emergency physician who uses a term like “sexual preference” can be interpreted by an LGBT person as being offensive, even if it's not meant that way.
If a patient is transitioning from one gender to the other, a question such as “how would you like me to refer to you?” is often all that is needed to determine gender identity, Dr. Moll said. This can also be in conflict with official patient identification because the insurance coverage may be listed under a different gender name.
A couple of basic questions on the registration form — what name and pronoun do you prefer? — can begin the process in a comfortable way, starting at the front desk and extending to when a name is called for service, Mr. Sanchez advised.
An exam room also may contain potentially unsettling triggers, Mr. Sanchez noted. Pink- and blue-labeled “female” and “male” cabinets are a way that stereotypes or gender identities are conveyed, he added. A physician or nurse who takes a speculum out of a rose-colored drawer to use for an individual who identifies as male, for example, can cause anxiety, even anguish, on the part of the patient, Mr. Sanchez added. Other colors can be just as distinctive, and they don't confer the “binary of male-versus-female,” he said.
Transgender patients or those in the transitional process are cases that call for heightened sensitivity, Dr. Moll agreed. Encounters with transitioning patients may be awkward for emergency physicians who largely are unfamiliar with such situations, and that's one reason LGBT-specific education is needed, Dr. Moll said. “Sometimes this discomfort may be diffused with humor” among staff members, he noted. That may lessen the discomfort for the health care provider, but it can be very hurtful to the patient and represent the medical staff poorly, he stressed. Rather than dismissing the situation as a rare event unlikely to happen again in the near future, the question should be: “Why aren't we being taught more about this?”
The Emergency Medicine Model of Clinical Practice doesn't include curricula on LGBT issues, Dr. Moll said, but he and his colleagues have presented different modules at meetings of the Society for Academic Emergency Medicine over the past few years that provide a template. Raising awareness of the need for it is another challenge. A survey of residency directors in 2014 found that almost one of five didn't see the necessity for support and additional training specific to LGBT, Dr. Moll said.
The American College of Physicians recently published the second edition of The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health, which now includes a revision to the original chapter on transgender health care. Two new chapters address gender identity and an overview of the transgender patient population. (See sidebar.)
The new edition was necessary because there is “a growing awareness, a growing need” for more information, explained Harvey Makadon, MD, who was asked to oversee the second edition of the book after writing the first one several years ago. Dr. Makadon is the director of the National LGBT Health Education Center at the Fenway Institute, a division of Fenway Health in Boston.
One way public awareness has been heightened is through Caitlyn Jenner's “sincere description of the personal process” in making such a transition, said Dr. Makadon, who also is a professor of medicine at Harvard Medical School. In fact, Americans seem to be undergoing a sea change in societal attitudes. A report on religiously affiliated U.S. citizens shows that nearly half now believe gay and lesbian couples should be entitled to the same marital rights as heterosexuals. (The American Values Atlas; http://ava.publicreligion.org/.)
Some of the possible confusion is easily solved by adopting more neutral terminology. Instead of asking about marital status, for instance, simply inquire about a “significant other” or “partner,” Dr. Moll said. “I can't tell you how many times I've been asked about whether my wife and I have kids,” said Dr. Moll, who is married but has a husband.
The opposite problem can occur, too. Often no question is even asked because of the presumption of heterosexuality. An infection that can be sexually transmitted may prompt asking about intercourse without determining what kind of sexual activity is occurring. An appropriate question is, “Do you have sex with women, men, or both?” Mr. Sanchez agreed, calling that inquiry “perfectly OK.”
And, if a pelvic exam is needed, transgender patients can be asked, “How would like me to address the body parts below your navel?” In many cases, the answer is simply to refer to them as “lower body parts” or “down there,” Mr. Sanchez advised.
Ease and satisfaction with health care can lead to tremendous commitment, and keep people engaged in care rather than avoiding regular checkups, which is the only way to achieve improved health outcomes, Mr. Sanchez asserted. He regularly flies to Boston to see the same medical team he has known for years. He legally and medically transitioned to male more than two decades ago, and he remains fiercely loyal to the doctors and nurses in the city where he lived during and after that period who provided such culturally competent care.
Serious health disparities are seen in transgender patient populations, according to researchers. Four years ago, the Institute of Medicine's report on the health of LGBT people revealed a paucity of clinical data on these populations. Last year, a study at a Massachusetts clinic showed that when transgender adults are compared with their non-transgender counterparts, there are no differences in substance abuse, smoking, or HIV status. But transgender patients are disproportionately affected by social stressors, including acts of discrimination and violence. (LGBT Health 2014;1:177.)
Acceptance and universal use of common and descriptive terminology would assist in collecting gender-identity data during a medical visit, said Madeline Deutsch, MD, an assistant clinical professor of family and community medicine at the University of California, San Francisco, and the clinical director for the Center of Excellence for Transgender Health. She and her colleague David Buchholz, MD, have demonstrated how an electronic medical record could be used to document identifiers associated with gender identity to make data collection inclusive of transgender patients. (J Gen Intern Med 2015;30:843.)
Such EMRs currently are in development, she said. “Though how complete, soon, and appropriate the outcomes of that process will be [remain] unclear,” she said.
A Resource for LGBT Health Care
Almost no long-term studies on transgender-specific health issues have been done, and those that have do not appear to have the kind of scientific rigor needed to make absolute recommendations.
But by combining the available medical literature along with firsthand knowledge, a group of authors led by Harvey Makadon, MD, have compiled what most in the health care community believe to be the definitive book on the matter, The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health.
Formal clinical training on transgender care is limited, so the text covers specific health considerations in this patient population. The guide points out that transgender women receiving estrogen for feminizing purposes are at heightened risk for thromboembolism, for example. Physicians should expect variable anatomy and a range of physical changes when providing transgender care, it advises. If hormonal therapy has been initiated, that can increase the risk of hypertension, diabetes, and hyperlipidemia.
Complicating control of such conditions is the fact that normal lab values for transgender adults haven't been established, and pharmacologic approaches can cause drug interactions with some feminizing and masculinizing medications. Mental health also “is an important area to assess and appropriately address,” according to The Fenway Guide. “Transgender people, in dealing with social stigma, can be at risk for higher levels of depressive and anxiety symptoms” as well as suicidal thoughts and ideation.
The book also contains a comprehensive list of websites with resources on LGBT health, encompassing scores of organizations that offer tools and training related to transgender people and their health care needs.
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