Transgender describes a person whose gender identity does not match the gender assigned at birth or does not align with traditional notions of expression of masculinity and femininity. Although there have always been transgender individuals, they have become more noticeable in the United States due to changes in laws and regulations as well as general societal awareness and acceptance. As a result, transgender individuals are becoming more open so that case managers are likely to encounter individuals who openly identify as transgender in the course of their work. Because of historic lack of visibility of transgender individuals in society and in health care, the case manager may not have an understanding of key concepts, communication skills, and health and human services needs and resources to know how to effectively work with transgender individuals. It is important to understand key concepts, medical and behavioral treatment options, nonclinical support, and other issues impacting transgender persons.
Understanding Terminology and Key Concepts
To be effective in working with a transgender individual, it is important to compare and contrast key terms that case managers will need to know when working with this population (National Center for Transgender Equality, 2014). See Table 1.
Sex is assigned at birth on the basis of an interpretation of genitalia. This has traditionally been a binary assignment as either male or female, established by the perception of the sex organs. We now understand that gender is on a continuum and that gender is not just about sex organs. Instead, gender should be understood as a socially constructed system that assigns roles, qualities, and attributes of masculinity and femininity. All of us express our gender by the way we act, dress, and communicate, based on the traditional roles of gender defined by society. A transgender person does not identify with the gender assigned at birth. A transgender person may seek hormone therapy, surgery, and other procedures to align the body with the person's self-identity.
There is the transwoman who was assigned male at birth but who lives and identifies as a female. There is the transman who was assigned female at birth but who lives and identifies as male. In contrast, a cisgender individual is one whose gender identity and expression align with the sex assigned at birth. There are also individuals who are gender nonconforming and see themselves as neither just male or just female but rather a blend.
Gender identity and gender expression involve the individual's understanding of who he or she is and how he or she presents in the world. The sexual orientation of an individual involves who the person is attracted to. Like gender, sexual orientation is seen as a continuum involving same sex, opposite sex, and asexual attractions.
The case manager needs to be able to understand and differentiate these concepts when working with transgender persons so that the appropriate language and terms are used when communicating.
Medical Issues for Transgender Persons
Transgender persons face many challenges with the health care system (Breland et al., 2016). There are health care professionals who do not understand transgender people, and there are others who express outright discriminatory behavior (Johnson, Mimiaga, & Bradford (2008). As a result, transgender people may be distrustful of the health care system. The case manager will need to build rapport and trust when working with a transgender person.
The case manager may work with a transgender person who has not accessed timely care due to concerns about working with health care professionals who understand the transgender person in providing appropriate care. For example, a transman may be reluctant to go to a provider for a pap smear or breast examination, although those preventive services should be provided when indicated. For a transwoman who is taking hormones, the transgender person needs to find providers who are willing to prescribe and dispense the hormones. The case manager may need to serve as an advocate and an educator with health care professionals regarding the needs of the transgender person. The case manager may also need to find health care professionals who specialize in working with transgender persons so that appropriate and nonjudgmental care can be delivered (Beagan, Fredericks, & Bryson, 2015).
The case manager may also need to verify the benefit coverage and network requirements for specific services for transgender individuals. For example, the benefit plan may identify particular specialists or centers of excellence for transgender individuals who have surgical procedures performed.
Behavioral Health and Social Issues for Transgender Persons
Transgender persons have more behavioral health issues than the general population, including increased incidents of depression, anxiety, suicidal thoughts, substance abuse, and so forth. It is important for the case manager to screen and then address behavioral health issues while working with transgender people.
There are also increased social issues for transgender persons. This includes a high prevalence of housing challenges, family-of-origin rejection, and involvement with the criminal justice system. When a case manager is working with a transgender person, there should be an assessment of the social issues that the transgender person may be encountering. The case manager should also inquire who the transgender person considers to be family so that the appropriate people are involved in support and involvement with the case. The social determinants of health (e.g., housing, transportation, living situation) may be significant issues for the transgender person, so the case manager needs to identify and then intervene with these issues in order to improve outcomes (The Henry J. Kaiser Family Foundation, 2015).
Medical Treatment Options for Transgender Persons
There are a number of medical treatment options available for transgender persons for the transition process, including hormone therapy to feminize or masculinize the body, surgery to change primary and/or secondary sex characteristics, and psychotherapy or counseling for exploring gender identity, role, and expression. The transgender person goes through a process of self-awareness and confirmation of gender identity before hormones and/or surgical procedures are considered. This may involve counseling or psychotherapy to assist in that process, and there may be peer support services that can assist in that process. Table 2 provides the most common criteria used in determining the appropriateness of hormone therapy and surgical procedures (The World Professional Association for Transgender Health (WPATH), 2012).
There may be additional criteria for specific surgical interventions. There may also be requirements on the sequencing of the therapies and surgical procedures. The case manager should discuss this with the treating physician the treatment protocol and confirm with the benefit plan their requirements.
For male-to-female transgender persons, the hormone estrogen may result in softening of the skin, redistribution of body fat to a more traditional feminine appearance, and reduction in body hair. For female-to-male transgender persons, the hormone testosterone may result in lowering of the voice, additional growth of body and facial hair, redistribution of body fat to a more masculine appearance, and cessation of the menstrual cycle (National Center for Transgender Equality, 2009).
Some surgical procedures also require a set number of months of hormone therapy prior to surgery. There is no single “sex change surgery.” Transgender persons have a range of genital reconstructive surgical options. Some surgical procedures also require living the desired gender role prior to surgery. Mental health screening and/or assessment are needed for referral to hormonal and surgical treatments of gender dysphoria. In contrast, psychotherapy is not a requirement, although highly recommended. Table 3 provides a summary of the most common surgical procedures for transgender individuals (The World Professional Association for Transgender Health (WPATH), 2012).
It should be noted that the transgender person may not choose hormones or surgery. Each transgender person must consider the right choices and treatments based on the individual's needs and goals in the transition journey. Whether or not someone takes hormones or has surgery should never make a difference in how the person is treated.
Alternative Options for Social Support and Changes in Gender Expression
Medical treatments are not the only services that a transgender person can seek during the transition process. There are a number of alternative, nonmedical options for social support for the transgender person in making the transition, and some of those are listed in Table 4 (The World Professional Association for Transgender Health (WPATH), 2012).
Hormones and surgical procedures are not the only means by which a transgender person navigates through the transition process. The transgender person has a variety of ways to express the desired gender. The decision by the transgender person regarding these options will depend on the preferences and the stage of the transition process for the individual.
Case Study: Outpatient Setting
A 45-year-old woman entered the clinic as a first-time patient. She told the receptionist that she had not seen a physician for more than 4 years and she was there for a full evaluation. She was given an intake form to fill out, on which she reported that her current gender identity was female and her sex assigned at birth was male. Her first name was Brenda, but her identification listed a masculine first name, Brian, because she had not yet changed her identification. Brenda had had a history of drug usage, but had gone through rehabilitation and now was currently employed where she finally had medical insurance coverage. She was taking hormones, but she had not gone through any surgical procedures due to lack of financial resources and no medical insurance. A nurse appeared with a chart and called for Brian. Brenda looked around sheepishly. The nurse called again for Brian. The other patients in the waiting room and some staff members laughed as Brenda got up and went to the counter. The nurse case manager took her to an examination room where she began her assessment interview.
The nurse case manager confirmed the preferred pronoun and asked questions about Brenda's transition process. Brenda discussed her discomfort about the reaction from the other patients and staff members, and she reiterated that her name was Brenda. The nurse case manager responded by saying that she would discuss with the care team the need for education of the staff as well as patients regarding patients who are transgender and apologized to Brenda. Brenda expressed her concerns about being treated fairly and respectfully as a transgender person, so the nurse case manager said that her role as Brenda's advocate was to make sure that her needs were met while receiving professional and nonjudgmental services. The nurse case manager went on to inquire the reasons for the visit and discovered that some of the health issues were not related to her transgender status, although Brenda was interested in learning more about health services and procedures for transgender services. The nurse case manager said that she would do research about transgender services including medical and community resources, as well as contact Brenda's medical insurance carrier to see what services that it might have available.
Case Study: Inpatient Setting
Trevor was a 35-year-old man who had recently transitioned from female to male. He had started testosterone and had had breast-reduction surgery. He was now in the hospital for a hysterectomy, because he had decided that he wanted this procedure as part of his overall transition. Trevor was gainfully employed and had no other health issues currently. He had felt awkward going through a procedure related to his female organs, so he had asked for his wife and a few close friends to be with him. The staff in the hospital were very confused with Trevor's identification as a male but who was undergoing a hysterectomy. The social work case manager entered the hospital room to conduct an assessment and to discuss discharge plans.
The social work case manager confirmed the preferred pronoun usage for not only Trevor but also his wife and close friends who were in the hospital room and who were also transgender. Trevor indicated that he would like a private room, and the social work case manager indicated that the hospital should be able to accommodate that request. The social work case manager reassured Trevor's wife and close friends that they would be welcome at the hospital throughout Trevor's stay. In addition, the social work case manager asked about the home setting and the support Trevor would need postsurgery, including implications for return to work. The social work case manager also discussed the confusion and lack of understanding that the staff had regarding this situation, and there was agreement that the social work case manager would inform the staff about Trevor and encourage them to talk to Trevor, his wife, and friends should they have any questions.
Case Management Guidelines in Working With Transgender Patients
- Transgender-inclusive patient education materials
- Not assuming sexual orientation or gender identity
- Asking what preferred name and pronouns patients use
- Using terms such as partner
- Displaying signs of LGBTQ (lesbian, gay, bisexual, and transgender) acceptance
- Mirroring language that patients use for themselves, their partners, and their bodies
- Providing LGBTQ training for all staff members.
There are a number of tips that case managers can use that support respectful and effective communication in working with transgender individuals:
- Provide care that is sensitive, respectful, and affirming that recognizes and honors the person's self-description or self-identification.
- Ask the individual what pronoun that is preferred and then use that pronoun.
- Avoid the potential of treating a transgender person as if the person is nothing more than the anatomy; the person's body belongs to him or her but the body does not define him or her.
- Use the term “transgender,” not “transgendered” or “transsexual.”
- Gender identity and sexual orientation are highly personal and should not be assumed; the case manager should only discuss these if there is a need to know and the person is willing to disclose that information.
- Use the term “transition” for the process that a transgender person goes through in living out a gender identity.
- Understand that a transgender patient views gender-affirming surgery and other treatments as aligning the body with the mind's perception of gender.
- Ask, when necessary, what transitioning and gender-affirming surgery mean to the patient.
- Understand that the transgender person may have health issues that are not directly related to being transgender.
- Develop transgender-inclusive policies, protocols, and patient education materials for case management practice.
- Create a welcoming environment for transgender patients; understand that they may have experienced many barriers before reaching you and accessing health care can be a vulnerable experience.
- Ask patients what name they would like to be called and their preferred pronoun; create intake forms that ask about sexual orientation, gender identity, and preferred name/pronoun.
- Don't reveal the patient's transgender status without the permission of the patient.
- Provide transgender-sensitive health care referrals.
- Include gender identity and expression in all nondiscrimination policies.
- Create gender-neutral bathrooms, if possible; if not possible, create a policy that transgender patients can use the bathroom that matches their gender identity.
- Provide transgender-sensitive and informed patient education materials.
- Don't ask unnecessarily invasive questions; make sure your questions are related to your patient's health care.
- Ask patients what language they would like used to refer to their body.
- Provide training for all staff members on transgender health and sensitivity.
- Educate yourself and other health care providers on current transgender health protocols and standards of care.
- Do not reveal a patient's gender identity or sexual orientation without receiving prior explicit permission from the individual.
- Provide referrals to health care professionals and facilities as well as community services that provide transgender-sensitive care and expertise.
- Do not ask unnecessarily invasive questions; make sure your questions are related to the person's medical, behavioral, and/or social needs.
- Educate yourself and other health care providers on current transgender health protocols and standards of care.
- Encourage pursuit of regular preventive care and chronic care checkups.
- Provide information regarding options for gender identity and expression, including possible medical interventions.
- Assess and discuss treatment options for coexisting behavioral health concerns.
- Understand the criteria for hormone therapy and surgical procedures, if applicable.
- Educate and advocate on behalf of transgender persons within the health care system, criminal justice system, and the community.
The case manager has the opportunity to provide support, education, and assistance to individuals who have not had positive experiences with the health care system. By working with transgender persons, the case manager can provide advocacy throughout the communities and systems involved in providing services to these individuals.
Beagan B., Fredericks E., Bryson M. (2015). Family physician perceptions of working with LBGTQ patients: Physician training needs. Canadian Medical Education Journal, 6, e14–e22.
Breland D. J., Crouch J. M., Evans Y., Gridley S. J., Eng W., Antoon E. A., Ahrens K. R. (2016). Understanding barriers to healthcare for transgender
youth. Journal of Adolescent Health, 58(4), S3–S4.
Johnson C. V., Mimiaga M. J., Bradford J. (2008). Health care issues among lesbian, gay, bisexual, transgender
, and intersex populations in the United States: An introduction. Journal of Homosexuality, 54(3), 213–224.
National Center for Transgender
Equality. (2009, May). Understanding transgender
: Frequently asked questions about transgender
people. Washington, DC: Author.
National Center for Transgender
Equality. (2014, January). Transgender
terminology. Washington, DC: Author.
The Henry J. Kaiser Family Foundation. (2015, November). Beyond health care: The role of social determinants in promoting health and health equity (Issue Brief). Menlo Park, CA: Author.
The World Professional Association for Transgender
Health (WPATH). (2012). Standards of care for the health of transsexual, transgender
, and gender non-conforming people, 7th Version. International Journal of Transgenderism, 13(4). doi:http://dx.doi.org/10.1080/15532739.2011.700873