How emergency physicians can tailor their approach to transgender individuals and establish patient trust

Nine months ago, Wesly Heney, near collapse from viral pneumonia, was taken by ambulance to a large teaching hospital near his home in London, Ontario. Paramedics asked whether he took any medications, so Heney disclosed that as a transgender person (female-to-male, or FTM) he was taking injectable testosterone. While he was waiting in the hospital hallway on a gurney, a nurse came over to put on his patient ID bracelet. “She must have heard the paramedics’ report,” Heney surmises, “because she referred to me as ‘it.’” Later, Heney heard two nurses arguing about who would do his blood draw because “neither of them wanted to touch me.”

Experiences like these illustrate why Heney and many other trans people are often reluctant to access health care. A survey of emergency department use, avoidance, and experiences conducted by Trans PULSE, a community-based research project investigating the impact of social exclusion and discrimination on the health of trans people, was recently published in Annals of Emergency Medicine.¹ The analysis of the respondent-driven sampling survey of 433 transgender participants found that 21 percent had avoided going to the ED because they feared negative experiences. Greta R. Bauer, PhD, MPH, associate professor in the department of epidemiology and biostatistics at Schulich School of Medicine & Dentistry at Western University in London, Canada, is coprincipal investigator of Trans PULSE and was lead author on the paper. The survey documents that there are unmet needs for emergency care among transgender persons. Heney believes that the numbers in the Trans PULSE project are low and that avoidance of care is underreported. By his own account, Heney often encounters a wide range of inappropriate and biased reactions from health care providers. As a result, “nine times out of 10, I delay going to the doctor,” he says.

Emergency physician Madeline B. Deutsch, MD, clinical assistant professor in the department of family and community medicine at the University of California, San Francisco, and clinical lead at the Center of Excellence for Transgender Health, was a coauthor of the survey analysis. Despite differences in health care delivery systems between Canada and the United States, Dr. Deutsch says the take-home messages from the Ontario survey are very relevant to her US colleagues. And, Dr. Bauer points out, in a country with universal access to primary care, the finding that 21 percent of transgender people avoid going to the ED is even more significant.

Wesly Heney, a transgender person, cites discrimination from health care professionals as a reason that he avoids visiting the doctor.

Ask the Patient

Providers who have not treated transgender patients may be uncomfortable about the encounter due to lack of training and/or reliance on social stereotypes. Delivering competent care for transgender patients begins with how patients are addressed, notes Dr. Bauer. “It’s important for physicians to be aware that when trans patients do come in, they may have had negative experiences and that doctors [and allied health professionals] should treat them with respect. For trans people that means making sure you use the name and pronoun that they use in their daily lives,” she says. Providers should avoid making assumptions about people’s gender based on their appearance or behavior. For example, a male-to-female transgender individual could be in the ED due to a car accident. If that person is dressed as a female but has not yet fully transitioned from male, the physician may be unsure about how the person self-identifies. In such a case, the physician need only ask for clarification: “How do you identify yourself, and how do you want me to refer to you while we are working together
here?”

“We can become desensitized in the ED. We’ve seen so much that everything becomes ‘open season.’ Sometimes it’s important to remember to keep personal boundaries.”
—Madeline B. Deutsch, MD

“If the preferred name and pronoun are not used, that immediately begins to color the patient’s experience,” notes Dr. Deutsch. A simple question such as the one above, says Heney, can open the door to establishing the trust that is necessary for the health care encounter. “The number-one message I often tell people is to ask permission to ask questions,” he says. “If you tell me, ‘I’ve not encountered this before, so I need to ask some clarifying questions to give you the best care I can,’ I will be a lot more open.” This rule of thumb works in any ED situation, notes Dr. Deutsch, who draws a parallel with the Russian patients she encounters in the San Francisco ED where she practices. “Walking in and totally mispronouncing their last name is not the way to do it,” she says. “After hello, I ask, ‘Can I ask you how to correctly pronounce your name?’”

Focus on the Care

Accurately capturing the percentage of people who identify as lesbian, gay, bisexual, or transgender (LGBT) is challenging due to the very factors that act as barriers to health care: negative experiences, poverty, and lack of social support services. An amalgamation of several health and epidemiological surveys in the past decade by The Williams Institute at the University of California, Los Angeles, estimates that 3.5 percent of the US population identifies as LGB people and 0.3 percent identify as transgender. There are, the institute estimates, approximately 9 million LGBT Americans.

As an educator for Regional HIV/AIDS Connection in London, Ontario, Heney knows that some providers may never have encountered transgender patients. They may be unsure about how to approach the transaction or what special concerns they should be addressing. In some acute care situations, questions about biological sex and/or hormone levels may be important for assessing risk or drug interactions. But in other cases (a broken ankle, for instance), gender identity may be irrelevant. (See “Transgender Health Issues of Special Consideration” for more on the medical needs of transgender patients in the ED.) Al Killen-Harvey, LCSW, is cofounder of The Harvey Institute, a San Diego-based training and consultation company dealing with issues of sexual health. He notes that providers should resist the impulse to ask irrelevant questions out of personal or intellectual curiosity: “No matter what we’re doing, we must ask ourselves, ‘How does what I’m doing or saying relate to the job I have at hand? Does it relate to what I need to know?’ And if it doesn’t, then it shouldn’t be part of the conversation.” Dr. Deutsch agrees and also observes that emergency physicians should not succumb to myths about trans patients. “Do not assume that a trans person with leg cramps must have blood clots due to being on a hormone regimen,” she says. “Maintain a broad differential diagnosis, remember that there may be no risk of blood clots for a trans person on hormones, and remember that the patient may be there for something unrelated to being trans.

“It’s important for physicians to be aware that when trans patients do come in, they may have had negative experiences.”
—Greta R. Bauer, PhD, MPH

“We can become desensitized in the ED,” Dr. Deutsch continues. “We’ve seen so much that everything becomes ‘open season.’ Sometimes it’s important to remember to keep personal boundaries.”

Emergency physicians can set the example, but it is important, our sources note, for all personnel to acquire some understanding and sensitivity to gender fluidity and the ways in which gender expresses itself. “All of your good intentions may fall by the wayside if the patient has already had several negative encounters with other people in the ER system,” said Killen-Harvey. Dr. Deutsch has done research on incorporating trans-specific terminology into the electronic health record and is lead author on the recently published World Professional Association for Transgender Health EMR Working Group recommendations on electronic medical records and transgender patients.²

Emergency physicians have the opportunity to be leaders in their institutions. As noted in the Trans PULSE survey, they tend to be more comfortable with novel situations than their colleagues in other specialties. The survey researchers concluded, “emergency physicians are poised to be on the forefront of enhancing and improving care access and quality for trans patients.

Gretchen Henkel is a medical journalist based in California.

References

1. Bauer GR, Scheim AI, Deutsch MB, et al. Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: results from a respondent-driven sampling survey. Ann Emerg Med. 2013 Oct 23. [Epub ahead of print]
2. Deutsch MB, Green J, Keatley J, et al. Electronic medical records and the transgender patient: recommendations from the World Professional Association for Transgender Health EMR Working Group. J Am Med Inform Assoc. 2013;20:700-703.