By Stephanie Aldrin, Medical Student
According to the Institute of Medicine, transgender and gender nonconforming patients access health care less often than their cisgender counterparts. And when transgender patients do seek medical attention, it is often with more serious ailments.1 While many factors contribute to these disparities, health care providers can play a crucial role in reducing the stigma associated with seeing the doctor and in promoting safer health care environments for the trans members of our communities.
In fall 2015, the clinic I work at, Smiley’s Family Medicine Clinic, asked its patients who identify as transgender or gender nonconforming to speak candidly about their experiences accessing primary care. I remember scrambling to take notes as I listened to the patients’ stories and feeling grateful for the opportunity to have this small window into the challenges of seeking health care as a trans person.
Three major themes emerged from the patients’ experiences. First, small changes in language can positively impact the way a patient feels during and after an encounter with health care providers. Second, trans patients see their doctors for a number of reasons, and, like their cisgender counterparts, want to be seen as any other patient and not have their gender identity be the focus of the visit. Finally, positive partnerships occur when physicians come into the exam room as their authentic selves, who genuinely care about the patient in front of them.
The words providers use with patients heavily impact the patient experience.
When someone fails to use a person’s correct pronoun(s), it feels disempowering because another person, often unwittingly, imposes the wrong gender identity onto the other person. This is called misgendering. It takes away that person’s self-determination and dismisses an important part of the patient’s identity. Another team member can counter this dynamic by correcting the use of an incorrect pronoun, thereby affirming the patient’s gender and part of their identity. The simple act builds trust between the patient and provider, creating a safe space for the patient. Another example of the power of inclusive language is when a patient requires specialty care, and hence a referral. The prospect of seeing another physician can cause anxiety because the patient is unsure of how another provider will treat them. During an appointment the PCP can message the specialist, educating their colleague on the patient’s name and pronoun(s). This reminds the other provider that honoring someone’s gender is an essential part of caring for an entire person and addresses the patient’s concerns.
Trans patients want to be seen as patients seeing the doctor for common ailments.
Going to the doctor to check out a cold, trans patients can find themselves instead in a lengthy conversation about gender reassignment surgery. Focusing on surgery diminishes the complexity of gender and makes it seem as though being a transgender person is a process or act. Being transgender is part of who someone is, an adjective not a verb. And not the patient’s only adjective. Patients also reported being screened for HIV whenever they presented to health care, even though they lacked risk factors for justifying the test. One patient had their testosterone prescription heavily questioned when being seen for another issue and left without their concern addressed. In these encounters, patients were only seen as one adjective, trans, and not as a person seeking health care. For some trans patients, feeling that their primary health concerns were addressed during a doctor’s appointment felt like an exceptional experience, rather than the norm. By making sure we address the reason the patient came into the office and by interacting with each trans patient as an intricate and unique individual, we can begin to work toward eliminating the disparities in health care access and quality for transgender and gender nonconforming patients.
Being authentic builds stronger relationships with patients.
Trans patients said they feel unimportant or uncared for when addressing concerns with physicians who appeared uncomfortable with them or the topic they came to address. Others cited positive instances in which they felt they were developing a partnership with their doctors. For example, when a provider admits they do not know the answer to a question and will look it up or ask another provider, they build patient-provider trust. Empowering patients often can be as simple as clarifying the limits of our knowledge and abilities, practicing humility, and emphasizing that we need to work together.
Trans patients need to access both primary care and specialized treatment for their medical conditions. At the beginning of this project, I was intent on learning tips to be a kinder provider. I thought listening to the stories of transgender patients would help me become a more compassionate provider for the trans community, but by the end, I realized that the ways of being a good trans-friendly provider are the same as being a good provider to all patients.
In reflecting afterward, I gained a deeper understanding of what it means to empower patients, and sometimes this means stepping up to affirm or stepping back to listen. I learned the best way to care for trans patients is not by having a deep understanding of the medical and surgical treatments available to these patients, but rather to accept people for exactly who they are (and ask people what pronouns they use).
1. Institute of Medicine Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, 2011