The year 2015 was a banner year for advances in transgender visibility. Caitlyn Jenner came out as a woman starring on the cover of the magazine Vanity Fair. TLC premiered a reality show based on following 14 year old Jazz in her daily life as a Florida trans teen. Amazon won a Golden Globe for Transparent a show about the metamorphous of an AARP-card-carrying father into a woman. These manifestations are evidence that this movement could be heralded as the next frontier in civil rights as more changes are made to protect this target population.

Transgender has no universally accepted definition. There is disagreement among health disciplines on category inclusion in this group of patients. The American Psychiatric Association considers transgender individuals to be those with a disturbance in sexual or gender identity. The American Psychological Association defines transgender as an umbrella term for persons whose gender identity, gender expression or behavior does not conform to that typically associated with the sex which they were assigned at birth. GLAAD has many terminology specific definitions to include all of the variations which can be included. The diagnosis of gender identity disorder is only established for people with clinically significant distress according to the American Psychiatric Association. They document that if untreated, gender identity disorder can result in psychologic dysfunction, depression, suicidal ideas, and even death.

How has the health care community approached this unique patient with special needs? In one 2011 survey of more than 6,000 transgender participants, 19% reported denial of health care delivery because of their transgender or non-conforming gender status. An additional 28% had postponed necessary health care when sick or injured and 14% delayed or ignored their preventive care.

Among the discriminating behaviors that were reported by a large LGBT 2010 survey, 70 percent of participants reported one or more of the following:

• Health care workers refusing to touch them
• Health care workers using excessive precautions usually reserved for contagious conditions
• Health care workers using abusive language
• Health care workers being unnecessarily rough or abusive
• Health care workers blaming them for their health conditions.
• Health care workers exhibiting inappropriate behavior such as laughter, pointing, yelling, mockery and negative comments.

This is a shameful list. Violations of confidentiality including use of the wrong name or pronoun for the patient are common. Prohibition of bathroom use and inappropriate room assignments have also been an issue as well as extremely long unnecessary wait times. All these conditions unite to create high barriers for a transgender patient to receive the proper health care.

Health care providers have a certain amount of discomfort when addressing treatment of transgender patients. Until recently, many in the female dominated workforce may not have been exposed to the concepts of transgender orientation. Depending on where you live, religious upbringing, private or public schooling, and rural versus urban living, information concerning this topic has only become prevalent in recent years. Demographics have a strong influence on attitudes. Baby boomers may have burned their bras and had a toke or two at Woodstock, but general information on this subject was taboo while they were growing up. If you lived in a small town in the rural South, it was not discussed. And that is an understatement. .

Anything out of the ordinary takes time for adjustment. Transgender men who were assigned female at birth but identify and live as a man still must have annual health care exams for their female anatomy. Finding access for these exams can represent a significant health issue. Last year the University of California San Francisco published a survey describing the health concerns for transgender men getting pregnant and having babies.  This study described 41 transgender men who had given birth. It was a small study but it demonstrated that approximately one third of the pregnancies were unplanned and more than a third reported not using contraceptives regularly. This is a clear indication that transgender patients are not having their medical needs acknowledged.

It is time for mainstream health care providers to initiate and provide for the medical needs of transgender patients. The first step in addressing the medical needs of the transgender patient is to ensure they are treated appropriately and respectfully. Simple general policies for non-discrimination are not enough. There are multiple methods a healthcare facility can take to better accommodate the transgender population. Transgender patients may be hesitant to designate a gender on an admission or outpatient intake form and can be very concerned with privacy. Review your forms and provide the privacy policy to all new patients explaining who will have access to their information. Provide the opportunity to identify a gender preference rather than just a checkbox. Provide a space for a preferred name and pronoun or nickname. (It may be different than the gender identity.)

Unimpeded access to restrooms is essential to all patients. Patients should be able to use restrooms consistent with their gender identity if at all possible. The same is true of room assignments. If the patient in a double occupancy room does not agree to the placement, the patient should be moved. Avoid focusing on the gender identity or expression unless necessary for treatment. Revise your policies, develop a complaint procedure, and train the staff on proper communication. Then encourage good communication.

We can provide better service to these patients, and should do so.*

*Want to discuss this topic further? Look for AHEC’s webinars or live events featuring this topic.