Caring for People who are Transgender: What the Health Care Community (And All of Us) Need to Talk About

**By Una Lee, MD**

gender-benderEnjoyment of the highest attainable standard of health is one of the fundamental rights of every human being.” –World Health Organization.

This quote supports the fundamental belief that every person deserves compassion and respect when receiving health care. I work at Virginia Mason because it is a health care organization that fosters this culture of respect and continual improvement, and because Virginia Mason understands the importance of creating a remarkable patient experience.

As a urologist specializing in female and male genital-urinary anatomy and function, I have cared for transgender patients throughout my medical career. I’ve shared in my patients’ joy and relief, feeling safe enough to open up about symptoms, concerns and past traumatic experiences. I’ve also seen the challenges transgender patients face in the health care setting that overwhelm and upset them. Providers of health care have a responsibility to treat all patients respectfully. Sometimes a simple lack of knowledge can be a barrier to more respectful interactions.

A basic understanding of preferred terminology and transgender culture is a positive first step toward better health care experiences for providers and patients. Read on for some current definitions and a short conversation guide to help anyone who wants to increase their transgender IQ.

Transgender is a broad term describing people who identify with or express a gender identity that differs from one corresponding to their sex at birth. Transgender is correctly used as an adjective, not a noun, therefore “transgender people” is appropriate but “transgenders” can be viewed as disrespectful. Many transgender people are prescribed hormones by their doctors to change their bodies. Some undergo surgery as well. But not all transgender people can or will take those steps, and a transgender identity is not dependent on undergoing medical intervention. A transgender person’s gender identity is separate from their sexual orientation. Transgender people may be straight, lesbian, gay, bisexual, or asexual, just as nontransgender people can be.

Gender nonconforming refers to people who do not follow other people’s ideas or stereotypes about how they should look or act based on the female or male sex they were assigned at birth.

“Trans” is shorthand for “transgender,” but be careful of using it at times when its meaning may not be precisely understood.

A transgender man is a transgender individual who currently identifies as a man. Some may also use FTM, an abbreviation for female-to-male. Some may prefer to simply be called men, without any modifier. It is best to ask which term an individual prefers.

A transgender woman is a term for a transgender individual who currently identifies as a woman. MTF is the abbreviation indicating male-to-female. As for a transgender man, a transgender woman may not choose to recognize a designation other than “woman.” Again, asking the individual is encouraged.

He, she or they?  Using someone’s preferred gender pronoun in their presence demonstrates respect. The person’s name may not be a good indicator of what that preference is, so it’s best to ask. Some people prefer the pronoun “they,” to indicate a non-binary (not male or female) identity.

Transsexual is generally considered an older medical term for people who want to live as someone opposite of their birth sex, and seeks treatment to transition from male to female or female to male.

Transition encompasses the multifaceted process of changing one’s sexual identity. Transition includes personal, medical and legal steps that can include: telling one’s family, friends, and coworkers; using a different name and new pronouns; changing appearance and dress; legally changing one’s name and/or sex on legal documents; hormone therapy and sometimes, one or more types of surgery. The exact timeline and stages of an individual’s transition are as varied as people themselves.

Sex reassignment surgery or gender reassignment surgery are clinical terms used in medicine. Gender alignment surgery (also gender affirmation or confirmation surgery) are preferred terms in the transgender community. These terms refer to actual surgical interventions; only one aspect of the transitioning process. However, not all transgender people choose (or are able to access) surgeries to physically align with their gender identity.

Gender dysphoria
In 2013, the American Psychiatric Association released the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, in which gender identity disorder was replaced with gender dysphoria. Gender dysphoria is a medical diagnosis describing the distress of an individual who experiences a difference between their gender identity and their biological sex. The discomfort caused by gender dysphoria can be so intense that it can interfere with the way people function in daily life. They may experience anxiety and depression trying to manage societal expectations that they live according to their gender at birth.

Things to remember when interacting with people who are transgender

  1. It’s OK to ask. Talking with people who are transgender doesn’t have to be complicated. Ask politely as you would with other patients: “You are listed here as Joseph Smith. What do you prefer to be called?” Listen carefully to their preferences and commit to honoring them.
  2. Be careful not to use pronouns and gendered descriptions that conflict with an individual’s personal expression of their gender identity.
  3. Avoid the use of slang or otherwise offensive terms. Examples are sex swap, sex change, tranny, pre-op, heshe, shemale.
  4. Be aware of your nonverbal communication, and when and where you talk about it. Facial expressions and body language can send negative messages despite what you’re actually saying. Also, if there’s no medical reason to discuss a patient’s sexual identity, it’s respectful to ask if the person is OK talking about it at all. Never forget that patients may hear hallway conversations between colleagues, or overhear your remarks at the coffee bar or other public places. Maya Angelou, the American poet and civil rights activist, once said: “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”
  5. Be aware that transgender people may be vulnerable. They may be isolated from social support, and unaware of their rights. Because of past mistreatment in the health care system and even outright discrimination, not to mention insurance coverage issues, one-third of transgender and gender nonconforming (TGNC) people avoid health care. Nationally, 19 percent of TGNC patients report being refused care by a medical provider. Most transgender people have experienced some form of harassment. More than half have suffered rejection by family. TGNC people have higher incidences of alcoholism, drug abuse, and suicide. Just as we have made progress serving other vulnerable communities, we need to provide a source of care and support for the TGNC community.
  6.  Remember that LGBTQ status is confidential patient information. LGBTQ status is considered personal health information, and is therefore protected under the HIPAA Privacy Rule, our national standard for the protection of patient health records. The Human Rights Campaign, the nation’s largest LGBTQ civil rights organization, provides more context for privacy violations, even if unintentional: “Transgender patients are the victims of privacy breaches, where staff or providers might feel the need to ‘warn’ the patient’s roommate about the patient’s transgender status, or invite other staff or providers to come see the patient. These privacy violations are not only unethical and illegal, but add to the high levels of discrimination transgender people already face in accessing health care, and discourage these patients from continuing or returning to seek care.

There are lots of excellent resources online for those interested in learning more. See the list below, help start conversations and be a force for awareness. Just as women’s rights are human rights, and civil rights are human rights, transgender rights are human rights.

For More Information
Health Care Education and Advocacy

National LGBT Health Education Center

UCSF Center of Excellence for Transgender Health

World Professional Association for Transgender Health (WPATH)

WPATH Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People

Cultural and Policy/Legal Support

Ingersoll Gender Center – All volunteer Seattle-based organization supporting individuals, communities, education and advocacy

Human Rights Campaign

National Center for Transgender Equality

Gay & Lesbian Alliance Against Defamation

Williams Institute — UCLA Law think tank focusing on sexual orientation and gender identity law


Lee_UnaUna Lee, MD is a urologist/urogynecologist with subspecialty certification in female pelvic medicine and reconstructive surgery. Her medical and surgical expertise encompasses the cosmetic and functional aspects of the genital, urinary, bowel and sexual organs.

 

Comments

  1. David Aboulafia says:

    Hi Una, Many thanks for your efforts to educate us all and for additional information regarding appropriate terms to be used !!
    This is a fast changing area of medicine and culture and we need more care givers trained to provide medical expertise

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