Transgender Health Care at Virginia Mason: Providers are ‘Driven to Do This Work’

Longtime Virginia Mason patient Samantha Forney and the nurse caring for her sat down to talk. The nurse had made a mistake by referring to Samantha, who is a transgender woman, with male pronouns. Samantha saw an opportunity for teaching, with a receptive caregiver.

“To me it’s much more important to make something a positive learning experience,” said Samantha. “Getting my feelings hurt or being angry won’t make things better for the next person.”

Samantha.Forney

Samantha Forney

Samantha’s steadfast advocacy for transgender health care first caught the attention of her primary care doctor, who asked if she would join the guiding team working to develop transgender health care at Virginia Mason. Eager to be involved, Samantha applied to become a Patient-Family Partner (PFP), a unique volunteer program that invites patients and families to be active co-designers of patient care. In her new role, Samantha made an impression on the PFP clinical team: would she be willing to share her personal story while presenting to the medical center’s board of directors?

Samantha began work on her board presentation in the summer of 2017, a time when Virginia Mason’s development of Transgender Health Services was well underway. A bolstered strategy to support diversity and the individual needs of patients ignited in 2016, when the organization signed on to the American Hospital Association Equity of Care pledge: a national call for eliminating health care disparities among patient populations. A commitment to providing affirming care for lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) people spawned system-wide changes, from policies and staff training, to new care guidelines across medical specialties.

Virginia Mason’s health equity work was already changing the organization when Samantha presented to the board in September 2017, but sharing her own experience shed light on the human toll of lifelong struggle, loss and fighting for acceptance. It was the compassionate care that Virginia Mason had already given her, she said, that made her certain they could be leaders in providing the support and health services transgender people are often denied.

“Virginia Mason has these wonderful providers who really do care, they are driven to do this work.” — Samantha Forney 

“I told the board about both positive and negative experiences I’ve had,” said Samantha. “But Virginia Mason has these wonderful providers who really do care, they are driven to do this work. I see the team come together for my appointments. It’s a culture, a willingness to collaborate with each other and with other doctors that treat me. It’s so amazing to find that.”

It was Virginia Mason’s destiny, Samantha put forward to the board that day, to welcome a chronically mistreated community into the dignity and safety of comprehensive medical care. Now after more than a year of advising the organization as a PFP and working with the transgender service line (TSL) guiding team, Samantha admits being in awe of what people are doing, both on the clinical and administrative sides. It’s their energy, professionalism and humanity, she says, that motivates her to personally connect with more Virginia Mason providers.

“Every time I see a new provider I say ‘before I go, can I ask you to please consider joining the WPATH [World Professional Association for Transgender Health]?’” says Samantha. “And I also ask them to join the guiding team, because we need them.”

A face-to-face connection can open people to new ideas, a power that drives the TSL guiding team. Providers from across the patient care spectrum – from clinical staff to administrators to physicians and surgeons – join with patient partners to learn from each other as they plan improvements to the care experience.

“Guiding team meetings are a safe space for clinicians and staff members to ask questions beyond their own areas of expertise,” says Maria Rearick, director, Ambulatory Services at Virginia Mason. “It’s a unique forum, to have open discussions across care teams for sharing our progress and where we see opportunities.”

As transgender health care services at Virginia Mason grow across specialties – including primary care, speech-language pathology, gynecology, facial surgery, endocrinology, and urology – the voices of patients like Samantha ensure that awareness and sensitivity toward all LGBTQ patients keeps growing too. Working goals for the TSL guiding team include more staff education through facilitated discussions, creating a welcoming environment with everything from all-gender restrooms to affirming medical forms, and continued outreach to partner organizations and the LGBTQ community.

“This a new frontier in medicine,” says Samantha. “I’m very proud of the giant step Virginia Mason has taken in this direction. They are passionate about equity in health care and making things better for people. It’s an exciting time.”


Transgender Health Services at Virginia Mason offers a range of primary and specialty care services for transgender and non-binary patients. We provide gender-affirming, evidence-based care to meet individual needs and goals in a welcoming and supportive environment.    

 

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.