I recently worked with a few transgender patients and I realized how much I have to learn about providing a safe and caring health care environment and experience for the trans community.
My colleagues and I have great intentions, but sometimes good intentions are not enough. Learning and practicing safe language and creating an environment that feels inclusive is important. We must include our trans friends, clients, and patients in our considerations of inclusivity and safety for all populations.
I realized that if I as a health care provider have good intentions but am not sure how to provide a safe and inclusive health care experience, that other health care providers would have the same questions as I did. So I decided to ask my friend Pace Smith, a transgender woman, to share some insight with me. I wanted to know what her experience and thoughts were about health care for the trans community.
Below is our conversation about her experience accessing health care as well as some insights for health care providers.
Prior to sharing our conversation, I want to provide a resource for you that explains Trans Terminology, provided here by the National Center for Transgender Equality. Additionally, for more information on the injustice the trans community faces, click here for access to the Report of the National Transgender Discrimination Survey.
TWBP:Hi, Pace! So glad you are here. Will you tell us a little about yourself?
Pace Smith: Hi there! I'm Pace Smith. I'm a 37-year-old transgender woman. I was assigned male at birth and I transitioned to female when I was 26. I live in Portland, OR and I love it here. I've been married to an amazing woman named Kyeli for nine years, and we recently made it legal thanks to Oregon allowing same-sex marriage! I'm a Pathfinding coach, I love to play Dance Dance Revolution, and my favorite genre of music is chiptune dubstep.
TWBP: You are so awesome, Pace! I am so glad you are here with us. When it comes to health care, can you share with us some examples of inclusive language versus language that is not inclusive of the trans community?
Pace Smith: One great example is "people of all genders" instead of "men and women." "People of all genders" includes the whole gender spectrum instead of just the gender binary, and helps people who don't fit into the gender binary feel welcome.
The biggest example of inclusive language, though, isn't really language at all, it's the "M" and "F" tickyboxes that are on so many medical forms. Just adding an "Other:" option with a fill-in-the-blank can go a long way toward making trans* folk feel safe and welcome. And that's something you can do on your paper forms even if your records software can't handle it. Another set of tickyboxes for "Preferred Gender Pronouns," even if the only three options are "he/him", "she/her", and an "Other:" option with a fill-in-the-blank, would be very considerate and respectful.
TWBP: What are signs you look for in a health care provider or clinic that let you know you are safe?
Pace Smith: Inclusive language or a statement like "Our providers are GLBTQ-knowledgeable and GLBTQ-friendly" help me feel safe.
TWBP: When it comes to your medical record, what kinds of things would you like to see included and what are some kinds of things you would not like included? (For example, the electronic medical record we used had "transsexualism" as the only code we could find to indicate a person was trans ---what are your thoughts on this?)
Pace Smith: This is a case where I as a patient could use some education. I'm not sure which types of health care providers need to know that I'm trans, and which don't. For example, does my chiropractor need to know? I could imagine that my chiropractor might need to know because it affects the bone structure of my pelvis, but I could also imagine that it's irrelevant. Any provider who deals with my endocrine system certainly needs to know about what hormones I've got, and where they're coming from, but I don't know who needs to know what.
What I do know is that I want to be treated with respect, and for me, that includes being treated as female -- regardless of what's in my medical record, regardless of my appearance or presentation.
It also includes using my chosen name instead of my birth name. So whatever y'all have to do with your behind-the-scenes record system, even if it involves hacking, post-it notes, or carrier pigeons -- make it happen.
TWBP: Do you have any personal experiences with health care that left you feeling marginalized? If so what could have been done differently to make things more inclusive?
Pace Smith: I've only had two bad experiences. Many trans folk I know have been much less lucky.
My first bad experience was with a therapist I sought out for help with my transition from male to female. During our first meeting, instead of having me fill out a form, she asked me questions and she entered my responses into some kind of form on her computer. One of the first questions was about my sex and gender. I said to her, "I was assigned male at birth, but I identify as female, and I'm currently transitioning to female both physically and socially." She said, "So, male then," and ticked the "M" tickybox. I felt unheard and disrespected. I wish I could say that I had the courage and self-assurance to stand up for myself, but I had precious little of those resources back then. I suffered through the initial consultation, then went outside to my car and sobbed. I found another therapist. I doubt the first one has any clue what happened or why.
If your internal software forces you to tick a tickybox, fine, whatever. But don't let the inadequacies of your medical record formats affect my right to be respected as a patient and as a person.
My second bad experience was with a gynecological exam. I won't go into the details here, but I will say that I haven't had a gyn exam since, and that was 9 years ago.
I think that's a perfect example of how making an effort to make trans* patients feel welcome, safe, and respected can have significant consequences for their health.
So please, make your best effort. We're counting on you.
TWBP: Thank you, Pace. I so appreciate you sharing your lived experiences with us. I know your insight and experiences will help many health care providers by giving them something important to consider. Your story matters and I know you sharing helps gives an important voice to the trans community accessing health care as well.
What I find most profound in talking with Pace is that one bad experience can affect the way a person interacts or accesses health care. Pace shared that she hasn't had a gyn exam for 9 years after a terrible experience.
Sometimes as health care providers we get so caught up in plowing through our schedules that we forget we are dealing with humans who care about how we make them feel.
Our lack of creating a safe and inclusive environment, our assumptions, our biases, our own filters --.all of these things matter and can affect the people we are supposed to be caring for in either really positive ways or in deeply hurtful ways.
After talking to Pace, and realizing we both had some questions, I wanted to reach out to my new friend Natalie, a nurse practitioner student at Vanderbilt and trans advocate, to ask her about her thoughts on providing safe care for the trans community and to ask her for some resources.
Natalie shared that the World Professional Association for Transgender Health (WPATH) has a standards of care publication that is highly respected and is an excellent resource for health care providers. She also shared the University of California San Francisco's Primary Care Protocol for Transgender Patient Care webpage here.
Another thing Natalie shared with me was that many people in the trans community prefer the term "gender confirmation surgery" instead of "Sex Reassignment Surgery" (SRS) because "SRS implies the only way one is 'really' the gender they identify with is through surgery and that it is only through the surgery that makes them the gender they identify with."
I also asked Natalie her thoughts on how often she feels a health care provider needs to know that a person is trans. Here is her response:
"I think a healthcare provider 100% of the time needs to know if a person is transgender, so as to know what services to offer and to help interpret labs. Even if you are not the one managing cross-gender hormone therapy, there are still other primary care issues to be aware of. For example, if a trans man has a cervix, he still needs a pap smear. Also, he is likely to have abnormal pap smear results due to cross-gender hormone therapy, which may or may not be indicative of actual cervical pathology. Also, the provider needs to be aware of all medications the patient is taking and why, in order to make informed prescribing decisions. Furthermore, it is important to have an accurate sexual history and understanding of what kind of sexual activities a patient engages in. For example, for a trans woman (or any person, really) who engages in anal receptive sex needs to think about having an anal pap smear and have an anal swab to test for chlamydia and gonorrhea as part of routine STI (sexually transmitted infection) testing. Here is a good link for preventative care for transgender individuals
To identify she is transgender in your charting, you could just say "[Initials] is an [age] y/o transgender woman, started on cross-gender hormone therapy on [date] by [provider], with the following procedures [procedures] and complications [complications]." Billing on the other hand is tricky. There is a code for "transsexualism," but as the term is offensive and risks the claim being denied by insurance companies who have line item exclusions for transgender-related care. Some people use the billing code for "endocrine disorder not otherwise specified" with trans patients. But, it is important to have the conversation with transgender patients about what they want in their medical record"
---Natalie Paul, BA, RN
I feel so honored that these two amazing individuals were willing to share with us both lived experiences (from Pace) and clinical implications and standards and ways to be inclusive and safe.
Thank you, Pace and Natalie. Your sharing your experience and knowledge is so helpful to me personally and professionally and I know you sharing is helpful for other providers and patients as well.
Pace Smith (pictured above) helps sensitive spiritual misfits follow their hearts to a wild crazy meaningful life. She’s a Pathfinding coach, a teacher, a speaker, a writer, a bi poly trans gamer geek, an open-source Reiki healer, and a tournament-level Dance Dance Revolution player. You can find her at PaceSmith.com.
Natalie Paul is a Registered Nurse in the state of Tennessee, and studying to be a Family Nurse Practitioner (FNP) at Vanderbilt University in Nashville, TN. She is also an LGBT health advocate and is involved in a varieties of causes including LGBT youth homelessness and health disparities, and is a transgender health advocate through the Trans Buddy program at Vanderbilt.