Case Objectives

• Define and distinguish the terms gender identity, gender expression, and gender variance.
• Delineate patient safety issues associated with transgender health.
• Appreciate the challenges that transgender patients who are transitioning experience.
• Describe how registration and clinic processes can be modified to ensure that transgender patients are treated with respect and compassion.

The Case

An 8-year-old child, born male who identified as and expressed externally (e.g., clothing, haircut, behavior) as a girl, presented for a new patient appointment. The patient's mother, aware that her child's preferred name was not consistent with her legal name and sex, had alerted the clinic of the child's preferred name at the time of making the appointment. When the patient and her mother arrived for the clinic visit, the medical staff was unaware of the registration documentation regarding the patient's preferred name and called for the patient in the waiting room using her legal (masculine) name.

The mother and child felt embarrassed and humiliated by this course of events. Both were visibly upset and the provider had to spend additional time during the clinical visit addressing the emotional impact of inappropriately calling this patient a masculine name. The clinic staff had received prior training in addressing transgender and gender-variant people by their preferred names but had not developed communication processes to best convey this information.

The clinician acknowledged the error when it occurred, apologized for the harm done, and reassured both mother and child that it was not the intention of the clinic to have the child feel her identity was questioned or undermined. The provider suggested that the parent contact the ombudsperson's office directly to comment specifically on what was done well at that visit and what specific behaviors could be improved in the future care of her child. The patient's mother did just that.

The Commentary

Gender identity is a person's private sense of one's own gender. Gender expression refers to how a person expresses one's gender identity—it is illustrated through one's external characteristics and behaviors. Gender variance is gender expression that does not conform to dominant gender norms of male and female.(1) In the medical community, Gender Identity Disorder (GID) or Gender Dysphoria are the formal terms used to describe individuals who experience discontent with the sex they were assigned at birth and/or the gender roles associated with that sex. This term is less than ideal, but a formal diagnosis may be required for medical care and conveys that this is a medical condition and not the individual's choice. Affected individuals are often called transgender.

Unfortunately, this case describes a common experience for transgender individuals, who often report acute discomfort when addressed according to a gender that is discordant with their self-identity. When use of the incorrect name/pronoun occur in health care settings, patients report lower satisfaction and are less likely to continue to seek care at that setting.(2,3)

We lack precise estimates for the incidence of gender variance, for several reasons. First, there is no routine surveillance of gender minorities in the United States. Moreover, transgender individuals often do not disclose their gender identity because of stigma and risk of harassment. The National Center for Transgender Equality estimates that between 0.25% to 1% of the population is transgender.(4) A recent study that drew from four national and two state-level population-based surveys suggests that there are nearly 700,000 transgender individuals in the US.(5) The classic estimate for prevalence of GID comes from the 1994 DSM-IV, which reported 1:30,000 natal males and 1:100,000 natal females (6) as transgender.

Transgender health raises a number of patient safety issues: lack of access to health care, increased risk factors, and difficulty transitioning. Transgender individuals commonly encounter a wide variety of discriminatory barriers. They also face difficulties accessing basic needs (getting a job, housing), which exacerbates health disparities.

Discrimination

Transgender individuals experience increased rates of discrimination, violence, and harassment.(7-9) Of importance, transgender populations face discrimination and harassment across a variety of critical social settings, including schools, workplaces, and health care systems.(10) Significant discrimination in health care settings may lead patients to avoid health care settings and delay seeking needed care.

Lack of access to health care

Transgender populations experience specific challenges with the health care system. The clearest and most troubling patient safety issue for transgender individuals is refusal of medical care. In one survey of transgender adults, participants reported that when they were sick or injured, they postponed medical care due to discrimination or inability to afford it. Respondents described serious hurdles to accessing health care, including refusal of care and harassment in medical settings. In addition, the majority of US health insurers do not cover hormone replacement therapy or sexual reassignment services.(11)

Health system barriers for transgender individuals include problems with identification forms (e.g., driver's license or health insurance card) that indicate assigned rather than preferred gender, a lack of a systematic approach by hospitals and clinics to collect current gender and preferred pronoun, and limited access to gender-neutral bathrooms. A national survey found that of those who presented identification that did not match their gender identity in health care settings, 40% reported being harassed, 3% reported being attacked or assaulted, and 15% reported being asked to leave.(12)

Health risks

Transgender individuals are not only a vulnerable and underserved part of the community, but they are also at increased risk for a number of issues. Lack of awareness about gender identity exacerbates family and societal rejection and stigmatization. Unfortunately, this leads to self-harming behaviors. Transgender communities in the US are among the groups at highest risk for human immunodeficiency virus (HIV) infection.(13) In 2009, the rate of newly identified HIV infection was 2.6% among transgender persons, compared with 0.9% for males and 0.3% for females.(14) Similarly, there are higher rates of drug use (12), homelessness (15), depression, and suicide among transgender populations. One in five transgender people in the US have been refused a home or apartment, and more than 1 in 10 have been evicted because of their gender identity.(15) A survey of San Francisco youth found that one-third of transgender youth have attempted suicide (16) and a recent national report revealed that 41% of transgender adults have attempted suicide.(12)

Transitioning

"Transitioning" refers to the process of using hormonal and/or surgical treatment to align preferred gender with appearance. Transitioning transgender individuals face a number of patient safety issues. Non-prescribed hormone use ("street hormones" such as estradiol and esterified, available under various trade names) is widespread throughout the US; the prevalence of non-prescribed hormone use ranges from 30% to 71%.(13,17-19) These findings are worrisome because non-prescribed hormone users may be at increased risk for health problems resulting from improper dosing and a lack of monitoring. Adverse effects include hormone-related cancers (20) and increased weight, decreased insulin sensitivity, poor lipid profile, and elevated hematocrit levels, raising concerns for cardiac and thromboembolic events.(21)

Recommendations

Patients should be able to identify sex at birth, current gender identity, and preferred gender pronoun separately during health care intake.(22) Staff should also be routinely trained, and clear communication across different providers and sites within a health system should be encouraged to address patients respectfully and in accordance with their wishes. In addition to addressing patients by their preferred name/pronoun, if a patient's gender is unclear, using gender-neutral phrasing such as "your next patient is here" is a suggested strategy. Allowing individuals to use the bathroom of the gender with which they identify is also recommended.

Best practices specific to electronic health records (EHRs) were developed by the World Professional Association for Transgender Health EMR Working Group.(23) These recommendations included (i) preferred name, gender identity, and pronoun preference should be incorporated as structured demographic variables within the EHR; (ii) the EHR should include an inventory of a patient's medical transition history and current anatomy; (iii) the EHR system should allow a smooth transition from one listed name, anatomical inventory, and/or sex to another, without affecting the integrity of the remainder of the patient's record; and (iv) the EHR system should alert providers and clinic staff of a patient's preferred name and/or pronoun.

An area of particular confusion for many providers is prevention screening in transgender patients. In general, transgender persons who have not undergone gender-affirmative surgeries or used hormonal therapy should be screened according to the guidelines established for their birth sex. However, for those patients who have undergone surgery or hormonal treatments, screening recommendations must be modified. A great starting point for providers is the UCSF Center of Excellence for Transgender Health's Web site. This site provides information for those interested in learning more about general prevention and screening for transgender patients. It includes a section emphasizing the areas of special consideration in which transgender-related medical treatments may have an impact on a patient's well-being.(22)

Guiding principles in caring for transgender populations are compassion and respect for the patient's expressed gender identity. Specific best practices include co-location of mental health services, peer support, and clinician training in transgender and gender-variant health issues.

Take-Home Points

• Transgender identity is a medical condition, not a person's choice, and care should focus on the patient's wishes.
• Health care teams should be trained to interact with transgender individuals in a courteous and patient-centered manner.
• Registration and other intake processes should capture information about general preference, and systems should be in place (including through the electronic medical record) to ensure that this information is available to all providers and is used in the care of the patient.
• Providers should pay particular attention to prevention screening in transgender patients.

Urmimala Sarkar, MD, MPH

Assistant Professor in Residence

School of Medicine

University of California, San Francisco

Faculty Disclosure: Dr. Sarkar has declared that neither she, nor any immediate member of her family, has a financial arrangement or other relationship with the manufacturers of any commercial products discussed in this continuing medical education activity. In addition, the commentary does not include information regarding investigational or off-label use of pharmaceutical products or medical devices.

References

1. Forcier MM, Haddad E. Health care for gender variant or gender non-conforming children. R I Med J (2013). 2013;96:17-21. [go to PubMed]

2. JSI Research and Training Institute, Inc. Access to health care for transgendered persons in greater Boston. Boston, MA: JSI Research and Training Institute, Inc. and GLBT Health Access Project; July 2000. [Available at]

3. Lombardi E. Enhancing transgender health care. Am J Public Health. 2001;91:869-872. [go to PubMed]

4. National Center for Transgender Equality. Understanding transgender: frequently asked questions about transgender people. Washington, DC: National Center for Transgender Equality; May 2009. [Available at]

5. Gates GJ. How many people are lesbian, gay, bisexual, and transgender? Los Angeles, CA: The Williams Institute, UCLA School of Law; April 2011. [Available at]

6. Olson J, Forbes C, Belzer M. Management of the transgender adolescent. Arch Pediatr Adolesc Med. 2011;165:171-176. [go to PubMed]

7. Clements-Nolle K, Marx R, Guzman R, Katz M. HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: implications for public health intervention. Am J Public Health. 2001;91:915-921. [go to PubMed]

8. Nuttbrock L, Hwahng S, Bockting W, et al. Psychiatric impact of gender-related abuse across the life course of male-to-female transgender persons. J Sex Res. 2010;47:12-23. [go to PubMed]

9. Lombardi EL, Wilchins RA, Priesing D, Malouf D. Gender violence: transgender experiences with violence and discrimination. J Homosex. 2001;42:89-101. [go to PubMed]

10. Grant JM, Mottet LA, Tanis J, Herman JL, Harrison J, Keisling M. National transgender discrimination survey—report on health and health care. Washington, DC: National Center for Transgender Equality and the National Gay and Lesbian Task Force; October 2010. [Available at]

11. National Coalition for LGBT Health. An overview of U.S. trans health priorities: a report by the Eliminating Disparities Working Group. Washington, DC: National Coalition for LGBT Health; 2004. [Available at]

12. Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at every turn: a report of the National Transgender Discrimination Survey. Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force; February 3, 2011. [Available at]

13. Clements-Nolle K, Marx R, Guzman R, Katz M. HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: implications for public health intervention. Am J Public Health. 2001;91:915-921. [go to PubMed]

14. HIV among transgender people. Atlanta, GA: Centers for Disease Control and Prevention; 2010. [Available at]

15. Housing and homelessness. Washington, DC: National Center for Transgender Equality; 2010. [Available at]

16. Clements-Nolle K, Marx R, Katz M. Attempted suicide among transgender persons: the influence of gender-based discrimination and victimization. J Homosex. 2006;51:53-69. [go to PubMed]

17. Garofalo R, Deleon J, Osmer E, Doll M, Harper GW. Overlooked, misunderstood and at-risk: exploring the lives and HIV risk of ethnic minority male-to-female transgender youth. J Adolesc Health. 2006;38:230-236. [go to PubMed]

18. Xavier J, Honnold JA, Bradford J. The health, health-related needs, and lifecourse experiences of transgender Virginians: Virginia Transgender Health Initiative Study Statewide Survey Report. Richmond, VA: Virginia Department of Health, Division of Disease Prevention; 2007. [Available at]

19. Xavier J. Final Report of the Washington Transgender Needs Assessment Survey. Washington, DC: Administration for HIV and AIDS. Government of the District of Columbia; 2000.

20. Mueller A, Gooren L. Hormone-related tumors in transsexuals receiving treatment with cross-sex hormones. Eur J Endocrinol. 2008;159:197-202. [go to PubMed]

21. Moore E, Wisniewski A, Dobs A. Endocrine treatment of transsexual people: a review of treatment regimens, outcomes, and adverse effects. J Clin Endocrinol Metab. 2003;88:3467-3473. [go to PubMed]

22. Center of Excellence for Transgender Health. Primary care protocol for transgender patient care. San Francisco, CA: University of California, San Francisco, Department of Family and Community Medicine; April 2011. [Available at]

23. Deutsch MB, Green J, Keatley J, Mayer G, Hastings J, Hall AM; World Professional Association for Transgender Health EMR Working Group. Electronic medical records and the transgender patient: recommendations from the World Professional Association for Transgender Health EMR Working Group. J Am Med Inform Assoc. 2013;20:700-703. [go to PubMed]