International and Domestic Health Equity and Leadership (IDHEAL) UCLA Emergency Medicine

GENDER IDENTITY
Module 4
Breena R. Taira, MD, MPH

Objectives

1. To recognize that the transgender population may have concerns about disclosing their gender identity and to discuss strategies to approach the subject when relevant to the ED visit.
2. To learn how to incorporate gender identity into clinical care.


Case

A 44-year-old English-speaking Latina female presented to the emergency department with chronic indolent left lower quadrant abdominal pain for 3 months. Patient says she has waited this long because of some bad experiences with the healthcare system in the past but today the pain was so bad she finally decided to come in. She gave a history of progressively worsening pain, localized to one specific point in the left lower quadrant without any bowel complaints such as diarrhea, or constipation. She denied nausea, fevers, dysuria or any other associated symptoms. After a history and physical, the initial physician decided the patient was a “rule out diverticulitis” workup. Lab work was normal. The patient was signed out to a second physician pending a CT scan of the abdomen. When the second physician received the read from radiology, it read “Left sided undescended testicle” with no sign of diverticulitis. The CT scan shows male genitalia. On receiving the read, the second physician thinks maybe she had misunderstood her sign-out and looked at the initial note. On review of the documentation, the note consistently refers to the patient as female and makes no mention of an exam of the genitalia. The second physician ponders how to best approach the situation with the patient, whom she has not yet met.


Discussion Questions

1. How would you approach this patient?

2. How do you typically initiate a discussion of gender identity?

3. Why is the second provider in the case uncomfortable about the pending discussion?

4. What measures can she take to facilitate a smooth and respectful interaction?


Teaching Points


1. Transgender patients may be uncomfortable disclosing their gender identity and not offer the information freely. Even if the transgender patient tries to disclose their gender identity, there may be no appropriate way to record a trans-person's gender in the electronic record. Most electronic health records only allow for "male" or female", which can make an awkward situation/choice for both the patient and the registration worker.

2. Discussing gender identity is something that all health care professionals should feel comfortable with. For those who have less experience talking with trans patients, thinking through respectful language and having a planned script in advance of the interaction can be helpful. It is okay to ask about gender identity when it relates to the medical problem at hand and encouraged to ascertain the patient's preferred pronoun. Providers should be weary of using judgmental or demeaning wording when asking about gender identity. It is also preferable to use unassuming terminology when referring to partners such as "significant other" when appropriate.

3. Transgender people may avoid ED visits and sometimes healthcare in general because of concern for lack of respect and knowledge amongst healthcare workers regarding gender identity.


Practical Questions


1. Do you know how gender is recorded in your electronic health record and what the answer options are?

2. What practical improvements could be made to processes in your ED to help minimize repeated questioning about gender identity and to make communication about gender identity more private?

3. Are there local resources available for transgender patients to obtain primary care in a supportive environment with providers who are expert in transgender care?


Recommended Screening Question(s)

1. What is your gender identity? (Check all that apply)

  • Male
  • Female
  • Transgender male, trans man, female-to-male, trans-masculine
  • Transgender female, trans woman, male-to-female, trans-feminine
  • Genderqueer, neither exclusively male nor female, non-binary, or gender nonconforming
  • Additional gender category/Other (please specify): ____
  • Choose not to disclose

2. What is your identifying pronoun?
  • He
  • She
  • They

3. What sex were you assigned at birth, or was listed on your birth certificate?
  • Male
  • Female
  • Intersex
  • Other
  • Unknown
  • Choose not to disclose


Paired Reading

Samuels EA, Tape C, Garber N, Bowman S, Choo EK. "Sometimes You Feel Like the Freak Show": A Qualitative Assessment of Emergency Care Experiences Among Transgender and Gender-Nonconforming Patients. Ann Emerg Med 2017.


Discussion Points from the Reading

1. Lack of privacy to disclose gender identity and repeated questioning from the healthcare team about gender identity is a source of distress and can produce a negative overall experience in the ED for transgender patients.

2. Basic education about trans patients is lacking in medical training curricula.

3. Clear communication about why sensitive questions and exams are necessary are helpful.

4. Binary gender documentation can be difficult to navigate for transgender patients and can cause confusion for the providers.


Additional Readings

1. Chisolm-Straker M, Jardine L, Bennouna C, et al. Transgender and Gender Nonconforming in Emergency Departments: A Qualitative Report of Patient Experiences. Transgend Health 2017;2:8-16.

2. Jalali S, Sauer LM. Improving Care for Lesbian, Gay, Bisexual, and Transgender Patients in the Emergency Department. Ann Emerg Med 2015;66:417-23.

3. Maragh-Bass AC, Torain M, Adler R, et al. Is It Okay To Ask: Transgender Patient Perspectives on Sexual Orientation and Gender Identity Collection in Healthcare. Acad Emerg Med 2017;24:655-67.

4. Maragh-Bass AC, Torain M, Adler R, et al. Risks, Benefits, and Importance of Collecting Sexual Orientation and Gender Identity Data in Healthcare Settings: A Multi-Method Analysis of Patient and Provider Perspectives. LGBT Health 2017;4:141-52.