PHILADELPHIA—Acknowledging the complexities of medical care for transgender (trans) and nonbinary or gender-diverse patients and emphasizing the urgency of doing it right, two experts offered guideposts to clinicians in an ACR Convergence 2022 session titled Dignity and Respect: How to Welcome and Care for Gender Diverse Patients in Your Practice, with advice on providing clinical care and tips on the subtleties of terminology when interacting with patients.
Clinical Care
Nathan Levitt, FNP-BC, MSN, RN, BSN, MA, director of LGBTQ and gender justice learning at Yale University School of Nursing, New Haven, Conn., offered his own experience as evidence of the type of problem the medical field needs to overcome.
“Maybe you are the most sensitive and informed clinician, but before that patient ever gets to your door, they’ve experienced discrimination outside your health center,” he said. “Many will avoid care in general. When I worked in primary care, we had a lot of transgender patients who had never come in for care before because of their fear of the discrimination they might face.”
An introduction using pronouns can help put patients at ease, he said. He suggested something along the lines of, “My name is Nathan. I’ll be your nurse practitioner today. I use he/him pronouns. What name or pronoun do you want me to use for you?”
“You can do this with everyone, and it communicates that you’re going to be a sensitive person to talk to,” he said.
He stressed the importance of putting patients at ease and making sure any gender-related questions are relevant to the medical issue at hand. A patient there for a cough, for example, doesn’t need to be asked about their genitalia, Mr. Levitt said.
Clinicians should find out any hormones the patient is taking, how they take them and understand the effects these treatments have. They will also need to ask about gender-affirming surgeries. Using that particular term will help tell the patient that you understand that these are, in fact, affirming. He challenged clinicians to give thought to how they can improve their management of trans and nonbinary or gender diverse patients.
“What are some strategies within your institution? What are some systems that make this challenging? What are some possible fixes? What can you do in your role? And what support do you need?” he said. “I really just want you all to think about this in your care, how to integrate this.”
Subtleties of Terminology
Lina Rosengren, MD, MPH, assistant professor of medicine at the University of North Carolina, Chapel Hill, tried to shepherd the audience through the labyrinth of terms associated with the care of patients who identify as lesbian, bisexual, gay, transgender, queer, intersexual, asexual (LGBTQIA+).
“The need to describe many intersecting identities has led to lots of different terms, and these terms evolve over time and with cultural trends,” said Dr. Rosengren, who identifies as queer. “Queer is very widely used within the queer community as a label of those sexual and romantic orientations as well as gender identity.” She said it’s a “very inclusive term without being explicit. … Plus, LGBTQIA+ is a mouthful.”
She offered these definitions. Sex is the assignment at birth based on chromosomes, anatomy and other factors. Gender is a social construct, with gender identity being the sense of who you are, and gender expression being how you present your gender identity.
“It’s very important to recognize that gender norms vary greatly across cultures, nations and regions,” Dr. Rosengren said. “The best way to identify your patient’s gender is to ask—and mirror the language they use.”
Sexual orientation is a person’s preferences for their sexual and romantic partners.
When considering sexual behavior and risk, she said it’s important to separate identity from behavior.
“An individual’s risk for sexually transmitted infections and HIV [human immunodeficiency virus] is actually a function of their sexual behavior—and not their anatomy or their identity,” she said. “Not all gay men have anal sex. Not only gay men have anal sex. Sexual behaviors are fluid.”
Specifying the pronouns you use for yourself and that you would like others to use when referring to you can be helpful, but only if this is backed up with appropriate care. One concern is that some people may think displaying pronouns is enough, and others may feel it’s an oversimplification. Some people may feel forced into a pronoun that doesn’t quite feel right to them.
“Displaying our pronouns may be a message that you provide a safe space, but you still have to practice engaged allyship,” Dr. Rosengren said.
Taking a sexual history is important to diagnosis and can help you be a better doctor, but it requires a direct approach with clear language, she said. Some patients, might, for example, not consider oral sex as “having sex,” and “sexual partner” might mean different things to different people.
“When I take a sexual history, I use language that almost anyone can understand,” she said. This includes clear, direct questions, such as, “Do you use your mouth or use your bottom?”
“You can feel uncomfortable at first, but you really will get better at it,” said Dr. Rosengren. “And you will take an excellent and very inclusive sexual history if you use this explicit language.”
Dr. Rosengren said that when clinicians make an effort, they will find the care satisfying. “It’s really a pleasure to care for these individuals and to be on their healthcare journey with them,” she said.
Thomas Collins is a freelance medical writer based in Florida.
