niversity of Utah Health’s Charles James Nabors Patient Voice series recently hosted a discussion to highlight the voices of transgender and gender diverse communities. I was joined by four panelists who shared their insights.  

• Taylor Delgado, identifies as a transgender female, uses she/her pronouns and is an emergency medicine physician. Taylor enjoys backcountry skiing, mountain biking, and whitewater paddle boarding.

• Sage Buch, identifies as a non-binary person, uses they/them pronouns, works at the Fourth Street Clinic and wants to apply for medical school. Sage loves the outdoors, especially whitewater kayaking.

• Tisha Olson, identifies as a transgender female, uses she/her pronouns, and retired after 22 years serving in the U.S. Marine Corps. She works as a peer support specialist for the VA and Odyssey House. Tisha loves to ride her Harley and restore old vehicles.

• River Jude August, identifies as agender, uses they/them pronouns, recently underwent phalloplasty surgery, and helps advocate for marginalized communities in their spare time. River likes to ski and ride motorcycles.

1. Know me — ask for my pronouns and name

When River was in the hospital following phalloplasty surgery, the nurses made a sign above their bed that let other providers know they used they/them pronouns. It was a simple gesture, but made a big difference for River to feel comfortable and cared for as a person. It also meant they wouldn’t have to continually explain it to every provider who came into the room over several days of recovery. It is an emotional burden for a person to explain themselves to everyone they encounter, especially in a health care setting, where everyone expects their care providers to know them as an individual.

One of the best ways that health care providers — including physicians, nurses, front desk staff, and others involved in a patient’s care — can build trust is by asking a person their chosen name and pronouns, and then using those. It’s an act of basic respect and can go a long way in showing a patient you care.

Many of the panelists had experienced misgendering or providers who assume their identity. River shared “…a provider in Utah assumed my identity, because of the type of surgery I was having, and I went through a pretty traumatic experience with that. So it's really important to be very clear about when interacting with your patients, what their needs are, and they're not always based upon how they present or the surgery.”

Sage added “As a non-binary person, I've had a lot of interactions where people have assumed the way that I should identify or told me how I should transition. I don't really have the ability to not come out every single time I interact with someone new. I have to remind everyone that I use ‘they/them.'” 

2. The environment matters

One way health care providers and facilities can create a welcoming environment is with visual signs of affirmation. Taylor shared “I love when I go in somewhere and I see even a tiny LGBTQ flag or a small card welcoming LGBTQ patients or customers. It’s almost like your level of anxiety goes down a bit, just because you realize that this place has made it open. Anybody that goes in there sees it. The more people see that and see us and meet me, the more they realize I’m just like you. One tiny symbol is actually really big.” 

River pays attention to what they call “genuine optics.” “Do the staff reflect the clientele too? Do you have gender diverse staff, transgender staff? That's huge for me as well. What does your mission statement say? What are some of the first things that people will see when they enter your clinic or they enter your room? Are you really reflecting what you want to create in your own practice and do your staff reflect that as well?”

When Tisha goes to a new place, she considers everything, including the parking. “I always make sure that wherever I do park, it's someplace where there's a lot of congestion, a lot of people around because there are still people out there that still get violent towards us. Sometimes I get weird looks from the valets or front desk when they hear the sound of my voice. It’s discouraging to me, but I understand that there is a learning curve on both sides. While I’ve known my whole life that I was a little bit different, I don’t expect everyone to understand and accept me the very first time you meet me. But what I do want is to not be ridiculed in the process. Just be open.”

3. Protect my privacy at check-in and in my record

Taylor remembered “When I went to the front desk of one provider in Utah, the receptionist said quite loudly so everyone else could hear in the waiting room ‘You're still listed as male on your insurance information.’ I understand that they have to ask those questions, but there was no confidentiality. I ended up leaving that clinic and never went back.”

River shared “Do you protect patient privacy? I've had similar experiences, and it's just like somebody talks really loud in the waiting room and everybody else can hear and you just feel yourself just kind of shrinking inside and you never want to return to that place again.”

Not everyone who is transgender or gender diverse is “out” publicly. Even those who are may face significant risk of emotional and physical harm when they are identified publicly as being transgender or gender diverse. A 2011 survey of almost 6,500 transgender people revealed that transgender people were often denied care because of their gender identity and that over a quarter were harassed or disrespected for being transgender. 

We do have correct ways to enter this information in the EHR using the “chosen name” field if it doesn’t match a patient’s legal name. Ensure that we’re doing it as respectfully as possible. 

4. Treat me as an individual

Sage looks for someone who will actually treat them. “I came out in 2014, and in the six years since then, I've had eight out of the eleven providers that I've tried to go to deny treating me on the basis of being trans. It's been a situation where they'll say something like, 'Hey, I have never treated a trans person before and I'm really worried about not giving you the best care that you can have, and so I'm gonna refer you to a trans specialist.'"

Sage continued “A lot of the primary care providers have built expertise in caring for trans patients. But most health care that trans people need doesn't have a lot to do with them being trans. Some of it absolutely does, like something having to do with HRT or with certain surgeries, but we go to podiatrists because most of us have feet. We go to oncologists when we have cancer. A lot of treating trans people is just like, 'We are human beings, treat us as human beings.'"

“99% of the time, I do not give a single care about someone's innate knowledge of transition matters and trans care, what I really care about is someone's ability to treat me like a fellow human being and their ability to really be honest with me about not knowing something where they can say like, 'Hey, I don't know about this, but I think I know someone who does, and I will go find out and I will work with you on getting the care that you need.'"

As with any patient — cisgender, transgender, gender diverse, male, female, non-binary, and LGBTQ+ — a transgender or gender diverse person’s care needs are highly individualized based on their health history, family history, and current health conditions. Discussing the patient’s gender affirming goals, performing an organ survey, and understanding their biological makeup can help create the appropriate individual care plan.

Providers must also understand the health implications of proper documentation for a transgender or gender diverse person. For example, a person may identify as a male or non-binary but still have female sex organs, such as breasts or ovaries. In that case, the physician should document that and recommend appropriate preventive screenings like mammograms and screening for ovarian cancer. 

Taylor, who is a physician, noted that it is completely appropriate to do an “organ survey” with a transgender or gender diverse patient to identify which organs they have so you can recommend the appropriate screenings, preventive care, and treatment. 

What to do next

Transgender and gender diverse health literacy is essential for everyone in health care, and requires ongoing education, experience, and training. The Transgender Health Program offers best practice training for clinicians, staff, and departments. There are also national resources for CME and CE credit to further your knowledge about caring for transgender and gender diverse patients.