CE / CME
Pharmacists: 0.50 contact hour (0.05 CEUs)
Nurses: 0.50 Nursing contact hour
Physicians: Maximum of 0.50 AMA PRA Category 1 Credit™
Released: July 14, 2023
Expiration: July 13, 2024
Introduction
In this interactive text module, Madeline B. Deutsch, MD, MPH, Medical Director for the Gender Affirming Health Program at the University of California, San Francisco, and primary care specialist, uses a series of practice scenarios captured in video simulations here to highlight helpful and unhelpful ways to interact and communicate with transgender patients across the spectrum of care, including initial phone contact, at the front desk, and in the exam room.
The key points discussed in this module are illustrated with thumbnails from an accompanying downloadable PowerPoint slideset that can be found here or downloaded by clicking any of the slide thumbnails in this module alongside the expert commentary.
Clinical Care Options plans to measure the educational impact of this activity. One question will be asked twice: once at the beginning of the activity and then once again after the discussion that informs the best choice. Your responses will be aggregated for analysis, and your specific responses will not be shared.
Before continuing with this educational activity, please take a moment to answer the following questions.
First Contact With a Transgender Patient: Best Practices on the Phone
In our first practice scenario, a transmasculine patient calls a doctor’s office as a potential new patient to schedule a checkup and cancer screening following his mother’s diagnosis with BRCA-positive breast cancer. He asks whether any of the clinic’s HCPs have experience conducting cancer screenings for transgender men.
An unhelpful way to respond to the patient would be to say, “Of course they do! We see a very diverse patient population here, including lots of people who are gay.” In this scenario, the receptionist incorrectly assumed the patient’s sexual orientation (ie, to whom a person is attracted) based on their gender identity (ie, an internalized sense of oneself as either male or female, neither, or both that may be distinct from sex assigned at birth)1 without clearly addressing the question asked about the clinic’s experience with caring for transgender men.
A more helpful way to respond would be to be honest about any uncertainty regarding your clinic’s experience, offer to get more information, and express the clinic’s commitment to ensuring optimal care for all patients. Helpful statements may sound like:
An Inclusive Waiting Room Atmosphere and Front Desk Experience
To foster an inclusive front desk or waiting room experience, it is critical to create an atmosphere of acceptance in a clinical practice.2 This can include hanging signs and posters demonstrating support for LGBTQ+ individuals and having staff wear pronoun badges. Clearly posting nondiscrimination and bathroom use policies, as well as using last name only to call for people in the waiting room, can go a long way toward making transgender patients feel comfortable and safe.
In addition to projecting inclusivity in your practice, it is just as important to increase awareness and understanding among all of your staff—such as through diversity, equity, and inclusion training—to provide optimal care for transgender patients.3 For example, it is essential that all staff—including reception staff, nurses, medical assistants, and physicians—use appropriate names and pronouns. The use of honorifics (eg, sir, ma’am, Mr, Mrs) also should be avoided. Any negative experience a patient has in the waiting room or at the front desk will follow them into the exam room and potentially affect their engagement in care.
Best Practices for Names and Pronouns
Proper use of chosen names and pronouns is very important to transgender individuals. In addition to the supportive signage and pronoun badges mentioned above, an inclusive experience can be created by staff asking how the patient would like to be addressed and sharing their own pronouns.4 This will give the patient the opportunity to let their HCPs and ancillary staff know the name and pronouns they use. It can be helpful to offer transgender patients multiple opportunities to share this information; once obtained, the patient’s correct name and pronouns should be used consistently in all documentation, including the electronic medical record (EMR), if possible. If staff are not mindful of using a transgender patient’s chosen name and pronouns, the patient may leave the clinic before being seen.
How to Apologize for Misgendering a Transgender Patient
In our second practice scenario, a nurse and nurse trainee are checking in the transmasculine patient above, who subsequently scheduled an appointment for a general health assessment and cancer screening and is now in the exam room. In asking the nurse trainee to get the patient a gown, the nurse misgenders the patient.
Flawed responses to misgendering a transgender patient would include:
A better, more authentic response for when you have made a pronoun mistake would be to apologize directly and sincerely. Don’t dwell on it or try to explain. Simply say something like, “I’m sorry for using the wrong pronoun. I know this is very important, and I want to make sure you have a good experience here” and then move on. If the patient corrected you, you also could thank them for the correction.
Mistakes happen, and most people will understand and appreciate you saying you are sorry. However, if it continues to happen or occurs a lot of the time, then it might be time to evaluate and adjust one’s views and biases.
Institutional Systems to Help HCPs Avoid Misgendering
Using the wrong name or pronoun when interacting with transgender patients will happen sometimes, especially in an office or clinic setting where measures or systems to document patients’ lived names and pronouns are not in place. Institutional systems can go a long way in helping their HCPs avoid misgendering transgender patients, such as including a patient’s photo, their lived name, and what pronouns they use in their EMR.4
Cancer Screenings in Transgender Individuals Based on Organ Inventory
In the final practice scenario, we will return to our transmasculine patient, who is in the exam room for a checkup and cancer screening based on his mother’s recent cancer diagnosis.
Regardless of family history, it is critical for transgender individuals to receive organ-specific cancer screening according to guideline recommendations.3,5 Because cancer screenings should be conducted based on the organs that are present, HCPs need to know what organs their patient has, whether based on their sex assigned at birth or their surgical history. The ideal situation is to include an accurate organ inventory for your transgender patients in their EMR, where it is linked to surgical history and the preventive health reminder module.6 For example, even if a transgender individual whose sex assigned at birth was female has changed their identity documents and is legally male, there still needs to be an inventory in their chart noting that this patient has a cervix so they can be appropriately screened for cervical cancer—unless they have had a hysterectomy, in which case the reminder would be turned off automatically in the system.
Some information may be collected directly from patients and added to their EMR, if they consent, while keeping in mind that some transgender patients may be unsure of their current anatomy or what cancer screenings they need. For example, our transmasculine patient had top surgery, so he assumed he no longer needed screening for breast cancer. However, his HCP recommended that he continue to undergo routine breast cancer screening because the remaining breast tissue is still a risk for development of this cancer. Risk stratification and clear communication can guide decision-making with your patient.
Taking a Gender- and Sex-Neutral Approach to Cancer Screenings in Transgender Individuals
To foster access to cancer screenings for transgender individuals, it is recommended that HCPs consider taking a gender- and sex-neutral approach to taking a medical history and performing a physical exam.3,4 The main difference from the basic elements of preventive care for all patients that HCPs are already familiar with is avoiding use of gendered terminology when describing anatomy and associated cancer screenings of organs aligned with a transgender patient’s sex assigned at birth. Gender dysphoria decreases a patient’s chance of undergoing cancer screening for birth sex organs, and a simple change in language can make a world of difference to the well-being of transgender patients in your care.
For example, considering our transmasculine patient, a flawed approach when discussing routine cancer screenings would be for the HCP to suggest a “breast exam” or “mammogram,” language that not only could make the patient feel uncomfortable, but also could lead him to forgo these potentially life-saving exams. A better approach would be to use gender-neutral language such as a “chest exam” and “screening for breast cancer.” You also can ask your patient what generic words they use to refer to their “top” and “bottom” parts.
Other transgender-friendly practices may include offering a support person in the exam room for any physical exam or procedures or, if an option, considering special office hours for patients when a procedure or test may be triggering or traumatic.
Alternate Cancer Screening Approaches
If a patient exhibits a high degree of discomfort at the idea of receiving cancer screening of organs associated with their sex assigned at birth, alternate cancer screening approaches, if available, can be considered. For example, at-home cervical screening may be an option for our transmasculine patient.
Numerous studies support the use of self-sampling as an effective primary screening approach for HPV. For example, in a study by Reisner and colleagues,7 high-risk HPV testing in female-to-male transgender patients using self- vs HCP-collected cervical samples showed concordance, with self-swab having a 94% negative predictive value compared with HCP-collected samples. Furthermore, a 2017 study showed that 57% of surveyed transgender men preferred self-sampling and that this group is much less likely than the general US population of cisgendered women to be up to date on cervical cancer screening (49% vs 69%, respectively).8 Having the option to take tests in a comfortable environment likely would improve the patient experience and encourage adherence to guideline recommendations.
This practice is already used in Europe and is coming to the United States in the near future.
Summary
HCPs and ancillary staff can create an inclusive clinical environment for transgender patients by being honest with their patients about their knowledge of transgender healthcare and expressing a commitment to their comfort and unique needs. The entire multidisciplinary team, from reception staff to physicians, should strive to use each patient’s lived name and pronouns, including working to create opportunities for patients to share this information, and ideally have procedures in place to document the information in the patient’s EMR. Although these practices are useful, misgendering of transgender patients still may happen, and this gives the HCP and ancillary staff the opportunity to learn from their mistakes while maintaining humility. Finally, in the exam room, gender-neutral language for anatomy and associated cancer screenings is important for improving the patient’s experience and adherence to guideline-recommended cancer screenings, all in an effort to optimize outcomes for our transgender patients.
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