Caring for the Transgender Patient: It Is More Than Using the Right Pronouns!

Trans individuals often face stigma and discrimination in their daily lives. Ideally, the health care setting should be a safe haven wherein they can be who they are – but is it always so? Unfortunately, the answer is still not a clear and resounding yes! Why are transgender patients stigmatized by society? The answer resides in how people are socialized to understand and enact gender. According to the Harvard Business Review, gendered behavior is learned. From a young age, boys and girls are encouraged to display stereotypically gendered behaviors and discouraged from displaying non-normative ones. My (KS) kindergartener was amazed that her male classmate’s favorite color was pink. There is no biological predilection toward color, yet there is a designation as to what is socially acceptable. Moreover, children pick up on subtle signals from their parents and others who enforce gender stereotypes. For example, when donning female garments during dress up, girls might be told they look pretty, while boys might be told they look silly. Children seek to fulfill gender expectations to secure parental and, later, peer acceptance. As we grow up, it becomes difficult to distinguish between expressions of gender we prefer and those we have been socially rewarded. Trans people face a unique quandary. For example, when a trans woman – whose sex was assigned male at birth and who knows herself to be female – adopts typically female clothing and jewelry, she breaks with expectations regarding how she should define and express her gender and, unfortunately, invites stigma and accompanying social devaluation. A 2015 survey by the National Center for Transgender Equality found that 77% of those who had held a job in the year prior took active steps to avoid mistreatment at work, such as hiding their gender identity, delaying their gender transition (or living as their true selves only after work and on weekends), refraining from asking their employers to use their correct pronouns (he, she, they, ze), or quitting their jobs. Sixty-seven percent reported negative outcomes such as being fired or forced to resign, not being hired, or being denied a promotion. This unfortunately occurs in the health care industry (asamonitor.pub/3FaECBG).

Over the last decade, social norms in American culture have undergone a revolutionary change. An individual’s gender identity is no longer limited by what is legally assigned at birth. There are now over 70 recorded gender expressions, with the most common nontraditional genders including transgender, gender fluid, non-binary, intersex, and genderqueer (Figure 1). The transgender community has seen an increase in support and resources on both the state and federal level in the last decade. In 2013, the first state, California, issued policies that included coverage for gender transition under its Medicaid program. In 2021, the designation of identifying as non-binary was recognized by the government and added to passports. In January 2020, President Biden signed an executive order prohibiting workplace discrimination for the LGBTQ+ population. As a result of evolving societal acceptance, the health care system has created more community-based transgender resource centers as well as increased access to surgical treatment at private and academic institutions (J Sex Med 2021;18:410-22).

It is imperative that health care providers receive education on how to provide quality, empathetic care to these individuals and understand relevant terminology. In 2016, a national survey of the transgender community estimated that there are 1.4 million adults in the United States who identify as transgender, representing a 100% growth from 15 years ago (Sex Med 2021;9:100448). As more transgender and nonbinary people feel comfortable identifying themselves, we will see an increase of not only transgender patients but also colleagues in the workplace. We can support patients and colleagues by understanding the history and disparities unique to the population, identifying implicit bias within ourselves, and actively using appropriate terminology and pronouns, as well as redesigning the health care environment to be inclusive.

Discourse and language around gender is evolving rapidly. This history is important when reviewing older medical records for diagnoses, as outdated and offensive terminology may be present. Identifying as transgender is not a new concept, as the first documented gender-affirming surgery was performed in 1930. However, the first two editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published in 1952 and 1968 contained no mention of gender identity (Diagnostic and Statistical Manual of Mental Disorders. 5th edition, 2013). With the publication of DSM-III in 1980, the diagnosis “transsexual” first appeared. In 1994, with the release of DSM-IV, “transsexualism” was replaced with “gender identity disorder in adults and adolescence.” The updated terminology was meant to reduce stigma, but the new definition was misconstrued as a pathologic diagnostic category rather than as a true disorder. In 2013, DSM-5 updated the terminology again to “gender dysphoria” to shift focus to the distress of the disorder (N Engl J Med 2019;381:2451-60). According to the newly revised version of the International Classification of Diseases (known as ICD-11) published by the World Health Organization, “gender identity disorder” is being replaced by “gender incongruence,” and this will be adopted as acceptable terminology (USTS May 2015).

An appreciation for the appropriate terminology and avoidance of offensive, outdated terms is paramount for making medical diagnoses and speaking with patients (Figure 2). The label of transgender indicates that one’s gender identity does not match the sex they were assigned at birth. Biological sex is gender-assigned at birth based on anatomical features and chromosomes. Gender identity is one’s internal sense of being male, female, both, or neither and can shift over time. Cisgender is identifying as your assigned gender at birth. Gender non-binary persons may identify as neither male nor female or as having features of both sexes (Diversity and Inclusion in Quality Patient Care. 2019). Gender dysphoria is the feeling of unease and dissatisfaction associated with one’s gender identity not matching their biological sex. One’s gender identity is typically established by 4 years of age. A study by Zaliznyak et al. included 210 transgender individuals in 2021 and found that transgender children develop gender dysphoria by 7 years old. The study also described that the mean number of years of persistent gender dysphoria one experiences before deciding to transition is between 22-27 years. This could explain the higher-than-average rates of depression, anxiety, and suicidal ideation that this population struggles with and why their mental health could improve following gender transition (Sex Med 2021;9:100448).

There are many approaches one can take to create a more inclusive environment for the transgender and non-binary community. Recognizing implicit bias is one step that can be difficult, as it is human nature to subconsciously make assumptions about someone’s gender identity based on their appearance or voice. We do this to auto-categorize people we do not know as “male” or “female” because it impacts our approach to an unknown person, whether that is for our perceived safety or to formulate a greeting. Honorifics (Mr./Ms.), pronouns (he/she), and titles to show respect (ma’am/sir) are frequently required to simply converse. When our assumption is wrong, it is called misgendering. Being misgendered can cause gender dysphoria in transgender individuals. A best practice to avoid misgendering people is to ask what their chosen name and pronouns are. This can be done on the initial interview or included on intake paperwork (Diversity and Inclusion in Quality Patient Care. 2019).

Strong leadership teams are instrumental to creating professional environments that promote safety and inclusivity in workplace culture. Electronic health records can be modified to include gender assigned at birth, chosen gender, and chosen pronouns. Using inclusive decor, wearing supportive lanyards, adding personal pronouns to email signatures, and having access to all-gender restrooms are small but impactful changes to a work environment (Diversity and Inclusion in Quality Patient Care. 2019). Using anatomical language such as “vagina and fallopian tubes” instead of “female reproductive system” can also help prevent dysphoria. All staff members, regardless of patient contact, should have access to transgender medical and sensitivity education, preferably mandated on an annual basis. Various resources, such as hospital protocols, standard of care videos, and cultural sensitivity trainings are readily available from the Human Rights Campaign and the World Professional Association for Transgender Health (asamonitor.pub/3BaVcQM; asamonitor.pub/3Y0YqQE).

Transgender patients form a very important subset in the health care scenario. According to the Trevor Project National Survey of transgender youth, 79% experience anxiety or other mental health issues (asamonitor.pub/3P7kwNx). In a landmark article, the American Journal of Psychiatry found that patients were less likely to seek mental health care after gender-affirming surgeries (Am J Psychiatry 2020;177:727-34). Many states approve insurance for gender-affirming surgeries; hence, this patient population is on the rise and it becomes crucial for every anesthesiologist to know how to treat them as a patient and as a person. According to the 2016 transgender survey, 33% of individuals reported at least one negative experience with a health care worker either via verbal harassment or refusal of treatment. Health care providers must recognize that this represents a significant disparity problem, confront their personal biases, and use their position and privilege to make the necessary changes required to serve this community (USTS May 2015). Only then can we truly do the best for our patients and live up to our Hippocratic Oath.