Redefining Safe Spaces for Transgender Patients

When transgender patients find the Columbia Fertility Association (CFA) in Washington D.C., it’s often been more than five years since they’ve seen a medical provider.

Foregoing treatment for a seemingly small problem can lead to the development of chronic conditions, but that’s a risk many gender and sexual minorities are willing to take. Often, the reluctance to seek medical care comes from expectations of discrimination — a fear that isn’t unfounded. 

Historically, transgender people have experienced trauma related to mistreatment from medical providers, resulting in widespread mistrust and poorer quality care. According to the 2011 National Transgender Discrimination Survey, 28 percent of transgender respondents reported harassment in medical settings, 19 percent reported refusal of care, and 10 percent reported sexual assault in at least one health care setting.

In this same survey, 50 percent of respondents said they had to teach a provider about transgender care.

Just because providers say they’re “LGBT-friendly” doesn’t mean they are, said Signey Olson, a nurse practitioner at CFA.

“It might mean they worked with a gay couple once, or that they have experience with sexual minorities, yet know nothing about gender,” said Olson, who provides gynecological, fertility and gender-affirming care for her patients.

Gender-affirmation includes transgender-specific services like administering hormone therapy and writing letters to support surgery. But transgender patients also seek primary care services like birth control prescriptions, STD and cancer screenings, and mental health care from providers who specialize in LGBT populations. Unfortunately, primary and specialty care for transgender people isn’t always available locally, so many patients have to travel to find an accommodating clinic.

Providers who claim to be “tolerant” or “accommodating” perpetuate the negative patient-provider dynamic that can leave patients feeling inferior or imposing. Olson said the only determinant of being LGBT-friendly is when people in the community affirm a provider as such.

According to a Gallup poll released this year, the number of self-identified LGBT people has increased significantly in the past five years; the highest spike was in the Pacific region, including California, Oregon, Alaska, Hawaii and Washington. With this increase comes a responsibility for providers to establish trust and respect for LGBT patients.

“We have to reframe health care as a safe place,” Olson urged, “so it’s really important for providers to be open to patient feedback and understand what the needs of the community are.”

According to Olson, many LGBT patients find providers via word of mouth after other gender and sexual minority patients make referrals on social media platforms. “Most of our patients get referred through Facebook groups,” she said.

People turn to online groups to find more than just medical providers in their area, though. Dan Green, a PhD student at the USC Suzanne Dworak-Peck School of Social Work, said members of LGBT communities use online forums to help each other cope with mistreatment and discrimination.

“Researchers often look at what’s going wrong, but they should be noticing what’s going right,” said Green, who maintained that online forums can offer insight into the positive outcomes of LGBT community support.

Green is studying Minority Stress Theory, which states that LGBT populations are at higher risk of encountering environmental factors like prejudice, violence, rejection and internalized homophobia, resulting in increased health disparities.

Taking these stressors into consideration is a critical part of providing quality care. “Providers have to understand there are unique differences among patients,” said Green. “An attitude like colorblindness doesn’t help anyone.”

Green explained that ignoring a patient’s gender identity and expression results in an inability to recognize the social determinants that affect their health outcomes. Affirming a patient’s identity can start simply, by asking about their preferred pronouns.

Some patients might be gender non-conforming, meaning they don’t identify with either a male or female gender, so providers should take the time to understand how patients prefer to be addressed. 

If a provider misspeaks, “just be honest and apologize,” Green said. The graphic below explains the meaning behind several terms of gender identity and expression that providers should become familiar with.

AFFIRMING GENDER IDENTITY AND EXPRESSION

People in LGBT communities use a variety of terms to indicate forms of gender identity and expression. These terms are defined by the National LGBT Health Education Institution but don’t encompass all the ways people may define their gender or sexuality.

It’s in everyone’s best interest to let a person choose what terms they use to define themselves.

BIRTH SEX

The sex (male, female or intersex) assigned to a child at birth, based on anatomy.

GENDER EXPRESSION

The way a person acts, dresses, speaks and behaves in order to show their gender as feminine, masculine, both, or neither.

GENDER IDENTITY

A person’s internal sense of being a man, woman, both, or neither.

GENDER NON-CONFORMING

People who express their gender differently than what is culturally expected of them regardless of their gender identity. Examples include a woman who dresses in a masculine style, a boy who likes to play with dolls, etc. A gender non-conforming person is not necessarily transgender.

GENDERQUEER

Used by some individuals who do not identify as male or female; or identify as both.

SEXUAL ORIENTATION

How people identify their physical and emotional attraction to others. It is not related to gender identity. Transgender people can be any sexual orientation.

TRANSGENDER (TRANS)

People whose gender identity is not the same as the sex they were assigned at birth.

TRANSITION/GENDER AFFIRMATION PROCESS

The process of coming to recognize, accept, and express one’s gender identity. Most often, when a person makes social, legal, and/or medical changes, such as changing their clothing, name, sex designation and using medical interventions. Actions such as these help people affirm their gender identity by making outward changes.

Source: National LGBT Health Education Center, A Program of the Fenway Institute

NPs can also be aware of unconscious biases during dialogue with patients, according to Dr. Nancy Tkacs, professor in the USC Suzanne Dworak-Peck School of Social Work Department of Nursing.

“Providers have the potential to contribute to health disparities if they aren’t conscious of their reaction when a transgender person comes into the room,” Tkacs said. “If you’re not accustomed to caring for transgender patients, then you first need to deal with your own biases and knowledge deficits.”

While NPs can’t change the history of patient-provider experiences for gender and sexual minorities, they should keep it in mind when working to help patients feel safe and comfortable in a clinical setting.

According to Olson, even these seemingly small changes can establish trust with patients.

Much of medical vocabulary is gendered, like referring to the person carrying an unborn child as “the mother,” but Olson encourages providers to consider how their language use creates barriers for transgender patients.

“There’s a saying, ‘Babies are born, pizzas are delivered,’” Olson said, emphasizing the importance of intentional language. She added that asking a patient’s preferred name is a good place to start.

“It sets a very different tone in a relationship, meaning that you really care about understanding who this person is,” she said.

Being intentional with language can go beyond dialogue, for example, in official documentation. Letting patients indicate gender identity and expression allows providers to better track health disparities and shows patients they are respected by understanding providers.

“We have to ask ourselves, ‘How sensitively are we documenting our care?’” Tkacs said.

Krishna Kothary, a nurse practitioner at Whitman-Walker Health Care, believes a safe space should ultimately be a place of humility, free of judgment. “It’s also a continuing space, one that you want patients to come back to,” she said. But just as providers don’t have the power to label themselves as LGBT-friendly, they aren’t the ones who decide whether a patient feels safe.

Instead of labeling an office as a “safe place,” Olson suggests asking patients for their feedback. For example, “I want you to feel safe here, so what can I do to make this experience more comfortable for you?” 

Olson has found that asking a patient’s permission to touch them before doing so can reduce the perception of a power dynamic, as can asking if the patient would prefer to be accompanied to an exam room. She said before every exam, she always holds a consultation with patients fully clothed in her office.

“So many people have an ingrained idea that you’re in a doctor’s office to do what a clinician recommends,” Olson said. “But just because you’re there doesn’t give the clinician consent to do whatever they want.”

Green and Olson cited the importance of leveling with a patient, and relinquishing the clinician ego. Being open-minded as a provider can help patients feel like they’re not the only vulnerable party. “It helps for patients to see us as human,” Green said.

“It’s always a patient’s body, a patient’s choice,” Olson added. “A patient knows best about what’s right for them.”

Providers must, however, take steps to ensure they are providing inclusive care, to keep themselves and their colleagues accountable. The Human Rights Campaign’s (HRC) National Healthcare Equality Index provides a toolkit for providers at any clinic or hospital to assess the inclusivity of care for LGBT patients.

Patients looking for providers who meet the criteria of inclusive care can use the HRC’s online map tool to find the clinic or hospital closest to their home.

“Of course, trauma-informed care applies to people who are gender nonconforming, but it also applies to everyone,” Olson said. “It’s just good practice.”

Citation for this content: Nursing@USC, the online FNP program from the University of Southern California