Authors: Ethan Wilson / Editor: Charlotte Davies / Codes: SLO1, SLO5, SLO7 / Published: 04/10/2022
5 Simple Tips for Getting the Basics Right
It’s June. It’s Pride month, and in fact it is 50 years since the UK’s first Pride march! That took place in 1972, just a few years after the Stonewall riots and protests in America in 1969, sparking a movement for change for the LGBT+ community.
Great progress has been made in a number of respects; such as the legalisation of same sex marriages; lifting of many restrictions, due to the blood donation ban, imposed on gay and bisexual men (or men who have sex with men); and Scotland being the first country in the world to embed LGBT+ education within the school curriculum.
The sad truth though is that despite some progressive movements for change, there are still a great many inequities faced by the LGBT+ community, particularly in healthcare. The transgender community is typically disproportionally affected by several of these issues too – and that is what we’re going to discuss here.
Emergency departments can be stressful, busy environments, where there is never enough time for all the things that need to be done. But I’d like to suggest five simple tips that could help make the experience feel safer, and more affirming, for a presenting patient from the transgender community.
But first, a bit of background: transgender health inequities
You may be wondering what the big deal is, and why awareness of how to better support the transgender patients that you see matters. Whilst this isn’t an article on the health inequities that they face – being aware of some of the context and background, is important reinforcement.
So, to begin with, some quick fire data and statistics:
- 41% of trans people, and 31% of non binary people, have faced hate crimes or incidents, due to their gender identity(1).
- It is not unusual for a wait time of 4-5+ years, for an initial appointment at a Gender Identity Clinic(2,3,4).
- 41% of trans people have felt that healthcare staff have had inadequate understanding of the health needs of the trans community(1), with 7% having been refused care due to them being LGBT+(1).
If someone were to tell you that 41% of patients with rheumatoid arthritis felt that healthcare staff didn’t know how to care for them, 7% had been refused care due to having rheumatoid arthritis, and they’d also have a 4-5+ year wait to be seen at a specialist clinic, you’d probably sit up and take note.
Consider, then, that there is an estimated 0.8% of the population in England with rheumatoid arthritis(5); and an estimated 1% of the UK population is transgender(6). Why is it, that the health inequities faced by the transgender community, are still being so overlooked? A question for another day, perhaps. For now, let’s look at five simple ways you can better support your transgender patients.
Tip #1: Use the correct pronouns for your patient. Not sure? Ask!
Pronouns are what we use to refer to an individual in place of their name. You do this ever day already without even thinking about it. It is, however, even more important to ensure you are using the correct pronouns for transgender individuals. This avoids invalidating their identities.
You might find there is a note in their patient file of which pronouns they use, but it’s important to find out if not. Just because a patient presents visually in a way that you interpret as, say, female, doesn’t mean they will use she/her pronouns. Some people may not use binary he/him or she/her pronouns, they might use more neutral ones such as they/them, or ones you may be unfamiliar with such as the neopronouns xe/xem or ze/zir.
It can be easy to check though, and can be incorporated into your own introduction – either by explicitly asking for their pronouns, or asking more generally about how to refer to them.
“Hello, my name is Dr Brad Pittella, and I use he/him pronouns. I’m going to be your doctor today – can I check your name and date of birth first, please?” … “That’s great, thanks. How would you like me to address you today?”
If you are still unsure about which pronouns your patient uses, why not just ask them. The simple act of using a person’s correct pronouns can save lives. The Trevor Project found that only 20% of young people felt their pronouns were respected; but that in those who did, they attempted suicide(7) at half the rate of those who didn’t.
Tip #2: If it isn’t relevant; don’t ask unnecessary questions
If you find yourself treating a transgender patient, consider whether asking anything about their gender identity and/or transition is actually relevant to what you’re seeing them for. If it’s not relevant, all you are doing is asking inappropriate, and personal questions. Think how you would feel if someone started asking about your genitals whilst treating you for a broken thumb!
There will be times that it is relevant though. For instance, a transgender person who was assigned female at birth, but identifies as male and presents in a stereotypically masculine way, presents with pain in the right iliac fossa region. You might want to assume it to be appendicitis, but it could be that he hasn’t had an oophorectomy and it is actually an ectopic pregnancy. In such case, it would be medically relevant to (sensitively!) understand what anatomy your patient does or does not have.
Tip #3: Advocate for your patient(s); even if they aren’t there
It may seem like a small, perhaps irrelevant, thing to consider. However, calling out other people who are misgendering, or using the birth name for a transgender patient is actually quite important. The patient may not be there, and in fact they may never even find out that you did advocate for them. But the issue here is much broader than one individual patient.
It’s about tackling transphobia within healthcare environments, and ensuring that it is challenged whenever noticed. Whilst changes on an individual interaction level will improve healthcare for transgender patients, larger systemic changes will improve healthcare, and other environments for transgender people as a whole.
Tip #4: Educate yourself on issues affecting the trans community
Nobody expects you to be an expert in everything – and if you don’t know much about the transgender, or wider LGBTQ+ community, that’s OK. Oftentimes the onus falls on those in the marginalised group to educate those around them, and that pressure should not fall on transgender patients in your care.
Instead, ideally you should take some time to learn more about the issues affecting transgender people in your area. These might be in healthcare, or wider. The internet has a wealth of reputable LGBTQ+ friendly advocacy groups and sites that provide great starting points.
You’ll also likely find local groups that it’s helpful to know about, possibly even to pass on to patients as information if they need support. It’s these little things that can positively impact a transgender patient’s visit and make the difference between them feeling safe and affirmed in a healthcare environment, or othered and dismissed.
Tip #5: Accept that you’ll probably make mistakes; and move on
You’ll make mistakes. You’ll get it wrong, slipping up with pronouns, accidentally using the wrong name. It happens to all of us – believe it or not, transgender people too can have these slip ups happen to them.
There’s no need to make a big deal out of it though, that only makes the situation worse. Just say sorry, apologise and move on. Then, get it right going forwards. You might well feel terrible about getting it wrong, but in these situations, it isn’t actually about you. Making a show out of apologising and riding reasons why you got it wrong, then overly trying to validate the person in front of you, will only serve to make them feel even more uncomfortable. Especially if it also draws attention to you both!
We are all human, and mistakes happen. How we deal with them and move forward is what really speaks to the situation.
And if all else fails…?
Despite all of your best efforts to genuinely try and be a good healthcare ally to the transgender community, sometimes you might just not know what to say or what to do. Most of the time there’s probably nothing wrong with a general sort of “I’m really sorry, this might be an uncomfortable question, but can I just check __? I want to make sure I get it right.”
Nothing fancy, no big deal – it can be simple, no more exciting or problematic than asking them how they are feeling. By normalising these conversations, healthcare environments can become a lot more comfortable and feel safer for the transgender community to be in.
There may well be a few terms used in this article, or that you may come across when meeting transgender patients, that are new to you. Perhaps you’ve heard the terms but have never really stopped to think about what they actually mean.
This quick glossary, at the end of the article here, is by no means a full and broad definition. It is also only one person’s interpretation of meaning, which may vary between individuals in the transgender community. But, it should be enough to help you get by for now.
- Sex vs Gender: sex denotes a person’s chromosomes, and biological attributes at birth such as genital development and hormone levels; whereas gender relates to a person’s identity and expression of self, and is about who they are
- Assigned Male at Birth (AMAB): this is preferred over referring to someone as a “male to female” transgender person
- Assigned Female at Birth (AFAB): this is preferred over referring to someone as a “female to male” transgender person
- Gender Identity: is a person’s perception of who they are, this may or may not match with their sex assigned at birth
- Transgender: is a person who has a gender identity different to their sex assigned at birth
- Transgender men (trans men) and transgender women (trans women) may use different language to define their identities, so it’s always better not to make assumptions. Typically, the use of “transsexual” is considered outdated
- Cisgender: is a person who has a gender identity the same as their sex assigned at birth
- Non Binary: is someone who does not identify with binary genders of “male” and “female” but rather something else on the spectrum of gender identities; this may be fixed, or it may change, it may be closer to a binary gender, or it may be an identity that is entirely absent of gender
- Gender Queer / Gender Non-Conforming / Genderfluid: these are other terms also used by a number of transgender individuals with non binary identities
- Gender Identity Clinic: these are the specialist clinics, with doctors, nurses, psychologists, and varied other healthcare staff, that support transgender people in their transitions
- Transition: this may be social (i.e. changing name, clothing, updating bank details, laser hair removal therapy, vocal coaching etc.), medical (i.e. accessing cross-sex hormone replacement therapy and/or puberty blockers etc.), surgical (i.e. chest masculinisation, facial feminisation, genital reconstruction, breast augmentation, etc.).
- It is worth remembering that not all transgender individuals feel they want or need the same things out of their transitions. There is no one way, nor a correct/incorrect way, to be transgender and/or transition. Terms not to use include things like “transgendered”, “transgendering”, “transman/transwoman”
- Gender Incongruence: this is the preferred term to gender dysphoria, and ties in with the national guidelines that are encouraging a move away from medicalising gender identity.
- Gender Dysphoria: previously used to define the physical feeling of unease one had with their gender identity not aligning with their sex assigned at birth, and formed part of the “diagnostic criteria” for a person to be deemed transgender.
- It is again worth noting, that not all transgender people will experience gender dysphoria, and that those who do will experience it differently from one another.
- Pronouns: words used in place of a person’s name, when referring to them. These might be she/her/hers, he/him/his, or they/them/theirs. They might also be something entirely different
- Neo Pronouns: these are ‘new’ pronouns that are commonly seen used by those within the transgender community. There are a great number of them, such as xe/xem/xirs, ze/zir/zirs, and kie/kir/kirs. If someone uses a neopronoun that you are unfamiliar with the pronunciation and conjugation of, you can respectfully ask them if they’d quickly run through it.
- It’s worth remembering that people may use more than one pronoun, for instance she/her/hers and xe/xem/xirs – if so, it’s really important to make sure you use both pronouns, as this is very affirmative and validating of an individual’s identity
- Misgendering: this is where you (or you hear someone else) use the wrong pronouns to refer to someone, regardless of whether it was accidental , or without knowledge of their pronouns, or purposeful.
- Birth Name / Dead Name: this is the name a transgender person had before they came out. Not all transgender people will necessarily change their names, but it’s really worth being aware of. Check in case there’s a note added to their record, they may still be registered in their birth name, but have a note that says they go by a different name.
In a healthcare setting, you can change your patient’s name on their record for them, if it hasn’t been already.
- Outing: this is where you (or someone else) shares a person’s identity, such that others then learn they are transgender. There are many circumstances that this can occur, from the individual first coming our to their friends or family, to accidentally or purposefully being outed.
- Generally it’s best to try and avoid outing someone, but if for instance you need to attend an multi-disciplinary meeting where it’s likely this will occur, check with the patient that they are OK for it to happen and if not, work with them to decide what the best approach is.
- Transphobia: this is a wide ranging term to cover various anti-trans acts towards or about transgender people. It can range from continually misgendering someone, to verbal and physical abuse, and hate crimes. By being a genuine ally to transgender people and advocating for them, and calling out transphobia when you see it, you can help make environments safer.
— georgie (@georgecxde) November 1, 2022
- Bachmann CL, Gooch B. LGBT in Britain – TRANS REPORT. Stonewall. 2018.
- Sandyford. Gender Identity Service.
- LOTIAN Sexual Health. Waiting times.
- Gender Identity Clinic. NHS. Waiting times.
- NHS Digital. Quality and Outcomes Framework, 2020-21.
- Stonewall. The Truth about Trans.
- National Survey on LGBTQ Youth Mental Health. The Trevor Project 2020.
- Landing page image by Alexander Grey on Unsplash.