- 02:43 The Gender Unicorn and how it helps us better understand gender identity, expression, and sex assigned at birth
- 11:18 Gender dysphoria
- 14:15 The organ or anatomical inventory
- 16:48 The inevitability of mistakes
- 18:37 Ways to ensure gender-affirming care in clinic
Pearl 1: Spectrum of a Patient Identity
How do the letters in LGBTQ+ relate to gender and sexuality, and how do you understand your approach to understanding your patients identity?
- The letters LGBTQ+ represent both sexuality and gender.
- The L,G and B of LGBT address an individual’s sexuality (meaning who they are attracted to)
- The “T” refers to a completely separate process – the individual’s gender identity (meaning what gender they themselves identify as)
- The “Q” at the end has multiple meanings but is most commonly interpreted as “queer” – a term that can serve as a catch-all for the entire LGBTQ+ community but that can also be used as an identity that is similar to non-binary
- Gender Unicorn:
- Gender identity: One’s internal sense of being male, female, neither of these, both, or another gender(s)
- Gender Expression: The physical manifestation of one’s gender identity through clothing, hairstyle, voice, body shape, etc.
- Physically/Sexually and/or emotionally attracted to: It is important to note that attraction can be from a variety of factors including but not limited to gender identity, gender expression/presentation, and sex assigned at birth.
- Sex Assigned at Birth: The assignment and classification of people as male, female, intersex, or another sex based on a combination of anatomy, hormones, chromosomes.
- Asking pronouns of your patients can be most easily done by introducing your own pronouns. This signals to patients that you are an ally and allows you to organically ask your patients’ pronouns too!
- On nametags/hospital IDs
- At the first visit
- On the bottom of your business card
Pearl 2: Gender Dysphoria
What is gender dysphoria? And why might you see that code in someone’s chart?
- Gender dysphoria can be defined as “where a person experiences discomfort or distress because there’s a mismatch between their biological sex and gender identity”
- While some trans patients may feel some form gender dysphoria, it should not be an ICD code populated for all trans patients clinicians see
- Some trans patients may prefer to not have “gender dysphoria” as a diagnosis within their chart. Consider alternative billing options specific to each individual patient
Pearl 3: The Organ Inventory
How do you ask about your patient’s body parts, and how do you minimize discomfort around that conversation?
- What is an organ inventory?
- Think of it as a series of open-ended questions that allow the patient to let us know what body parts they have and how they refer to them.
- Using an organ inventory helps the patient to feel comfortable talking about their body with you – and helps you as a provider determine future preventive screenings (more on this in Trans Care, Part 2!)
- Note that this doesn’t have to happen during the first meeting – you can conduct an organ screening when you’ve developed more rapport with your patient.
- Examples of questions for organ inventories
- Can you tell me what organs you have or what you’ve had removed as a part of your transition?
- Do you still have a cervix or not? And is that a word you’re comfortable with?
Pearl 4: Mistakes
What’s your approach if and when you make a mistake with a transgender patient?
- Many who care for LGBTQ+ patients will be quick to acknowledge that mistakes happen – even to the most experienced among us.
- How clinicians respond to their mistakes is important:
- Stay in tune with the verbal and nonverbal responses of your patients, which may signal that something you’ve said has been incorrect.
- Apologize and make a plan to avoid similar mistakes in the future.
- Lastly, move on and continue with the patient encounter rather than agonizing over the blunder!
Pearl 5: The Clinical Environment
What are some strategies to promote a gender-affirming clinical environment?
- Think about your clinic’s physical atmosphere as an extension of your practice, and work to create an inclusive and affirming environment for your trans patients.
- A few places that might benefit from some trans-affirming improvements:
- Your clinic’s pre-visit form: how are you asking about gender and sex on these forms? (You may only be asking about one)
- Patient education and reading materials in waiting rooms: do they depict trans or LGBTQ+ people?
- Patient bathrooms: are the bathrooms in your clinic separated by gender?
- Trans pride flag sticker or pronoun pins: how prevalent are these throughout your clinic space?
Nathan: I remember the first time I went to get like HIV testing, STI testing, and they asked me if I had sex with men, women or both, which I get that we’ve come a very long way to ask. But I remember responding men and then they continued to talk about me as if I’m a cisgender man and my partner’s a cisgender man. So all the information they gave me was not relevant to our bodies. And about midway in between, I was like, surprise, I’m a trans man and my partner’s a trans man and none of the information you gave me is helpful.
S: That is inimitable Nathan Levitt describing one of a few particularly memorable encounters with the health system as a transgender male, which actually inspired him to become a nurse practitioner and an advocate and educator in the transgender community.
M: And with that welcome to Core IM 5 pearls podcast, this is Dr. Marty Fried, a primary care physician at THE Ohio State Wexner Medical Center, and Dr. Shreya Trivedi, a population health fellow at NYU. Today we beginning a two-part series on comprehensive transgender care, starting with a deep dive into gender-affirming care.
S: We have many to thank for this episode starting with Gaby Mayer. Gaby quarterbacked some of the off-air production and show notes for the transgender episodes.
M: So before we get started I wanted to quickly acknowledge the incredible importance of language around this topic probably more so than the other topics we’ve covered in 5 Pearls. Shreya and I tried really hard to but we acknowledge we are approaching this from the cis perspective and still have blind spots. SO if there is something in our language or phrasing that can be improved please shoot us a tweet @coreimpodcast to help educate us and the amazing #medtwitter community. Without further ado, let’s get started on the pearls we’ll be covering.
S: Remember, the more you test yourself the deeper your learning gains.
- Patient Identity
- How do the letters in LGBTQ+ relate to gender and sexuality, and what is your approach to understanding your patients identity?
- Gender Dysphoria
- What is gender dysphoria? What are alternative ways you might you code your care for a transgender patient?
- The Organ Inventory
- How do you ask about patient’s body parts, and how do you minimize discomfort around that conversation?
- The Clinical Environment
- What strategies can you use to promote a gender-affirming clinical environment?
- What’s your approach if and when you make a mistake with a transgender patient?
Pearl 1: Gender and Sexuality
S: So to Nathan’s point from the intro story that you heard was that we can’t make assumptions that just because Nathan is attracted to men that he is one, a cis gener gay man and two, how he identifies himself can be very different.
Richard: Affirming care really begins with understanding the full complexity of who our patients are and using the right language to address them.
M: Thats Dr. Richard Greene, not only a good friend and trusted mentor, but he runs the Pride Center at Bellevue Hospital in New York City. Alright Shrey – can we start with the super basic – the letters “LGBTQ+.” That plus acknowledging that these letters are somewhat reductionist and probably don’t include everyone who identifies within the broader LGBTQ community.
Richard: So understanding their gender and their sexuality is really important. Often we use the term LGBTQ or LGBTQ plus and there are so many letters and I think sometimes we start to confuse sexuality and gender. When we’re talking about gender affirming care, we’re really trying to understand our patient’s gender and really affirmed that for them.
S: I had to replay that a bunch.
M: Yeah I never really appreciated the really important differences in gender vs sexuality. The letters we toss around all the time – LGBTQ – the LGB lesbian, gay, bisexual are examples of sexuality or sexual orientation which describe who someone is physically and emotionally attracted to. The T, for transgender, is actually much different than sexuality because it describes how ones gender identity might be different than ones sex assigned at birth.
S: And this idea is explained nicely in the Gender Unicorn infographic – if you haven’t seen it, we will link in our transcript. The Gender Unicorn goes through different parts of one self: theres someones gender identity, gender expression, sex assigned at birth and then who they are physically and emotionally attracted to — all of these we will break down in a minute but the main message is these parts of ones self can really be on a spectrum for our patients.
Brandon: So to start off with gender identity, that’s once deeply held belief of, of who they are. So terms that people will use to describe their gender identity will be man, woman, um, trans man, trans woman, perhaps non-binary. And so you know, someone that identifies as non binary means that, you know, maybe not exclusively man or woman somewhere in between.
Other terms: trans- it is is from the Latin term opposite. So that means that someone’s gender identity is different from their sex assigned at birth. Again, that’s kind of an umbrella term. And then CIS means on the same side. So someone’s gender identity aligns with their sex assigned at birth.
S: That’s Dr. Brandon Pollak, a primary care HIV specialist with a strong clinical interest in LGBTQ health at The Ohio State University.
Brandon: The next thing on the gender unicorn is his gender expression. So this is a culturally defined concept that is one’s outward portrayal of their gender identity. It might not be all the time, depending on the situation someone feels safe, et cetera. It could be very fluid. If someone identifies as gender queer, some days they might present more feminine or masculine and vice versa. But examples in Western culture would be like dressed, so like clothing.
S: And so that’s one way to think about gender – identity and expression both on their own spectrum – but that is different from a person’s sexuality, which is ones physical and/or emotional attraction
M: Laying this out helps us understand what Q in LGBTQ+ can mean- It can mean questioning either who they are sexually attracted to or questioning their gender with which they identify, but Q can actually more commonly be referred to as Queer, which used to described someone whose sexual orientation is not exclusively heterosexual or whose gender identity is not exclusively cisgender
Brandon: In the younger generation, it’s kind of been reclaimed as basically saying that you are different from kind of the mainstream norm. So in terms of sexual orientation, it, you know, someone that does identify as gay might also identify as queer.
It might have some, some kind of spectrum between maybe pansexual or bisexual or asexual, whatever. It just means that they’re kind of identifying probably outside of the norm. Um, and then in terms of gender identity, I think people also use, um, gender queer or queer, meaning that their gender identity is, is something different than someone that identifies as cis. So again, it might mean someone that might be presenting more like a trans woman or a trans man, but then they might use queer and it’s a totally kind of separate gender identity and it’s sort of kind of a unique experience to that person.
M: So, Dr. Pollak is really hammering home the idea that this term “queer” is a catchall term that is individually defined and means something different to everyone – so if we hear it we can ask for clarification – “what does being queer mean to you?” The other important thing is that it USED to be weaponized against these people and now it is being reclaimed in a really powerful and positive light.
S: Another time our patients identity comes up is in our documentation – I think peoples documentation, including my own before this episode, was usually for transgender patients MTF for male to female or FTM for female to male.
M: Right and the problem with MTF or FTM is that it grounds people in a biology that doesn’t at all reflect the spectrum of their identity.
S: So what we learned documenting assigned female at birth and assigned male at birth (M: shorthand AFAB or AMAB) helps because what that does is that it leaves a lot room to understand their spectrum of how the patient currently identifies.
M: So this is usually a two step process – first identifying their gender followed by their sex assigned at birth. This might look like “35-year-old man assigned female at birth who is presenting for preventive care and screenings.” Now remember, acknowledging someones sex assigned at birth is relevant sometimes – like if they are in clinic for a pap test – but probably isn’t relevant if patient is presenting for elbow pain or headache. So be careful here to identify sex assigned at birth in when it is clinically relevant. Alright, the last thing we should cover on identity is how the pronouns our patients use are crucial to gender-affirming care.
S: I think the big win for the larger transgender conversation is more and more clinicians are getting training and adopting asking our patients pronouns. Dr. Carl Streed, the research lead for Boston University Center for Transgender Medicine and Surgery, talks very practically about addressing pronouns.
Carl: So I often try to lead them by example. I’ll say who I am. Like, hi, I’m Carl, I’m going to be your doctor for today. My pronouns are he, him, his, um, if there’s a situation where that might not naturally flow at the moment, especially if I’m in a rush as we often are in the clinic, um, I do have pronoun pins actually on my ID. Um, I think that makes a big difference in terms of at least at minimum signaling to the individual that they could share their own.
M: And the question is important not only collect that information for our trans patients but also as a teaching opportunity for others who might feel less familiar with the idea of pronouns.
S: And just to highlight that with a quick story – the other day my father who has grown up in a quite traditional society in India for decades went to his PCP and was asked about his pronouns, to which my dad very dearly responded, “What is pronoun?!” It turned out to be a teaching moment on many levels — because yes, he did learn what a pronoun was, but it was actually good role modeling that understanding how individuals want to be identified is the norm and accepted in our society.
M: Love it. Let’s summarize pearl 1. First remember that the letters LGBTQ+ represent both sexuality and gender. The point is that gender and sexuality both exist on their own unique spectrum and we should be careful about making assumptions about sexual attraction or behavior based on gender identity or expression. We can introduce our own pronouns, in a number of ways on our nametag, at the first visit, on the bottom of our cards and it opens the doors to have our patients to know we are allies and want to learn their pronouns.
S: And if a patient is confused by the pronoun question, then it is an opportunity to educate!
Pearl 2: Gender Dysphoria
S: Alright so we are in the clinic and are starting to have a shared understanding of gender identity and sexual preferences, but as you go to open up a note, you see in the chart a diagnosis of “gender dysphoria.”
M: I remember learning about gender dysphoria as this deep conflict between someone’s internal identity and external presentation. And I used to think every trans person probably has it to some degree or another, but Nathan explains that it’s a more nuanced area than we realize.
Nathan: Dysphoria is tough because I think for some trans patients, they may really identify with that. They feel dysphoric, right? They feel like their body doesn’t match the way that they feel on the inside their identity. Uh, and for some patients they don’t. And so I think there’s this messaging that all trans patients feel dysphoria, which is absolutely not true. Uh, like for myself, I don’t, um, perhaps I did at one point in my life, but I wouldn’t use that language to describe myself and I don’t love that diagnosis being in my chart.
M: So this was really transformative for me – that just because a person identifies as transgender does not mean they automatically HAVE gender dysphoria… but then THAT got me thinking about what we write in the chart and how we document that might not actually reflect what’s going on with the patient…
Nathan: We use this diagnosis code often it makes it easier to get things covered. We know that you may not at all identify with his language, but we want to let you know that you might see this in your chart and I have feelings about what it’s about, sort of what is the longterm effects of having this in someone’s chart. And I don’t have easy answers.
But I also feel like people getting their surgery, I’ve had a patient say to me, use whatever you want so I can get my surgery covered.
S: That’s eye-opening, thinking about what we do to get things done for our patients in the current insurance system. But say you are not worried about insurance coverage for an upcoming procedure or something, what other diagnosis could use to reflect the care that we provide?
M: Yeah, I’ve started using the code ‘hormone imbalance’ when I’m not dealing with surgery, because I think it’s correct from a physiologic perspective without the baggage of the term dysphoria.
Richard: So an example of how we would turn that diagnosis around is rather than having a psychiatric diagnosis for what’s going on with trans non binary people to really think about normalizing the condition and saying, so for example, a transgender man lacks testosterone. And so we could call that condition hypogonadism the same as we would in any man who lacks testosterone. Uh, and so to not frame things in a medical context as pathology, but only in terms of what we’re doing to restore normal order.
S: I can only hope to be one day be this thoughtful about all my ICD codes as Dr. Greene or Marty. Alright so to recap, what i took away from gender dysphoria is be careful not to assume that all trans people have gender dysphoria, and when documenting and coding visits consider alternative diagnoses that might better capture the clinical encounter. And if you do see gender dysphoria in the chart, be open minded as to from an insurance or system level perspective.
Pearl 3: Organ Inventory
M: The pitfalls during the care of transgender people often involve assumptions, right, and we just discussed avoiding the assumption that all trans people have gender dysphoria. A related idea is that we should avoid assumptions around body parts.
S: Some refer to this discussion around body parts as an ‘organ inventory’. This is basically an open-ended question or two that allows the patient to let us know how they refer to their body parts.
Richard: So, for example, I might say to my patient, Hey, I really want to make sure I know what parts of your body might need to be screened. Can you tell me what organs you have or what you’ve had removed as a part of your transition? Uh, and then people can name their body parts for me. Uh, and I sometimes might say, you know, a word that I might describe as your vagina. What word would you use to describe that body part? And then do you still have a cervix or not? And is that a word you’re comfortable with?
S: It took me a while to get comfortable asking patients about their transitions, if they had any surgeries and what they call their body parts but can be quite meaningful.
Nathan: I remember before I had chest surgery, um, all the clinicians would say like breast cancer screening or breast screenings, or we need to examine your breasts. And I remember finally after like the 20th time someone said it, I said, can you just say chest? And that was it. Right? That was a life changing for me. It’s just use a different word.
M: I’ve listened to Nathans interview soo many times and I’m constantly shocked by the simplicity of this intervention – “use a different word”. I’m also struck by how long it took him to ask for that – he said something like the 20th time. And he’s like the model patient! So if it took Nathan 20 times to say something then others are probably just getting steamrolled with the language we are using that could unintentionally make them uncomfortable.
S: To summarize about the ‘organ inventory,’ Start with asking open-endedly “tell me about your transition” and if it doesn’t come up on its own you can say something to the effect of “i want to make sure you get the preventive health screening you need so tell me more about if you have had any surgeries as a part of your transition?” This not only helps determine future preventive screenings (M: plug for episode 2 airing next Wednesday) but also gives us information about how patients refer to sensitive areas of their body.
M: And this doesn’t have to happen during the first meeting!
Pearl 4: Mistakes
S: I think one of the things that I really took home from our conversations with these experts is that all clinicans will make mistakes…
M: Naturally, Nathan had a few unfortunate stories:
Nathan: I’ve come in to urgent care for just a, a cough that wouldn’t go away. And I had questions about my genitalia when the clinician learned that I was trans. Now I’m also a provider, so I know like when and if to share certain information. Like I didn’t necessarily think my trans status was important to the cough.
M: I’m going to go out on a limb here and suggest that Nathan’s genitalia were not relevant to his cough…
S: Yep fishing for some zebras in the urgent care setting. The point though is that learning how to do better about gender affirming care means leaving your comfort zone and asking questions that are unnatural and awkward at first.
Carl: I, I definitely, I definitely messed up on occasion. And the way I really explain it is like, you’ll recognize a facial expression change or the tone change and be like, I’m so sorry. I, I, if you immediately recognize it, just say like, Oh, I’m so sorry I’m to correct myself. Um, or if you say something you’re not fully aware. Sometimes you can ask the patient, I’m sorry, did I say something incorrect? My apologies. Can you tell me what I can do better next time? Things like that.
M: And Nathan reminded us of a MAJOR pitfall to avoid when apologizing…
Nathan: Don’t spend a lot of time sort of going over and over. Oh, I’m usually so great about trans care. I have a trans friend, whatever it might be, which are all things I’ve gotten before.
M: Oh my. Okay, so to sum up this pearl – mistakes happen when providing trans care and that’s OK. Look for evidence of mistakes in the verbal and nonverbal responses of your patients. Apologize and make a plan to avoid similar mistakes in the future. The apology is probably not the right time to mention how much your trans neighbor really loves you…
Pearl 5: The Clinical Environment
M: Ok so we’ve spent a lot of time this episode discussing strategies for gender affirming care within the patient-provider relationship. But what about gender-affirming clinical environment? How can we walk the walk after we talk the talk?
S: Or even get a chance to talk the talk – we might be cutting people off even before they enter the room. One trans person noted, “If there is not a place for me on your forms, there is not a place for me in your office”. So it made me think about when was the last time you reviewed the sex/gender field on your clinic’s pre-visit checklist?
M: Ideally our patient should be provided with a two-step method of gender identification: the sex assigned at birth and a separate gender identity question with both ‘check all that apply’ options and “not specficied” with a fill-in-the-blank field.
S: Right, and one of blindspot that the twitter community also pointed out is is that patients often get clinical forms mailed to them before a visit so there may already be messages about a clinic’s gender-affirming environment even before they get to our office.
M: And thinking about the physical space of the clinic, Dr. Greene actually has a great story about how he really thoroughly considered even the entrance to the clinic as a potential barrier for care:
Richard: Our systems are often really challenging for them to navigate. And so an example that I like to give people is something that’s very difficult for our trans male patients is to think about cervical cancer screening. Having a pap, if that body part is something that makes you uncomfortable, is going to be a really exquisitely uncomfortable thing to do.
I called the head of GYN and said, listen, I have a trans man who’s uncomfortable having this exam. What can I do to really smooth this process for him?
The head of GYN at this new clinic said, uh, why don’t we schedule him as the first patient of the day? And when he gets there, he’ll check in with the administrator and they’ll take him immediately back to a room. So he doesn’t sit in a waiting room full of women wondering why he’s there without a female partner.
S: The other thing to think about is patient bathrooms. Are the bathrooms in your clinic separated by gender? And if so, do they have to be?
M: Or even think about the reading materials in your waiting room. A way to promote gender-affirming care is to think how many of those magazines highlight LGBTQ+ people. We encourage you to take an inventory today about the messages you are sending to your patients in the waiting room before they see anybody from the clinical team.
S: The last point about the clinical environment is to have subtle but obvious clues it’s a safe environment for LGBTQ+ people. Trans pride flag sticker or pronoun pins go a long way to let patients know they are in a judgement free zone and safe space.
M: And we really should be training all staff, particularly patient-facing staff, around LGBTQ competencies. Subpoint – this should not be in the form of a mandated webinar. Please please please any administrators out there who happen to be listening to this episode – the answer to this problem is not another webinar….
S: In summary, gender-affirming care actually starts way before you get a chance to see your transgender patients. You can work with clinic and hospital leadership to address predictable issues like gendered bathrooms or non-inclusive forms.
And that’s a wrap for today’s episode. Next Wednesday we will get more into hormone therapy and prevention in transgender care. Thank you to our on-air experts and off-air producers! Thank you to Harit Shah for his audio editing and thanks to you! As always, we are always learning and welcome any feedback that the greater community can learn from.
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