INDEX

    ED Trans Care – Best Practices

    Special Populations

    Last Updated Feb 10, 2021
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    Context

    We can take many steps as providers to improve the experience of transgender and gender non-conforming patients presenting to the ED.

    The ultimate goal is to decrease the negative experiences transgender people have in our departments, so we can begin to address the many health inequities facing this community.

    Ask About Name and Pronouns

    If you’re unsure about which name or pronoun to use, just ask!

    For many providers and those outside the LGBTQ+ community, pronoun use causes a lot of confusion. We usually infer what pronouns to use for any person simply by looking at the name on the chart and the patient’s appearance. However, this can be difficult in transgender or gender non-conforming patients. They may challenge our preconceived notions of what a particular gender should look like and whose pronouns may be out of sync with those written in their chart.

    The only way to know for sure what pronouns are correct for a person is to ask. Some genderqueer people (and increasingly, providers!) have adopted the use of pronoun pins to identify their pronouns. If you see a pronoun pin, use those pronouns for that patient.

    ED providers often avoid asking LGBTQ patients about their gender identity to not make patients feel different or singled out. Providers may worry that the patient would perceive the question negatively. We may also avoid asking when we don’t feel the patient’s gender identity is relevant to their presenting complaint.

    A recent study in BMJ showed that while providers often do not perceive gender identity as medically relevant, patients perceive it to be important in most cases. By extension, patients feel better understood and cared for when gender identity is discussed, even briefly. Extensive personal anecdotes and expert advice accompany this literature. It is overwhelmingly clear that LGBTQ+ patients want to be asked about their identities, preferred name, and pronouns. Many gender diverse people avoid accessing healthcare due to fear of being misgendered or deadnamed (being called by their former name), and anticipate experiencing discrimination. If done correctly, asking about gender identity can build back that trust to create a more productive therapeutic relationship. This can be as simple and direct as asking, “What pronouns would you prefer?” Normalizing these conversations decreases the barriers for gender diverse patients to access healthcare.

    Use Gender-Neutral Language When Pronouns are Not Known

    Adopt “they” as a singular pronoun.

    Developing a habit of applying gender-neutral language to all your patients and their partner(s) by embracing the use of the gender-neutral “they” is best practice in queer competent care. There is often pushback from providers when patients request this due to a feeling that it is confusing or “grammatically incorrect”. However, the singular “they” has been in use for hundreds of years, and is already used commonly in everyday situations when a person’s gender isn’t known. For example, “I paged the senior from Internal Medicine and they haven’t called back yet!” This also helps us avoid sexist tropes, such as referring to an unknown nurse or caregiver as “she” or an unknown family doctor as “he”.

    Most of your patients won’t notice this small change. But patients who are gender minorities will notice, and be more comfortable disclosing their identity. It also avoids the awkward situation of being corrected by a patient, either directly or indirectly. And if you can practice using this language for everyone, it will come more naturally when you have to change your default phrases or use they/them pronouns for gender non-conforming patients.

    Consistently Use Chosen Names and Pronouns

    Try not to repetitively ask the patient about their preferred name/pronouns. It’s okay to make a mistake – just apologize and move on!

    Once established, it is important to continue using a person’s chosen name and pronouns. While asking once or twice is considerate, repetitive questioning does single people out and makes them feel they are not being believed when they report their identity. Honouring their request is a professional obligation and a cornerstone of providing safe care.

    When we make mistakes, we should politely correct ourselves. Briefly and sincerely apologize without pressuring them to accept, then move on without repeating the same mistake. Patients understand that we are imperfect, and this correction validates the patient’s identity. On the flip side, it can be very damaging to the patient-provider relationship for a patient to be misgendered (called by the wrong name or pronouns), especially repeatedly. This can deter patients from seeking timely care.

    Insist on Clarity in Charting

    The name/pronoun on a patient’s chart is not always correct. With their consent, chart their correct name/pronoun. Communicate this early to colleagues.

    What’s on a patient’s chart is based on their PHN, linked to their government ID. Many trans and non-binary folks experience significant barriers to legally changing their name and gender on IDs and other official documents. This process can take up to a year and require hundreds of dollars in fees, complex government bureaucracy, and significant emotional stress. We cannot always rely on these documents to be correct. This leads to confusion, repetitive questions, incorrect pronouns and names, or even “outing” someone to others in the ED.

    When you can, and with the patient’s explicit consent, take the time to correct a patient’s chart with their chosen name and/or pronouns. Please speak with your colleagues to ensure they are also aware of this information. Consider highlighting or circling this person’s chosen name and pronouns as early as on the triage note to communicate to other providers.

    Provide Appropriate Confidentiality

    Transgender patients are at risk for assault and harassment. Safety and confidentiality are paramount.

    One reason why trans people feel so unsafe in the ED is a fear of being “outed” to their family, community, or even to a waiting room of threatening strangers. This is not an imagined risk. Physical assaults and trauma are also more common, especially for those who are visibly gender variant or not “passing”.

    61% of Ontario trans youth surveyed reported physical assault. 36% of BC trans youth had been physically threatened or injured within the last year.

    Safe care for transgender patients includes:

    • Finding a private space for discussion,
    • Asking permission to disclose to other providers, and
    • Being sensitive about what name someone is called in open spaces.

    Don’t Over-Ask About Surgeries or Anatomy

    If not relevant to their presenting complaint, do not ask about gender surgeries.

    One common theme is that providers persistently and disproportionately ask about a trans person’s surgeries. In one review, more than half of ED physicians would always ask about a trans person’s gender-related surgeries and genital anatomy, even if completely irrelevant to the complaint. Outside of a healthcare context, trans people are already over-asked about their surgeries and genitals by strangers or well-meaning but unthinking acquaintances. You can imagine how dehumanizing and embarrassing this is, and why they might be sensitive to questions perceived as simply provider curiosity.

    If it’s not relevant to their presenting complaint, your patients will appreciate the privacy. If it is relevant, take an extra moment before asking to explain why you need to know. And remember that this is distinct from asking about a patient’s name and pronouns, which are essential to a person’s identity, whereas genitalia are not!
    When determining a trans or non-binary person’s risk factors based on their assigned sex, it is likely more relevant to ask about their hormone medications. Or, when necessary, ask about assigned sex at birth instead of phenotypic genitalia.

    Don’t Over-Examine

    Avoid invasive physical examinations if possible, or offer alternative testing.

    It is also inappropriate to perform a sensitive exam unless strictly necessary, or to invite multiple learners to observe. A vulnerable and visibly gender variant person might already feel like a “spectacle”, and it is important to avoid further marginalizing them.

    If you do need to perform a sensitive exam, take a moment to explain exactly what you need to do and what you are looking for. Consider offering alternate testing, like a self-swab or urine nucleic acid testing for an STI rather than pelvic exam, or a transabdominal ultrasound without a transvaginal approach. Remember, performing sensitive exams on a trans person can induce significant gender dysphoria, and should be performed only when necessary.

    Embrace Continuing Medical Education on Gender-Diverse Topics

    Care providers are largely undereducated on transgender care. Seek out further knowledge. If you don’t know, ask!

    In an Ontario survey, over 50% of patients reported having to educate their providers about trans issues. A 2021 study by BC’s Health Equity Commission found “the number one barrier to care identified by study participants was a lack of health care providers knowledgeable in intersectional issues”. It identified healthcare provider education as one of three key areas of action.

    There is a well studied, consistent pattern of falling short of our role as experts. This leaves patients feeling burdened and frustrated. It forces them to assume an educational role when searching for help.

    Trans people don’t expect us to know everything, so if you don’t know, ask – and be open to being educated. Some patients will be familiar with this practice and enthusiastically willing to teach. Others will not, and we should not be offended when patients do not wish to educate us. We should take this as an opportunity to learn and “read around our cases”.

    As a community of providers, we should all work towards a better collective understanding so that transgender patients can come to us for the same knowledge and advice we give to cisgender patients, not just access to tests and treatments. Progress has been made in formal medical school curriculum, but CME and self-teaching will have to take its place for those already in practice.

    Take Complaints Seriously

    Transgender patients are at high risk for adverse outcomes, so err on the side of caution.

    It is important to keep in mind the many ways in which transgender people are marginalized by family, friends, healthcare providers and society at large. Because of this, our transgender and gender non-conforming patients face higher rates of substance abuse, mental health issues and social issues such as homelessness and poverty. They are often on hormonal medications that we do not often see or learn about, some of which have poorly understood side effects. They may have unfamiliar surgical histories. They face huge barriers in accessing safe and competent care. All of this combines to place these patients at high risk of adverse outcomes, or having a serious missed diagnoses.

    If a story doesn’t add up perfectly, it may be reasonable to over-investigate and err on the side of taking complaints more seriously. Our usual decision rules may not apply. If we decide not to investigate, we should take time to explain our rationale to avoid perpetuating the view of many marginalized patients that they are not being believed, or that their concerns are not being addressed due to discrimination.

    Display Outward Signs of Acceptance

    Signalling to your patients they are in a safe space makes a big difference.

    Rainbow stickers or pronoun pins can be an important step in letting patients know that we will care for them, and that they can trust us. Queer positive identifiers signal to queer patients that you intend to create a safe space for them. Patients that are not part of the LGBTQ+ community will often not notice these small signs of acceptance, but for queer patients, it signals they can feel safe disclosing the most sensitive details of their lives, which even their own family may not know. This is easy and can make a huge difference. (Printable triangle poster via positivespace.utoronto.ca.)

    Conclusion

    It is important to acknowledge that a transgender person’s social circumstances, and often trauma, may have coloured their perceptions of healthcare and the world around them in ways we cannot appreciate. We know there are challenging psychosocial circumstances for many trans patients, and we know that what underlies these experiences is often outside of their control. As such, patients may often be defensive, guarded, or hostile when dealing with healthcare providers. As with any marginalized population, we must avoid allowing a few negative experiences to colour our perceptions of the group as a whole. These negative emotions can often be overcome with patience, kindness and, most importantly, safe care.

    We hope that this resource allows you to become more comfortable providing this type of care to our transgender patients. Doing so will increase the therapeutic relationship between ED providers and the wider transgender community, and lead to better health outcomes for our trans patients.

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