Visiting a hospital emergency room for medical attention can make anyone feel vulnerable. But for transgender patients, the experience can be even more harrowing. Gaps in staff knowledge about transgender health contribute to patients’ uncertainty about receiving prejudice-free, competent care. That in turn leads to alarming statistics about the well-being of the transgender community.
Today, roughly 0.6 to 0.7 percent of the American population identifies as transgender, and these people have disproportionately high rates of illness and death—in part due to widespread reluctance to seek out emergency treatment and even routine checkups over concerns about the quality of care. (Here's how science is helping us understand gender.)
In a study in the February edition of the Annals of Emergency Medicine, transgender adults who visited the ER overwhelmingly reported that health care providers lacked competency in issues specific to the transgender community. For instance, many providers did not understand the meaning of “transgender,” and they lacked experience with and knowledge in trans-specific treatment, such as the effects of hormone therapy or complications from reassignment surgery.
One subject in particular said prior hospital experiences left them feeling “like the freak show.” Similar encounters led to many participants saying they had avoided seeking out emergency care for fear of mistreatment, discrimination, and harassment.
“When you’re that vulnerable, that’s the worst time to have to worry about people reacting to you,” one participant said. Often, the burden falls on patients themselves to educate their health care providers, according to a survey conducted by the National LGBTQ Task Force. But as transgender awareness grows, so does interest in formally educating medical professionals.
“This is a population with specific needs, and a certain level of competency is absolutely necessary to provide optimal care,” says Acey Mercer, a senior consultant with the Training Institute for Gender, Relationships, Identity & Sexuality (TIGRIS) and a psychotherapist with Choices Counseling & Consulting. “My hope is that in time, transgender health will be included in mandated trainings.”
Training for Transgender Care
In a recent poll of lesbian, gay, bisexual, transgender, and queer (LGBTQ) Americans, 20 percent of respondents reported being personally discriminated against when visiting a doctor or health clinic. A separate survey conducted by the nonprofit Lambda Legal found that 70 percent of transgender and gender-nonconforming individuals have faced serious discrimination in a healthcare setting.
And in the 2015 U.S. Transgender Survey, 33 percent of respondents who had seen a health care provider in the past year reported having at least one negative experience, including being refused treatment, verbal harassment, physical or sexual assault, or having to teach providers how to give appropriate care. The rates of these experiences are even higher for transgender people of color and those with disabilities.
In the past few years, several transgender training initiatives have rolled out in health care facilities across the country, and they are showing a path toward improvement.
In 2015, the University of Louisville School of Medicine in Kentucky launched a pilot program called the eQuality Project, which introduces a new curriculum that includes LGBTQ competencies published by the Association of American Medical Colleges (AAMC). The program trains first- and second-year students in common health care concerns for people who identify as transgender or gender non-conforming, or who are born with different sex development.
The transgender-inclusive learning materials are incorporated into multiple facets of the curriculum, and so far there’s been positive feedback from students, faculty, and community members, says Amy Holthouser, senior associate dean for medical education at the school of medicine.
At Case Western Reserve University in Ohio, students receive four hours of mandatory instruction on LGBTQ patient care, which includes learning transgender terminology, barriers to care, and sorting out any personal biases.
The University of California, San Francisco, which is home to the Center of Excellence for Transgender Health, has full-access guidelines for primary care providers, while Mount Sinai Hospital in New York has a new Center for Transgender Medicine and Surgery, where they are offering the first U.S. psychiatry and surgery fellowships in transgender care.
At New York University Langone Medical Center, transgender actors are trained to serve as so-called standardized patients, people who act out common health scenarios, to better prepare future professionals for patients with non-binary gender identities. Richard Greene, the director of gender and health education at the medical center, says it’s instrumental to have transgender individuals act as patients to keep the training authentic.
Greene’s work caught the attention of Kate Terrell, a 54-year-old transgender advocate residing in upstate New York. Terrell socially transitioned in the late 1980s, and she says the medical care situation is “much better now” than it was a decade or two ago. But for her, there’s still room for improvement. After experiencing verbal discrimination, denial of care, and even being groped in a hospital setting, she has dedicated herself to bettering the education process so others don’t have these kinds of experiences.
“If I have chest pain, I’ll sit there and think about how bad it is,” she says. “Do I want to put up with the crap I’ll have to put up with at a hospital?” Now, Terrell has used the NYU materials to co-create a training program for the Columbia-Bassett Medical School Degree Program.
Transgender individuals are also taking matters into their own hands to helps the community find competent practitioners. Services like MyTransHealth and Rad Remedy offer streamlined databases for networks of accepting, inclusive, and educated health care professionals.
Samuel Horton-Martin, who transitioned in 2000, has had his own share of unfavorable experiences in health care environments, but he describes his current primary care provider as “phenomenal.”
“She’s aware, she’s respectful—she respects my gender identity and my pronouns—and she understands the complexities of treating trans patients,” says Horton-Martin.
Though improved, sensitivity training for interacting with transgender individuals is “definitely spotty,” he adds. In addition to educating the current and future crop of doctors, Horton-Martin wants to see ongoing education for veteran doctors who did not have the resources available now.
“Even though transgender health education has gotten much better, there are still circumstances where a provider is respectful, and they still look at you like an oddity,” says Horton-Martin.
According to Mercer, the TIGRIS consultant, the conversation also needs to continue beyond the early education system for medical professionals.
“If you, yourself, are not of trans experience, understanding isn’t necessarily a possibility. That’s not the end goal,” says Mercer. “The end goal is more of how do you make space for that which you can never understand.”
And to truly create an inclusive, competent health care experience for transgender patients, all health care workers—not just doctors—need basic education and training, says Elizabeth Samuels, lead author of the emergency room study and a postdoc with the Yale National Clinician Scholars Program.
“Everyone needs to know how to speak to trans people, how to ask them questions, how to ask about pronouns—ultimately fundamentals of good, patient-centered care to create a welcoming, gender-affirming environment,” Samuels says.
The bare minimum, Terrell says, is for providers to be normal around their transgender patients. The most important thing doctors can learn or remind themselves, she says, is to “treat humans like human beings.”
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