Respectfully Treating Transgender Patients

October 19, 2016

As acceptance of transgender members of society grows, so too do inquiries from physicians on how to respectfully treat transgender patients.

I have been working with physicians for many years. As acceptance of transgender members of society grows, so do the number of inquiries I receive from my physician clients regarding how to properly and respectfully treat transgender patients that come to their office and how to train staff and physicians in handling such interactions.  

Most physicians with whom I discuss this topic say that most employees simply feel a sense of awkwardness or discomfort about how to handle interactions with transgender patients.  While getting to know patients better can help overcome this issue, planning ahead can help put both providers and patients more at ease. 

I recently came across an interesting presentation regarding emergency care of the transgender patient by Ann Daul, emergency physician at this year's conference of the American College of Emergency Physicians.  Dr. Daul reflected on the fact that most emergency medicine physicians and trainees lack training in caring for LGBTQ patients, let alone transgender patients and this can lead to delays in medical care.   Daul presented a chart with suggested language and guidance in the care of transgender patients that could prove helpful to physicians of all specialties as they engage with transgender patients.  Among the suggestions was to use terminology such as "spouse," "partner,"  and "parents," as opposed to specific terminology such as "husband," "wife," "boyfriend,"  "girlfriend," "mom and dad," or "he/she."  Moreover, if you are simply not sure, you can use such phrases as "What is your current gender identity?; "What sex were you assigned at birth?"; or "What pronoun do you prefer?"

A significant issue to take into account in dealing with transgender patients is to be aware of particular sensitivity to chest or genital exams which are counter to the sexual identity of the patient.  For example, a patient identifying as a male may never have actually had surgery to remove breasts or genitals, and will still need to have a pap smear and a breast exam in order to completely protect the patient from the normal risks associated with "female" biological health.  This needs to be explained to the patient who may balk at undergoing testing related to the gender with which they do not identify.  Moreover, it can, understandably be uncomfortable for someone who appears to be a male to go to an ob/gyn's office for an exam, or for a patient who appears "female" to be subject to a prostate exam.  This discomfort is further heightened if staff does not respond professionally with the goal of putting the patient at ease.  Unfortunately, transgender patients may avoid appropriate medical testing due to discomfort with putting themselves in such situations.  Even more unfortunate is that between 13 percent and 19 percent of transgender patients report being denied care in some way when seeking medical attention, according to a survey from the National Center for Transgender Equality and the National Gay and Lesbian Taskforce.

As medical practices should be aware, HHS issued a final rule implementing Section 1557 of the Affordable Care Act (ACA).  The final rule is intended to help advance equity and reduce health disparities by protecting some of the populations that have been most vulnerable to discrimination.  The rule specifically prohibits denial of healthcare or health coverage based on an individual's sex, including discrimination based on pregnancy, gender identity, and sex stereotyping.  The final rule also requires covered health programs and activities to treat individuals consistent with their gender identity. 

The final rule went into effect on Oct. 16, 2016, and requires, in part, that covered practices post notices of their discrimination policy (which should be updated to include sex discrimination), as well as meeting certain language access and other requirements.  For more information on this rule, you can visit here. As part of your practice's efforts to comply with Section 1557, be sure to educate your staff on the proper treatment of transgender patients and how to best handle situations that might make patients feel unwelcome or uncomfortable.  Staff members who are unwilling or unable to comply with the practice's commitment to non-discriminatory practices should be disciplined and/or terminated.  Consequences for failure to comply with the rule can be significant for a practice, including the right of a patient to bring a suit against the practice related to discrimination, as well as compensatory damages.  Talk to your counsel for more guidance on protecting the practice and developing appropriate non-discrimination policies and training for your staff.