AUSTIN, Texas — Transgender and gender-diverse patients, which make up a vulnerable patient population in every service area, are often misunderstood and overlooked by healthcare providers. Eric Lowe, MD, FACEP, FAEMS, introduced NAEMSP Annual Meeting attendees to the terminology and significant healthcare issues this patient population faces.
Lowe delivered this education program to physicians, EMS providers and law enforcement officers because medical education has historically included little related to this population, and one third of self-identified transgender individuals report negative interactions with healthcare providers related to their gender status. He described what it means to be transgender, health-related vulnerabilities, and assessment tips to affirm and care for this population.
Memorable quotes on transgender patient assessment and care
Lowe began his presentation by relaying his personal experience as the parent of a transgender child. Here are three memorable quotes from Lowe’s NAEMSP presentation:
“In EMS, we work with some of the most vulnerable populations at the most vulnerable times in their lives. It is our job to be sensitive to our patients’ needs.”
“Always refer to somebody by the identity they know themselves to be.”
“EMS has the chance to set the tone for these individuals as they enter the healthcare system. We have a chance to make a difference.”
Top takeaways on transgender patient care
Transgender individuals exist in every community. An estimated 0.6 percent of the population identifies as transgender or gender diverse, and this population has many health vulnerabilities that may bring them in contact with EMS. As caregivers, EMS providers have a responsibility to understand this patient population. Here are my three top takeaways.
1. Understand the terminology
Lowe began his presentation by clarifying the importance of healthcare providers using a shared set of definitions for the terms sex, gender and sexuality.
- Sex is the physical characteristics and biology of a person
- Gender is one’s internal deeply held sense of who they are. Gender identity is a sense of who one is. Gender expression is how we demonstrate that identity to the outside world.
- Sexuality is an expression through behaviors and emotions.
Two additional terms introduced during the presentation were cisgender and transgender.
- Cisgender is the alignment of gender identity and biological sex.
- Transgender is a contrast of biological sex and gender identity (biological sex and gender identity are different).
Lowe also reviewed the transition options some individuals undertake, including:
- Social changes
- Gender-affirming medications
- Gender-affirming procedures
2. Transgender statistics and health risks
Many transgender or gender non-conforming individuals have suffered from harassment, physical assault and sexual assault while in primary education. “Forty percent of transgender adults reported having attempted suicide,” Lowe said.
Family support makes a significant difference to transgender individuals. The rate of suicide attempt increases to 60 percent for adolescents who report having an unsupportive family.
In the 2015 U.S. Transgender Survey, nearly one-third of respondents limited their food and water intake to limit their daily need for using school or public bathrooms. Those individuals are at increased risk of weak and dizzy spells, urinary tract infections and insufficient body weight; problems which may put them in contact with EMS providers, school nurses and emergency physicians.
One-third of transgender patients report having negative interactions with healthcare providers in the past year, primarily because of not being called by their preferred gender pronouns (being misgendered and misnamed), denial of their gender identity by healthcare providers, and having to explain their gender identity to skeptical or under-informed healthcare providers.
Tip: Name and pronouns are very important to gender identity. Use the patient’s preferred name and pronouns in verbal interactions with the patient, handoff report to emergency department staff and ePCR documentation.
3. Safe and affirming care environment
Lowe concluded the presentation by discussing what we can do better. “For all patients, we should create an environment that is safe and affirming,” Lowe said.
Tip: Ask the patient two simple questions:
- What name would you like me to call you?
- What pronouns do you prefer?
“If you can do any one thing, do this (asking the above questions). It makes an enormous difference,” Lowe said.
From what I’m hearing in this lecture, the “low hanging fruit” of transgender care is simply RECOGNITION. Use the patient’s preferred pronouns, understand what transgender means, and respect WHO that person is.
Costs nothing. Means the world to trans people. #NAEMSP2019
— Erin Lincoln (@ErinTWL) January 11, 2019
He acknowledged that at first, these questions might feel uncomfortable or awkward before explaining we use nicknames and variations (like Mike instead of Michael or Beth instead of Elizabeth). “This just takes practice and getting used to it,” Lowe said.
For patients with complaints that are dependent on understanding the patient’s anatomy, like abdominal pain, Lowe described how to conduct an organ inventory with three questions.
- What sex were you assigned at birth?
- Have you been on any gender-affirming medications?
- Have you had any gender-affirming procedures or surgeries?
Finally, there are other actions EMS agencies and emergency departments can take to be inclusive and make patients feel welcome:
- Inclusive signs, images
- Awareness of how other providers interact with patients
- Understanding organization policies
One of the images Lowe shared was the Montana #Open2All logo.
Other opportunities for safe and affirming environment include:
- Adding the patient’s preferred name, pronouns and gender identity to ePCR documentation
- Adding patient’s preferred name field in the patient hand-off note, which can make a difference for all patients.
40% of transgender adults reported attempted suicide. Who are typically the first people to interact with patients after a suicide attempt? EMS #NAEMSP2019
— Tom Grawey (@EMtgDO) January 11, 2019
Dr. Eric Lowe: “We in EMS have the chance to set the tone for transgendered patients as the enter the healthcare system.” We can’t tolerate pejorative language, mocking, or ignoring of a patient’s gender identity. #EMSdocs can help model and teach compassionate care. #NAEMSP2019 pic.twitter.com/yBFtIjmaWC
— Brian Miller, MD (@BLM_2014) January 11, 2019
Not sure how to appropriately address a #transgender patient? Just ask! “What name would you like me to call you?” “What pronouns do you prefer”. Earn #respect and put them at ease… it’s easy! #NAEMSP2019
— Aurora Lybeck (@AuroraLybeck) January 11, 2019
Learn more and get involved
Learning terminology and understanding the known health risks transgender patients experience is an important starting point for EMS providers, emergency physicians and all healthcare providers. One starting point is the Genderbread Person, a tool Lowe shared for understanding biological sex, gender expression and gender identity.