Making your practice safe for transgender patients requires subtle yet vital considerations.
In 2011, the National Center for Transgender Equality and the National Gay and Lesbian Taskforce published a report analyzing the current state of discrimination against transgender individuals in the United States. They found that 25 percent of the surveyed group of transgender people experienced some form of harassment in a medical setting.
Further, 19 percent had been denied medical care due to their transgender status. Others — about 28 percent — avoided medical care due to fears about harassment or because of past medical experiences.
The tide of health care is changing. With the transition to value-based care, it is more important than ever to consider patient needs. And that goes for all patients, including those of social and gender minorities who have experienced stigma and discrimination leading to significant health-care disparities, notes Katarzyna J. Macura, MD, PhD, FACR, chair of the ACR Commission on Women and General Diversity. For transgender and other gender non-conforming patients, a variety of needs must be met in order for patients to have a safe and positive imaging experience.
To understand the individual needs of a transgender person, we must first understand what “transgender” means. Transgender individuals experience their gender as different from the one assigned at birth. It is important to note that gender falls along a spectrum, rather than the binary of male or female. The term “transgender” can include individuals who are agender (having no gender), are bigender (having more than one gender), or experience gender in other ways outside the gender binary. “Transgender is a broad term that includes a wide range of people with varying concepts of gender identity and at different stages of transitioning. We are not talking about one specific group but individual people with varied needs and varied levels of comfort in a medical setting,” says Jordana Phillips, MD, radiologist at Beth Israel Deaconess Medical Center and lead author of the article “Breast Imaging in the Transgender Patient.”
Charles Girard, a transgender man and activist, explains being transgender like this: “I was raised female, but as I got older I realized it wasn’t an accurate representation of who I am. I couldn’t figure out what felt wrong, but I often felt this nagging feeling in the back of my mind. Once, someone spoke to me about my being an aunt and I remember thinking, ‘I could never be an aunt. I’d be an uncle.’ Once I began taking hormones and people began calling me ‘sir’ in public, I felt social anxiety melt away and I began to feel happier. It’s ultimately about happiness and being comfortable in your skin.”
How can you help your transgender patients feel comfortable in the imaging suite? One of the simplest and easiest ways is to consider the language you use with your patients verbally, on your intake forms, and in your reports. “In our office, we make sure to use our transgender patients’ preferred names and pronouns, rather than the ones assigned at birth. It’s important not to make any assumptions, and it’s also okay to ask,” says Phillips.
Girard adds that not asking for a patient’s preferred name can have damaging consequences for the transgender patient. For example, consider a transgender man who goes by James while his legal name is still Jessica. If a staff person calls out, “Jessica?” in the waiting room, James — and potentially other patients in the room — may feel the space is no longer safe or comfortable, says Girard. He notes that you can also help address preferred pronouns and gender by allowing patients to fill in the space for gender, rather than having a checked box for “male” or “female.” It’s also helpful to provide a space for the patient’s name and pronouns.
Training your staff on cultural competency is also key, notes Phillips. Girard says, “It’s important that staff react appropriately in the office and over the phone. As a trans person, each time you call a physician to make an appointment, you have to come out all over again. Hearing the other person sound confused or judgmental over the phone is devastating.”
Physicians should also consider the way they and their staff interact directly with the patient. For example, if a staff person is helping the patient and needs to discuss a part of the body that is specifically gendered, such as the chest or genitals, have your staff ask what kind of language to use, says Girard. If a transgender man is having his reproductive organs imaged, using the terms “ovaries” or “womb” may be uncomfortable for him. He may have other words the physician could use. The physician could also offer to point to the body parts on a chart.
You can also help transgender patients feel more comfortable by evaluating the way your waiting, imaging, and changing rooms are laid out. “Lesbian, gay, bisexual, and transgender patients search for subtle cues in the environment to determine acceptance — it’s important that practices have ways of acknowledging that they are safe spaces for these individuals,” says Macura. One of the things she suggests is to develop and display non-discrimination policies that include sexual orientation and gender identity.
Adds Girard, “Try making your office and waiting area more gender neutral. For example, the excessive use of pink or of female images on the wall at a breast imaging facility might invalidate a transgender man’s identity as male. By coming into an office like that, you stand out. You’ve come out to the entire office just by walking in.”
Also consider your changing areas, says Phillips. “Many breast imaging practices have changing rooms for women, and our transgender women feel comfortable there. However, these areas may not be comfortable for transgender men — one of our patients once commented that he felt out of place and exposed there. That discomfort frequently makes transgender men who have not had top surgery skip mammography. And as a physician, that is concerning to me — these patients may be more likely to present with more advanced breast cancer because they are not getting routine screening,” she says.
Phillips says that her institution addresses this issue by escorting their transgender male patients directly into the mammography rooms, so that no one has to use a changing area.
Most of the considerations made for transgender patients can be so subtle that cisgender (non-transgender) patients wouldn’t notice, but they make a huge difference in the lives of transgender patients. “There are so many places that are unwelcoming to transgender people, so having a safe space — especially a medical one — is vital,” says Girard. “Radiologists can help make that happen.”
The American Society of Radiologic Technologists recently launched “Patient-Centered Care for Diverse Populations,” an online series to aid medical professionals in caring for patients from a variety of backgrounds.
By Meghan Edwards, copywriter for the ACR Bulletin