How to Care for Your Transgender Patient

2/5/2018

HOW TO CARE FOR YOUR TRANSGENDER PATIENT

Meghan Whitfield, MSN, CRNP Hanne Harbison, MPH, MSN, CRNP Nick Van Wagoner, MD, PhD University of Alabama Birmingham

Disclosures

• No financial disclosures

Objectives

1. Become familiar with the concepts of sex, gender and sexual orientation 2. List 3 health-related concerns for transgender people 3. Name 3 ways to make a clinic more welcoming to transgender patients 4. Name resources available at UAB for transgender patients

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SEX, GENDER AND SEXUAL ORIENTATION

Gender Identity Sexual Orientation • What your internal sense • Whom you are physically tells you your gender is and emotionally attracted to • Whom you have sex with • How you identify your Sex sexuality • Refers to the presence of specific anatomy. Also may be referred to as ‘Assigned Sex at Birth’

Gender Expression • How you present your gender to society through clothing, mannerisms, etc.

Physical aspects of maleness and femaleness.

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The state of being male or female—typically used with reference to social and cultural differences rather than biological ones

Refers to one’s internal, deeply held sense of gender

The external manifestation of gender, expressed through one’s name, pronouns, clothing, haircut behavior, or body characteristics

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Behaviors, attitudes, and personality traits that a society (in a given culture and historical period) designates as feminine or masculine and/or that society associates with or considers typical of the social role of men or women

Gender Identity does not always equal gender expression or gender role

Erin DeMeglio

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Gender Identity and/or gender expression differs from what is typically associated with their sex designated at birth

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How a person identifies their physical and emotional attraction to others

Attraction What gender(s) are you attracted to physically and emotionally?

Identity Do you consider Behavior yourself gay, lesbian, Do you have bisexual sex with…? straight, queer?

Sexual Orientation is on a spectrum

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How a person identifies their physical and emotional attraction to others

Attraction What gender(s) are you attracted to physically and emotionally?

Identity Do you consider Behavior yourself gay, lesbian, Do you have bisexual sex with…? straight, queer?

Gender Expression • How you present your gender to society through clothing, mannerisms, etc.

HEALTH CARE FOR TRANSGENDER PEOPLE

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Increased Visibility of Transgender People

Balian Bushbaum- German Chaz Bono - activist Olympic Pole Vaulter

Ian Harvie - Comedian

Why would you see a transgender patient in your clinic?

• Transgender patients still need GYN care • Pap smears, cancer screening, STI testing, etc.

• Transgender patients may want to preserve their fertility options

• Transgender patients can get pregnant and will need pregnancy care

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Health Care for Transgender Patients

Health Status- - Poor health status (OR = 1.7 ) - Lack of insurance (OR = 1.8) - Lack a PCP (OR = 1.5) Reproductive Cancers- • Individuals should be screened for cancer according to their body parts, regardless of hormone use • FTM (masculinizing hormones) MAY increase risk for endometrial and ovarian cancers, does not affect breast or cervical cancers ( may cause abnormal Paps due to atrophic changes) • MTF (feminizing hormones) can get breast cancer – number of years on therapy, family history, obesity and use of progestins all influence risk • World Professional Association for Transgender Health Standards of Care Volume 7 (2011) STD/HIV prevention and treatment • 2.64% HIV infection rate (0.6% general population) • No data on STD rates in transgender individuals

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Health Care Contd.

Fertility Testosterone • ↓ fertility • Can cause permanent anatomic changes to a developing fetus • Increases libido and induces clitoral enlargement Feminizing Hormones • May ↓ fertility • May ↓ libido • May impair erections World Professional Association for Transgender Health Standards of Care Volume 7 (2011) Mental Health • 41% ever attempted suicide (1.6% of general population) • No difference in depression rates

1) Center for Excellence in Transgender Health, 2) Injustice at every turn- A report of the National Transgender Discrimination Survey (2011), 3) Williams Institute at UCLA School of Law, 4) Meyer et al. AJPH April 2017

Discrimination in Health Care

• 70% of Transgender and Gender Non-conforming individuals have experienced discrimination in health care. Lambda Legal, “When healthcare isn’t caring” (2010)

• 19%- 25% were refused care due to gender expression • 28% were verbally harassed by healthcare staff • 2% were physically assaulted by healthcare staff

Forms of Discrimination

• Mis-gendering- calling patient by incorrect name, using incorrect pronouns • Refusal to touch • Harsh treatment- being told the provider does not know what to do with you because you are not a “male” or a “female” • Inappropriate questions and/or examinations- doing a pelvic exam when patient is being seen for bronchitis • Refusal to provide transition related care- this will be a requirement to achieve Leadership Status through the HRC starting in 2018

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AN OB/GYN VISIT

The Clinic Visit

• Let’s take a walk through a clinic visit and see small changes that help make the visit more comfortable and friendly for all patients

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A welcoming space!

• Front office staff Education: • Diversity training • Proper use of pronouns or gender neutral terms • Examples: they, use a gender neutral welcome • Check medical record to ensure correct identifiers being used • Basic people skills, keep in mind providers are often the leaders and role models for their staff

• Gender Neutral • Artwork/color scheme Restroom-should be easy to find!!

Review for any Unisex or non-binary opportunities for balance Use appropriate signage Seek opportunities for gender neutral artwork

LGBQT friendly literature should be included with informational pamphlets and reading material (print these pamphlets from http://transhealth.ucsf.edu/pdf/2013- 0514_Web_Trans-Persons-and-Fertility_ENG.pdf)

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• Bill of Rights should be displayed where patients can see the clinic is committed to all patients’ rights

Approaching the front desk…

How to ask for gender pronouns: • Use them first yourself, allow patient to reciprocate • “Can you remind me which pronouns you use?” • “May I ask your name and what pronouns you use?” • Use sign in sheets – add a column with preferred name, preferred pronoun

Communication is key…

Be sure to communicate ahead of time how preferred name/ pronouns will be relayed to other staff Variation due to different clinic flows, and differences with how clients and staff move through clinic

Decide how your clinic can document preferred name/ pronouns for each patient. Normalize the process. Bring IT or your HSIS into the discussion if you need them – they can also help develop or implement a gender neutral template to use for charting physical exams and symptoms

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Getting to know your patient…

• Keep in mind, the patient may not be comfortable relaying symptoms, reasons for seeking care in an open triage style room. Good idea to get brief history and vital signs in exam room for privacy. • Providers should speak to patient before having them undress for an exam. Take this opportunity to help patient get familiar with provider, room, any equipment to be used. • Acknowledge barriers to care or to an exam. Try to address them, explain purpose of the exam (if indicated) • Only have patient undress from waist up or waist down, as indicated

Questions to ask:

Gender identity (two-step): • Sites of exposure to • What is your gender identity? ☐ Male STI’s ☐ Female • ☐ Transgender man / Transman Surgeries ☐ Transgender woman / • Barriers to exam- Transwoman ☐ Genderqueer / Gender assault, etc nonconforming Additional identity (fill in) • Preservation of ______fertility options ☐ Decline to state • What sex were you assigned • Birth control- at birth? transmen still need ☐ Male ☐ Female to use Birth Control ☐ Decline to state

Making the pelvic exam easier:

• Have patient apply • Use as much lubrication lidocaine to introitus as necessary after history • Insert single digit prior taken/before exam to speculum, if needed • Review procedure, • Let patient assist with equipment again speculum placement • Review relaxation • Move as efficiently as techniques patient possible already employs, allow • Educate patient that the use of music or there may be a small meditation amount of bleeding after • Use pediatric or small exam speculum

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UAB RESOURCES

UAB Medicine Resources

• Deborah Grimes- Chief Diversity Officer, UAB Health System [email protected] • Dr. Deidra Gunn- Reproductive Endocrinology and Infertility [email protected] 205-934-1030 • Dr. Amy Warriner, Dr. Deepti Bahl, Dr. Tom Brooks Vaughan- Endocrinology 205-996-3636 • Dr. Hussein Abdul-Latif- Children’s Hospital Endocrinology. Avelyn Smith assistant 205-996- 7724 • LGBT Mental Health and Wellness Clinic – Dept of Psychiatry. Stephanie Perry administrator 205- 934-7008 Option 1

UAB Campus Resources

• Sexual Health Clinic at Student Health • Tuesday AM and Thursday PM • Appointments made online through the Patient Portal or call 934-3580 • Student Counseling Services • Appointments 934-3580

• Border Trans • Transgender student support group • Leucas Miller [email protected]

• Office of Gender and Sexuality Diversity • Coordinator Maigen Sullivan [email protected]

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Summary

• Sex, gender and sexual orientation are distinct and complex

• Transgender people experience discrimination in healthcare settings and have worse health outcomes

• There are several simple things you can do to improve your transgender patient’s experiences

• Reach out to the available resources if you have questions or concerns