Advocating, caring for transgender patients
No patient should be worried about discrimination in the back of an ambulance
First responders must be culturally competent in the communities we serve. At least 0.6% of people in the U.S., or about 1.4 million people, are transgender . We should expect to interact with transgender people as our patients, coworkers and other healthcare colleagues. Unfortunately, transgender patients frequently have negative interactions with medical providers due to stigma and lack of knowledge about transgender care. [At the end of this article, download an easy-to-reference Tip Sheet with gender expression terminology]
You are dispatched to a 24-year-old patient complaining of lower abdominal pain. On scene, you find a woman lying on the couch in the fetal position. She introduces herself as Jessica. She informs you that the pain started suddenly about 4 hours ago and is a 9/10. She has thrown up twice and is unable to walk due to the pain. As you obtain her vitals, she tells you she is trans.
Understanding vocabulary around sex and gender
Trans, short for transgender, is an umbrella term used to describe someone whose gender identify differs from their sex assigned at birth (SAAB). People whose gender identiy aligns with their sex assigned at birth are cisgender [2-4].
Sex describes how anatomy, hormones, chromosomes and other physiological features are grouped. Sex is assigned at birth – primarily based on external physical characteristics – to one of three categories: female, male or intersex. People who are intersex have chromosomes, internal organs, external genitalia and/or hormones that are a combination of those seen in males and females.
Gender identity is based on our internal sense of gender.
- A cisgender man is someone assigned male at birth who has a male gender identity.
- A cisgender woman is someone assigned female at birth who has a female gender identity.
- A transgender man is someone assigned female at birth who has a male gender identity.
- A transgender woman is someone assigned male at birth who has a female gender identity, as is the case with our patient Jessica.
Transgender people can be binary or nonbinary. Binary trans people have a gender identity that aligns with one end of the gender spectrum or the other (male or female). Nonbinary trans people have a gender identity that does not fully align with either end of the spectrum.
Gender expression is how we present our gender outwardly, including our name, pronouns, mannerisms and dress. Being gender non-conforming (GNC) is not the same as being transgender/nonbinary, although some trans people are also GNC. GNC people face many of the same discrimination issues as trans people.
You continue taking Jessica’s vitals while obtaining an history of present illness and past medical history. You inform her that because sources of abdominal pain can vary depending on anatomy, it would be helpful to know what reproductive organs she has, and whether she’s had any abdominal surgeries. Jessica responds that her assigned gender at birth was male, and she has been taking hormones for 6 years. She reports that she has a penis and testes, and denies having any surgeries besides a breast augmentation 2 years ago.
Because she denies having an orchiectomy (testicle removal surgery), your partner asks if Jessica has any pain in her testicles or penis, and if she has noticed any lumps, swelling or irregularities. Jessica confirms that the pain radiates to her testicles, and is worse if she moves certain ways. Based on her symptoms, you are concerned she may be experiencing a testicular torsion, which is a surgical emergency.
Performing an affirming history and assessment
Performing an organ inventory using open-ended questions is the best way to assess your patient. While there is a correlation between assigned sex at birth and anatomy, both cis and trans patients can have a variety of anatomical arrangements. Often, medical professionals use sex or gender identity as a proxy for asking about our patient’s anatomy.
Asking what organs the patient has will provide the information necessary to guide your assessment and treatment without making assumptions based on the patient’s sex or gender.
Avoid assigning gender to medical history questions or using euphemisms, such as “have you ever had female cancer?” Use the correct medical and anatomical terms when you ask questions, and limit questions to relevant body systems. If our patient was a transgender man with a vagina and uterus, it would be appropriate to ask about pregnancy and menstruation.
You inform Jessica that based on your assessment, you are concerned she has a testicular torsion and needs to be seen at the hospital immediately. She consents to transport, and you gather her purse, keys and phone. Before using the stair chair to move her to the ambulance, you start an IV and administer pain medication and an anti-emetic, which improves her pain from a 9 to a 7. She thanks you for treating her pain. She then tells you that a couple of years ago she developed an infection and had to call 911. The ambulance crew told her that maybe if she wasn’t on so many pills, she wouldn’t be sick.
Barriers to accessing healthcare for transgender people
The term “trans broken arm syndrome” was coined in 2015 to describe the experience transgender patients have when a healthcare provider attributes all medical complaints to being trans or overly emphasizes the patient being transgender during assessment and treatment .
A 2015 survey showed that about one-third of transgender people had experienced a negative interaction with a healthcare provider during the previous year. About one quarter had deliberately avoided seeking medical care because of concerns about discrimination [6,7].
A marked mismatch in the perception of transgender healthcare amongst EMS providers and trans patients has been documented. A 2020 survey in Minnesota showed that while 85% of EMS providers report feeling confident in their ability to treat transgender patients, 85% of transgender patients do not feel EMS is knowledgeable about transgender healthcare .
While en route to the hospital, Jessica’s vitals remain stable and you administer a second dose of pain medication. You ask for her ID and the name of her insurance provider. You also ask if her insurance is under the same name as her ID. She informs you that she is still on her parent’s insurance, and is listed under the name “Jason.” You tell her when the ambulance arrives at the hospital, you will explain to the nurses and doctors what is going on. You will have to give registration the name Jason so there aren’t issues with insurance, but will introduce her to the staff as Jessica, and use she/her pronouns. Jessica agrees that will be fine.
Communicating in an affirming way
A common issue transgender people face in healthcare settings is a lack of affirmation, or validation, that they are who they are. This includes providers arguing with the patient about their gender identity, using the wrong pronouns (misgendering), using the wrong name (deadnaming), or misusing gendered language [6,7].
The No. 1 thing we can do to affirm our patients is to listen to them.
Use the name, pronouns, and vocabulary they use. Limit your questions to those that will influence patient care or are necessary to complete the patient care record. If you use the wrong pronouns or wrong name, say, “I’m sorry,” repeat the correct information and move on. If you don’t understand something or aren’t sure how to ask, say, "May I ask some clarifying questions so I don't miss anything medically necessary for your care?".
Final takeaways on treating transgender patients
Understanding the differences between sex, gender, gender identity and gender expression can help first responders provide compassionate and affirming care. Jessica’s assigned sex at birth is male. Her gender identity is woman. Her gender expression is the things she does to display her gender outwardly, including her name, pronouns, appearance and dress.
For first responders to provide culturally competent patient care to trans people, we must show knowledge, compassion and respect throughout the whole interaction. Asking for pronouns is not sufficient, and is often irrelevant in the first few minutes of a patient encounter – especially if asking for pronouns is used as a proxy for asking someone “what are you?”
Listen to your patient. Follow their lead on names, vocabulary and pronouns, and ensure that other medical professionals you come into contact with follow your example. Advocate for your patient, because no patient, no matter who they are, should be worried about discrimination in the back of an ambulance.
Introduction to affirming EMS care for transgender and gender-diverse patients
Create a safe and affirming environment for all patients by knowing and calling patients by their preferred name and pronouns
- UCLA School of Law Williams Institute. (2016). “How Many Adults Identify as Transgender in the United States?” Retrieved June, 2021, from https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/
- GLAAD. (Ongoing). “Media Reference Guide - Transgender.” GLAAD. Retrieved June, 2021, from https://www.glaad.org/reference/transgender
- OHSU. (Ongoing). “Terms and Tips. Transgender Health Program.” Retrieved June, 2021, from https://www.ohsu.edu/transgender-health/transgender-health-program-terms-and-tips
- TLP. (Ongoing). “Transgender Language Primer.” Retrieved June, 2021, from https://www.translanguageprimer.org/primer
- Payton, N. (2015, July 9). “The dangers of trans broken arm syndrome.” PinkNews. Retrieved June, 2021, from https://www.pinknews.co.uk/2015/07/09/feature-the-dangers-of-trans-broken-arm-syndrome/
- Kcomt, L., Gorey, K.M., Barrett, B.J., & McCabe, S.E. (2020). “Healthcare avoidance due to anticipated discrimination among transgender people: A call to create trans-affirmative environments.” SSM - Population Health, 11(100608). https://doi.org/10.1016/j.ssmph.2020.100608
- James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). “The Report of the 2015 U.S. Transgender Survey.” Washington, DC: National Center for Transgender Equality.
- Washick, M., Wesley, K., Bevis, E., & Zappa, MJ. (2020, June 30). “Minnesota EMS Providers Share Results of Research on EMS Care of Transgender Patients.” JEMS. https://www.jems.com/patient-care/minnesota-ems-providers-share-results-of-research-on-ems-care-of-transgender-patients/