Looking Through the Prism: Comprehensive Care of Sexual Minority and Gender-nonconforming Patients in the Acute Care Setting
My legal name should be on the last page of forms, hidden under pages of other records, because that name leads to confusion that is just hurtful. I am sitting in the ED waiting room, and they dead-name me, use a name I haven't heard in years. I am outed in front of the whole waiting room. I am a trans woman; my birth name is not gender neutral. I want a form that has my preferred name, my preferred pronouns. I don't want to have to stand up and react to that other name. There is a look on the nurse's face that says, “this isn't you.” But it is me. I'm trapped. I need medical care. I just want to leave and never be in this situation again, and we haven't even started.
Competent and appropriate clinical care demands precise communication between patient and clinician. Standardized terminology that transcends ambivalence, embarrassment, and misunderstanding establishes a linguistic foundation with the individual and an overarching commitment to respect and inclusivity. EM clinicians must accurately determine the biologic sex of their patients, their current gender identities, and their social and sexual orientation by collecting accurate data and nomenclature and obtaining and using patients’ preferred names. Health care intake forms and EMRs should record the patient's preferred name and pronouns, sex at birth, and current gender identity. The clinician's history should begin with this information, clarifying and adding appropriate details. When this information is not provided, clinicians should inquire with the patient their preferred name and pronouns. The effective clinician must truly carry a “tabula rasa” (clean slate) upon which the patient can record the facts of their life as well as their medical history.
I was admitted to the hospital. A resident came in. He wanted to know if he could ask a few questions. Of course I said yes, it was a teaching hospital. I openly acknowledged that I was a gay man and was HIV positive. Then he started his inquisition, “So, I see you're HIV+. Are you still sexually active?”
He went on, “Did you got HIV because you were receiving or giving?” And then he got really specific about the details. I told him to get out of my room. “Do not come back. Ever. You're not allowed to ask those questions. I will not answer them.” He was intrusive. He was trying to shame me. It was a horrible conversation. He could stick his judgment.
In the ED, I always am uncomfortable when they ask, “What medications are you on?” and I say, “Truvada.” I just don't know what kind of reaction I'm going to get. There is a lot of judgment. I explain what the drug is and why I am on it, but I am just giving them fuel. I am asking them to think of me as one of the ‘good ones’ because I am HIV negative; I am tested regularly. I take care of myself. I'm lucky. I have a job, insurance. But there's all this internalized homophobia that I'm fighting when really all they should want are the names of my drugs and doses. Listing my meds shouldn't be the hardest part of the ER visit.
Patients who identify as LGBTQI expect to encounter stigma and bias from health care providers and their expectations may unfortunately be accurate. The 2015 U.S. Transgender Survey reported that 23% of transgender patients avoid health care out of fear of mistreatment, 33% report trans-specific negative experiences, and 24% report that they needed to educate clinicians to obtain appropriate care.2 Even in an ED-based study, Bauer et al.3 reported that 52% of trans patients had a negative experience, 32% were subject to insulting language, and 10% were refused care altogether. Clearly, it is important for EM clinicians to suspend preconceptions, bias, stigma, and ignorance with regard to their LGBTQI patients.
LGBTQI patients have a much higher probability of having suffered violence and trauma in their lives.4 Seeking and receiving health care should not increase the suffering of these vulnerable patients. EM clinicians should seek to understand the trauma that these patients may have undergone. Sensitivity in obtaining a thorough history with a clear understanding of the signs and symptoms of trauma is needed. EM policies and procedures as well as personal practices should integrate the knowledge of how to guide the traumatized patient along the often roughly paved road of the ED, avoiding opening old wounds or creating new ones. Examinations and procedures must be discussed and negotiated before proceeding to create empowerment and trust. Significant others and support persons should always be present if the patient wishes.
Sexual trauma, gender-affirming body modification, fear, and shame demand that any examination of the genitalia must be undertaken with extreme sensitivity, caution, and an understanding of medical and surgical gender affirming body modifications and their clinical complication. Transwomen may use breast prosthetics and may tuck their penis and scrotum, which can lead to scrotal and urinary trauma, reflux, epidydimoorchitis, urinary tract infections, and prostatitis. They may be taking exogenous estrogen with associated risks of deep venous thrombosis, pulmonary embolism, and cerebrovascular accident. Surgeries for transwomen may include breast augmentation, orchiectomy, and vaginoplasty. Transmen may bind their breasts that restrict breathing and cause skin irritation, cutaneous fungal infection, and breast pain. They may be taking testosterone, which increases risks of uterine bleeding and cancer and may opt for mastectomy, metoidioplasty, or phalloplasty.
Being an effective, competent, and caring clinician in the ED, a health care provider and healer for all people who seek our care no matter how different their lives may seem from ours, requires medical knowledge, emotional intelligence, deep-seated empathy, and honest self-evaluation. When we walk into an examination room to examine and treat a patient, we are wearing lenses that have been shaped for us and by us throughout our lives. We see the patient as they are, but also as we are, what we have come to believe, what has been inculcated, often unfiltered into our minds and hearts throughout our lives by family, friends, teachers, and the media. Know the medicine, know your patient, know yourself. Being open to learning and to the human being in front of you as well as the one inside of you will help us provide more competent and compassionate patient centered care.
