Published in the March 2016 issue of Today’s Hospitalist
THE PLEASANT LADY in a lace blouse and plaid skirt was not my first transgender patient. She’d been referred to me by another patient, and I was grateful that I didn’t have to figure out the situation for myself (or do a pelvic). Like most doctors, though, I had a lot to learn about making my L, G, B or T patients comfortable and in dealing with problems that affect them.
If you want to stop reading, please don’t
We are not all comfortable talking about our patients’ sexuality. Your upbringing may make you want to leave the room when a male patient introduces another man as his husband.
“Oh, you won’t need to do a pelvic exam, doctor—I’m a preop transsexual.”
If you have a partner willing to trade that patient for another with problems you’d rather handle, great. If not … just how many drug-addicted sociopaths have you taken care of? Domestic abusers? Patients handcuffed to their beds and accompanied by deputy sheriffs? You may just have to grit your teeth and remember that at least the lesbian couple isn’t breaking any laws, and the surgery ahead for that transgender patient is no picnic.
Even 30-plus years after immune deficiency was recognized in gay men, these patients still need special treatment and efforts to make them comfortable. A 2009 study conducted by Lambda Legal found that more than half of LGBT patients reported abusive remarks, excessive infection precautions and health care professionals who refused to provide care, with transgender patients receiving the most rudeness. A patient who expects to be treated badly, even if it’s just receiving a cold reception from nursing assistants, is a patient who will delay getting medical help or avoid it whenever possible.
“We’re married now, isn’t that enough?”
The Supreme Court’s ruling in favor of same-sex marriage made it much easier for hospital personnel to determine who should be an LGBT patient’s surrogate if he or she can’t give consent or understand medical issues. But family frictions may continue, especially in conservative parts of the country. You or the nurses may request that the patient be moved to another room and listed under a pseudonym if arguments get too heated.
Case managers may have surprisingly helpful suggestions for connecting patients with community support: programs for young people no longer welcome at home, support organizations for adoptive parents and similar resources. Offer access to mental health and other counseling, and remember that suicides among LGBT young people are double or triple those for the majority. It’s a good idea to know a family lawyer in your area, because powers of attorney and wills may need rewriting if a couple recently legalized their relationship.
A bigger problem is the patient whose sexual orientation is still a secret from family members. Some social or religious groups will quietly tolerate unmarried aunts or uncles as long as they stay in the closet; unfortunately, these groups are where you find the largest number of LGBT people who try to find acceptance by marrying and having children. They may then seek relationships or anonymous encounters elsewhere, putting them at risk for multiple infections. If one of these folks confides his or her sexual history to you, it may be time for a talk aimed at leading the unsuspecting spouse to get tested.
Transgender life: It’s complicated
Even for someone firmly convinced that his or her birth sex was a mistake of nature, making the change is a long process. Counseling is essential not only to diagnose true gender dysphoria, but to prepare the individual for the stages of change. Yes, insurance will usually cover the transition, and Aetna provides an excellent summary of the steps by which patients demonstrate the diagnosis and prepare for surgery and life after it.
Not every transgender person, even with generous insurance coverage, chooses to undergo the entire process. Counseling, gender role reversal, hormone treatment and cosmetic changes may allow some to lead the lives they want. Others, meanwhile, are willing to have major surgery and a series of cosmetic procedures as well. The results are more successful than most people would expect, but it’s a good idea to make sure the patient is getting long-term follow-up on health screening and has someone to answer questions, such as when to taper estrogens to allow a trans woman to go through menopause.
And you need to ask some questions yourself, because the answers can be critical in a diagnostic workup. Most male-to-female operations leave the prostate in place (and PSA levels will be falsely low if the patient is on estrogen therapy). Some female-to-male procedures may leave the uterus and ovaries, along with enough breast tissue to justify mammograms as screening or as part of a workup for a patient with bone metastases.
The University of California, San Francisco has a center specializing in transgender people’s problems that can provide both you and your patients with guidelines and references.
By now your hospital should have figured out that “M or F” doesn’t adequately describe all patients. You are still pretty much guaranteed, though, to run into some interesting situations involving the EMR, semiprivate rooms and the occasional, baffled radiologist.
Yes, hospitalists have a limited amount of time to form a relationship with new patients. But there are simple measures that will help, beginning with a solid handshake and ending with a friendly pat on the back that emphasize you’re on the patient’s side. If patients have a chip on their shoulder, understand that it isn’t your fault. Ask how the staff is treating them, and follow up on both positive and negative comments.
This country has made a lot of strides in accepting people who are different. The food service people no longer avoid entering a gay man’s hospital room for fear of getting AIDS, while nurses on the urology floor are prepared for complications of gender-reassignment surgery, and “a spouse is a spouse” has replaced some of the snarky (or worse) comments we used to hear about boys who like boys.
Encourage feedback from your patients, and keep in mind that even well-intentioned questions and opinions may give the wrong impression or be misinterpreted. And remember: They are ALL our patients, and giving them the treatment they need is what we went into medicine for.