How often should a man get breast and cervical cancer screenings? Should a woman get screened for prostate cancer? The answer to these questions and more depends on knowing if your patient is transgender.
The Williams Institute at the University of California Los Angeles estimated the transgender population in the U.S. to be 1.4 million in 2016. A recent study in Minnesota of 9th and 11th graders found nearly 3% of students identify as transgender or gender non-conforming.
When it comes to healthcare, are we ready to meet these patients' needs? Several cases where a transgender or gender-expansive person was not properly identified, or their provider simply was not aware of issues regarding transgender individuals, have been in the news lately.
My county hospital is rolling out changes to our health information management system (HIMS) to try to capture this complete information on all of our patients, including transgender and gender-expansive patients. These questions are called SOGIE, which stands for Sexual Orientation, Gender Identity, and Expression. At intake, we ask:
- What is the sex listed on your original birth certificate?
- What is your gender identity?
- What is your sexual orientation?
Our initial goal is to capture 10% of our patient population with rolling increases as we move forward. In the hopes of meeting all of our patients' needs, we will ask these questions just one time over the patient's lifetime. However, the patient can initiate changes at any time in the future.
Our LGBTQ patients can have health issues that are occult if we don't have correct data. A female-to-male (FTM) person with residual breast cancer did not know he needed breast cancer screenings. By the time it was diagnosed, the cancer was advanced. Another patient, male to female (MTF)did not discover her prostate cancer until it metastasized to her bones.
What are the barriers to care for transgender patients? The first is the patient's comfort with disclosing information about their sex assigned at birth and current gender identity. For a variety of reasons, transgender and gender-expansive patients might not trust their caregiver or the healthcare system in general. A person who has transitioned has spent a great amount of personal capital to live the life they need to live. It's not a lifestyle change. It is the core of a person's being.
A 16-year-old patient who has made the transition from FTM tells me "I'm not transgender. I'm a boy." He does not identify as transgender. Practitioners find this a common outlook in their transgender patients. Some transgender individuals may feel that they have always known their gender, and that it was society and other persons who incorrectly assigned or perpetuated a gender identity on their behalf -- one that did not ring true for them.
Sharing this information with a caregiver who is not familiar with the patient might not happen if the patient is not trusting, or believes the information is not germane to the situation. For a primary care provider not in the know, this creates problems with preventative care with serious consequences. The SOGIE questions start a conversation that might not otherwise have occurred.
Another barrier is on our side of the street. Are we comfortable asking a patient if they are gay and/or transgender? While rolling out our new SOGIE questions, we find push back in unlikely places. Care providers and nurses at our in-service had these objections:
"My patients will be insulted."
"Patients of some cultures will be offended if I ask that."
"Some patients will not understand the difference between sexual orientation and gender identity."
"This will take too much time."
For some, a supposed patient objection is a mirror of their own feelings. "I would be offended if someone asked me if I'm gay." For others, cultural taboos of their own might get in the way. Are we projecting our issues onto our patients? Personally, I'm excited to see my patients' reactions to the questions, and I look forward to educating them on the meaning of the terms. It's a valuable tool to identify healthcare needs and an opportunity to destigmatize a subject that might seem uncomfortable.
You can't tell if a patient is gay, straight, or anything else just by looking. The original birth certificate does not indicate the patient's current sexual orientation. Often, a transgender person will legally change their birth certificate to reflect their correct gender identity. We just don't know by looking at a person or their documents what gender identity or sexual orientation they are. Health issues can't be addressed if we don't know.
Annette Smith, a 35-year nursing veteran at Santa Clara Valley Medical Center in San Jose, California, offered insight into changes in practice like the new SOGIE questions. "At the beginning, there is a lot of push-back: 'The sky is falling! The sky is falling!,'" she said. "But after a while, the process becomes normalized and it's not a big deal. We end up wondering what all the fuss was about!"
Spencer Miller, RN, is an emergency department nurse who has worked at various hospitals in Florida, Georgia, and California as a traveler. This story was originally published by Minority Nurse/The Nurse Professional, a trusted source for nursing news and information and a portal for the latest jobs, scholarships, and books from Springer Publishing Company.
Primary Source
Journal of Adolescent Health
Source Reference: Eisenberg ME, et al "Risk and Protective Factors in the Lives of Transgender/Gender Nonconforming Adolescents" J Adolesc Health 2018; DOI:10.1016/j.jadohealth.2017.04.014.