Gender identity and care of transgender and gender non-conforming patients

– [Instructor] Welcome
to the CREOG modules on caring for transgender and
gender non-conforming patients for the obstetrician-gynecologist. This module is the
first of several modules that will introduce you to the role of the obstetrician-gynecologist in providing care for
this patient population. These modules were
created with the support of the CREOG empower award, and with the support of
the University of Michigan. Through all these modules, any hormones mentioned for
gender affirmation are off-label. Module one: an introduction to gender, gender identity, and the role of the obstetrician-gynecologist
in the care of transgender and gender non-conforming people. After completing this module, you should become familiar
with correct terminology regarding transgender and
gender non-conforming patients, and understand some of the specific issues pertaining to the health
care of these patients. Please pause the video and take a minute to answer the following questions. Differences between sex and gender. The terms sex and gender are
often used interchangeably in both lay and medical texts,
but have distinct meanings. The term sex is commonly
defined as the reproductive, genital, and biological
characteristics of an individual, including the anatomy of their genitalia and reproductive organs,
concentrations of sex hormones, and the genetic makeup of
their 23rd set of chromosomes. These can align as typically male, with a karyotype of 46 XY, typically female, with
a karyotype of 46 XX, or a host of other
combinations of genitalia and chromosomes that fall
under the category of intersex. Where useful to distinguish
biological characteristics of natal sex, we will use
the term sex at birth, which relates to the sex determined, usually by rapid examination of the genitalia when one is born. In contrast, the term
gender relates to the social and cultural roles and characteristics associated with a certain sex. For example, masculine refers to the roles and characteristics that
are often associated with having a male body, and these are culturally
and historically variable. So, what is gender identity? Gender identity is a person’s internal, deeply felt sense of being male, female, or somewhere in between. Gender identity can correlate
with sex assigned at birth, or it can differ from it completely. Everyone has a gender identity. When a person’s gender identity aligns with their sex assigned at birth, we say that a person is cisgender. For example, a person who
understands themselves as a woman and who was assigned female at birth is a cisgender woman. When a person’s gender identity differs from their sex assigned at birth, we say that a person is transgender. For example, a person who
understands themselves as a man, and who was assigned female at
birth, is a transgender man. Some people may identify as non-binary, gender non-conforming, gender queer, or use other terms that best capture a gender identity that
does not fall squarely into a male or female category. Gender dysphoria, in a medical context, we may use the term gender dysphoria. This is a diagnostic term
based on the DSM version five, which refers to the distress a transgender or gender non-conforming
person experiences in relation to their birth sex. Sexual orientation, it
is important to note that sexual orientation is
different from gender identity. Sexual orientation is a person’s sense of gender-based attraction
to other people. People use words such as gay, lesbian, bisexual, straight,
queer, pansexual, asexual, and other terms to describe
their sexual orientation. Everyone has a sexual orientation, including transgender people. For example, a transgender
woman may be primarily attracted to women, and
identify as lesbian. Or she may be primarily attracted to men and identify as straight. A transgender person
may decide to transition to living outwardly in
a way that corresponds with their gender identity. There is no best way to transition, and the journey looks
different for many people. Transitioning can include
several dimensions, including legal, or changing
the name and gender on identity documents such as driver’s
license, passport, et cetera. Social, or coming out to people in one’s life as transgender, and
letting people what name and pronouns they use for themselves. Psychological, or adjusting
to changes in thinking, emotions, behavior, and
relationships resulting from the mental shift of accepting
one’s gender identity. And medical, or accessing
transition-related health treatments such as
hormone therapy or surgery. Affirming care, many transgender,
or gender non-conforming people may seek care from an OBGYN. They may have gynecological concerns such as vulvar pain, or abnormal bleeding, need obstetric or fertility-related care, present for routine screening, or request gender affirming care, including hormones and surgery. We will go into each of these in more detail in the upcoming modules. The term affirming care relates to care that is respectful, acknowledging, and supportive of one’s gender identity. Our role as physicians is to
care for all of our patients in the most respectful, knowledgeable way, and to ensure that their specific needs and concerns are addressed. Recent national estimates
suggest that .5 to .6% of the adults living in the United States, or one in 200 people
identify as transgender. This comes out to about
1.5 million people. The transgender population is diverse, spanning across age categories, races, urban, and rural locations. Overall, the transgender population is more likely to attend college, yet have higher poverty
rates when compared to the general population. These higher poverty
rates are likely related to employment discrimination
and loss of social networks that many transgender and gender
non-conforming people face. We should note that
higher educational rates are common in internet-based surveys. In our survey, trans
people who have attained a college education may be more likely to come out and identify as such than those who have not
attained a college education, skewing the survey population. Health risks and disparities. Transgender and gender
non-conforming people face significant health
disparities due to discrimination. These may range from violence
and social isolation, leading to loss of social networks, to unemployment, lack of insurance, and lack of financial resources. Because of these, transgender people are at a high risk for homelessness, which may cause them to
engage in survival sex, and are also at a higher risk
for depression and anxiety, substance abuse, and other consequences of discrimination and isolation. Family acceptance is a significant protective factor with
each of these outcomes. It is important to note
that many of the barriers to care are from within
the health care system. 19% of transgender people
report being refused medical care due to their gender identity. 28% report experiencing harassment
within a medical setting. And 50% of transgender
and gender non-conforming people had to teach their providers about care for transgender people, and this lack of knowledge correlated with an increased propensity
to delay needed care. Best practices, because
of these experiences of discrimination, a patient may feel anxious in clinical settings, even if you have expressed no ill will. To maximize safety and reduce risk, you should utilize some
of these best practices to ensure the safety and comfort of transgender and gender
non-conforming patients. Use correct patient identifiers, both in the chart and in person. Being addressed in a way
that is congruent with, and respectful to who they
are is vital for all patients, and shows patients that we respect them. For transgender patients, this
is of particular importance. Be particularly aware in
waiting rooms and public spaces. Addressing a patient incorrectly in public can lead to outing, or
publicly exposing the person, which can lead to unsafe situations. In some clinics, all patients
are called by their last name. This eliminates the need to
make decisions about prefixes such as Mr, Mrs, and Ms. Some health systems have locations in the medical chart for gender pronouns. It helps when they are easily found, such as in the headline, and can allow patients to
tell their first provider, or fill it out in their forms, and not need to continue
to correct people. Many EMR systems are
moving to enable this. When writing in the chart, some
providers note trans status. For example, transgender
man in the first line. And then write their note
using the appropriate pronouns, such as he, him, or his. When asking about patient sex
and gender on intake forms, a simple two-step question
relating to sex and gender ensures that all patients are respected, and that you can get
the range of information you need to treat your patient. When discussing this
with patients in person, start by asking how a person
would like to be addressed, and what pronouns they use. You may feel awkward asking the question, but skipping that step and assuming incorrectly could be much worse. An interaction may go as such. Hi, I’m Doctor Stroumsa and
I’ll be seeing you today. How would you like me to address you? My name is Mike, I use
he, him, or his pronouns. If asking detailed questions about trans-related health information, it is important to provide
your patient with rationale around why this information
is medically relevant. As always, when interacting
with patients, don’t assume. If you’re unsure, clarify. You can say something like, I noticed you filled out a different name than is in your chart. Which name would you like me to use? Refrain from asking people and patients about their genitalia unless
it is medically relevant to the care you are giving them today. You can learn about their medications and any relevant surgeries when you obtain the past medical history
and past surgical history. Mistakes happen, even with
the best of intentions. If you mis-gender a patient, or unintentionally address
them by the wrong name, simply acknowledge your
mistake, apologize, and move on. Ensure that all staff,
not just clinical workers, have appropriate training. Since the frontline staff
are often the first people to encounter our patients in clinic, and often do so publicly, such as when calling a patient in from the waiting room to their appointment, these staff have a
particularly important role in ensuring the privacy
and safety of patients. For transgender patients, calling them by a name or
title that does not align with how they would like to be addressed, may inadvertently out them publicly. For example, a transgender woman may have a male gender marker
on her insurance card. If she’s addressed as Mr.
So-and-so in the waiting room, that may cause significant discomfort, may make her less likely to
disclose health concerns, and may even endanger her safety. Be sure to educate your staff
on these issues pertaining to transgender and gender
non-conforming patients. Having non-gendered
single stall bathrooms, or family all gender bathrooms, ensures that everybody
can use the bathrooms, and sends a welcoming message. Additionally, a small
placard stating the location of the nearest all-gender restroom located under the signs
for the gendered restrooms can allow people to find these locations if they are not readily apparent. If your clinic is a standalone
women’s health clinic, consider placing signs that clarify that they are affirming of all patients. Some examples are demonstrated here. To conclude, in this module, we learned key terms such as sex, gender identity,
transgender, and cisgender. We also learned that
transgender individuals face many barriers to care. However, simple measures
can facilitate creating a welcoming environment
for all of our patients. Let’s review the self-assessment questions that you saw earlier in this module. Number one: a transgender man
is someone who was assigned female at birth, but identifies as male. This is true. Number two: the best way to
assess which pronoun to use when addressing a transgender patient is to use the sex listed
in their medical record. This is false, the best way to
know what to call a patient, and what pronouns they
use, is to ask them. Thank you for viewing module one, which provided a basic introduction to the care of transgender and
gender non-conforming people. For more information, you might consider reviewing the following sources.

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