Transgender-Affirming Care in the Wound Clinic: Does Your Environment Welcome Diversity?

With today’s increasing attention to political correctness and diversity awareness, healthcare providers should be well versed in communicating with various patient populations. This article gives an introduction to the transgender community.

Providing competent healthcare for members of the transgender population is becoming strikingly more salient as recent research has highlighted disparities and discrimination experienced by this cohort.¹ Additionally, as awareness of these disparities becomes more publically discussed and addressed, transgender patients may feel empowered to openly present to other settings. This article will provide some key introductory terminology in describing the population and caveats to using these terms. We will then discuss some of the health inequalities and disparities that exist in the transgender population. We will provide some practical advice on ways in which healthcare providers can evaluate their environments of care to provide a more welcoming and affirming setting. Lastly, we will provide some key resources for further learning and advocacy.

Terminology & Language

Having knowledge of terminology is important to understanding gender identity. “Sex” is a term that generally refers to the biological traits that classify one as male or female at birth. Examples of these biological traits include reproductive organs, genetics, or physical anatomy. “Gender” refers to socially constructed traits that society generally associates with the male and female sex. “Gender identity” is an internal sense of self as a man or a woman, and “gender expression” is how one outwardly expresses one’s gender identity. “Transgender” is a term used to describe individuals whose gender identity or expression differs from what is associated with their sex that was assigned to them at birth. “Cisgender” is the term to describe individuals whose gender identity or expression is consistent with what was associated with their sex assigned at birth. “Intersex” describes individuals who are born with physical traits that do not fit the typical pattern of male or female. 

It’s important to distinguish the difference between gender identity and sexual orientation. Although these concepts are related, as they both describe an aspect of identity, they are separate constructs in themselves. “Sexual orientation” relates to sexual and romantic attraction to others. One way to differentiate between these terms is to conceptualize sexual orientation as a way that one feels about others while gender identity is a sense of self. This distinction is important, as you cannot make assumptions about one’s gender identity based on sexual orientation. There are many ways in which one might describe oneself other than “transgender” within this broad and complex umbrella term. The best way to get a sense of how individuals identify themselves is to give them the opportunity to explain it, whether that’s through direct questioning or on a demographic form. Such a form may be needed to be kept on file in addition to an admissions/discharge/transfer (ADT) form or demographic form built into one’s electronic health record (EHR), especially when considering that most EHR forms aren’t going to offer gender-identity options beyond “male” or “female.” Updates to ADT forms within an EHR may be needed throughout the healthcare industry moving forward if providers are going to allow for the two-step approach of offering patients the opportunity to report both sex at birth as well as gender identity, as recommended by the World Professional Association for Transgender Health (WPATH), a nonprofit, interdisciplinary professional and educational organization devoted to transgender health. WPATH officials recommend options for sex at birth as “male” and “female,” as well as “other.” Inclusive options for assessing current gender identity can include “male,” “female,” “transgender man,” “transgender woman,” “gender queer or nonconforming,” or other options for filling in other identities. WPATH also recommends data collection on pronoun preferences such as “masculine,” “feminine,” “neutral,” “none,” or some alternative option.²  

Wound care clinicians and program managers can work with their records or informatics departments on incorporating a two-step approach in assessing gender identity to one’s recordkeeping system. There are some examples of work being done nationwide to implement separate fields for sex at birth and current gender identity into an EHR that is consistent with these recommendations from WPATH.^3-5 It’s also important to understand there are many ways in which one might experience gender or make changes to alter gender expression. For example, an individual may have a transgender identity but make no changes to physical appearance or social presentation. Some individuals may make changes to their name, but may not have pursued hormone therapy. Others chose to initiate cross-sex hormones or undergo some aspect of gender-confirming surgery. This variety of possibilities for gender expression supports the notion that providers should avoid making assumptions that may lead to “guessing” about someone’s gender identity by appearance alone.

Access to Care:  Discrimination & Disparities

One important aspect of maintaining awareness of the experiences of the transgender population is to understand the current and historic sociopolitical environment in which these individuals have interacted within healthcare systems. The term “health disparities” refers to population-specific differences in the presence of disease, health outcomes, quality of healthcare, and access to healthcare services. For example, healthcare was the most commonly reported area in which transgender individuals reported experiences of discrimination.⁶ There are various concepts related to disparities in access to healthcare settings that might delay transgender individuals from accessing care, such as lack of an available provider who is knowledgeable about transgender concerns, the need to travel a great distance to find competent providers, or prohibitive costs of getting care for the uninsured and non- or underemployed.⁷ Given the experiences of discrimination the transgender community faces, it’s important to evaluate healthcare settings for ways in which the environment of care could be altered to convey a welcoming atmosphere for all. The following are recommendations by a number of agencies, including the Joint Commission, the Center of Excellence for Transgender Health, an organization that seeks to increase access to comprehensive, effective, and affirming healthcare services for trans communities, and WPATH.

Comfort Using Affirming Language. All staff in the wound clinic, ranging from the front desk to the providers, should be aware of transgender patients and be comfortable asking about preferences for how patients would like to be referred. Communication from healthcare leadership should reflect a welcoming attitude that allows transgender individuals to expect to be treated with dignity and respect. Often, discomfort stems from a fear of “saying the wrong thing.” Staff education on terminology, the history of discrimination in healthcare settings, and practical tips on how to incorporate affirming practices into the clinic can allay this fear. This is important because documentation (eg, driver’s license, insurance cards) may not be consistent with the patient’s preferences, especially considering the challenges and barriers that exist in making official changes to these records.

Healthcare Atmosphere. Creating an environment that shows visible cues for a safe and welcoming space for transgender individuals is a concrete task that can be accomplished in several ways. Some examples include placing brochures, literature, and reading materials on transgender health in waiting areas. This may involve the use of artwork or posters stating the clinic is welcome to all individuals and sharing contact information for local transgender-specific support services. Use of bathrooms consistent with one’s gender identity is an important policy a healthcare system can adopt to communicate that the needs of transgender individuals are important. Some facilities accomplish this by creating “gender neutral” or single-stall bathrooms. Facilities should also assess current policies on inpatient room assignments for shared rooms, nondiscrimination policies that include the language “gender identity” as a protected status, and visitation rights.

Transgender-Specific Medical Knowledge 

While it’s beyond the scope of this article to outline detailed aspects of medical knowledge specific to transgender health, there are medical needs and interventions unique to the transgender population. For example, gender-affirming hormone treatment is a common medical intervention that aims to alter or create sex characteristics that are in line with one’s gender identity. Surgical interventions typically involve the reproductive organs, breasts, facial features, tracheal cartilage, or vocal folds. Recovery from gender-affirming surgery may involve extensive postoperative care. Postoperative care guidelines/suggestions for masculinizing chest surgery, feminizing augmentation mammaplasty, vaginoplasty, and phalloplasty are available).⁸ Standards of care set forth by the WPATH⁹ also provide an overview of types of surgical procedures, recommendations on criteria for receiving surgeries, competencies of surgeons, techniques and complications, and postoperative care and follow-up. Reviewing such resources will help to develop one’s body of knowledge and skills for working with transgender individuals in meaningful and culturally competent ways. 

Lynette J. Adams and Jennifer L. Gaskins are on staff with the U.S. Department of Veterans Affairs. 

References

1. Shukla V, Asp A, Dwyer M, Georgescu C, Duggan J. Barriers to healthcare in the transgender community: a case report. LGBT Health. 2014;1(3):229-32. 

2. Deutsch MB, Green J, Keatley J, Mayer G, Hastings J, Hall AM. Electronic medical records and the transgender patient: recommendations from the World Professional Association for Transgender Health EMR Working Group. Am Med Inform Assoc. 2013;20:700-03.

3. Hagland M. Meeting the Needs of Transgender Patients: Medical Informaticists Work through the EHR Challenges. Healthcare Informatics. Accessed online: www.healthcare-informatics.com/article/meeting-needs-transgender-patients-medical-informaticists-work-through-ehr-challenges  

4. Leventhal R. UC Davis Health System to Include Sexual Orientation, Gender as EHR Elements. Healthcare Informatics. Accessed online: www.healthcare-informatics.com/news-item/uc-davis-health-system-include-sexual-orientation-gender-ehr-elements 

5. Healthcare Equality Index. HEI 2017 Resource Guide. Accessed online: https://hrc-assets.s3-website-us-east-1.amazonaws.com//files/assets/resources/HEI_Resource_Guide.pdf 

6.  Bradford J, Reisner SL, Honnold JA, Xavier J. Experiences of transgender-related discrimination and implications for health: Results from the Virginia Transgender Health Initiative Study. Am J Public Health. 2013; 103(10): 1820-1829.

7. Cruz TM. Assessing access to care for transgender and gender nonconforming people: A consideration of diversity in combating discrimination. Soc Sci Med. 2014;110:65-73.

8. Deutsch MB. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. Center of Excellence for Transgender Health. Accessed online: https://transhealth.ucsf.edu/protocols

9. The Standards of Care. WPATH. Accessed online: www.wpath.org/site_page.cfm?pk_association_webpage_menu=1351&pk_association_webpage=465