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Bioethics Forum Essay

When Words Matter: Medical Education and the Care of Transgender Patients

I was only there to learn how to place IV lines. But as my anesthesia attending and I gathered our needles, tourniquet, and gauze, I noticed that our patient, whom I’ll call Jamie, didn’t appear to fit into a narrowly defined version of gender. I wasn’t sure whether to refer to Jamie as she, he, or some other alternative, but imagined it could be quite hurtful if I used the wrong pronoun. I wanted to eliminate that potential for harm. Rather than draw my own conclusions about Jamie’s gender identity, I wanted to know Jamie’s perspective.

In my head, I practiced asking Jamie, “What pronouns do you prefer?” By asking about pronoun preference, I hoped I would communicate my desire to respect Jamie’s gender identity. With Jamie’s answer, I could be sure to use the right language when talking about Jamie with other providers.

But before the words came out of my mouth, I hesitated. I wasn’t entirely sure it was the right thing to say.

This uncertainty felt very familiar. As a medical student, I routinely doubt whether I’m saying the right thing to my patients. I’m not talking about when I don’t know the answer to a patient’s question about a medication side effect or surgical procedure. When those types of scenarios arise, which they regularly do, it’s easy for me to say I’m not sure. My deeper uncertainty arises in circumstances in which my words touch on a topic that is likely deeply personal for the patient, and for which the patient may have experienced prejudice, stigma, or trauma. These situations can range from asking a patient about her suicidal thoughts to making small talk with a pregnant 17 –year -old, from discussing condom use to initiating a conversation on smoking cessation.

I’ve learned that sometimes my own discomfort broaching a potentially sensitive topic is far greater than my patient’s. Each week in our first year of medical school, we learned a new set of interview questions and then practiced them by visiting patients in the hospital. When it came time to practice our questions about alcohol use, I dreaded asking. I was convinced that there was no way of asking a patient how much he drank without sounding judgmental. But then, when I overcame my nerves and finally asked, my patient, an older man with liver failure, openly shared with me his decades-long struggle with alcoholism. It almost seemed like he was glad I had asked.

But these conversations have not always gone so smoothly. In my primary care clinic, I attempted to have a conversation with an overweight 35-year-old man about increasing his exercise, and was promptly told, “I don’t think this conversation is going anywhere.” While I felt badly that my tactic had apparently misfired, I was at least glad he told me. What concerns me is all the times I have tried to ask questions sensitively or respond with understanding but failed without realizing it. I know from my own limited experiences as a patient that in moments of vulnerability, a doctor’s words can become magnified and meaningful, both positively and negatively. The doctor often never learns how her words made her patient feel.

And so, at the bedside with Jamie, these thoughts ran through my head. I found myself thinking not only of the patient in front of me, but the larger social context for patients like Jamie. Transgender individuals not only experience alarmingly high rates of violence, sexual assault, homelessness, and job discrimination, but they also routinely face prejudice and ignorance in health care settings. While I thought asking Jamie about gender pronoun preference could be a way to create a more positive health care experience for Jamie, I also started to weigh the reasons not to ask.

For one, my role in Jamie’s care was limited. Aside from introducing myself and making a little small talk as I gathered my IV line equipment, my tasks involved minimal communication. Jamie’s answer wasn’t necessary for me to do my job. Furthermore, I wasn’t alone in the room with Jamie. Multiple nurses and physicians were there preparing to perform a procedure; several patients awaited treatment on the other side of a flimsy curtain. There wasn’t a way for me to ask this personal question while ensuring Jamie’s privacy. As I weighed these concerns, I defaulted to silence.

Ultimately, since Jamie had been to the clinic multiple times before, I reasoned that the regular clinic staff had probably addressed the question of Jamie’s gender identity. When I heard the nurse refer to Jamie as “she,” I decided to do the same. Throughout our encounter, Jamie appeared to be comfortable and happy. But I left the clinic still uncertain how I should have handled this situation.

Medical school isn’t perfect at addressing the challenges of talking with patients about sensitive topics. But over time, I’ve begun to feel much more equipped to tackle certain issues than others. Over the course of my psychiatry rotation, my discomfort asking patients about suicidal thoughts faded, such that I could focus more on the answer to the question rather than my own nervousness. In obstetrics and gynecology, discussing birth control options quickly became normalized. And to prepare us for the difficult task of delivering bad news to a patient, my school required each of us to meet with a patient-actor in a mock exam room and tell her she had metastatic cancer, while a faculty member took notes on how we could improve our communication skills.

When it comes to caring for patients like Jamie, in my experience, avenues for improving communication skills seem to be lacking. While many communication skills are transferable from one scenario to another, there are also unique issues that arise in caring for transgender patients. My medical school had in fact attempted to teach me how to handle situations like my encounter with Jamie in a lecture on asking patients questions about sexual orientation and gender identity. But real life medical encounters are almost always more complex than the versions presented in a lecture hall.

In my encounter with Jamie, I wasn’t lacking a specific learning point on the care of transgender patients. I don’t think there was only one correct thing to say to Jamie. Rather, in order to address the needs of transgender and gender nonconforming patients, we need physician-mentors experienced in transgender patient care who can help us work through our uncertainty. We need opportunities to gain experience and comfort, through elective rotations in specific LGBT health centers or through simulated encounters with patient-actors. And we need an institutional culture that says loudly and clearly: it’s important to do this well.

Colleen Farrell is a fourth year student at Harvard Medical School.

Posted by Susan Gilbert at 06/16/2015 04:59:47 PM |

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