Five Questions about providing safe care to transgender patients with Susan Boisvert

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Susan Boisvert

Transgender people face many of the same challenges as other patients, including finding providers, accessing information, choosing appropriate treatment and understanding insurance coverage. Transgender men and women, however, face additional hurdles when they need health care – from providers’ lack of experience with or understanding of their biological conditions to outright discrimination.

Susan Boisvert, BSN, MHSA, CPHRM, is a Senior Risk Specialist at Coverys, a leading provider of medical professional liability insurance. She recalls that clients started asking her about caring for transgender patients more than 10 years ago. She began to study and understand the issues involved. Later, her own child came out as transgender while he was in college. At that point, Boisvert resolved to learn everything she could and has since become well known as a resource and educator for transgender patient care. Recently she described strategies providers can use to improve patient safety for this population.

Betsy Lehman Center: Do transgender patients face specific safety risks in health care? What is unique about this population that may increase the risk of medical error?

Sue Boisvert: The unique feature of the transgender population is that it is invisible, which is the single most important risk transgender patients face in health care and almost every other aspect of their lives. We do not record gender identity in census data or medical records. We can’t do retrospective studies, so there is very little evidence-based guidance for transgender patients. For example, we don’t know the long-term effects of gender reassignment procedures or hormone replacement therapies. Treatment of transgender children may include using medication to delay puberty, but we don’t know the long-term effects of the drugs, which generally have not been used on children. Transgender care is not informed by long-term, evidenced-base medicine; that’s about as unique a patient safety risk as you can get. In addition, transgender patients often feel misunderstood and stigmatized, which hampers communication and can lead to errors.

Betsy Lehman Center: Could you suggest a few things primary care providers can do to reduce the risk of harm to transgender patients?

Sue Boisvert: First, they really need to check their biases; most primary care physicians are exceptionally good at that with other populations. They may not be as familiar with transgender patients as with, say, gay or lesbian patients, but the way that bias can distract from patient-centered care is the same.

It’s also important for the clinic or physician’s office to be a welcoming space for transgender patients, which includes ensuring that all staff members are trained and supportive. Providers can offer gender-neutral bathroom access and information in waiting rooms about transgender care. They can also signal acceptance by using graphics such as rainbows and the Human Rights Campaign’s logo.

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Providers may need to clear the air with a transgender patient who is new to the practice by saying something like, “I’m very happy to be working with you, but I don’t have a lot of experience with transgender patients. I just want to let you know that and I hope you’ll feel comfortable pointing out any action or comment that is insensitive or incorrect to your gender identity.  Feel free to let me know if I’ve misspoken or if there is anything you want to discuss.”

Betsy Lehman Center: In addition to providing better access to care, will understanding and respect for transgender patients also improve the safety of their care?

Sue Boisvert: Poor communication is often the root cause of adverse events. Transgender patients who feel accepted and respected are more likely to ask questions and give providers honest feedback. A transgender patient who feels shy or threatened may not provide the information the provider needs, for example, to make an accurate diagnosis. Some issues that transgender patients should discuss with their providers are potentially sensitive, such as mental health and gender-specific screening. Rates of depression and attempted suicide are very high among transgender people. They may need cancer screening for organs they were born with but which do not match the gender with which they identify. Feeling comfortable is often a prerequisite for honest discussion of these and other issues. Avoiding them can pose real dangers.

Betsy Lehman Center: Transgender patients face barriers and risks in other health care settings, such as emergency, acute and long-term care, as well as radiology and laboratory services. What can primary care providers do to help their transgender patients avoid harm in all settings?

Sue Boisvert: The most important thing providers can do is to provide access to a list of specialists who have experience with transgender patients. Very few practices and health systems are doing this. If you have a teenager who is gender questioning, they should be offered mental health support from a provider who has expertise in adolescent or child LGBQT concerns. You should not send them to just any therapist. Transgender males who want to have their breasts removed need an appropriate referral. What about a transmale with breast cancer? It’s not easy! 

Betsy Lehman Center: How do you see these concerns evolving in the next 10 years? Will transgender patients tend to be treated in practices that offer transgender care services as a specialty, or do you think primary care will become better equipped overall to handle unique needs of this population over time? 

Sue Boisvert: Every primary care provider needs to be able to take care of transgender patients. They don’t have to provide all services, but they must be able to refer the transgender patient to the right specialist when needed and otherwise provide high quality patient-centered care. 

With improved education and connections on the internet, more young people are becoming aware of their gender fluidity, and providers are improving their ability to care for transgender patients. Lacking census data about the transgender population, public policy experts recently used data from the CDC to estimate that 0.6% of U.S. adults, or approximately 1.4 million individuals, identify as transgender. That is double the number estimated in 2011. With growing awareness and openness about gender identity, there is a growing need for knowledgeable, experienced providers.

As a risk manager, nurse and mother, I see the transgender movement bringing health care together in terms of communication, connectedness and patient centeredness perhaps more than anything else has before. There’s a huge wave coming that’s positive for all of us.

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