Creating a safe and welcoming clinic environment

Introduction

Transgender people may avoid seeking care due to prior discrimination or disrespect in a clinic setting.[1,2] Providing a safe, welcoming and culturally appropriate clinic environment is essential to insure that transgender people not only seek care, but return for follow-up. There are several key components to creating an appropriate setting for transgender care.

Cultural humility: is a concept through which individuals recognize that their own experiences or identities may not project onto the experiences or identities of others. Each patient should be approached as an individual with no preconceptions. Individual preferences of terminology, complex or novel gender identities, and differing desires for gender affirming treatments will be encountered daily in the clinic. Meeting patients "where they are" without judgment or editorializing (including in some cases, even positive remarks about appearance) will enhance the patient-provider relationship and avoids the perception of stigma or pathologization. While some patients may be empowered by serving as a source of information for medical providers,[3] others may be uncomfortable doing so. It should not be routinely expected that patients explicitly "teach" their providers, and providers should limit historical questions to those that are relevant to the current visit or problem.

Staff training: In addition to healthcare providers, front desk staff, nursing staff, lab and x-ray staff, etc. are often on the front lines of patient care. Training on transgender health issues should be provided to all clinic staff and providers, and should be integrated into the standard hiring and on-boarding process for all employees.

Waiting areas: should include transgender-themed posters, artwork, pamphlets, magazines, etc. to indicate a commitment to serving the transgender community.

Bathroom: policies should either define all bathrooms as gender-neutral, or specifically state that patients may choose either the women's or men's rooms based on their own preference. In this latter case, making at least one gender-neutral bathroom available will provide a safe space for nonbinary people as well as for those in transition and who feel uncomfortable in any gendered space.

Fluency of terminology: Providers should be aware of basic terminology used by the trans community. In addition to the terminology described in these guidelines (which are based on North American English language use), other local or individual terms may exist and also may change over time. Terminology in other countries or languages may vary. Providers should familiarize themselves with local terminology, and approach individuals with cultural humility when determining which specific terms to use.

Gender identity data: includes chosen name, chosen pronouns, current gender identity, and sex listed on original birth certificate. Failure to collect and use gender identity data has several important repercussions, including invisibility of gender and sexual minority populations to policy makers and researchers,[4] difficulties in tracking the organ inventories and preventive health needs of transgender people,[5] and reduced patient satisfaction due to a failure to use chosen names and pronouns.[6] Gender identity data have been added to the requirements for the U.S. Department of Health and Human Services Office of the National Coordinator for Health Information Technology Meaningful Use Stage 3 guidelines.[7]

The UCSF Center of Excellence for Transgender Health, Fenway Health in Boston, University of California, Davis, the Mayo Clinic, the U.S. Centers for Disease Control and Prevention (CDC), and many other organizations and experts advocate for the use of the "two-step" method for the collection of gender identity data. This method queries both gender identity as well as the sex listed on one's original birth certificate; transgender people can be identified as those whose gender identity differs from their birth sex. This method has been found to be superior to a single question querying gender/sex with choices of "male," "female," and "transgender," since some transgender people may choose "male" or "female,"resulting in effective invisibility of their transgender status.[8]

Unfortunately many EMR vendors have lagged in developing functionality for gender identity data, resulting in a patchwork of practices and locations in which these data are stored within the record.[9] In addition to gender identity and birth sex, transgender people may also have a chosen name which differs from their legal name, and may use pronouns which differ from those associated with the legal sex listed on their identity documents. As such it is also recommended that EMRs contain functionality for the recording of chosen name and pronoun. An ideal EMR will then allow chosen name and pronoun to be displayed for all users in all views. Furthermore, EMRs there should include functionality to remove indicators of transgender status from the view of casual users once legal documents have been changed to reflect gender identity and chosen name, allowing transgender people to maintain privacy. Specific details regarding one's transgender status and transition history, including an inventory of organs and information on hormone use can be stored in the medical and surgical history sections of the chart.[6]

Recommended terminology for the collection of gender identity data is listed below.[10] Clinics can integrate these questions into their intake forms or processes by including a brief description or disclaimer to avoid confusing those patients to whom these questions do not apply.

Gender identity (two-step):

1. What is your gender identity?
   ☐ Male
   ☐ Female
   ☐ Transgender man / Transman
   ☐ Transgender woman / Transwoman
   ☐ Genderqueer / Gender nonconforming
   Additional identity (fill in) ________________
   ☐ Decline to state
    
2. What sex were you assigned at birth?
   ☐ Male
   ☐ Female
   ☐ Decline to state

References

1. Melendez RM, Pinto RM. HIV prevention and primary care for transgender women in a community-based clinic. J Assoc Nurses AIDS Care JANAC. 2009 Oct;20(5):387-97.
2. Grant JM, Mottet LA, Tanis J, Harrison J, Herman J, Keisling M. Injustice at every turn: a report of the National Transgender Discrimination Survey . National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011 [cited 2016 Mar 17].
3. Deutsch MB. Evaluation of patient-oriented, internet-based information on gender-affirming hormone treatments. LGBT Health. 2016 Feb 1.
4. Bauer GR, Hammond R, Travers R, Kaay M, Hohenadel KM, Boyce M. "I don't think this is theoretical; this is our lives": how erasure impacts health care for transgender people. J Assoc Nurses AIDS Care JANAC. 2009 Oct;20(5):348-61.
5. Deutsch MB, Green J, Keatley J, Mayer G, Hastings J, Hall AM, et al. Electronic medical records and the transgender patient: recommendations from the World Professional Association for Transgender Health EMR Working Group. J Am Med Inform Assoc JAMIA. 2013 Aug;20(4):700-3.
6. Deutsch MB, Buchholz D. Electronic health records and transgender patients--practical recommendations for the collection of gender identity data. J Gen Intern Med. 2015 Jun;30(6):843-7.
7. Cahill SR, Baker K, Deutsch MB, Keatley J, Makadon HJ. inclusion of sexual orientation and gender identity in Stage 3 Meaningful Use Guidelines : a huge step forward for LGBT health. LGBT Health . 2015 Dec 24 [cited 2015 Dec 31].
8. Tate CC, Ledbetter JN, Youssef CP. A two-question method for assessing gender categories in the social and medical sciences. J Sex Res. 2012 Sep 18;1-10.
9. Deutsch MB, Keatley J, Sevelius J, Shade SB. Collection of gender identity data using electronic medical records: survey of current end-user practices. J Assoc Nurses AIDS Care JANAC. 2014 Apr 12.
10. Cahill S, Makadon H.Sexual orientation and gender identity data collection in clinical settings and in electronic health records: a key to ending LGBT health disparities. LGBT Health. 2013 [cited 2013 Aug 25].