Medical Knowledge and Clinical Skills
Taking a Patient History
When taking a medical history or interviewing patients, it is important to use cultural humility and gender-affirming practices. In order to do this, medical providers should ask, and then refer to the patient by their preferred name and pronouns (this may differ than the name on their medical record). For instance, if “Julie” comes in for a checkup, and they tell you they prefer the name “Ash,” then medical team should only refer to “Ash,” as “Ash.”
Asking The Right Questions
In order to give best care for patients, it is imperative that physicians understand their medical histories. However, it is important to keep in mind that unless the information gathered is clinically relevant, it is inappropriate to ask probing questions about a patient’s gender identity, expression, or personal experience with their sexuality or gender. While some patients may find it empowering to serve as a source of information, others may feel uncomfortable to do so. Patients should not be expected to “teach” about or share their experience.
Clinicians and staff should only ask questions that are relevant to a patient’s chief complaint. When appropriate, it may be relevant to ask about a patient’s gender affirmation practices. Using clinical judgement as a guide of importance, ask: “Have you ever or are you currently taking hormones, or any other medication related to gender presentation?” or, “Have you ever had any surgeries to align your body with your gender?” Similarly, if an individual has undergone surgical therapies, it may be pertinent to ask an Anatomic (or Organ) Inventory, which allows a clinician to indicate the presence or absence of individual sexual or reproductive organs. Some EHR systems may built-in anatomical inventories. However, providers can ask, “Have you removed any organs as a part of your transition?” or, “Can you tell me what reproductive organs you have? Is there a certain term you’d prefer we use when discussing these organs?” The organ inventory is additionally useful as it can help guide differential diagnoses, medical screenings, what types of shielding is needed for radiology exam, or if pregnancy tests are necessary.
Physical Exam
Examination and testing should only be performed on anatomy that is clinically relevant for the specific complaint of the patient’s visit. It is inappropriate to ask about or examine a patient’s body parts out of curiosity. Further, clinicians should be mindful that an individual undergoing medical gender affirmation therapies may have a spectrum of secondary sex characteristics based on duration of hormone use and age of initiation.
Lastly, some patients prefer specific terminology when referring to their own body parts. They may offer this wording on their own, which the provider should then repeat when doing the physical exam the exam. If the patient does not offer terminology, the provider can ask, “Is there a certain way you refer to your body parts?” and then continue to use the terms given.
There are special considerations for performing physical exams on TGD populations, especially during pelvic or genital exams. Please refer to: https://transcare.ucsf.edu/guidelines/physical-examination or the EMRA transgender care guide for more information on how to perform physical exams on transgender patients.
Making Mistakes
Mistakes happen. However, mistakes should be corrected and not repeated throughout the patient encounter. Apologize sincerely, but succinctly –and do not let an overdrawn apology become an additional barrier in your patients’ care. Guidelines recommend the phrase, “I apologize for using the wrong pronoun, I did not mean to disrespect you,” which can be tailored to any mistake made in the encounter, and then moving on with your questioning or exam. Within the clinic, it is important to maintain an environment of accountability – do not be afraid to politely correct colleagues if they use the wrong names, pronouns, or if they make insensitive comments. Gossiping or making fun of someone’s gender identity or expression should not be tolerated at any level.