Transgender Patient Preferences When Discussing Gender in Health Care Settings

Key Points Question How do transgender patients prefer to discuss gender-related information in health care settings, and what is the subsequent impact on health care experiences? Findings In this qualitative study that included 27 transgender and/or nonbinary adults, 4 themes were identified. These themes were (1) impact of provider (clinicians, health care organizations, health care systems) behaviors, (2) engaging in relational risk assessment, (3) receiving affirming vs medically competent care, and (4) “how are you going to fit [me] into your system?” Meaning This study suggests that multilevel interventions are required for gender-affirming, competent health care for transgender patients; specific provider- and hospital-level recommendations are provided.


Introduction
1][12][13] Consequently, trans patients sometimes withhold gender-related information to avoid discrimination. 14Furthermore, discriminatory policies creating barriers to health care access for trans people are in flux across the US. 15 Multiply marginalized (eg, Black individuals, Indigenous individuals, members of other racial or ethnic minority groups, disabled individuals, people with lower socioeconomic status) trans people are already more likely to use emergency departments for primary care, which is associated with worse health outcomes compared with visiting primary care physicians. 16,17Although these experiences are increasingly well documented, there is a dearth of scholarship investigating specific aspects of gender-affirming health care practices.Given these challenges, we posed the following research questions: (1) What influences patients' decision-making regarding sharing gender-related information with health care providers (clinicians, health care organizations, health care systems)?
(2) How do patients want to be asked gender-related questions? (3) How does provider understanding of gender impact patients' health care experiences?

Setting, Participants, and Study Design
From August 10 to September 11, 2020, we recruited (eg, via social media, listservs) and interviewed 27 trans adults.Additional eligibility criteria included having accessed health care in the past 5 years and ability to complete a telephone or video interview in English or Spanish.Recruitment materials advertised that interviews would be conducted by trans interviewers and that the majority of the research team was trans.All study procedures were approved by the University of Washington institutional review board, and this qualitative study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guideline.Participants provided written informed consent.

Procedures and Data Collection
After signing informed consent, participants completed a demographic questionnaire and a 45-to 90-minute semistructured interview 18 conducted on video (Zoom) by 1 of 2 trans research team members (V.H. and A.L.O.).Interviews explored participants' experiences receiving health care (general, trans-specific, and emergency) and how providers in various care settings can be more inclusive and affirming.At the conclusion of their interview, participants were given the opportunity to reflect on and/or redact any part of their responses.Participants received a $75 gift card for participation.

Data Analysis
Data analysis took place from October 2020 through January 2022.0][21] Aligned with the interpretivist phenomenological approach, the team completed regular memorandas and analytic discussions. 22terviews were audio recorded, transcribed verbatim, validated, deidentified, and stored in REDCap. 23,24Transcripts were analyzed using Dedoose, version 9.0.17(SocioCultural Research Consultants, LLC), 25 following thematic analysis procedures. 26Methods for extracting and highlighting themes from the data included several strategies to increase trustworthiness of the results.One of us (V.H.) created an initial code list via inductive coding of 3 transcripts and a list of a priori codes. 19,26Next, the team discussed and refined codes based on consensus.Transcripts were then coded by 3 team members (V.H., B.C., and J.C.) across the following domains: health care spaces or types, experiences of services, structural or individual oppression, context, and suggestions.
Biweekly meetings were held to discuss coding, describe and interpret themes, and identify salient quotes.

Results
Participants included 27 trans adults (mean [SD] age, 30.9 [10.4]Participants suggested that gender-related information be asked when medically relevant, which requires careful screening: "Ask when it's relevant, and if …something could be relevant if the person's trans, that means you have to ask everyone because you can't tell who's trans" (participant 20).Participants wanted clear, specific justifications for collecting information (eg, legal name for insurance purposes), biometric data (eg, hormone levels, anatomy), and explanations for how information would be shared and stored: "I thought they were asking me a completely unnecessary personal question, [but] it was shockingly relevant [to ask about gender]" (participant 20).
Participants expressed concerns about the potential for receiving harmful care, particularly in emergency department settings where trans patients are unable to avoid transphobic providers.
Participants feared losing access to hormone replacement therapy, experiencing microaggressions, receiving subpar care, or even being refused emergency care.Unnecessarily gendered language in any health care setting (ie, "women's health") prompted dysphoric feelings and fears of care refusal.

Impact of Provider Behaviors
Individual providers' actions had significant positive and negative impact on participants' experiences, depending on how attuned, informed, and prepared the provider was.

Examples
I tried this [provider] because it [the health setting] was supposed to be like a queer-friendly place and she said, "Yeah, no problem.I have a place for pronouns and you know, trans men come in here all the time to take care of their lady parts."And I said, "All right, we're okay.We're good.We're done.Any efforts to include more collection of, like, gender and sexual minority data needs to be accompanied with the necessary training and protocols and process because, if you're not doing that and having that set up before you even ask, you're asking marginalized people to disclose things that could get them in trouble or put in harm's way.(Participant 23)

Engaging in Relational Risk Assessment
This theme evolved from respondents sharing how they weighed a variety of implicit and explicit safety cues when deciding what and how to share information with their providers in a variety of health care settings.Participants noted how vulnerable health care spaces felt for them, with several directly mentioning the power imbalance between patient and provider.

Examples
Until I know that there are strict regulations in place to protect me, which there are not, um, I would rather be misgendered than have my life be at risk.( The benefit to having a conversation with a provider is to gauge their reaction… and get a good sense of if they're going to be a good fit for me or not.…I mean, seeing [inclusive gender options] on the form is like a flag …it's flagging, right?If, when they come in and introduce themselves, they don't default to my birth name-which has happened even with providers that tout themselves as transfriendly-or not using a prefix that I don't use, especially when it's in a waiting room and it's public …those kinds of things immediately signal that you read the Participants spoke to their needs as patients often being at odds with the health care system status quo.Whether that meant not fitting neatly into a prescribed identity label (ie, gender assigned at birth) or the health care system prioritizing very different tasks or interventions, respondents reported that their needs simply did not fit into current medical practices, policies, and procedures.I think we get really, really caught up in these, like, "Are we asking the right questions? Are we getting it right?Can you please tell us that we're doing the right thing?" more so than some of the deeper, real, real shit that people need to.So again, that's not necessarily helpful.We need, like, a larger trans health, um, reckoning… because this is the easy stuff.(Participant 9)

These 2
boxes (man or woman) have just come to represent so much more information than they really do.(Participant 20) Not all nationalities have the same idea of gender.The country that I'm from, there's the oldest recorded-what the Western culture calls-trans community in history, …they're not trans, these are like blessed beings, you know?It's who you are.There's a culture behind it.It's hard to explain, but how are you going to fit that into your system?(Participant 4) I don't know why fucking cis people love the word preferred …like they "prefer" oat milk.…I just think the language is trash and it's rooted in transphobia.Just ask what their pronouns are.(Participant 11)

Table 2 .
years; range, 21-69 years) from 13 US states (Table1).Most participants were White (n = 22) and nonbinary (n = 18).Additional demographic characteristics are found in Four major themes (Box) were identified: impact of provider behaviors, engaging in relational risk assessment, receiving affirming vs medically competent care, and "how are you going to fit [me] into your system?" Provider interactions significantly impacted with participants; the nature of the impact depended on how attuned to and informed the provider was.Participants highlighted the importance of providers recognizing risks inherent in patients outing themselves: "[Collecting these] data needs to be accompanied with the necessary training and protocols and process because… you're asking marginalized people to disclose things that… put [us] in harm's way" (participant 23).Others mentioned the risk of receiving subpar care or being refused care: "Your transness is always relevant if you're in danger or the care you're about to receive is going to be impacted" (participant 4).

Table 2 .
Participant Characteristics " To me it flagged immediately… you don't understand.It's still like a gender essentialist view, right?Like a biological and sex essentialist view… and so regardless of how nice you are to use our language, you don't get it.(Participant 23) I went on birth control for a little bit and the whole language around [it] made me super uncomfortable, but it was a thing that I needed to have.So, I feel like procedures should be very nongendered.Like, "Oh, you're on this pill for this reason.Here's some side effects."…Not, "This is a woman pill for women things."(Participant 13) … Ask when it's relevant, and if …something could be relevant if the person's trans, that means you have to ask everyone because you can't tell who's trans.
(Participant 20)Your transness is always relevant if you're in danger or if the care you're about to receive is going to be impacted.And that's [something of] relevance you have really no control over.(Participant4) Gender-or trans-affirming, transition-related, and medically competent care are all distinct and subjective, although at times overlapping aspects of health encounters.Participants spoke at the most length and detail about affirming and medically competent care, noting that they have had to, at times, choose to prioritize one type of care over another.Or is it important that I receive the medical care that I need?And I feel like I'm always balancing that in general… when I'm going into anaphylactic shock, it just doesn't matter.The fact that I'm trans doesn't matter, because epinephrine works no matter what, and that's what I need.You need to know that I'm a hard stick and that my right arm is probably the best place to try.That's the information we need at the moment.(Participant10) … Life has just turned completely upside down and I was in a lot of pain.It was almost impossible to self-advocate.And if they had used my pronouns when referring to and talking with me that would have just brought a little bit more ease to that very difficult situation… it feels important to have it recognized, especially in the urgent care and [emergency department] settings to help with not making it more traumatic than it already is.(Participant19) I think the bottom line for medical providers is if they're well informed and they really see us for who we are, we'll know …and if they don't …we'll know.I think that trans people are really good at sniffing out who's an ally and who's not, and who's trying to do good by us and maybe who's learning but still figuring it out.(Participant 11) … The doctor I am currently going to was the first person who explained to me what you're really checking for when you do the blood work at the different phases after a shot… and that instantly gave me a good feeling because he told me something I didn't know… because it's kind of tiring when you deal with providers where you're clearly the expert.(Participant 16) "How Are You Going to Fit [Me] Into Your System?"