Envisioning Trans Care

Saturday, February 2, 2019

Listen to your patients.

Health sciences students at UCSF are told repeatedly that this is key to practicing safe and effective care for their patients. Given the current political climate, there are likely few groups more in need of this sort of careful, compassionate, and trauma-informed care than transgender patients.

The first panel of the Deboncoeur workshop series, occurring in Cory Hall on January 23, brought together community members who were experts on caring for transgender and gender-nonconforming people.

The workshop series is dedicated to the memory of Emma Deboncoeur, a trans nursing student who died last year. She wished to create interprofessional awareness and advocacy for marginalized communities - especially those that are in part marginalized by the healthcare system itself.

As a student leader in ASSN and community advocate, Emma Deboncoeur’s goal with the Deboncoeur workshop series was to not only integrate the care of transgender and gender-nonconforming patients into curricula, but also to make this and other panels like it mandatory.

With this first panel, they are one step further towards making both this and better care for transgender and gender-nonconforming patients a reality.

Panelists walked the audience through how transgender and gender-nonconforming patients approach medical visits and highlighted challenges commonly faced at clinics or hospitals. J. M Jaffe, who founded Trans Health Consulting and formerly was Trans Health Manager at Lyon Martin Health Services, emphasized how important it was to use the pronouns the patient has chosen for themselves. These are terms that often evolve over time as people try things out and see if they identify with them, and they eventually arrive at terms that are best for them. Simply using these terms not only helps trans folks feel more comfortable, but also has distinct social and health benefits. The key, then, is to ask.

When patients arrive at the clinic, they can face another issue: most medicine is practiced by cis people based on assumptions from research on overwhelmingly cis bodies; as a result, said Emiliano Lemus, clinical herbalist and UCSF JMP student, some subtleties - and sadly even large issues - in how one must practice can be missed.

On top of this, providers may make assumptions about what kinds of care trans and gender-nonconforming patients may be seeking. They may assume these patients are seeking hormone therapy. In fact, they may be seeking assistance to deal with other social or structural determinants of their health, or may just be coming in for a routine screening that has nothing to do with being transgender.

Dealing with these structural and social aspects of health are exceptionally important as medical providers, given that many rise from inadequate medical knowledge and inadequate (and often problematic) training providers receive, stated Jenna Rapues, the Director of Gender Health SF. Individuals in these populations can carry great trauma, and though being trans is not a mental illness in and of itself, the daily transphobic experiences people face have the cumulative effect of traumatizing trans people, often leading to mental health comorbidities.

According to the National Center for Transgender Equality, more than 25% of transgender folks have faced violence directed at them due to their identity; these rates are even higher for transgender women and those of color.

Like all people facing difficult circumstances, harmful coping habits can develop, which can develop into eating disorders, self-harm, and substance use disorders. While one hopes medical establishments can help protect these patients, they instead can exacerbate this trauma and stigma.

Jenna Rapues lamented the fact that transgender patients sometimes have to teach their providers how to care for them. We do not expect cis patients to teach their doctors how to practice, so this double standard is alarming. Moreover, Rapues said, restrictive insurance coverage means these patients do not always have access to trans-competent care teams.

So how do these issues get solved?

Much of the change, Lemus starts at the level of education. Incorporating transgender health into curriculum, especially for nursing and medical school, would provide early exposure to these patients.

The spaces in which we practice must change too - hiring trans staff, having gender-neutral restrooms, ensuring patient education materials aren’t gendered, and displaying art and signage that welcomes transgender and gender-nonconforming bodies would make spaces safer and less traumatic.

After all, when patients feel safer in the space, the relationship with their provider will improve and more assistive care can be provided. Having peer educators, said Janessa Broussard, a nurse specializing in LGBTQ+ patients at the SF AIDS Foundation, helps patients feel more guided and comfortable as well. It can bridge the gap between medical and social care we provide.

Ultimately, the biggest improvements will come with changes in those who practice medicine.

When asked what the ultimate goal of improving transgender healthcare is, Lemus enthusiastically stated, “Transgender health care providers caring for transgender patients.” The panel agreed that ideally each occupation in the healthcare setting could and would be filled with transgender or nonbinary people: not just physicians, but nurses, pharmacists, therapists, medical assistants, front desk staff, billers, janitorial staff, and beyond.

Along with this would come new standards for care that are set by transgender, not cisgender, people. Jaffe, had two additional suggestions: social support groups for patients and having a list of solid physician referrals once could direct patients to if needed.

Everyone has the responsibility to champion their patients, regardless of their identities.