A new study published in Annals of Family Medicine explores encounters between 30 transgender people and their health care clinicians.
Investigating these experiences in the U.S. is timely given the current national push to address health disparities by collecting information on patients’ sexual orientation and gender identity, the researchers said.
“Trans people have been invisible in data for a long time, but asking people about their sexual orientation and gender identity comes with risks,” said Ash Alpert, MD, MFA, lead author of the study.
Alpert joined Yale School of Medicine as an instructor of medicine (hematology) in September 2023. As part of their work, they care for patients with lymphoma at Smilow Cancer Hospital, in New Haven, and investigate ways to improve the experiences and outcomes of transgender people with cancer. Alpert recently completed a postdoctoral fellowship in health services research at the Brown University School of Public Health, where part of this research was conducted.
Researchers in the study conducted focus groups to gain insights about the experiences of participants when physicians learn they are transgender. They also looked at the decisions participants made involving sharing, modifying, or withholding health information during clinical interactions.
We need to reconceptualize medical institutions and medicine more broadly to rethink our relationships with the people we care for.
Ash Alpert, MD, MFA
In their findings, the researchers noted that participants questioned the motives behind their clinicians’ questions, which they often perceived as irrelevant, invasive, stigmatizing, or intended to protect the physician against liability.
Alpert cited, as an example, a participant in the study whose physician’s questions seemed irrelevant to the respiratory issues that had prompted the visit.
“I saw a pulmonologist earlier in the year and one of his first questions was, ‘When are you getting genital surgery?’” the participant told researchers. “And I was like, ‘I’m here for my lungs.’”
Alpert pointed out that transgender people often experience voyeurism. “We are asked intrusive questions because people, including clinicians, may be interested in us as ‘exotic others,’” they said.
Patients in the study described receiving poorer care after clinicians learned they were transgender. In one example, a patient was discharged early without adequate pain management. In another, a provider, perceiving a transgender person as dangerous, backed away from a hospital bed.
“I don’t feel comfortable sharing medical records with physicians anyway because it’s a guarantee that I’m not gonna get services,” a study participant told researchers. “So I lost [my medical records] and they’re good wherever they are now, far away from me.”
Due to the frequency of these harmful experiences, study participants weighed the risks of disclosing gender identity against the risks of withholding that information. Transgender patients were forced to choose between the potential harms associated with clinicians’ transphobia and the harms of substandard medical care based on limited health information, the study found.
“That’s an impossible choice for patients to make,” Alpert said.
To improve the safety of encounters for transgender people in medical settings, the research team recommends that clinicians ask only medically relevant questions and document information in a non-stigmatizing way in patients’ electronic health records. The researchers also urge clinicians to advocate for patients who are stigmatized by other physicians and to work with colleagues to shift medical culture by revising curriculum guidelines, policies, procedures, documents, and discourse to be inclusive of transgender people.
Alpert hopes the study will be the impetus for structural changes and solutions that humanize patients. “We need to reconceptualize medical institutions and medicine more broadly to rethink our relationships with the people we care for,” they said.
Other authors of the paper include Jamie E. Mehringer, MD; Sunshine J. Orta, PA-C; Tresne Hernandez, BA; Emile Redwood, MD; Lexis Rivers, MSN, RN, CNL; Charlie Manzano, BA, Roman Ruddick, Spencer Adams, BS, Jae Sevelius, PhD, Emma Belanger, Don Operario, PhD, and Jennifer J. Griggs, MD, MPH.