8 things patients wish physicians knew about gender diverse care

A person’s gender identity is what feels natural to them. Some may know early on in their life that they feel more comfortable being gender diverse—a term that is used to describe people who have a gender identity beyond societal expectations based on their sex assigned at birth. Meanwhile, others may explore their gender identity for many years.

One problem is that people who are transgender or gender diverse often face high rates of stigma and socioeconomic and structural barriers that negatively affect health care use. That is why it is important for physicians and their care teams to provide gender-affirming care as part of delivering high-quality care to LGBTQ+ patients.

Two AMA members took time to discuss some keys that many patients wish their physicians knew about caring for patients who are transgender or gender diverse. They are:

• Kameryn J. Lee, MD, MSPH, an ob-gyn and founder of Radically Inclusive Consulting Collective in Rehoboth Beach, Delaware, a consultancy that focuses on racial, LGBTQ+ and gender-diverse health equity, social justice and education. She was also a member of the inaugural cohort of the Medical Justice in Advocacy Fellowship, a joint venture of the AMA and the Satcher Health Leadership Institute at Morehouse School of Medicine.
• Dustin Nowaskie, MD, a clinical assistant professor of Psychiatry at the Keck School of Medicine of the University of Southern California and founder and president of OutCare Health, an international nonprofit LGBTQ+ health equity organization. Dr. Nowaskie also received an Excellence in LGBTQ+ Health Award from the AMA Foundation.

“Language is difficult and is always changing. And that’s true for all populations of people—truer in LGBTQ+ people, but especially true with trans folks,” said Dr. Lee, who uses she/her pronouns. “Even those of us in the community sometimes have difficulty in keeping up with language.”

Even a long-used word in transgender care such as “transition” is seeing a usage change, explained Dr. Nowaskie, who uses they/them pronouns.

“We're shifting away from that because transition implies that you're at one point and you're going to another,” they said. “But, actually, for the trans and gender diverse experience, they've always been this way.”

“Instead of saying, ‘Are you going through a transitioning?’ It's really gender affirmation. We are affirming who you are as a person,” Dr. Nowaskie said.

“The term gender nonconforming is one of many terms that is used to describe people who don’t necessarily fit into a societal gender binary,” Dr. Lee said. “For example, I am a female and woman-identified, so my pronouns are she/her and I consider myself a transgender woman. Some may consider themselves transgender men.”

“Folks who don’t necessarily fit into the binary are unnecessarily always called gender nonconforming to say that you are not abiding by society’s rules—you’re not conforming to whatever the norm is—and some take offense to that,” she said.

“Gender nonconforming—three years ago, everyone thought that made sense,” said Dr. Nowaskie. “And now it's: Well, can we broaden that? So, ‘gender diverse’ right now at this point in time is probably the most inclusive. ... Next year it could be something else.”

“Sexual orientation and gender identity are on a spectrum. That’s very important because when you realize that identities are on a spectrum, you realize that it’s not a binary,” said Dr. Nowaskie. “There are a lot of trans people who are binary in the sense that they are either trans women or trans men, so they exclusively identify as a man or a woman.

“There are also many people who are trans and most people who are gender diverse who do not label themselves in a binary way,” they added. “So, there’s somewhere on the spectrum of what it means to be male or female, masculine or feminine or not at all.”

“Sometimes people have a blend of identities and other times they do not recognize any identity, so you’ll see terminology like nonbinary gender, genderfluid or agender,” said Dr. Nowaskie.

“Identities in a spectrum can change and they can change in many different ways,” said Dr. Nowaskie, noting “they can change across time, and we definitely see that with definitions of particular words and phrase changes for LGBTQ+ communities.”

“They also vary across geographic locations. Groups of people may define words, phrases and identities in different ways compared to even the next state over, but also definition terms and identities change with particular people,” Dr. Nowaskie said. That’s why physicians should “ask patients about their identities over the course of other visits, not just the first visit.”

“The norm is that physicians, if they do ask, would ask on that first visit and then they would assume that is the identity or the definition that the patient uses their entire lives,” said Dr. Nowaskie, adding that people can use different terms or labels over the course of their life, which is why it is important to ask about identity beyond the first visit.

It is important to “be open and nonjudgmental as much as possible in the beginning,” said Dr. Nowaskie. But “it’s always amazing when physicians convey their name and their pronouns immediately.”

Beyond that, “patients wish that their physicians would also disclose some of their identities,” they said. “It’s not just name and pronouns, but it’s describing their sexual orientation or gender identity to some degree.”

“You don’t have to come out to your patients—unless you want to—but you can integrate some of those identities into your care,” Dr. Nowaskie said. “For instance, I always give the example I’m from southern Indiana. I came out at a very young age, and I experienced a lot of stigma and discrimination because of my identity.”

“Not everyone goes through gender-affirming surgeries,” said Dr. Nowaskie. “There are many different forms of gender affirmation. It can be medical, which is hormones and surgeries, but it can also be social—appearance, clothing, name changes, gender-marker changes.”

“There are a lot of different things that go into gender affirmation, so patients feel more comfortable whenever they realize that the physicians are letting patients lead their journeys,” Dr. Nowaskie added.

“All of us are very different in terms of how we present as transgender,” said Dr. Lee. “There’s no one way to be trans. We are often seen as monolithic, but no two trans folks are alike just like no two cisgender people are alike.”

“Even if you were to compare two people who identify in the exact same way, have the exact same life experiences and live in the exact same city, their gender affirmation still will be vastly different,” said Dr. Nowaskie. “It is very much an individualized experience that may have a very linear trajectory, or it may not.”

“It takes a lot of courage to go into any place where the expectation for affirmation is unknown,” said Dr. Lee. “There are LGBTQ+ clinics, centers and practices that feel safe when patients enter.”

“The majority of gender-diverse Americans aren’t going to those places because they’re not close by, so we take our chances by walking into offices that may or may not be affirming,” she said. “It is because we are in need of competent health care that we ended up in your office, but often, we have negative experiences before making it back to your exam room, so we ask that the physician be especially sensitive to that.”

“Research has shown that a lot of stigma and discrimination that’s experienced by LGBTQ+ people occur at the front desk,” said Dr. Nowaskie. “One of the easiest, quickest ways that you can be inclusive and affirming to the LGBTQ+ community is to have as much competency at the front desk as much as possible.”

This may include “asking your people at the front desk to take trainings, watching how they interact with all patients, how they make phone calls, how they leave emails and messages, if they’re asking people about their names and pronouns,” Dr. Nowaskie said. “All of these things can absolutely help improve the experience.”

“If you’re a physician who is competent and affirming, we want you to open your mouth wherever and whenever you get the opportunity to do so because we need the support and affirmation,” Dr. Lee said. “The political and health care climates are difficult, and we need your help.”

“We appreciate you seeing us one patient at a time, but your voice as a physician goes a really long way, so be an advocate as well.”