By Hala Helm, JD, MBA, CPHRM, DFASHRM; Josh Hyatt; and David M. Sine
Transgender individuals face ongoing scrutiny and judgment by individuals and society, including in healthcare. This mistreatment is often linked to long-standing heteronormative and gender-normative paradigms (personal and social beliefs and/or experiences), as well as operational constraints (e.g., policies, forms, and a lack of diversity training). How should hospital admissions of transgender persons—which we readily acknowledge is an imprecise umbrella term—be addressed to ensure fair and equal treatment, respect patient autonomy, and provide quality care? These issues challenge healthcare providers and risk managers because not addressing them can result in a distrust of the medical team, a reluctance to disclose critical healthcare concerns out of fear of retaliation or embarrassment, and a greater risk of patient dissatisfaction and litigation.
Submitted for your consideration are strategies to mitigate these risks and provide care that is fair and just.
The beginnings of biomedical ethics, and the subsequent relationship between ethics and risk management, vary depending on who is telling the tale. One version ties the origin of bioethics to the Oath of Hippocrates, dating from the fifth century BCE. Another version names the starting point as Thomas Percival, who in 1803 published a code of medical ethics. Still another locates it more recently, with the initial meeting of the AMA in 1847. No matter the narrative, we agree with Albert Jonsen, who may have had as much to do with the origins of the profession as anyone: Disciplines like biomedical ethics and risk management are not born, but grow slowly, gradually taking a shape distinct enough to merit a name (Jonsen, 2003). However, events in medicine have shaken our understandings and assumptions so profoundly that they have necessitated a change in the trajectory of ethics and risk management. One such event was the invention of the mechanical respirator, which caused physicians and theologians to rethink the definition of what it meant for a person to be alive. If mechanical respirations could be provided almost indefinitely, under what circumstances could they be curtailed? By whom? What would Hippocrates have to say about that? We continue to visit these unresolved issues today in our discussions regarding access, end of life, and futile care—all of which are chapters in many risk management texts.
A more recent change has been triggered by the perfection of the human genome (a project launched in 1988), which allows us to have our genes analyzed. If the advertising is to be believed, such analysis is intended to clarify ancestry, but what of the discovery of medical issues? Should the tissues provided never be used to obtain health information? Should a customer not be told of, for example, an increased risk of breast cancer if that risk is tangentially discovered? Is the “right to not know” an irreducible result of patient autonomy?
Tectonic shifts such as these force risk managers to balance legislative requirements and ethical standards. But bioethics are imperfect and often without answers that can be translated to a hospital operational environment. We are also in the midst of another shift that will require risk managers, medicine, and organizations to revisit some long-held assumptions and to be prepared for a protracted period of uncertainty. That shift is the challenge of providing care to transgender patients—which, if not done in an open, authentic, and patient-centered manner, may present unique situations and clinical questions, as well as a potential increase in liability.
To this end, it is important that the risk manager is aware of the ongoing plight of transgender individuals, linked both to paradigms of heteronormativity and gender normativity as well as operational constraints (Roberts, Rosario, Corliss, Koenen, & Austin, 2012; Harrison, Grant, & Herman, 2012). Prevailing social science holds that both sexual orientation and gender (an individual’s self-identified view, not necessarily their biological sex) can be fluid throughout one’s life. Institutional heteronormativity and gender normativity, meanwhile, are the rules and policies that promote the primacy of traditional sexual orientation and gender identities, and that emphasize the notion of distinct gender roles. This will often play out in micro-messaging to gender nonconforming individuals (e.g., tone of voice, misuse of pronouns, and language on forms) that is subtly diminishing and disheartening. In aggregate, these barriers can foster distrust of care providers, leading affected individuals to potentially not disclose healthcare concerns and making dissatisfaction and litigation more likely (Harrison et al., 2012).
The on-again, off-again federal policies on transgender military service have placed a spotlight on the issue of gender identity. How should hospital admissions of transgender persons be conducted to ensure respect, fairness, and equality, not to mention high-quality care? For risk managers, the discussion must go beyond the question of which bathroom patients should use, which has clumsily been addressed by legislative actions. This is not to suggest that the bathroom issues are superficial—they require thoughtful deliberation that considers the rights and mores of staff, patients, and the community. The Veterans Health Administration (VA), for example, has issued several policy documents clarifying that federal facilities are exempt from the state legislative actions that impact the communities in which VA hospitals are located. Assumptions regarding normativity in a community may (or may not) change depending on where one stands when asking the question (Veterans Health Administration, 2018).
We offer for the reader several abbreviated case studies that, while not terribly alarming, should demonstrate that hospital risk, safety, and ethics committees have preparation and reflection to do. But first, some definitions.
Transitioning: This is the broad term used when a transgender individual is changing their gender, which is a multifaceted process. Understanding some of these facets can help develop policies and programs for working with transgender patients. There are three principal components (legal, social, and medical) that can be focused on.
Legal transition: This process includes updating the information on documents such as one’s driver’s license, birth certificate, and insurance cards. Approximately 21% of those who have transitioned update all of their information, and 33% do not update any of their legal documents.
Social transition: An individual’s gender is acknowledged both on a personal/familial level and on a broader social level. The social transition is often coupled with reports of victimization and fear of rejection, isolation, and stigmatization. Therefore, a patient might identify as a specific gender but have identification and insurance information with a different name, for example.
Medical transition: Medical transitioning is the point at which a transgender individual enters the healthcare realm in need of treatment, preventive care, and/or support to help match their external body with their internal sense of self. In this capacity, providers can be faced with patients requesting hormone replacement therapy, puberty suppression treatment, support counseling for gender dysphoria, and gender affirmation surgery (plastic surgery).
Gender dysphoria: This is the diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) for persons who experience distress related to an incongruence between the gender with which they identify and their birth sex. Not all transgender people meet the full criteria for this diagnosis.
Case studies (briefly)
A patient enters the emergency room complaining of abdominal pain. The EHR identifies her as female, but she has male sex organs. This results in a misunderstanding that delays the patient’s diagnosis and treatment, plus puts her at risk for a patient identification error.
Risk mitigation: EHRs are traditionally binary in nature and lack gender markers for self-identification. To address this, ensure that both the patient’s sex and gender are understood by the clinical team and documented appropriately in the medical record. The risk manager should consider educational programs and processes that support patient rights and give staff the awareness to appropriately engage and support transgender patients. Include contract staff in this education (Association of American Medical Colleges, 2014).
A patient contacts a hospital security guard to report a male in the women’s bathroom. When the guard enters the bathroom to investigate, he sees a transgender woman exit the toilet stall and begin washing her hands. The guard tells her she must leave the women’s bathroom and only use the men’s bathroom.
Risk mitigation: Patients may experience discrimination from a myriad of individuals during a healthcare encounter, not just the healthcare team itself. In this case, the risk manager reviewed the event, reached out to the transgender woman, and apologized. She was invited to be part of the Patient and Family Resource Group; she joined and has worked to provide training to staff, physicians, and contract employees. Establish cultural competency programs for physicians, staff, and the community. Make the facility an open and accepting place for transgender patients and family members. Review your policies and ensure that they are inclusive. Invite transgender leaders in your community to address micro-messaging your facility may not be aware of. Contact the Human Rights Campaign Foundation to learn more about the Healthcare Equality Index, a national benchmarking tool that evaluates policies and processes related to the equality and inclusion of LGBTQ patients, visitors, and employees (Human Rights Campaign Foundation, 2019).
The staff at a women’s clinic are confronted with atypical procedures regarding the transgender patients seen at the clinic. They are unsure which screenings are appropriate to conduct (e.g., prostate exams) or not to conduct (e.g., Pap smears) for these patients.
Risk mitigation: There must be a process in place to ensure that appropriate screenings occur for every patient (Department of Veterans Affairs, 2011; Coleman et al., 2012). Female-to-male transgender patients who have not had a total hysterectomy or reconstructive “bottom” surgery are at high risk of cervical cancer because screenings are often not considered or requested. Male-to-female transgender patients have a high risk of prostate cancer for the same reasons. If an EHR gender field is being used to determine sex-based medical health screenings, this can present a challenge. Maintain a system to recommend medical screenings based on a patient’s prevailing health risk factors. Split the EHR’s gender field into “birth sex” and “self-identified gender identity” (SIGI) fields. Use birth sex for determining sex-based medical health screenings and SIGI for addressing the patient.
A post-orchiectomy patient changes their mind and wants their testicles “re-implanted” several years after surgery.
Risk mitigation: Ensure and maintain proper documentation of all pre-screenings and evaluations, including required psychiatric evaluations. Conduct comprehensive informed consent discussions that address risks, benefits, and alternatives, including nonsurgical options. Provide supplemental patient education on the specifics of all procedures performed, addressing their permanence or potential for reversal, if applicable. Informed consent discussions should be well documented and reflect understanding and acceptance by the patient.
A patient transitioning from male to female calls a plastic surgeon’s office to request breast augmentation consultation. The surgeon cancels the consultation, stating that he “doesn’t do transgender patients.”
Risk mitigation: Physicians should educate themselves on similarities and differences in this patient population. Health networks should invest in training and resources for physicians who have interest in serving transgender patients but insufficient experience (Association of American Medical Colleges, 2014). Referral networks of LGBTQ-experienced physicians should be developed in advance. Scripting for staff and physicians should be prepared prior to referrals to ensure appropriate messaging to patients.
LGBTQ patients have difficulty finding primary care physicians with relevant expertise (sexual health, endocrinology, etc.).
Risk mitigation: Health networks/groups should query physicians on their experience and interest. Create an interface to connect patients with LGBTQ-friendly doctors. Help connect interested and experienced physicians with community resources. According to the Virginia Transgender Health Initiative Study (2013), many transgender individuals need but do not receive:
> Hormonal therapy support, resulting in approximately 60% of male-to-female transgender patients using non-prescribed hormones
> Transgender-related surgery
> Birth sex cancer screening exams
> Mental health support services; approximately 40% of transgender patients attempt suicide at least once in their lifetime compared to the general population statistic of 4.6%
> Critical gynecological care
We offer these case studies as a starting point for conversation and discussion. Obviously, the list above is neither exhaustive nor exclusive. But because transgender individuals face widespread stigma, discrimination, and care disparities (Horrom, 2017; The Joint Commission, 2011), can anyone doubt that a greater understanding of their experiences in healthcare systems would inform future efforts to improve care?
Hala Helm is vice president of risk, compliance, and legal at Palomar Health. Josh Hyatt is executive director of integrated ethics at Keck Medicine, University of Southern California. David Sine is a certified professional risk manager and former federal executive with experience in multiple disciplines including enterprise risk management, organizational ethics, high reliability, and patient safety.
The authors declare that they have no conflicts of interest and received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Further, this article is an opinion piece and no research subjects, PII, or PHI are involved. The article, therefore, does not require informed consent or survey instruments. Since no identifiable information was gathered or analyzed, there is zero risk of a data breach, and the article meets one of the categories for exemption from IRB review since it is not research as specified in federal regulations.
Association of American Medical Colleges. (2014). Implementing curricular and institutional climate changes to improve health care for individuals who are LGBT, gender nonconforming, or born with DSD: A resource for medical educators. Washington, D.C.: Association for American Medical Colleges.
Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., … Zucker, K. (2012, August 27). Standards of care for the health of transsexual, transgender, and gender non-conforming people, version 7. International Journal of Transgenderism, 13(4), 165–232.
Department of Veterans Affairs. (2011, May). Management of transgender veteran patients. Patient Care Memorandum 11-046-LM.
Harrison, J, Grant, J., & Herman, J. (2012, April). A gender not listed here: Genderqueers, gender rebels, and OtherWise in the National Transgender Discrimination Survey. LGBTQ Policy Journal at the Harvard Kennedy School, 2, 13–24.
Horrom, T. (2017, September 6). Study: Majority of transgender veterans satisfied with VA care. VA Research Currents.
Human Rights Campaign Foundation. (2019). Healthcare equality index 2019. Retrieved from www.hrc.org/hei
The Joint Commission (2011). Advancing effective communication, cultural competence, and patient- and family-centered care for the lesbian, gay, bisexual, and transgender (LBGT) community: A field guide. Oakbrook Terrace, IL: The Joint Commission.
Jonsen, A. R. (2003). The birth of bioethics. Oxford, New York: Oxford University Press.
Roberts, A. L., Rosario, M., Corliss, H. L., Koenen, K. C., & Austin, S. B. (2012, March). Childhood gender nonconformity: A risk indicator for childhood abuse and posttraumatic stress in youth. Pediatrics, 129(3), 410–417.
Veterans Health Administration. (2018). Providing health care for transgender and intersex veterans. VHA Directive 1341.