Stella has done a great job of making her new clients feel welcome. However, the forms the clinic uses have offensive or problematic language that is not inclusive of transgender people. Another problem is that Stella gets the correct name and appropriate pronoun, but the next person who sees the patient didn’t get that information. If a client or patient is passed from reception to intake to a nurse and then a doctor there are four different people who need to know this important information. Clinics need to create ways to pass this information on to the next staff member who will see the client. Put these in the chart or on the paperwork that is generated by the visit. At SFGH, put the name on the gold card.
In charts there needs to be a way to indicate the preferred name and the appropriate pronoun. This can be a challenge in EMRs/EHRs. You can create pop ups in some records that are reminders about upcoming health needs, tests, vaccinations, etc. You can use these fields, but people must know to look there.
These are examples of problematic questions on CBHS forms:
What was your name at birth?
Forms that list identities such as gay, straight, bisexual can be problematic as well.
Most people don’t want to be “other.” However, EMR’s and EHR’s have restricted choices around categories. So in CBHS, it is male, female, other and unknown.
Stella hands paperwork to Arnold to complete. He only gives his legal name and ignores the question about birth name. He marks M and crosses out other and writes in third-gender. He skips the question about sexual orientation. His partner is a woman who is a lesbian and so he is unsure how to answer the question since it only says gay, straight, or bisexual. These categories don’t fit for him.
Explain why you are asking what you are asking. Let clients know that you understand that there are problems with the paperwork and explain that these forms were designed by the State of California and we are required to use them. If they are offensive, say so. During intake include information regarding non-discrimination related to gender as well as information about filing grievances.
Later, when Stella does data entry, she is frustrated. Transgender people answer questions with choices she cannot enter onto the data screen. Sometimes it feels like working with transgender people is just too complicated.
It’s not the clients, it’s the forms. We have forms that ask questions that can be offensive. Sometimes these are not forms that an individual clinic designed, but are still required to use.
Stella doesn’t understand why Arnold makes such a big deal of it. She asks everyone the same questions. She treats everyone the same. Lots of people change their names.
It may feel trivial to Stella, but when an individual has worked for years to correct their name and leave that identity behind to live as their true self they may be bothered by the request for a birth name. Sometimes asking for AKA’s (Also Known As) can be offensive. It may feel as though the clinic is simply prying into a person’s background when they are no longer known by that name. Many trans people would prefer not to be reminded of their previous body or history. It also may have been entirely irrelevant in their life for decades. Never ask for a persons’ “real” name meaning their birth name. The same is true with their gender.
It frequently happens that once someone knows that an individual was at birth was assigned a different sex than their sex or gender now, providers may begin to use the wrong pronoun with that person.
Let the clients or patients know they have choices. They can choose to disclose information with their health care provider rather than completing the form in the lobby. Let them know that they can say: Decline to state. Use language on forms like “partner” rather than gendered language such as husband, wife, girlfriend, etc. In person, use non gendered language unless the patient or client uses those words.
Stella goes to her boss to say they must change their agencies’ forms. Gender diversity can be complicated, but she figures out how to manage it for her client’s sake. She advocates to make her clinic feel more welcoming and accessible for clients and easier for her to do data entry.
Designing new forms?
The two question version. This is the City’s current version.
1. What is your gender ?
2. What was your sex at birth? * see details below
This may give people the data that they are attempting to get.
Some clients are offended by the two question protocol. It can feel that the clinic doesn’t really accept their gender and this second question is a way to prove they are biologically different than the gender they say are. They may feel that the clinic is humoring them about their gender. It’s the issue of “you say you are female, what are you really. What you born as?” What are you really?” Remember, it may not be your intention, but your client has a lifetime history of medical care before she/he or ze has come into your office. Clients may be guarded.
Many people do not disclose to their provider that they are transgender for fear of being treated different or being discriminated against.
If you utilize forms like this, it is important to explain WHY you are asking for information that is intrusive. That the City needs to know how many people are receiving gender related services for increased funding and relevant care. Explain that these are demographics like race or ethnicity and it’s about improving care.
If you are creating forms consider language like:
another gender (NOT “other”)
You can attempt to list genders and leave blank spaces as well. It is impossible to list them all as our language grows and changes.
(Genderqueer, transman, masculine spectrum, transwoman, third gender, bi-gendered, omnigender, agender, both, neither, etc.)
Make sure people can make more than one choice.
You can also simply leave a blank line.
It is important that transgender clients or patients feel safe in the waiting room.
Stella is at the front desk and notices that John Smith, is staring in a hostile manner at Maria Chavez, a transgender woman. He is making her uncomfortable.
Your agency should already have a policy regarding intervention when there is a problem in the waiting room. For instance, call the therapist who is to see John Smith and have that therapist remove their client. Call the nursing supervisor and ask her to intervene. DO NOT REMOVE THE TRANSGENDER CLIENT if she/he/ze is not the aggressor. It is the person who is behaving inappropriately who should be addressed about their behavior and not the target of the behavior.
Someone may be upset by the presence of a transgender person in the waiting room, or in a group or in the bathroom, but transgender people are welcome everywhere in the City of San Francisco. Transgender people have legal rights to participate in the same activities that cisgendered people do.
Clients or patients can use whatever bathroom is appropriate. That is the law. Creating single occupant bathrooms can address the bathroom issue for many people. Even if you have an additional unisex bathroom, transgender people may choose to use the men’s room or women’s room. It is illegal to ask for ID from a transgender person unless you ask everyone for ID.
In truth, bathrooms are more dangerous for transgender people than for cisgender people. Many transgender people are assaulted and harassed in bathrooms. Negative interactions between patients or clients can occur in the restroom as a result of a patient policing the bathroom, deciding who is permitted and who is not. Many transgender people are so concerned about negative experiences in the bathroom they will avoid using public bathrooms. Imagine, not urinating all day because you are fearful of being harassed.
Reception staff are likely the people who will encounter complaints from patients about the bathroom. As with waiting room incidents, the program should have policies in place regarding the legal right of people to use bathrooms and how to intervene with patients.
If a transgender man wants to participate in a men’s group, he certainly may.
If a transgender woman wants to participate in a women’s group, she certainly may.
Remember, this another area where an accidental outing can occur if a receptionist says: “Maria, that group is for women only.”
People decide for themselves their own gender identity and groups must welcome transgender participants. This can be very upsetting to clinicians in various programs, particularly those who work with traumatized women. It can feel confusing when a woman’s group is filled with women who have been hurt by men and a transgender woman joins the group. A woman with a penis is reduced to simply a penis. In situations like this, education must be provided to staff and clients regarding gender diversity. Transgender women are women. Transgender men are men.
Policy and Advisory
Include transgender people on paid staff, management, boards of directors and in volunteer opportunities or other patient events sponsored by your program or clinic. It is critical to hire transgender people to provide services for the transgender community to increase access and comfort. It is also important for cisgendered people to have staff members who are transgender as well. Knowing a person who is different-whether that is race, gender, ethnicity or orientation/preference promotes comfort and reduces discrimination.
Actively solicit consultation about making policies and procedures transgender friendly.
Miscellaneous and Additional Information
Most people get their information (and mis-information) about transgender people from television. Be careful of stereotypes and assumptions about transgender people. There are stereotypes that transgender people are drugs addicts, mentally ill, sex workers, drama queens, entitled, that they have HIV, are uneducated and unemployed. Each person is an individual and not a stereotype.
Medical professionals who have gotten information about transgender people from studies will find work that is related to HIV because that is who was funding the studies. We don’t have lots of studies on people who are well functioning. Providers may know what they know from articles about people with HIV. Transgender people, particularly women of color and people who are perceived to be transgender are often among the people who are the most stigmatized and discriminated against. If you can’t work, you cannot feed or house yourself. People are forced into survival sex. GID remaining in the DSM reinforces the idea that transgender people are mentally ill.
Do not use transgender patients or clients to educate you. “Is it true that…? Have you had…? How did you choose your name?” A transgender person in the clinic is not an educational opportunity.
Be professional in your interactions with all patients. Be careful of platitudes or statements such as “I know someone who is transgender. I have no problem with you people, some of my best friends…” “I would never have guessed. You are so brave. I think transgender is … I believe you are a man (or a woman.)” Never say that you can see the male or female in the person. They may have worked hard to bury any aspect that could be perceived as the opposite of their gender identity.
Be respectful and do not inquire about whether or not a person has had or intends to have surgeries or about their body parts. This could be construed as sexual harassment. It is human to be curious, remember you can ask questions of the training committee.
Often in almost casual conversation, people offer advice or opinions about what procedures they feel a client should or should not consider. Sometimes staff members will offer advice or criticism on the choices patients have made. This should be avoided as it can be very problematic for clients. “I don’t think
Watching clients transition their bodies from male to female or female to male can be an incredible experience. In talking with other people, you might want to discuss your beliefs about whether a person “passes” or what their “real” gender is. It’s important to avoid this. Finally, unless a patient asks you for grooming or fashion advice, it is best not to offer tips or ideas. The patient needs to move at his or her own pace and will have their own ideas about how they want to present.
Despite your best attempts at welcoming a client, he/she/ze may still be guarded or distrusting of you. Do not take this personally. Remember, many transgender people have been refused care or poorly treated by medical and mental health providers. Your patients may simply be protecting themselves. By demonstrating that you are trustworthy and professional, very like over time your patient will relax with you.
(3) Trans Male
(4) Trans Female
[Survey forms would include options 1-5. Coding should also allow for options 6 and 7]
(6) Declined / Not stated
(7) Question Not Asked
 These definitions should be considered as being fluid rather than static variables.
(1) Male – the behavioral, cultural, biological, or psychological traits typically associated with males
(2) Female – the behavioral, cultural, biological, or psychological traits typically associated with females
(3) Trans Male – transgender men, transmasculine, or transmen, sometimes referred to as female-to-male or FTMs
(4) Trans Female – transgender women, transfeminine, or transwomen, sometimes referred to ‘male-to-female or MTFs
(7) Question Not Asked – this category allows the provider to mark ‘Question Not Asked’ if the sex or gender question was not asked in an effort to alleviate any provider assumptions.
2. What was your sex at birth? (Check one)
[Survey forms would include options 1-2. Coding should also allow options 3 and 4]
(3) Declined / Not stated
(4) Question Not Asked