Introduction to the idea of this guide
The front desk sets the stage for the experience that clients or patients will have in a medical or therapy office. They are the social face of a practice and create the first impression. While there are trainings for nurses or doctors or therapists, the administrative staff is ignored. Administrative staff who want to be professional and do good work encounter practical issues due to unfamiliarity and discomfort. Paperwork and data entry issues can be frustrating as well and cause problems at the front desk or at intake.
This guide is a living document, and if you identify errors, misunderstandings or misstatements, please feel free to email me and I will make changes. If you looked at this 2 weeks ago, it is now slightly different. Criticism is always welcome.
This guide is product of many hours listening to clients express pain and anger over barriers to receiving adequate health care and being mistreated and at time humiliated. This document was also informed by transgender friends, colleagues and acquaintances, and reading everything I could find. Thus, it is the product of the community. It is being offered back to the community to use.
This document will use vignettes to follow two clients and a receptionist/data entry person through some common problems that arise.
Best practices for office and intake staff serving transgender patients and clients
Lack of familiarity with gender non-conforming, transgender and transsexual people interferes with general professionalism and politeness. Staff may be uncertain what is appropriate to say and to do. Another significant barriers for reception staff, medical, and mental health providers is the fear that they will do or say something offensive. When people try too hard they often make mistakes because they are self-conscious. A little bit of information can make us behave unnaturally.
Clients or patients may misread this discomfort and assume the staff member is uncomfortable with them as a person rather than that the staff member is unsure or overcompensating in an effort to not be offensive.
Using gender neutral language can take some practice. It may feel awkward. Each person has to find their own way of asking sensitive questions using words that work for them. Having considered the possibilities of interacting with transgender patient ahead of time can assist staff to be prepared and increase their comfort.
A final issue is that in public health, we’re very busy and overworked. When we are rushing we are likely to make errors. Our society is very polarized in terms of gender and sex. We are raised to believe that there are males and females. Males look like we have been socialized to expect men to look and sound like we expect men to sound. The same is true for women and females. Over the phone we think we hear a man’s voice but it is a woman. We have to slow down and think before we respond. That is hard is busy jobs.When we have to go against our socialization and we are rushing, it’s easy to make mistakes.
Stella works at reception and data entry at a clinic. She is a professional and is respectful of patients and clients. However, she is anxious that she will unintentionally say something wrong to a transgender client.
Maria Chacon is a transgender woman who is currently transitioning. She is someone who many people would perceive to be transgender and is very tall. She came today because she has had the flu for two weeks.
Arnold Johnson is a masculine appearing transgender man who transitioned ten years ago and is visually indistinguishable from cisgender men. Arnold is at the clinic for a pap smear.
Maria does not feel well today. On the way to the clinic, she was harassed by someone asking if she were a male or a female on the bus. When she refused to answer, that harasser called her “he/she” and faggot. Maria wandered around looking for the clinic instead of asking for directions because she was afraid someone might be rude or hostile to her again. By the time Maria gets to Stella’s desk, she is agitated.
Be welcoming. Smile.
Transgender people are often discriminated against so going the extra mile can help a person feel at ease. You may be the only person who has smiled at this client today. Remember, she is here because she doesn’t feel well or needs help. It may have taken a lot of courage for her to come in today given that medical and mental health providers have often treated transgender people poorly. It may help to think about how you want to be treated when you are at the doctor’s office when you don’t feel well or need help.
Stella smiles and Maria feel more comfortable. Stella is not sure if looking at Maria will be misconstrued as staring. If she makes brief eye contact and looks away, she worries the client may believe she is uncomfortable and transphobic. If she looks too long, maybe the client will think she is being rude. Stella is not sure how to behave.
Stella knows that Maria is transitioning and that people likely stare at her a lot. A person is in the process of transitioning may feel very vulnerable regarding appearance and that effects both self-esteem and self-concept. Genuinely smiling and connecting with the client non-verbally will let her know she is welcome. A receptionist who smiles and says hello and genuinely welcomes a person matters a lot. Eye contact matters. Some people who are perceived to be transgender get used looking down so that they don’t see people sneering and snickering.
Everyone is different. Some transgender people are invisible to gender scrutiny and other people are perceived to be transgender. Some people are in the process of transition and may have physical characteristics of both sexes. (Men with breasts and beards, women with five o’clock shadow and fashionable dresses.) Some people identify as both male and female, neither male nor female or another gender. Some people do not want anyone to know they have a transgender history and others don’t care if anyone knows or they may want people to know. Gender identity can feel complex in our binary world, but we don’t have to fully understand every nuance to do our jobs well and be professionals.
Stella is trying to make Maria comfortable but worries she will do the wrong thing. Concretely, treating Maria the ways she would want to be treated when she is at the doctor’s office because she feels sick is a good place to start.
Stella, the receptionist, is being kind and welcoming, but Maria is defensive and distrusting.
Many people have been harmed by medical and mental health providers. Some people feel held hostage by healthcare providers, that they have to put up with substandard care or abuse in order to receive necessary medications (hormones) or access to needed medical procedures like referrals for gender related surgery. Patients or clients may have a healthy cultural paranoia. Over time, your clinic will have the opportunity to prove that you truly care about appropriately serving transgender people.
Before today, Stella didn’t think transgender people used her clinic.
Don’t assume there are no transgender people in your practice or office—rather assume there are and you want to make them feel at ease. Transgender people need all the same sorts of medical care that cisgender people. Remember, not everything is related to gender identity.
Make sure your reception and waiting area is welcoming.
Photographs, posters, flyers, handouts, magazines and patient education materials should reflect the diversity of your patients, including transgender, transsexual and gender non-conforming patients. For instance, transgender flags, resource guides, and information about events such as Transgender Day of Remembrance or the Trans March. You can post a sign that explicitly states that transgender, transsexual and gender non-conforming people are welcome in your clinic.
Names and Pronouns and Medical Records
When speaking with a client or patient, use the name and pronoun that a client or patient requests—even if it is NOT their legal name or the name on their chart. While we want to ensure that no medication or clinical error is made related to the wrong person, it is also our job to help people feel comfortable and at ease in our clinics. Imagine if your doctor refused to call you by the name you requested.
The name a person requests the clinic to use and the appropriate pronoun should be on the intake paperwork. The paperwork a client has completed may assist you what to say.
If you are unsure of what pronoun to use, ask the client politely: “What pronoun is appropriate?”
Notice that it is appropriate and not preferred. Most transgender people do not feel their gender is a preference, rather it is intrinsic to who they are.
There are at least two schools of thought regarding asking about pronouns.
You could base it on how a person is dressed. A person in a dress is female, for instance and you would automatically use female pronouns and honorifics, she and Ms. If someone is wearing a dress and you ask what pronoun is appropriate, she may feel you are indirectly pointing out that you do not believe she is successful as appearing female. If you guess based on how the person is dressed that may mean you guess wrong at times. Increasingly, people are not binary in their presentation.
Ask every new client or patient what name they prefer and what pronoun is appropriate. If you only ask the people whom you believe are transgender, you are indirectly outing them to anyone who you haven’t asked. You are treating them differently than cisgendered patients related to name and pronoun use. We cannot tell gender by looking or by how a person dresses, wears their hair, how they sound or by their name.
There are also a variety of pronouns that people use, some of which you may not have heard of: Ze, Hir, Shim, They, etc.
Stella is uncomfortable asking a woman with a baby or a man with a beard what pronoun they prefer. It seems silly.
Arnold, a transgender man with a full beard, knows when is is asked this question that the clinic is trying to be respectful. Jane Doe, another patient, has a child who is gender non-conforming. When Stella asks her about name and pronoun use, she knows she can take a risk and tell the doctor or therapist about her child. It can be an educational experience for cisgendered people that there are transgender people using the same services and this models respectful treatment.
It is possible that someone might be offended when aked what pronoun they prefer. If Maria spent all morning getting ready and felt she looked her best and then is asked that question, she might feel like everything about her dress and manner says “female.” She wonders why are you asking. When she hears that Jane and Arnold are asked the same question, she knows that it is simply part of the sign in procedure at reception. Having an explanation at hand can be helpful.
Stella explains: Our clinic has a diverse group of clients and we try to ask new patients in order to avoid making assumptions.
Policies regarding name and gender change in your records
It is important to be familiar with your clinic’s policies about names and medical records. Electronic health records can be particularly problematic.
Patients may ask office staff to make changes to names and pronouns in patient records. Knowing the clinic policies is important so that patients won’t feel discriminated against if receptionists don’t have the power to make those changes. Office staff can provide clients with the information they will need to in order to make those changes.
Each patient and their provider must make a decision about whether and when to have pronouns changed in medical records. There are implications in different healthcare systems for making those changes. For instance, for an FTM with a family history of cervical cancer, who may need frequent pap smears, changing his pronoun to “M” in his medical records may lead to problems with reimbursement in healthcare systems. For that reason, it is important to consult with your managers before making changes related to names and pronouns, even if a client or patient asks you to do so.
When referring to a client or patient
When speaking with others about the patient use the name they have given you and the appropriate pronoun. Generally, there is no reason to use the word transgender to describe a person. “There is a transgender patient in the waiting room” becomes “your 3:30 appointment is here or “Ms. Chacon is waiting for you.” When you are unsure of the correct name or pronoun, you can simply speak generally. If you need to refer to the client or patient, and you are unaware of an individuals pronoun, you can say “Your appointment is here.” “Your patient is waiting.”
Never use the term “it,” when referring to a person. That may seem like a ridiculous and obvious thing to say, but we have received records from other programs that refer to clients in this way. When calling for a patient in the waiting room, you can use their last name instead of using a gendered first name. This would need to be a clinic wide policy.
When English is not the primary language for staff members, it can make this even more complicated. Some languages don’t have genders and others have gendered nouns.
If you make an error, apologize (or fix it) and move on.
Stella accidentally referred to Maria as he when she was looking at Maria’s records. She looked at Maria and said, ‘I’m sorry,’ and then used the appropriate pronoun ‘she’ in her interactions after her mistake. Maria is not upset and is pleased that Stella apologized.
Many people over-apologize when they made a mistake or they might freeze. Both of these behaviors can end up shining a spot light on the person they are talking with.
Don’t make the patient responsible for your discomfort.
If you find yourself making an error regarding pronouns or names repeatedly, seek supervision or support. This is important. Some people harass transgender people by intentionally using the wrong name or pronoun. It’s like saying “you think you’re a woman, but I will decide whether you are.” Using the wrong name or pronoun may be construed as harassment. It’s against the policies of the City and County of San Francisco to intentionally use the incorrect pronoun or name.
If you do not hear a person’s name, don’t guess, ask again. This is especially important on the phone. Some names are considered male or female. Robin sounds like Robert and you can offend someone by guessing they are male when they are working hard to have their voice in the female range.
Frequently, mistakes happen because we are rushing and not thinking. It’s important that we slow down and concentrate because we are going against how we have been trained to perceive men and women. (Male voice, female voice, appearance, etc.)
Do not use transgender as a noun and in general avoid using it as a description. It is an adjective, a part description of a person, like tall, dark and handsome or artistic and smart. The word “Tranny” is generally felt to be offensive. The word hermaphrodite is not used anymore. “He/she” is offensive to many people, but not all. Generally, it’s best to avoid language like this. In working with a client, it is important for providers to use the language a client or patient uses.
Sometime a word may be technically incorrect, for instance is a client says my husband when she is not legally married. Correcting the person in an effort to be accurate legally can be very disempowering and insulting and ruin your relationship with the client. We want to honor people’s experiences and relationships, regardless of whether the law does or not.
Accidentally “outing” a client
Be careful not to accidentally out a client or patient. Their gender identity is considered protected health information and outing a person can be a violation of HIPAA. You may also be placing the person at risk. While you may be welcoming of people who are transgender, there are people who are violent towards transgender people.
How accidentally outing happens
In an effort to be helpful or to ensure documentation or procedure-related coding errors don’t happen, you might accidentally out someone.
“Oh, Arnold you are here for a pap smear, there must be a mistake.”
“Maria, it says you’re due for a prostate check, that must be an error.”
“Maria, this is the women’s clinic. The transgender clinic is Tuesday.”
Staff members may mistakenly assume that a transgender person only wants care in a transgender specific program. Some people want to be seen in the clinic closest to their home, or the one that speaks their native language. Other people may be more comfortable in transgender specific programs.
Writing on a white board where people get their health care can accidentally out clients. If you have a male client who goes to Lyon-Martin Health Services, you very likely have outed them if you have their name visible with Lyon-Martin, a clinic for women and transgender people.
Stella thinks Arnold should be out and proud of who he is rather than hiding as a man.
It’s up to clients to decide who they are and with whom they want to share information. We may be well-meaning but we can create pressure on people when we encourage them to be “out.” Being “out” is the patient or client’s choice.
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