Enhancing Clinical Skills with Transgender and Non-Binary Patients

Dr. Turck:
Welcome to ACR Action Center on ReachMD.  I’m Dr. Charles Turck.  And joining me today to discuss strategies to enhance our clinical skills when taking care of transgender and nonbinary patients is Nathan Levitt, who is a nurse practitioner and director of LGBTQ and Gender Justice Learning at Yale School of Nursing.  Nathan will be presenting a session on this topic at the 2022 ACR Convergence. 

Nathan, welcome to the program. 

Nathan Levitt:
Thank you so much.  I’m happy to be here. 

Dr. Turck:
Well before we dive in, Nathan, can you tell us a little bit about your upcoming presentation at this year’s ACR Convergence? 

Nathan Levitt:
Sure.  So I have been doing transgender health care for about 20 years now.  I’m a family nurse practitioner, and I also teach LGBTQ and trans health at Yale’s nursing school to nurse practitioner students.  So I’m taking a lot of that knowledge and experience that I have and bringing it to the conference to speak, not only about general transgender health issues like definitions and terms, but also how does this relate to the field of rheumatology? How can healthcare providers and those within the field be more sensitive and clinically informed to take care of this community?  So that’s what I’ll be focusing on in the presentation. 

Dr. Turck:
And what are some current challenges that exist between healthcare professionals and their transgender and nonbinary patients? 

Nathan Levitt:
So there are many challenges, one of the most being that often transgender and nonbinary health care is not included in health professional education, so as a nurse practitioner myself, I never received information on the care of transgender and nonbinary populations within school or within my clinical practice, and so this was information that I really had to get on my own.  Luckily now, there are a lot more evidence-based information out there, publications, and protocols so that there’s more for healthcare providers to follow, but within medical school, social work school, health professional schools, and nursing schools, there really is very little knowledge and education on this topic, so what that does is it produces healthcare providers that really don’t know how to take care of this community.  So one of the biggest challenges is just lack of healthcare information on this population and lack of information around how to be sensitive and caring and welcoming, so that’s one big challenge. 

Another really large challenge for this population is the discrimination they face within health care.  So again, there’s not that information within health professional schools, and so patients are coming in, whether it be through rheumatology, whether it be through the emergency room, cardiology, primary care, whatever the case may be that they’re coming in for, they’re facing healthcare providers that are unaware of their health needs, and that can range from someone, let’s say, at the front desk who doesn’t understand why their name might be different than the name on their identification, why they might look different than their identification, too, a clinical care issue where it’s difficult to understand how to interpret gendered labs, or how to think about someone’s anatomy when they come in because we often really gender health care.  We’ve got women’s health care and men’s health care, and that is not a very open and welcoming place for transgender and nonbinary population, so experiencing discrimination gives a really high level of fear in the population coming in for care and then facing healthcare providers that are unaware of their health needs and a healthcare system that isn’t well equipped to take care of this population. 

Dr. Turck:
For those just tuning in, you’re listening to ACR Action Center on ReachMD.  I’m Dr. Charles Turck, and I’m speaking with Nathan Levitt about how clinicians may improve their clinical skills working with their transgender and nonbinary patients. 

So, Nathan, what strategies can healthcare professionals use when working with transgender and nonbinary patients? 

Nathan Levitt:
So there’s a few strategies out there.  Luckily, we are in a place now where we have some really great protocols.  So there are protocols from the UCSF Center of Excellence for Transgender Care where you can, as a healthcare provider, download for free on how to take care of patients that are starting gender-affirming hormones, such as testosterone or estrogen, that maybe are interested in gender-affirming surgeries, of which there are many different kinds of surgeries: genital surgeries or what we call top or chest surgeries.  And in those protocols, you can find out how best to do preoperative care, postoperative care,  or prescribing hormones.  And maybe if you’re not someone that is prescribing or feels comfortable prescribing hormones, you might be a rheumatologist where you’re not really sure how to understand the labs.  Often our labs come reported to us as male range and female range, and with our transgender population, so people that were assigned one sex at birth and now identify with a different gender, they may have medically transitioned in a particular way, taking hormones or surgery, so we might need to interpret those labs differently, or we might need to know how to use correct language for our patients. 

So something I do is I introduce myself to each patient saying, “My name is Nathan Levitt.  I use he/him pronouns.  What name and pronouns would you like me to use for you today?”  And I say that to every single patient no matter if I know that they’re trans or not because we don’t necessarily know by looking at someone if they are.

Another strategy is called an anatomy inventory. So instead of saying you’re a woman, you need this, you’re a man, you need this, we talk more about what body parts you have.  So if you have this body part, this is how you take care of it.  And that is actually helpful for everyone because we have non-transgender people or cisgender people who have different body parts related to, let’s say, cancer, accidents, or whatever it might be, so in actuality it’s really helpful for us to ask questions around what body parts people have versus gendering them so thinking about the education that is out there, the protocols that are out there, using sensitive language, asking pronouns and names that people go by, and then being clinically informed to really understand clinically what our patients are going through. 

So some strategies around language is, I’ve had providers and I do this as a medical provider, as well, ask patients what language they use for their body parts.    So this could be something as simple as saying chest instead of breasts for someone who really doesn’t identify with that or using different words for their genitalia.  It’s a very easy strategy and something that builds a lot of trust with your patients.  And it’s not just for our trans and nonbinary patients.  A lot of other patients have different names for their body parts, or they have experienced maybe trauma related to their body, so they would like to use different words and build trust with you. 

So that language piece is really important, asking all of your patients their names and pronouns that they go by, talking about their bodies in ways that feel comfortable for them, educating the rest of your staff, so we call it touchpoints basically, anywhere where the patient might come in contact with the healthcare system, whether it be a phone call from a registration desk, from the desk when they come in, to the nurse, the social worker, the medical provider, making sure each part is sensitive around language and around clinical care and really getting the resources that you need because they’re all out there now.  When I was in practice, we didn’t have protocols on trans and nonbinary care, and now we have UCSF, we have World Professional Association of Transgender Health, we have the American Endocrine Society, we have LGBT health centers, so we really have some great training opportunities out there for healthcare providers. 

Dr. Turck:
Before we conclude our discussion, Nathan, any final thoughts you’d like to share with our audience today? 

Nathan Levitt:
Well I’m really glad that everyone is here listening today.  I think that the most important thing is that you are aware of how important it is for this population to get quality, informed, and nondiscriminatory care.  Because we face very high rates, levels of anxiety, depression, and have a really hard time accessing the healthcare system.  So I know that all you healthcare providers out there are committed to quality, improved care for this population, and so really educating yourself, and even something as simple as putting a rainbow on your nametag goes a long way because it communicates to the community that you’re going to be a sensitive person to talk to.  So understanding what medical transition is, such as hormones and surgery, and understanding that for some people transition means using a different name, using a different pronoun, and just wanting to have their respect and affirmation, and so finding a healthcare provider that they can trust and that they can feel comfortable with is so incredibly important for them to take care of their health. 

Dr. Turck:
Well this has been a very informative look at the strategies clinicians can use to enhance their skills when working with transgender and nonbinary patients.  I want to thank my guest, Nathan Levitt, for sharing his insights. 

Nathan, it was a pleasure speaking with you. 

Nathan Levitt:
Thank you so much.  It was a pleasure to do this. 

Dr. Turck:
For ReachMD, I’m Dr. Charles Turck.  To access this and other episodes in our series, visit ReachMD.com/ACR where you can Be Part of the Knowledge.  Thanks for listening.