Creating an Inclusive Space

Guidance for creating a more inclusive practice for your gender-diverse patients

When a person who identifies as transgender or non-binary comes into your clinic, health care may not be their biggest concern.

Studies suggest that gender-diverse patients may have already had a harrowing health care encounter, one in which they may have been dismissed as confused, seen as a curiosity or outright rejected. Most of us do not think we are biased, but we all carry unconscious biases that can influence how we interact with others.

As a result of being subjected to previous trauma and microaggressions, patients may approach health care interactions in a guarded and wary manner.

“This makes it so critically important that physicians create an inclusive, non-judgmental environment, where people feel safe to come forward and are able to talk about the health issues they are dealing with,” said Dr. Alex Abramovich, an Independent Scientist with the Institute for Mental Health Policy Research at CAMH, and an Assistant Professor at the Dalla Lana School of Public Health and the Department of Psychiatry at the University of Toronto.

Dr. Abramovich, a transgender man, has been addressing the issue of Two Spirit, lesbian, gay, bisexual, transgender, queer and questioning (2SLGBTQIA+) youth homelessness for almost 15 years. He investigates the health and social inequities experienced by 2SLGBTQIA+ individuals, with a focus on understanding and improving the health and service needs of these youth and young adults. One of his recent studies, for example, found mistrust in the health care system and previous traumatic experiences engaging with health care providers were leading reasons why transgender young people (16-29 years) chose not to get a COVID-19 vaccine.

Perhaps the biggest reason for the alienation is that some health care professionals continue to pathologize transgender people. It’s a perspective that Dr. Abramovich describes as transphobic and inappropriate. A psychological state is considered a mental disorder only if it causes significant distress, impairment of personal functioning or disability. Identifying as transgender is not a mental illness, he said. For many transgender individuals, distress typically experienced within the context of health care lies in accessing gender-affirming care — such as hormone therapy, medical procedures and finding a health care environment that allows them to freely express their gender identity, he said.

Some transgender individuals have no desire to medically transition, but even those who choose to move forward with hormone therapy or gender-affirming surgery(ies) or both, can be treated within a primary care practice. Using educational tools, such as those produced by Sherbourne Health and Rainbow Health Ontario, primary physicians have access to the resources required to confidently initiate and monitor hormone therapy and assess referral for surgery.

“Having a physician that you can trust and speak openly with and feel respected by can be life-saving.”

“Gender affirming care leads to improved quality of life, it leads to improved mental health and well-being. It’s so important, but unfortunately, it continues to be a missing component for so many trans people,” said Dr. Abramovich.

Use inclusive intake forms that allow patients to self-identify their gender identity, their name in use, and pronouns (Not Male/Female/Other). The easier it is for 2SLGBTQIA+ patients to complete the forms with answers that reflect who they are, the likelier it will be to promote a sense of trust and the more forthcoming they will be in discussing their issues of concern. The Center for Excellence in Transgender Health has a template form that health care professionals can use.

“The questions asked on intake and registration forms, and surveys truly matter. Not only can these questions help people feel welcome and safe, but they can help us collect important data so that we can better understand the health needs of the transgender population,” says Dr. Abramovich. See below: “Higher Rates of Co-Morbidities Found in Trans Patients.”

Train Front Staff. Issues and concerns experienced by transgender patients often arise at the front desk and in waiting areas because those are the first points of contact for most patients. However, these issues can be prevented by training all staff in some basic principles and strategies.

If you have single-stall bathrooms, they can easily be converted to “all-gender” bathrooms rather than designating one for men and one for women, which can be uncomfortable and difficult to navigate for transgender and non-binary patients. All-gender bathrooms create a more inclusive space for all patients.

When greeting a new patient, introduce yourself and your pronouns. Then ask the patient what name they would like to be called and what pronoun they go by. It is important to understand that some patients may be struggling with coming out or disclosing their identity and may not have an answer for you. If some patients are puzzled by your question, explain that you ask all patients these questions to ensure that everyone can self-identify and because not everyone’s OHIP card aligns with their identity.

Broach the issue of pronouns with patients you have had in your practice for years. “Gender identity can change over time. So, just because someone identified as a woman at one point in time doesn’t mean that they’re always going to identify that way. I think it’s important to also let long-time patients know that you are open to speaking about changes in their gender identity,” said Dr. Abramovich.

Only ask questions pertinent to health care and explain to the patient the medical rationale for asking certain questions. Asking questions to satisfy curiosity or to develop professional knowledge is not appropriate or professional. “It’s not the patient’s job to educate you. And asking them to do that is the opposite of creating an inclusive environment,” said Dr. Abramovich.

Ensure their privacy. Not all transgender individuals are comfortable disclosing their identity publicly. Ask permission to include information about a patient’s sexual orientation and/or gender identity in their medical record, remind the patient of its importance to quality health care and assure the patient that the information will be kept confidential.

If a patient wishes to medically transition with hormone therapy and/or transition-related surgery(ies), and you don’t have the competencies to enable you to provide gender-affirming care, then refer to or consult with a physician who does. Don’t question whether the person is “trans enough” to be a candidate.

When a child or adolescent tells you that their gender identity differs from their sex assigned at birth, take them seriously and do not suggest that they are “going through a phase.” Respect the fact that they feel safe enough sharing this information with you. “Keep your practice a safe space for this person and let them know that you look forward to having an ongoing conversation with them about their concerns and desires for the future,” said Dr. Abramovich.

In the end, says Dr. Abramovich, it all comes down to respect. “It’s not complicated. Whether the patient is 10 years old or 50 years old, each person knows their own body best and should be respected in their self-identified gender. A person’s name, pronouns and gender identity are never up for debate. Having a physician that you can trust and speak openly with and feel respected by can be life-saving.”

Higher rates of comorbidities found in trans patients, study

Transgender individuals in Ontario are more likely to experience chronic health conditions and have higher health service use than the general population, a recent study found.

Lead author Dr. Alex Abramovich says the study demonstrates both the need to provide transgender competent and inclusive health care, and the need to improve the capacity to identify transgender individuals in administrative health data, so the factors underlying the high rates of disease burden can be understood.

The large cross-sectional study of 2,085 individuals was published in JAMA Network Open.

Dr. Abramovich says the impetus for the study was the lack of data on gender identity and limited information on transgender health. “The lack of information presents a challenge to health care professionals as we try to determine how to provide transgender people with the best possible care.”

Previous research has either relied on data from self-reported surveys, making it difficult to understand health care utilization patterns and health outcomes among transgender individuals, or on provincial health care data — including OHIP, which uses sex designation instead of gender identity, thereby not reliably identifying transgender individuals.

Specifically, it found higher rates of asthma, COPD, diabetes and HIV, and greater rates of mental health comorbidity.

The researchers linked primary health data from four clinics specializing in serving the transgender population. Dr. Abramovich explained that because the clinics collect data on self-defined gender identity, a more accurate picture of the health conditions that affect the transgender population was able to emerge.

While previous research has indicated that transgender individuals may avoid health services, Dr. Abramovich’s study shows transgender individuals use health services at much higher rates than the general population.

Specifically, it found higher rates of asthma, COPD, diabetes and HIV, and greater rates of mental health comorbidity. Transgender individuals were much more likely to see their primary care physician, visit the ED and be admitted to the hospital, particularly for mental health and self-harm-related reasons, compared with the general population.

The study assessed transgender individuals who were attached to primary care, some of whom may have been actively medically transitioning either through transition-related surgery and/or hormone therapy, which may explain primary care physician visits. “However, the high rates of ED visits are worrisome in the context of primary care physician attachment, especially given that all participating clinics specialized in transgender health. The higher rates of health service use for mental health and self-harm-related reasons may reflect the health service manifestation of stigma and discrimination,” said Dr. Abramovich.

The study found transgender individuals are more likely to live in lower-income neighbourhoods and receive lower income, as determined by a higher prevalence of low-income markers, such as usage of the provincial drug plan.

The study’s results and conclusions provide valuable feedback to clinicians who have transgender patients. It makes evident that it is essential for caregivers to identify a patient as transgender, and then remain mindful of their unique health needs as members of the transgender community and of the inequities they face. Furthermore, particular attention must be given to psychiatric care.