As a podiatrist who treats mainly skin disorders of the lower extremity, I am fortunate to see a textbook’s worth of pathology in a wide variety of patients. I often see patients who identify as a member of the lesbian, gay, bisexual, transgender and gender nonconforming (LGBTGNC) community. It is well documented that LGBTGNC patients may have difficulty in obtaining quality care, often due to the physician’s lack of knowledge in communicating with these patients starting from the office paperwork to the actual visit.
Let us start with some terminology. Gender is assigned at birth based on genitalia but gender identity is how the patients view themselves and how they fit into the world. These terms are not interchangeable.
A transgender person has a different gender identity than the sex that was assigned at birth. A transgender man or a female-to-male transgender person (FTM) was assigned female at birth but identifies as a male. A transgender female or male-to-female (MTF) transgender person was assigned male at birth but identifies as a female. Gender dysphoria refers to the stress experienced for individuals whose sex and gender identity are not congruent. Cisgender or non-transgender people identify themselves as the sex that was assigned at birth.
Many patients avoid seeking care due to fear of judgment and/or poor experiences with physicians in the past.1 It is important to train staff and fellow clinicians on how to make the office a safe and non-judgmental environment for the transgender patient.
This begins with paperwork you may have asking the patient to identify as female or male. If you have only those two options, you may want to consider modifying your paperwork to accommodate the transgender/gender nonconforming patient population.2 Training office staff to ask patients the name they prefer to be called and what pronouns they wish you to use as well as documenting this in the chart are respectful ways to start the visit. The name and gender they prefer you to use may not be the same as their legal identification. These patients may not have had a legal name change yet or may be in the midst of making the name change legal.
The staff should ask: “What is your preferred name? When I speak about you to other providers, what pronoun should I use? Thank you.”1 The pronouns the patient prefers may be he, she or they. In my practice, I have a patient who prefers me to use “they” and “them” in my communication with them. The patient recently changed the legal name and gender marker on the patient’s driver’s license, so when I see this patient next, I will ask if the patient’s pronoun preference has changed.
As podiatrists, we will not be prescribing these patients hormonal therapy but as surgeons, we may be taking them to the OR or admitting them to the hospital. In that case, the gender and name listed on the hospital record may be different than how the patient identifies himself or herself.2 In this case, when you are charting or dictating, you can state: “The patient’s legal name is John. The patient identifies as Mary. Going forth in the chart, I will refer to her as Mary and use the female pronouns as she wishes.”2
Hormonal therapy can cause a variety of physical changes for patients. However, from a lower extremity standpoint, we may see the following: testosterone will cause increased body hair and oiliness of skin where estrogen and anti-androgen therapy may cause decreased body hair and dry skin.3 Transgender women may also be at risk for deep vein thrombosis (DVT) if they smoke and take estrogen. In patients who refuse to stop smoking, a transdermal estrogen patch may be warranted as it carries a lower risk of DVT.1
Many of us did not have this training in medical school or residency. It is now time to incorporate this training for our students, residents and colleagues so we can be comprehensive in our care to all people.
- Hashemi L, Weinreb J, Weimer AK, Weiss RL. Transgender care in the primary care setting: a review of guidelines and literature. Fed Pract. 2018 July;35(7):30-37.
- Drescher J. Do transgender patients feel welcome in your practice? Medscape Dermatology. Available at https://www.medscape.com/viewarticle/886895?src=WNL_infoc_171104_MSCPEDIT_TEMP2&uac=96834HG&impID=1473075&faf=1. Published Oct. 16, 2017.
- Brunk D. Respect is key when treating dermatologic conditions in transgender youth. Dermatology News. Available at https://www.mdedge.com/edermatologynews/article/171364/dermatology/respect-key-when-treating-dermatologic-conditions?utm_source=News_DERM_eNL_073118_F&utm_medium=email&utm_content=AAD%202018:%20Fingernails%20hold%20diagnostic%20clues . Published July 30, 2018.