Bioethics in Practice: Ethical Issues in the Care of Transgender Patients

Introduction

A young man, JT, arrives at the clinic to establish care. The front desk staff is confused because his gender is listed as female in the chart. After several minutes of discussion, your assistant walks out and calls for “Ms T.” When you walk into the room, he is clearly upset with the process.

Transgender describes a person whose gender identity differs from the sex assigned at birth. Gender identity is a person's inherent sense of being female, male, or an alternative gender.1 To adequately treat gender nonconforming patients, healthcare providers should recognize that not all patients fit into a binary gender description.

In Louisiana, transgender people represent approximately 0.6% of the population, or 20,900 people.2 Transgender individuals experience a high degree of homelessness, violence, abuse, and hate crimes.3 Furthermore, transgender individuals have a suicide attempt rate of 41% that far surpasses the national average of 4.6%.4 In addition, transgender individuals battle extensive healthcare disparities, but aligning the treatment of transgender patients with the ethical principles of autonomy, nonmaleficence, benefice, and justice can help eliminate these disparities.

Autonomy

Transgender patients have the right to have their self-identification respected by staff, and their preferred name and gender identity should be recorded in the electronic medical record (EMR). Providers should consider the role of partners and chosen family in healthcare decision making.5 These relationships may vary from traditional family ties by incorporating a social support network that validates the patient's identity.

In addition, transgender patients have the right to make healthcare decisions collaboratively with their providers under the principle of informed consent. Transgender patients' decisions to proceed with hormonal and/or surgical therapy deserve respect and should be considered confidential by healthcare providers.6

Nonmaleficence

Nonmaleficence implies a commitment to medical competence by minimizing harm to patients. In healthcare, harm is seen in barriers to access care, perpetuation of stigma and discrimination, and omission of risks. Healthcare providers may need to reflect on their approach to gender identity and patient experience and should critically assess gaps in their knowledge and acceptance of gender nonconforming patients.5

Physicians are encouraged to assess the transgender patient's presenting complaint and realize that this complaint may or may not be related to the individual's transition. Periodic health maintenance should be based on the patient's existing anatomy.1 A patient who is identified in the EMR as transgender should prompt the provider to discuss the patient's anatomy and provide appropriate preventive screening.

The EMR may tie procedures and insurance reimbursement to a binary gender, making it difficult to order tests and obtain reimbursement for gender binary diagnoses such as prostate cancer or pregnancy.1 Care should be taken during medical billing to ensure the billing name and pronoun match the patient's insurance.7,8

Normal laboratory values are often based on gender and do not take into account transgender or transitioning individuals. Hormonal therapy may change the normal range of values for a wide variety of laboratory parameters, and providers should have access to resources to appropriately interpret normal and abnormal laboratory testing.8-11

Beneficence

Beneficence implies addressing barriers to care and healthcare disparities on both the population and the individual level. The approach to healthcare for all patients should be affirmative, understanding, and nonjudgmental. Among patients receiving trans-affirmative healthcare, 80% reported improved quality of life and decreased mental health concerns.12

Mental health providers with expertise in trans-affirmative mental health care that is respectful, aware, and supportive of the life experiences of transgender people are scarce in the United States. Transgender patients may view mental health assessments as an important gateway to accessing surgeons, endocrinologists, and legal changes.1 This perception could create a vulnerable power differential, making patients incredibly cautious during initial appointments.

Cultural sensitivity training on issues affecting transgender patients—including how to ensure a welcoming environment to all of our patients, how to develop an understanding of a patient's gender identity and preferred name/pronoun usage, and how to be nonjudgmental in the provision of care—improves the patient experience. Providers are encouraged to link transgender patients to gender-affirming providers to establish better overall healthcare.13

Justice

The principle of justice affirms that transgender patients are equally entitled to a fair distribution of healthcare resources; however, transgender patients are less likely to have health insurance and access to medical services.

Conclusion

In the case of patient JT introduced above, discussion of his gender among front desk staff and calling for him as Ms. T violated his autonomy and caused psychological harm by placing him in a vulnerable and potentially hostile environment. Attention to the ethical principle of beneficence by providing a welcoming introduction to his clinic visit could have made him more comfortable. The principle of justice could be fulfilled if small changes in the healthcare setting eliminated some of the barriers to seeking care.

The ethical principles discussed here briefly introduce the barriers transgender patients face and how we, as healthcare providers, can ensure we provide a safe environment for all patients.