A Transgender Learning Gap in the Emergency Room

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As an emergency physician, I’m always engaging in a fast-tempo, often awkward, all too stressful dance with strangers. Lately, though, I’ve noticed a particular gap in my own medical education and training, as well as in that of my colleagues, that’s further tripping up our steps: how to provide optimal health care for transgender patients.

The gap is amplified in the emergency room, where even under the best of circumstances the interaction we have with patients is typically rushed and never entirely comfortable — and where I’m usually meeting a patient for the first time and don’t have the patient’s medical history at my fingertips. Because transgender people are less likely to have health insurance and are four times more likely to live in poverty compared to the general population, the emergency room serves as a particularly important safety net for these patients.

Sometimes the patient is registered as the wrong gender immediately from triage, resulting in a strained communication from the get-go. Other times, a staff member lets out a surprised gasp as a patient undresses for a physical exam. Then there are the moments when providers call a patient a “he/she” or “they” on rounds. Private rooms are also hard to come by in busy, overcrowded emergency rooms, and patients may be inappropriately clustered by gender.

None of this, for the most part, is out of malice. Instead it’s because of our own ignorance — and stems from our lack of education and training on providing sensitive and evidence-based care for transgender patients.

Currently, American medical schools’ curriculums are not sufficiently addressing the health needs and concerns of the lesbian, gay, bisexual and transgender community. A comprehensive survey of schools in the United States and Canada revealed that less than five hours in medical schools are devoted to L.G.B.T. health over all; some medical schools reported zero hours of training. While I did learn about providing health care for lesbian, gay and bisexual patients when I went to medical school over a decade ago, I didn’t receive any special education on the particular health needs and concerns of the estimated 1.4 million adults living in the United States who identify as transgender.

In one study, half of these patients had to teach their doctors about transgender health issues at some point. A Twitter hashtag #transhealthfail started trending in August of 2015, when transgender patients shared stories about their negative experiences with the health care system. Patients continue to use the hashtag today.

These holes in medical education and training can cost lives. Over 70 percent of transgender people nationwide say they have experienced serious discrimination in a health care setting. A third of transgender people postpone — or completely avoid — seeking health care because of the fear of discrimination. One in five have yet to disclose their transgender status to any medical provider.

Though still in the nascent stages, our medical education system may be on the cusp of changing. The American Association of Medical Colleges released its first medical education guidelines for L.G.B.T. health in November 2014. The University of Louisville School of Medicine became the national pilot site to implement a new model of physician training. The initiative, called the eQuality Project, was fully integrated into the curriculum this academic year.

Dr. Amy Holthouser, the associate dean for medical education at Louisville, explained that one way the program is unique is that instead of having an isolated module designated for learning about L.G.B.T. health, the issues pertinent to L.G.B.T. patients are integrated into the entire curriculum. In the pharmacology block, for instance, students may learn about hormone therapies used for transitioning, in the same way that they might learn about medications to treat high blood pressure. When students are educated about routine pap smears, the importance of screening transgender men is also taught; the same goes for prostate exams and transgender women.

Some schools make the commendable effort of allocating hours to L.G.B.T. health, but often they focus too narrowly on subjects like sexually transmitted infections and H.I.V., Dr. Holthouser explained, which can further stigmatize patients. “Instead, we want to teach students how to provide all aspects of patient care,” she said.

All in all, the school now has revised about 50 hours of its curriculum to include L.G.B.T. health — which puts it far ahead of the curve. The medical colleges’ association’s standards are not mandatory. But Dr. Holthouser predicts that “once they start putting questions specific to L.G.B.T. health on board exams and require them in reports for accrediting bodies, schools will quickly catch up.”

At New York University School of Medicine, Richard Greene, the director of gender health education, is working on incorporating L.G.B.T. education into both undergraduate medical education and residency training. For all medical students and those residents training to become primary-care physicians, he has already implemented standardized patient exams — simulated clinical scenarios in which actors play patients — that test candidates’ competency with transgender health issues. He is working on expanding this across all residency training programs, regardless of the specialty.

Dr. Greene’s efforts have been met with enthusiasm. “I find young learners, like new medical students and new residents, are really excited to learn about transgender health. I’m really optimistic about the next generation,” he told me. “Senior providers don’t know what they know.”

For doctors like me who didn’t get the training in our earlier years, there are easily accessible learning resources. The National LGBT Health Education Center, a part of the Fenway Institute, provides free web-based interactive modules, which I recently took. The University of California-San Francisco and the World Professional Association for Transgender Health also have extensive online resources and learning modules. Conferences and webinars are routinely available for physicians to attend and learn more about providing health care to the L.G.B.T. community.

But the first step is simply recognizing our own deficiencies — and realizing that learning about transgender health is as pressing as mastering dosages of the newest cholesterol-lowering drug or memorizing the latest protocol for resuscitating a patient from cardiac arrest. “This is something that’s not going away,” Dr. Greene said. “In fact, it’s becoming more urgent.”