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Lessons from treating a transgender patient

I was recently reminded that you always learn something from your patients, no matter how long your medical profession is. I was reminded of this when I had the opportunity to treat a young person in transition. I reviewed the chart before walking into the exam room. Among other things, it listed the patient’s chief complaint (i.e., in this case, lower back pain), age of nineteen, female sex, and a female name for the patient. As I entered the exam room, I assumed there had been a mistake with the chart. “I am sorry, I think I have the wrong chart,” I said—maybe before I had even said hello. “You do not,” the patient explained, with a tired expression as if they had made the same correction many times before.

It turns out that the patient was in the process of transitioning from female to male. He preferred to be called Marco. Marco had not legally changed his birth name yet, but he was—I later learned—engaged in separate medical care for gender dysmorphia. Surprisingly, my chart did not include any notes about Marco’s transition. I was, therefore, caught unprepared. I had treated transgender patients in the past, but this was the first time in 35 years of practicing medicine that I was treating a person in the early stages of transition (i.e., where their legal and major sexual characteristics had not yet caught up to the rest of the process).

I must admit that I fumbled for a minute but then collected myself and performed the required physical examination of the patient’s back pain. Although I was missing the medical history regarding Marco’s gender transition, I decided not to ask. I told myself it was not relevant to his back pain.

As human beings, we all have biases that are deeply ingrained in our psychology. They are the product of our life experiences and cultural and personal stereotypes with which we have grown up. Importantly, our biases may impact our thoughts, beliefs, and actions in ways we may not realize. By acknowledging our biases and consciously recognizing and questioning them, we can help prevent them from negatively affecting our decisions and behavior. This increased self-awareness can lead to a more equitable and just society where people are judged based on their merits rather than their race, gender, religion, or other personal characteristics. In Marco’s case, I was driven by fear of not asking questions about his transition. My discomfort—born of my own biases—prevented me from providing the absolute best care at that moment because I failed to ask the questions that may have made me understand the patient’s condition and build a better doctor/patient relationship.

After reviewing a preliminary lumbar X-ray and an MRI report, I recommended lumbar facet joint injections under fluoroscopic guidance. Physical therapy had been ineffective for Marco. We followed the surgical center’s standard protocol to prepare the patient for the procedure. However, almost right away, my staff needed to learn how to proceed. Several nurses approached me about obtaining the required pregnancy test. They did not know how to approach Marco about it. Sadly, I felt uneasy, too. I consulted the medical director to let them make a decision. The patient was then asked to provide a urine sample for a pregnancy test by one of our practitioners. Marco wanted to be happier about the bureaucratic requirement. I am sure it felt unfair and unnecessary to him. My obvious discomfort in managing the patient did not help matters.

In truth, the experience left me questioning my competency and level of empathy. In the state of Florida, before renewing our medical licenses, the state requires medical doctors to take mandatory courses on sex trafficking, domestic violence, medical errors, and controlled substance prescriptions. Surprisingly, these courses still do not cover transgender issues, regardless of the medical specialty.

In hindsight, I realized I had so many questions I could not answer. What is the best way to document a patient’s transgender status in a medical chart? How many questions about the specific treatment are appropriate? Medication histories are critical in a surgical setting, but what about other interventions? If a pregnancy test is required for a person identifying as male, what is the best way to explain that to the patient without disrespecting them?

Some doctors, I suspect, avoid specific topics and questions with transgender patients, particularly those who are in the early stages of transition. What might we be missing by failing to engage professionally and respectfully? Doctors and other medical professionals would be in a better position to provide high-quality health care services if they possessed a comprehensive understanding of the medical implications that gender issues can have on the overall health of individuals. By better grasping the various gender-related concerns that a patient may have, doctors can tailor their diagnosis, treatment, and care to meet each patient’s specific needs, thereby enhancing the overall quality of care provided. Medical training must evolve to better prepare doctors for this population in medical school and continuing education settings. This will ensure that doctors in the back half of their careers are as equipped with the appropriate protocols and pertinent medical information as the younger generations. The effective treatment of these patients demands it.

Francisco M. Torres is an interventional physiatrist specializing in diagnosing and treating patients with spine-related pain syndromes. He is certified by the American Board of Physical Medicine and Rehabilitation and the American Board of Pain Medicine and can be reached at Florida Spine Institute and Wellness. 

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